Surgical Abortion Paula Bednarek, MD, MPH Assistant Professor Dept of Obstetrics and Gynecology Oregon Health & Science University

SCOPE OF THE PROBLEM Worldwide: United States 100 million sex acts per day 175 million pregnancies per year 75 million unintended pregnancies per year United States Highest rate of teen pregnancy in world Half of pregnancies unintended

Teenage pregnancy is more common in the United States than in most other industrialized countries In addition, while the pregnancy rate among U.S. teenagers declined by 17% from its peak in 1990 to 1996, it is still one of the highest among industrialized nations. Source: AGI, Fulfilling the Promise, p. 35.

Half of all pregnancies in the United States each year are unintended Even as clinics work to broaden their public health focus, much work remains to be done to achieve their goal of eliminating unintended pregnancy. Each year, half of all pregnancies in the United States are unintended, and half of unintended pregnancies - or one in four pregnancies overall - end in abortion. Rates of unintended pregnancy remain highest among young and low-income women -- the groups the publicly funded family planning clinic network serves. Source: AGI, Fulfilling the Promise, pp. 34-35. Pregnancies (6.3 million)

Rate of Abortion by Age Group The abortion rate of teenagers has declined markedly in recent years, in large part because of use of long-acting hormonal contraceptives, mainly the injectable. 43% of women in the USA will have an abortion at some time in their life Source: Jones et al., 2002

Abortions by Gestational Age (Weeks Since Last Menstrual Period) % of Abortions Weeks of Gestation at Time of Abortion: Almost 90% of abortions are performed in the first trimester of pregnancy (in the first 12 weeks after the first day of the woman’s last menstrual period). Six in 10 abortions are performed before 9 weeks after the last menstrual period, or within 5 weeks of the first missed period. The proportion of abortions performed very early in pregnancy (at 6 weeks or before) increased from 14% in 1992 to 25% in 2001. Fewer than 2% of abortions are performed after 20 weeks. An estimated 0.08% of abortions are performed after 24 weeks, when the fetus may be viable. Weeks Source: Henshaw adjustments to Strauss et al., 2004 (2001 data)

The small proportion of women who do not use contraceptives . . . . . . account for roughly half of all unintended pregnancies In fact, the likelihood of pregnancy in the absence of contraceptive use is so great that the 7% of American women aged 15-44 using no method while at risk of unintended pregnancy account for nearly half (47%) of all unintended pregnancies. Source: AGI, Fulfilling the Promise, p. 10. Women at risk of unintended pregnancy (42 million) Women experiencing unintended pregnancies (3 million)

Any contraceptive method is better than none, . . . . . . but choice of method makes a difference Contraception is key to helping women and their partners realize their family-size goals. Some of the most widely used contraceptive methods reduce the risk of unintended pregnancy by more than 90%. Source: AGI, Fulfilling the Promise, p. 10. % of users becoming pregnant within one year

ABORTION Legal Aspects Abortion is protected by the U. S. Supreme Court decision Roe v. Wade decided in 1973. Decision made in privacy with a women and her physician. Based on the principle of maternal rights superseding the rights of the fetus.

ABORTION Viability = gestational age at which a fetus will survive outside of the womb albeit with artificial support. Physicians have an ethical responsibility to provide information and appropriate referral for abortion or contraceptive services that a patient might request.

ABORTION Technique Discussion of the alternatives. Informed consent. Careful pelvic exam. Ultrasound assessment of gestational age. Not yet the standard of care. Most large volume providers include as part of the abortion package. Procedure depends on gestational age (stated from the first day of the last menstrual period) Same technique used for managing unsuccessful pregnancies

Suction abortion technique: <14 weeks gestational age Anesthetic choices: Paracervical block with local anesthetic. Oral or IV sedation may be used in addition. General anesthetic used in more difficult 1st trimester procedures Dilation of the cervix to allow passage of a suction cannula into the uterine cavity.

Suction abortion technique: <14 weeks gestational age Direct dilation with dilator <12-14 weeks Laminaria for pregnancies >12-14 weeks gestation. Absorb moisture and swell to dilate the cervix. Misoprostol also effective. Sterilized pieces of the seaweed Laminaria japonicum. Dilapan (Synthetic sponge cervical dilator) Mifepristone??

Suction abortion technique: <14 weeks gestational age Size of canulas in mm diameter used equals the gestational age in weeks Suction is applied with an electric pump and the pregnancy is removed from the uterus. Suctioning continues until uterus feels empty Tissue carefully inspected to assure that the entire pregnancy has been removed.

