1. DR.FARZIPOUR Induced Abortion

2. Recent estimates find that approximately 1.29 million abortions were performed in the United States in 2003

3. Abortion Counseling This type of counseling has three primary goals: helping the patient make an informed decision about her pregnancy, increasing the patient's knowledge and comfort with the abortion procedure, and alleviating anxiety and pain during the procedure while providing emotional support for her decision.

4. Preprocedure Assessment Prior to providing an abortion procedure, whether medication or surgical, each patient requires a preoperative assessment. Obstetric, medical, and surgical history should be recorded, emphasizing sexually transmitted disease history, contraception, menstrual history, the outcomes of previous pregnancies, previous uterine or cervical surgery, and any medication allergies.

5. prophylactic periabortal antibiotics should be administered to all patients regardless of preprocedure cervical screening. While Pap testing can be done for women who are due for their annual screening Accurate estimation of gestational age is key to both procedure selection and ascertainment of surgical risk If the patient is too early in gestation to detect a gestational sac, the procedure should be delayed until a sac is visible.

6. Laboratory tests should include Rh(D) typing, with administration of Rh immune globulin to Rh- negative patients immediately after their procedure as well as hemoglobin/hematocrit to assess for anemia. Most generally healthy women can safely obtain abortion procedures in the outpatient setting. Induction termination procedures generally are performed in a hospital setting.

7. Surgical Abortion in the First Trimester Surgical abortion in the first trimester can be performed between approximately 5 and 13 completed weeks gestation a first-trimester surgical procedure is very effective (99.0% efficacy rate), very safe (major complication rate of 0.5%) The D&C procedure includes both dilation of the cervix, which can be achieved chemically, mechanically, or a combination of the two Anesthesia for first-trimester procedures typically is achieved by using deep paracervical infiltration Many providers also offer the option of light to moderate intravenous sedation

8. Cervical Dilation Cervical dilation is one of the most important aspects of abortion care, as it confers safety to the procedure. Inadequate or forced dilation is the primary cause of surgical complications in the first trimester Dilation can be achieved chemically with the use of cervical ripening agents such as misoprostol or mechanically by using rigid cervical dilators. A mixed approach is employed most often, particularly after 10 weeks gestation. Use of a uterine sound to measure uterine size prior to dilation is discouraged

9. Mechanical dilation should never be forced. Forcing mechanical dilation can lead to cervical fracture, uterine perforation, or creation of a false passage within the cervix. Ultrasound guidance can be employed in patients with a tortuous cervical canal or other anatomic abnormality. Patients can be given a low (200 to 400 mcg) dose orally the night before the procedure; alternately, 400 to 800 mcg of misoprostol can be administered vaginally 40- to 90-minutes preprocedure or 400 mcg buccally or sublingually 20 to 40 minutes prior.

11. Suction Aspiration Once the cervix has been adequately dilated, a suction cannula is advanced gently to the uterine fundus. Suction can then be generated either with a mechanical suction aspirator or traditional electric suction aspirator. A mechanical vacuum aspirator consists of a 60-cc locking syringe with a single or double value system that generates approximately 60 to 70 mm Hg of pressure A gentle curetting motion also can be employed MVA is most often employed before 9 weeks gestation but can be used for later gestations, including dilation and evacuation (D&E) up to 16 weeks gestation.

12. For gestations >8-9 weeks, many providers prefer electric suction aspiration, which has the advantage of providing continuous suction without reloading of the collection chamber signs of complete uterine evacuation include bubbles in the suction tubing and the characteristic gritty texture of the empty uterine cavity.

13. Second-trimester Abortion Approximately 12% of abortions performed in the United States occur after 12 completed weeks gestation. More than 95% of these are performed surgically by D&E. Abortion after the first trimester is a riskier procedure than earlier procedures; while the major complication rate is still <1%, the overall risk of mortality is ten times that of suction D&C in the first trimester.

14. Dilation and Evacuation D&E is the most common method of second- trimester abortion. This is achieved with osmotic dilators and often augmented with pharmacologic agents such as misoprostol. There are three types of osmotic dilators: Laminaria japonica, Dilapan, and Lamicel

15. Analgesia for second-trimester D&E can range from local anesthesia with a paracervical block and NSAIDs many practitioners prefer a deeper level of sedation for later-term procedures. remove the products of conception through a cervical os dilated to sufficient diameter to admit and allow manipulation of the instruments (at least 1.0 to 1.5 cm). Blood loss with these procedures typically is in the 100- to 300-mL range.

16. Intact Dilation and Extraction In situations where cervical dilation is adequate (2 to 5 cm, depending on gestational age), it is possible to perform a D&E procedure where the majority of the fetus is removed relatively intact via a modified breech extraction technique This procedure is referred to as intact dilation and extraction (D&X). no difference in major complication rates, blood loss, or future pregnancy outcomes.

17. Medications used in pregnancy termination

18. Medication Abortion Regimens Standard Food and Drug Administration Regimen According the regimen approved by the FDA for gestations up to 49 days, medication abortion is completed over 3 days. On day 1, the woman takes mifepristone, 600 mg orally. Rh(D) immune globulin should be administered prior to misoprostol, if indicated. On day 3, the woman returns to the provider's office. These trials demonstrated an efficacy of up to 95% for gestations at <49 days. Evidence-Based Regimens Using 800 mcg vaginally, misoprostol increases the efficacy of medication abortion.

20. Complications of Medication Abortion Complications of medication abortion are rare and experienced by <0.5% of women. Endometritis following medication abortion occurs rarely (0.09% to 0.05%) and is one of the advantages of medication abortion.

21. Thank You