1. Abortion Brenda Pereda, MD Assistant Professor Family Planning

2. Options Counseling  Lucy presents to your office for an annual exam and when you take the menstrual history, she reports that her last period was 7 weeks ago. You astutely obtain the history that she is sexually active using no contraception, and obtain a pregnancy test which is positive.

3. Options  You are an OB-GYN morally opposed to abortion.  How would you talk to Lucy?

4. Options  You are an OB-GYN not morally opposed to abortion.  How would you talk to Lucy?  After counseling, she decides on an abortion. What do you do next?

7. How do you do an abortion? SurgicalMedical

8. Surgical Abortion  Accounts for 95% of abortions  SAFE, SAFE, SAFE  Serious morbidity in less than 1% of procedures  Death rates of 4 per million if performed<8wks  ~9 per 100,000 for >=21 wks ( less than 2% of procedures )

9. Abortion  Options counseling…parent, adoption plan, abortion.  If patient choses abortion discuss available techniques  Emotional support  Contraception plan: initiate contraception immediately post procedure

10. Surgical Abortion  Compared to maternal mortality with continued pregnancy of 11.8/100,000 deliveries  60% of 1.3 million US abortion are performed under 9 weeks and 27% are less than 7weeks

11. Surgical Abortion Description:  Uterine aspiration when <14wks  Standard Dilation and Evacuation >14wks Effectiveness:  98-99%, failures due to incomplete abortion

12. Surgical Abortion Procedure:  Informed consent (local law), procedure type determined by GA, pt pref.  Bimanual to assess size and uterine position  If 2 nd trimester cervical dilators, prostaglandin analogues  Perioperative antibiotics reduce risk of post procedure infection-doxycycline  Cervical anesthesia: cervical block: lidocaine, vassopressin

13. Surgical Abortion  Mechanically dilate cervix if <10 or cervical preparation with dilators or medication  Sterile technique insert canula apply suction with electric machine or manual vacuum aspiration syringe (MVA),  +/- sharp curette

14. Surgical Abortion  Confirm presence of placental villi / gestational sac  If >9 weeks visualize fetal tissue  If no villi then what?  Rh status

15. Surgical Abortion Advantages:  Complete control of fertility  Prevent unwanted pregnancy, defective birth, halt pregnancy that poses risk to maternal life.  Safe and rapid (maybe done in one day)

16. Surgical Abortion  No increased risk of breast cancer, infertility, cervical incompetence, preterm labor, congenital anomalies in next pregnancy  Fewer risk to maternal health than continuing pregnancy  Can be provided as early as intrauterine pregnancy is diagnosed

17. Surgical abortion Disadvantages:  Cramping and pain  Possible regret  Regret equal for undesired pregnancy that is continued…

18. Surgical abortion Complications:  Infection<1%  Incomplete abortion 0.5%-1.0%  Hemorrhage 0.03%-1.0%  Post-abortal syndrome(hematometra) <1%  Asherman’s syndrome  Mortality: elective surgical abortion<1 per 100,000

19. Medical Abortion  Most medical abortions in the US use mifepristone.  Mifepristone is an:  anti-progesterone  blocks progesterone receptors causing decidual necrosis and detachment of products of conception  causes cervical softening  Dose: 600mg FDA approved  Dose evidence based: 200mg

20. Medical Abortion Effectiveness:  92-98% depends on GA and mifepristone dose  Can be used up to 63 days Contraindications:  Ectopic pregnancy  Chronic corticosteriod users, adrenal failures, porphyrias Complications:  Mortality ~1/100,000  Infection<1%, Incomplete abortion 0.5-1.0%, hematometra <1%, asherman’s

21. Complications  Sylvia just underwent uterine aspiration at 10 weeks. At the time of placing the suction cannula, brisk bright red bleeding began. Bleeding continues.  Differential?  Management?

22. Complications  Melanie had a medical abortion. She placed the misoprostol 24 hours ago and had bleeding and cramping that peaked 20 hours ago. She now has severe abdominal cramping, no fever.  Differential?  Management?

23. Complications  Mariam presents to the ER in Bamako, Mali, with severe abdominal pain and fever. On physical exam, there is bowel coming out of the vagina.  Differential?  Management?

24. Legal abortion is safe Sources: All births and abortions: Grimes DA, 2006; Abortion by gestation: Bartlett et al., 2004 (1988–1997 data) Deaths per 100,000 abortions Abortions by gestational age

25. Safety of Abortion  Abortion is one of the safest common surgical procedures for women in the United States.  Abortion is safe over the long term and carries little or no risk of fertility-related problems, cancer or psychological illnesses.  Laws criminalizing abortion make abortions unsafe, but do not eliminate them.

26. Complications of unsafe abortion  Complications from unsafe abortion  13% of maternal deaths  67,000 deaths per year.  220,000 children lose a mother every year because of abortion-related deaths. Singh, 2006; WHO 2007; Grimes 2006 5 million women hospitalized annually Sepsis Hemorrage

27. Ethics  Is it moral to require an individual to participate in an abortion?  An OB-GYN?  What if the woman’s life is in danger and there is no one else to perform it?

28. Ethics  Answering a phone call from a patient who wants an abortion?  Getting a speculum out of the Pyxis for an abortion?  Talking to a patient who has had an abortion in the past?

29. Ethics  Is it moral to be against legal abortion?

30. The legal status of abortion does not predict its incidence Lowest abortion rates: Europe, where abortion is legal and available. < 10 per 1,000 Highest: Africa, Latin America and Caribbean, where abortion law is most restrictive and illegal 30 per 1,000 The U.S. is in-between: 21 per 1,000 Sedgh et al., 2007

31. Abortion rates in countries where it is illegal or highly restricted Source: Boonstra, 2006 Abortions per 1,000 women 15–44

32. Percentage of Maternal Mortality Worldwide Due to Unsafe Abortion Source: WHO, 1998 (Estimates for 1995–2000) Unsafe abortion Other causes

33. Efforts to provide medical services by videoconference, a notion known as telemedicine, are expanding, but Planned Parenthood of the Heartland in Iowa is the first in the nation, and so far the only ones, experts say, to provide abortions this way. Advocates say the idea offers an answer to an essential struggle that has long troubled those who favor abortion rights: How to make abortions available in far-flung, rural places and communities where abortion providers are unable or unwilling to travel. Abortion Drugs Given in Iowa via Video Link 93% of counties in Iowa have no abortion provider

34. Medical Abortion Protocol:  Labs: Rh, hemoglobin  Mifepristone 200mg in clinic  Misoprostol 800μgm buccal, vaginal, oral  When to take it 6-72 hours  based on womens needs/ schedule

35. Medical Abortion  Anticipatory guidance: Bleeding precautions, contact information, antibiotics, pain medications  Sustained fever, and pain, prolonged bleeding, N/V/ D> 24hrs CALL US!!

36. Medical Abortion  Follow up 2-14 days after misoprostol use  We see patients 1 week later, + US to establish +/- of GS  If + GS  D&C  If + GC  repeat misoprostol

37. Medical Abortion Advantages:  Avoids a surgical procedure  Available early pregnancy  High Success 94-97%  Private Disadvantages:  Multiple visits  Days to weeks until complete

38. Contraception  All methods can be started on day of abortion procedure  Advantages… we know patient is not pregnant, immediate protection!  For medication abortions  start on follow up day when termination of pregnancy confirmed.

40. refs  Managing Contraception  National Abortion Federation