MANUAL VACUUM ASPIRATION Technique:   Speculum to visualize cervix Cleanse with antiseptic, paracervical block Dilate as necessary to allow insertion of the cannula Insert cannula to fundus Create suction with syringe and perform curettage. Take care to not lose the vacuum by pulling the cannula through the cervical os before an adequate amount of tissue has been obtained

MANUAL VACUUM ASPIRATION Technique (cont’d): Continue curettage until uterus feels empty Expel syringe contents into dish to inspect tissue Careful inspection of tissue. If products of conception not seen, follow‑up ultrasound to confirm completion

MANUAL VACUUM ASPIRATION Advantages: Earlier procedures require less cervical dilation, less bleeding and less cramping Less noisy than suction machine Less time for patient with pregnancy side effects Electricity not needed Re‑usable syringes

MANUAL VACUUM ASPIRATION Disadvantages: Slightly more difficult technique? Need more than one aspiration for greater gestaional age pregnancies Inability to find products of conception raises question of failure of the technique or ectopic pregnancy

Complications of Surgical Abortion Risk of complications increases with increasing gestational age Reporting of all complications required to state health department

Perforation of the uterus Approximately 1 in 1000 first trimester suction abortions Managed by observation in the hospital or clinic Risk of bowel injury or significant internal bleeding is <1%. Approximately 1 in 300 D&E's. Immediate laparoscopy or laparotomy is usually indicated.

Incomplete abortion Defined as a need to have another suction procedure to complete the abortion Incidence is approximately 1 in 250 abortions

Infection The incidence of infection is about 1 in 200. Almost always successfully treated as an outpatient.

Abortion Risks in Perspective Chance of death Risk from terminating pregnancy: per year: Before 9 weeks 1 in 1,000,000 Between 9 and 10 weeks 1 in 500,000 Between 13 and 15 weeks 1 in 60,000 After 20 weeks 1 in 11,000 Risk to persons who participate in: Motorcycling 1 in 1,000 Automobile driving 1 in 5,900 Power-boating 1 in 5,900 Playing football 1 in 25,000 Risk to women aged 15–44 from: Having sexual intercourse (PID) 1 in 50,000 Using tampons 1 in 350,000 Risk of Death from Abortion in Perspective: The risk of dying from an abortion is low compared with many other risks that people are exposed to. PID is pelvic inflammatory disease, an infection of the upper reproductive organs in women, which can result from sexually transmitted infection. Source: Bartlett et al., 2004 (1988–1997 data); Contraceptive Technology, 2005

International Perspective on Abortion A very small proportion of abortions worldwide take place in the United States. Most unsafe abortions occur in countries where abortion is illegal.

20 Million Unsafe Abortions Occur Each Year Source: Sedgh G et al., Legal abortion worldwide: incidence and recent trends, International Family Planning Perspectives, 2007, 33(3):106– 116. Abortion in Developed and Developing Countries: Abortion happens at about the same rate in regions of the world where it is highly restricted and where it is broadly legal. Overall abortion levels are strikingly similar among women living in developed and developing regions (39 per 1,000 and 34 per 1,000, respectively). The key difference is safety. Women in developing countries with restrictive abortion laws often go to untrained providers.

Almost All Abortion-Related Deaths Occur in Developing Countries Deaths per 100,000 unsafe abortions, 2003 Source: World Health Organization (WHO), Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality, in 2003, fifth ed., Geneva: WHO, 2007.

Complications of Unsafe Abortion An estimated five million women are hospitalized each year for treatment of abortion-related complications, such as hemorrhage and sepsis. Complications from unsafe abortion procedures account for 13% of maternal deaths, or 67,000 per year. Approximately 220,000 children worldwide lose their mothers every year because of abortion-related deaths. Sources: Singh S et al., Abortion Worldwide: A Decade of Uneven Progress, New York: Guttmacher Institute, 2009.; World Health Organization (WHO), Unsafe Abortion: Global and Regional Estimates of Incidence of Unsafe Abortion and Associated Mortality, in 2003, fifth ed., Geneva: WHO, 2007.; Grimes DA et al., Unsafe abortion: the preventable pandemic, Lancet. 2006 Nov 25;368(9550):1908-19. Unsafe Abortion and Maternal Mortality: Abortion-related mortality rates are hundreds of times higher in developing countries, where abortion is often illegal or highly restricted, than in developed countries. According to World Health Organization (WHO) estimates, unsafe abortions account for 13% of all maternal deaths worldwide. Most unsafe abortions occur where abortion is illegal. WHO estimates that 67,000 of the more than 536,000 pregnancy-related deaths that occur each year result from unsafe abortions.

