1. Pregnancy Termination: Indications, Procedures and Challenges
Michele K. Silverstein, MD, FACOG
Thank you. I would like to take this opportunity thank you for the invitation to speak today. It is a privilege to participate in this conference

2. Overview Indications for Pregnancy Termination
Methods/Choice of Procedure
Complications
As noted, the scope of my presentation will include these three categories

3. Abortion
The termination of a pregnancy after, accompanied by, resulting in or closely followed by the death of an embryo or fetus.
Spontaneous expulsion of a human fetus (i.e. miscarriage)
The medical procedure of inducing expulsion of a human fetus to terminate a pregnancy.
The definition of of abortion as noted in the Merriam Webster dictionary
It is a word that often evokes a visceral response,even when used in clinical context and not a political debate

4. Induced abortion is one of the most commonly performed gynecologic procedures in the US
<50% done at less than or equal to 8 weeks of gestation
90% done within the first twelve weeks of gestation
1% done after 20 weeks of gestation

5. Safety
From a public health perspective, safe and legal abortion services are a cornerstone of maternal health care
The risk of death from abortion at 16 weeks of gestation or less is 5-10 fold less than that of a continuing pregnancy
Maternal mortality in the US is approximately 23 per 100,000 live births
This safety of abortion is a very important consideration because there is a misconception that not intervening in certain situations poses less risk than an intervention.

6. Indications for Pregnancy Termination
Elective
Fetal
Maternal
Ectopic location of pregnancy
This is a useful way to categorize the different indications for pregancy termination. I just want to touch on the first and last. Elective indication is purely that. An ectopic pregnancy is one in which implantation takes place outside of the endometrial cavity, most commonly the fallopian tube. It can be located in the ovary, abdomen or cervix, all of which are life threatening to the mother.

7. Fetal indications for pregnancy termination
Fetal demise at any gestational age
Diagnosis of genetic abnormality by chorionic villus sampling (CVS) or amniocentesis -chromosomal -inherited genetic disorders
Structural abnormality detected on detailed anatomy ultrasound -i.e. cardiac malformations, anencephaly
3% of all live births affected by a major congenital anomaly
Fetal demise is confirmed by ultrasound.

8. Fetal indications for pregnancy termination (2)
Abnormal placentation -placenta previa, accreta, percreta -cesarean scar implantation
Concerns for exposure to teratogens -radiation or other environmental concerns -medications
There are only a few medications that are known teratogens. Teratogenic exposure accounts for 3-6% of all birth defects. (ACE Inhibitors, isotretinoin, ethanol, methotrexate,phenytoin, valgorate, warfarin)

9. Maternal Indications for Pregnancy Termination
Medical Conditions
Psychosocial Conditions
Cases of rape or incest

10. Considerations of Maternal Disease and Pregnancy
What is the impact of the disease on the pregnancy?
What is the impact of pregnancy on the disease, both short and long term?
What management would be recommended without pregnancy?
Can the change in management be justified?
What are the risks/benefits to the mother and fetus and are they aligned or contrary to each other?
Advances in both medicine and surgical techniques have changed the playing field for many with underlying medical conditions. This underscores the need for both excellent pre-conceptual counselling and interdisciplinary collaboration to achieve the best outcomes. Despite this, serious medical or obstetrical conditions do arise that present critical issues for women and couples with an otherwise desired pregnancy. The physiologic changes of pregnancy are vast, and dynamic.

11. Maternal Medical Conditions
Cardiovascular Disease
Surgically Corrected Structural Heart Disease
Chronic Hypertension
Diabetes
Malignancy
Neurologic
Psychiatric
Surgery
The most common indication for medical termination for maternal indication is cardiovascular disease. This includes congenital malformations that may have been repaired (Ebstein’s anomaly/valvular disease) or acquired diseases like cardiomyopathy

12. Psychosocial Factors Relationship Issues Other life stressors
Financial
Impact on the family

13. Other Indications Elective, no medical or other factors considered
Ectopic pregnancy which requires surgery or other medical management

14. Options/Methods of Pregnancy Termination
Choices are gestational age dependent
Surgical
Medical
Expectant (in the cases of fetal demise)

15. Surgical Methods of Pregnancy Termination
Transcervical Evacuation
Dilatation and Curettage (D&C)
Dilatation and Evacuation (D&E)
Major Operations
Hysterotomy
Hysterectomy

16. Dilatation and Curettage
Curettage by vacuum aspiration performed at gestational age of less than or equal to 12 weeks
Technique of Menstrual Extraction can be used in the earliest of cases
Use of a flexible cannula attached to an aspirator or syringe
Manual Vacuum Aspiration (MVA)
Generally does not require cervical dilation
Electric Vacuum Extraction (EVA) more commonly performed
Requires cervical dilation
Use of either local or general anesthesia
Greater than 6 weeks

17. Dilatation and Evacuation
Term used for cervical dilatation followed by evacuation of the products of conception after 12 weeks
Predominant method of termination beyond 12 weeks
Requires a greater degree of cervical dilatation which necessitates the use of osmotic dilators for a period of 6-48 hours prior to the procedure
Tents of Laminaria Japonica, a natural seaweed are the most commonly used dilators
Use of special forceps to remove the larger volumes of tissue
Prostaglandins may also be used for cervical ripening.

18. Major Operations Rarely Performed
Hysterotomy - a surgical incision in the uterus by a transabdominal approach, in essence, a cesarean section
Hysterectomy
Most commonly performed with abnormal placentation or to complete a failed or complicated D&E

19. Non-surgical Options
Medical Abortion
Induction of Labor

20. Medical Abortion
May be used up to 63 days of gestation, calculated by the LMP or 9 weeks gestational age by sonogram
Most common regimen in the US is mifepristone 200 mg PO followed by buccal administration of 800 mcg of misoprostol hours later
Usually causes expulsion of the pregnancy within several hours of the misoprostol dose
Up to 5% require surgical intervention
Increased risk of Clostridial infection
Misoprostol is taken in the privacy of one’s home

21. Induction of Labor
Termination of Pregnancy by stimulation of labor like contractions that cause eventual expulsion of the fetus
Instillation of hypertonic solution of saline or urea into the uterine cavity to cause contractions
More commonly, prostaglandins and/or oxytocin are used
Gestational age dependent
Must be done in a hospital setting

22. Risks and Complications of Pregnancy Termination
Immediate
Delayed
Late
Both medical and surgical methods have risk of complications

23. Immediate Complications
During or within 3 hours of procedure
Uterine perforation (3-20/1000)
Hemorrhage
Cervical injury
Anesthetic Complications
Amniotic Fluid Embolism

24. Delayed Complications
3 hours to 28 days post-procedure
Infection
Hemorrhage
Failed procedure, retained products of conception

25. Late Complications Asherman’s Syndrome- Intrauterine Adhesions
Cervical Incompetence
Psychological Effects
Guilt
Depression
Anxiety

26. Abortion is never simple, no matter the state, the stage of pregnancy nor the reason.