1. Pregnancy Options Julie Moldenhauer, MD Reproductive Genetics Maternal Fetal Medicine Obstetrics and Gynecology

2. Objectives  Review background information relating to pregnancy options  Discuss management options for pregnancy  Review timing, benefits and risks of various options  Review options in multiple gestations

3. In the U.S. 47% of pregnancies are unplanned. Finer 2006, Perspectives on Sexual and Reproductive Health Henshaw SK: Family Planning Perspectives 1998;30:24-29. Pregnancy intendedness is associated with adverse obstetric, neonatal and parenting outcomes

4. Every woman who is diagnosed with an unplanned pregnancy should be made aware of all of her options. Continuation of pregnancy  Termination  Adoption Hacker, Moore and Gambone. Essentials of Obstetrics and Gynecology, 4 th Ed.

5. Background 1973 Roe v. Wade Supreme Court decision legalized abortion in the U.S. Abortion laws vary state by state Gestational age limits 24 hour wait time prior to procedure Teens and parental notification

6. Pregnancy Termination Language: Termination Abortion Elective abortion Therapeutic abortion Interruption of pregnancy Definition: The removal of a fetus or embryo from the uterus before the stage of viability Indications Personal choice Medical recommendation Anomalous fetus Intrauterine infection or Septic abortion Methods Dependent upon gestational age and provider abilities

7. Medications Used in Medical Abortions Medical abortions are performed early in gestation – typically < 9 weeks (63 days) from LMP (Last Menstrual Period) Mifepristone – progestin analogue that binds to the progesterone receptor and acts as an antiprogestin. Results in separation of the trophoblast from the endometrial wall, increases endogenous prostaglandin release, sensitizes the myometrium to exogenous prostaglandins, and softens the cervix. Administered orally. Side effects: abdominal pain, nausea, vomiting, diarrhea, dizziness, fatigue, and fever. Misoprostol – prostaglandin E1 analogue that causes uterine contractions resulting in cervical softening and dilation. Administered orally and vaginally. Side effects: nausea, vomiting, fevers, chills. Methotrexate – antimetabolite that inhibits the enzyme dihydrofolate reductase interfering with DNA production. It targets rapidly dividing cells and interferes with implantation. Contraindicated in women with kidney disease, liver dysfunction or anemia. Administered orally or intramuscularly. Side effects: nausea, vomiting, diarrhea, fever, chills, headache, dizziness, and oral ulcers.

8. Termination in Early Gestation: Medical Abortion < 49 days from LMP Mifepristone followed 2 days later by misoprostol orally FDA approved: 600 mg mifepristone/400micrograms misoprostol 92-99% complete abortion Most effective method of termination < 49 days from LMP Variation on dosing and route Studies validate this regimen up to 63 days from LMP Performed as outpatient, readily available and pain managed with NSAIDS Proportion of women will require surgical procedure to evacuate contents of uterus if incomplete. Recommend follow-up visit to check for negative pregnancy test or ultrasound. Bleeding occurs for about 14 days after procedure

9. Termination in Early Gestation: Medical Abortion Methotrexate followed by misoprostol < 49 days from LMP ~ 95% complete abortion Misoprostol alone Typically used <63 days from LMP Varying doses and routes of administration > 85% effective

10. Termination in Early Gestation: Surgical – Vacuum Aspiration Up to 12 completed weeks Suction procedure Manual vacuum aspiration Electric vacuum aspiration 95-100% effective < 0.1% complication rate Inexpensive Typically done as outpatient with local anesthesia or premedication When performed <6 weeks more likelihood of retained products http://www.who.int/reproductive-health/impac/Procedures/Manual www.ipas.org/Library/News/News World Health Organization. Safe abortion : technical and policy guidance for health systems. 2003.

11. Surgical Procedures: D&C and D&E Require accurate determination of gestational age Involve manual dilation of cervix and removal of intrauterine contents Require anesthesia and typically more expensive Destructive procedures requiring both aspiration and sharp curettage D&C: Dilation and Curettage – “Sharp curettage” Up to 12 weeks Can typically be done with minimal anesthesia as outpatient D&E: Dilation and Evacuation 12+ weeks Typically done in an OR setting using heavy sedation/anesthesia Requires more operator skill World Health Organization. Safe abortion : technical and policy guidance for health systems. 2003.

12. Barcointernational.se Cookmedical.com www.berkeleymedevices.com/dispbles.html thomasmedical.com Laminaria Dilipan Cervical Dilators Curettes

13. Second Trimester Medical Management Typically used > 14 weeks Similar to an induction of labor – many options for management Cervical ripening Misoprostol Foley bulb Laminaria Multiple agents Pitocin Misoprostol** Inpatient procedure – expensive Pain management Most women will deliver within 24 hours Fetus delivered intact – autopsy available Risk of failure/retained products of conception and the need for D&C or D&E

14. World Health Organization Recommendations World Health Organization. Safe abortion : technical and policy guidance for health systems. 2003.

15. Maternal Mortality in the United States: 12.1 deaths per 100,000 live births Hoyert DL. Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 3(33). 2007.

16. Safety Grimes DA et al. Lancet 2006;368:1908-1919 According to WHO an unsafe abortion is defined as: A procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.

17. Safety Grimes DA et al. Lancet 2006;368:1908-1919 Morbidities associated with unsafe abortion: Bleeding Infection Poisoning Damage to vagina, cervix, uterus, and other abdominal organs Death

18. Safety Approximately 20 million unsafe abortions take place annually worldwide –97% of these occur in developing nations –68,000 women die –Case-fatality rate 367 deaths/100,000 unsafe abortions In the United States the case-fatality rate is < 1 death per 100,000 procedures Overall complication rate: –0.7/1000 procedures requiring hospitalization –8/1000 procedures less serious complications Grimes DA et al. Lancet 2006;368:1908-1919 Grimes DA and Creinin MD. Ann Int Med 2004;140:620-626. Hakim-Elahi et al. Obstet Gynecol 1990;76:129-135.

19. Special Consideration: Multiples Higher order multiples – triplets, quads,etc High risk pregnancy category with outcomes dependent upon gestational age at delivery Option of MultiFetal Pregnancy Reduction (MFPR) Ultrasound guided needle technique to deliver cardiotoxic agent to fetus(es) to reduce the overall number

20. Special Consideration: Multiples Selective Reduction of an abnormal co-twin to optimize survival or outcome for normal twin Procedure dependent upon placentation, clinical picture and practitioner skill Cardiotoxic agents cannot be used in monochorionic cases Options for monochorionic: Umbilical cord ligation Radiofrequency Ablation Alcohol/Sclerosing Agents http://www.chop.edu/consumer/jsp/division/generic. http://fetus.ucsfmedicalcenter.org/twin/trap_sequence.asp

21. Adoption Open Adoption Birth parent(s) choose adoptive parents and are involved after adoption completed. Semi-Open Adoption Birth parent(s) choose adoptive parents, but are not involved after birth/adoption completed. Closed Adoption No identifying information is known on either side of the adoption. Typically medical history is shared.

22. Adoption Birth records can also be “sealed” Legal agreements between adoptive adults are void once the child reaches the age of majority, typically 18 Laws vary state by state Adoptions can be arranged privately or through governmental programs

23. Summary Options are available to women/couples diagnosed with unplanned pregnancies and they should be counseled about these options. Pregnancy prevention is preferred. Routine prenatal care should occur in continuing pregnancies. Termination of pregnancy is a safe option. Method is dependent upon gestational age and patient preference. Laws vary state by state. Adoptions can be set up to meet the expectations of both the biological and adoptive parents.