Mortality trends for abortion

Long-Term Safety of Abortion First trimester abortions pose virtually no risk of Infertility Ectopic pregnancy Miscarriage Birth defect Preterm delivery or low birth weight Abortion is not associated with breast cancer. Abortion does not pose a hazard to women’s mental health. Source: Boonstra H et al., Abortion in Women’s Lives, New York: Guttmacher Institute, 2006. Long-Term Safety: The preponderance of evidence from well-designed and well-executed studies indicates that first-trimester abortion is safe over the long term and carries little or no risk of fertility-related problems, cancer or psychological illnesses. Vacuum aspiration, the modern method most commonly used during first-trimester abortions, poses virtually no long-term risks of fertility-related problems. Exhaustive reviews by panels convened by the U.S. and British governments have consistently found no association between abortion and breast cancer. The available evidence also indicates that abortion is not a risk factor for other types of cancer and may even protect against certain kinds of cancers. The decision to terminate a pregnancy is often complex and sometimes difficult. However, well-designed studies continue to find that abortion is no more likely to cause mental health problems than is continuing an unwanted pregnancy.

Abortion Is Safer the Earlier in Pregnancy It Is Performed Deaths per 100,000 abortions Sources: Grimes DA et al., Unsafe abortion: the preventable pandemic, Lancet. 2006 Nov 25;368(9550):1908-19; and Bartlett LA et al., Risk factors for legal induced abortion–related mortality in the United States, Obstetrics & Gynecology, 2004, 103(4):729–737. Safety of Abortion: Abortion is one of the safest surgical procedures for women. The risk of death associated with abortion is low—approximately 0.6 deaths per 100,000 abortions—and the risk of major complications is less than 1%. The risk of death when a pregnancy is continued to birth is about 12 times as great as the risk of death associated with induced abortion. (Note: The calculation of mortality associated with childbirth omits deaths related to miscarriage and ectopic pregnancy.) On average, eight women each year die from complications of induced abortion, compared with about 280 who die from complications of pregnancy and childbirth, excluding abortion and ectopic pregnancy. Abortion is safer the earlier in pregnancy it is performed. Gestation at abortion

Obstacles to Obtaining Abortion Services Although most women obtain abortions early in pregnancy, some women face substantial obstacles to access. Nearly four in 10 women of reproductive age receive coverage under Medicaid, yet 32 states allow Medicaid funding for abortion only in cases of rape, incest or life endangerment. Lacking insurance coverage, poor women often require time to find the money to pay for an abortion, if they are able to at all. Legal requirements such as parental consent for minors or waiting periods are likely to cause further delays, increasing the risk of complications.

Reasons for Abortions After 16 Weeks Since Last Menstrual Period Woman did not realize she was pregnant 71% Difficulty making arrangements for abortion 48% Afraid to tell parents or partner 33% Needed time to make decision 24% Hoped relationship would change 8% Pressure not to have abortion 8% Something changed during pregnancy 6% Didn’t know timing was important 6% Didn’t know she could get an abortion 5% Fetal abnormality diagnosed late 2% Other 11% Barriers that Cause Delay: 11% of women who obtain an abortion do so after the first trimester. Because abortion is stigmatized, women often delay the acknowledgment of their unintended pregnancies. Many women do not feel the physical changes, hope that they are not pregnant or fail to recognize the pregnancy because of irregular periods. Nearly half (48%) of women who had late abortions attributed the delay to difficulty in making arrangements for the procedure, meaning that they needed time to raise money or get a Medicaid card, they had to arrange transportation, there was no local abortion provider, they were minors subject to state laws requiring parental involvement, or they had difficulty securing child care. Source: Torres and Forrest, 1988 (1987 data)

Dilation and Evacuation (D & E) >14 weeks gestational age Fetus and placenta extracted through the cervix. Anesthetic choices: Same as <14 weeks gestational age suction procedures. This is not the procedure used in intact dilation and extraction (“partial birth abortions”)

2nd Trimester Abortion Complications Hemorrhage Uterine Atony Placental Abnormalities Disseminated Intravascular Coagulopathy Uterine Injury Tears of the Cervical Os Perforation Uterine Rupture Asherman Syndrome Amniotic Fluid Embolism Infection

Hemorrhage in 2nd Trimester Abortion Definition: > 250 or 500cc, or needing transfusion Increasing risk with gestational age Risk Factors: maternal age parity prior cesarean delivery fibroids history of postabortion or postpartum bleeding

Uterine Atony in 2nd Trimester Abortion Prevention Vasopressin in paracervical block Methergine IM Treatment Manual uterine compression Oxytocin IV or IM Hemabate IM Misoprostol 600 ug intravaginally or rectally Volume expansion, transfusion as needed

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