This chapter should be cited as follows: This chapter was last updated:
Borgatta, L, Stubblefield, P, Glob. libr. women's med.,
(ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10439
March 2009

Pregnancy termination

Induced Abortion: Indications, Counseling, and Services

Lynn Borgatta, MD, MPH
Associate Professor of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
Phillip G. Stubblefield, MD
Emeritus Professor of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA

INTRODUCTION

Indications for abortion reflect the laws of the country and the locality. Until the early 1970s, United States medical practice followed the model penal code suggested by the American Law Institute. Legal abortions could be performed when “continuation of pregnancy would greatly impair the physical or mental health of the mother, or where the child would be born with grave physical or mental defect, or where pregnancy resulted from rape, incest, or other felonious intercourse.”1 Those hospitals that provided abortions set up committees to review the circumstances in each case and to determine which women would be allowed a legal “therapeutic abortion.” The numbers of abortions so provided were few, and they were often done in the late first trimester or midtrimester because of the delay in processing after women applied for abortion. With the landmark decision of the US Supreme Court, Roe v. Wade, in 1973, abortion in the first and second trimesters became legal on consultation of the pregnant woman with her physician.2 However, states can and do impose restrictions and barriers to access to and the affordability of abortion. The United States was in concert with many other countries in liberalization of laws; for instance, between 1977 and 1988, 35 countries liberalized laws3 and since 1998 16 more countries have liberalized their laws to allow legal abortion for more indications.4 Currently, in the United States, the most frequent indication for abortion is that the woman requests abortion for personal reasons.5 The terminology of therapeutic abortion persists, possibly because of local political and financial considerations. For instance, some insurance plans, including Medicaid in most states, will not pay for “elective” abortions but will pay for an abortion on medical grounds. Abortion in the first trimester and early second trimester is safer for the woman than continuing a pregnancy to delivery and therefore can be justified on the basis of health concerns. The woman may not be concerned with this distinction, as she may be intent on abortion regardless of the relative risk. Where abortion is illegal, women may risk their health and even life to obtain an abortion, because they consider continuing the pregnancy unacceptable under any circumstances.

Indications for abortion in the laws of 196 countries are listed in Table 1.4 Approximately 26% of the world's population live in countries that do not allow legal abortion at all, or only allow it to save the woman's life.4 Ten per cent live in the 35 countries that allow legal abortion to protect a woman's health without specifying whether mental health is included. Since the World Health Organization defines health broadly as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" it could be argued that mental and social well-being should be an indication for abortion in those countries.6 In 23 countries with 4% of the world's population mental health is specifically named as a justification. Fourteen countries with 20% of the world population allow socioeconomic factors as justification and 56 countries with almost 40% of the world's population permit abortion almost without restriction.

 

Table 1. Countries by restrictiveness of abortion laws, according to region, August 2008. (Boland, R, Katzive, L; Developments in Laws on Induced Abortion: 1998-2007. Inter Family Planning Perspectives 2008;34 (September, 2008): 111.) -------------------------------------------------------------------------------------------------

Prohibited altogether or to save the woman’s life 

THE AMERICAS AND THE CARIBBEAN Antigua & Barbuda, Brazil (R), Chile (ND), Dominica, Dominican Republic, El Salvador (ND), Guatemala, Haiti, Honduras, Mexico* (F/R), Nicaragua (ND), Panama (F/R/PA), Paraguay, Suriname, Venezuela 

CENTRAL ASIA,THE MIDDLE EAST AND NORTH AFRICA Afghanistan, Egypt, Iran (F), Iraq, Lebanon, Libya (PA), Oman, Syria (PA/SA), United Arab Emirates (PA/SA), West Bank and Gaza Strip,Yemen 

EAST AND SOUTH ASIA AND THE PACIFIC Bangladesh, Bhutan (I/R/X), Brunei, Darussalam, Indonesia, Kiribati, Laos, Marshall Islands (U), Micronesia (U), Myanmar, Palau (U), Papua New Guinea, Philippines, Solomon Islands, Sri Lanka, Tonga, Tuvalu 

EUROPE Andorra, Ireland, Malta, Monaco, San Marino 

SUB-SAHARAN AFRICA Angola, Central African Republic, Congo (Brazzaville), Côte d’Ivoire, Democratic Republic of Congo, Gabon, Guinea-Bissau, Kenya, Lesotho, Madagascar, Malawi (SA), Mali (I/R), Mauritania, Mauritius, Nigeria, Sao Tome and Principe, Senegal, Somalia, Sudan (R), Tanzania, Uganda   

Physical health

THE AMERICAS AND THE CARIBBEAN Argentina (RM) , Bahamas, Bolivia (I/R), Costa Rica, Ecuador (RM), Grenada, Peru, Uruguay (R) 

CENTRAL ASIA,THE MIDDLE EAST AND NORTHAFRICA Jordan, Kuwait (F/PA/SA), Morocco (SA), Qatar (F), Saudi Arabia (PA/SA) 

EAST AND SOUTH ASIA AND THE PACIFIC Maldives (SA), Pakistan, Republic of Korea (F/I/R/SA),Vanuatu 

EUROPE Liechtenstein (X), Poland (F/I/R/PA) 

SUB-SAHARAN AFRICA Benin (F/I/R), Burkina Faso (F/I/R), Burundi, Cameroon (R), Chad (F), Comoros, Djibouti, Equatorial Guinea (PA/SA), Eritrea (I/R), Ethiopia(F/I/R/X), Guinea (F/I/R), Mozambique, Niger (F), Rwanda, Togo (F/I/R), Zimbabwe (F/I/R) 

Physical and mental health 

THE AMERICAS AND THE CARIBBEAN Colombia (F/I/R), Jamaica (PA), Saint Kitts and Nevis, Saint Lucia (I/R), Trinidad and Tobago 

CENTRAL ASIA, THE MIDDLE EAST AND NORTH AFRICA Algeria, Israel (F/I/R/X) 

EAST AND SOUTH ASIA AND THE PACIFIC Hong Kong (F/I/R), Malaysia, Nauru, New Zealand (F/I), Samoa, Thailand (F/R) 

EUROPE Northern Ireland, Spain (F/R)

SUB-SAHARAN AFRICA Botswana (F/I/R), Gambia, Ghana (F/I/R), Liberia (F/I/R), Namibia (F/I/R), Seychelles (F/I/R), Sierra Leone, Swaziland (F/I/R) 

Physical and mental health, and socioeconomic grounds 

THE AMERICAS AND THE CARIBBEAN Barbados (F/I/R/PA), Belize (F), Saint Vincent and Grenadines (F/I/R) 

EAST AND SOUTH ASIA AND THE PACIFIC Australia*, Fiji, India (F/R/PA), Japan (SA), Taiwan (F/I/PA/SA)

EUROPE Cyprus (F/R), Finland (F/R/X), Iceland (F/I/R/X), Luxembourg (F/R/PA), Great Britain (F)

SUB-SAHARAN AFRICA Zambia (F) 

Without restriction as to reason 

THE AMERICAS AND THE CARIBBEAN Canada (L), Cuba§ (PA), Guyana†, Puerto Rico*†, United States*,*† (PA)

CENTRAL ASIA, THE MIDDLE EAST AND NORTH AFRICA Armenia§, Azerbaijan§, Bahrain§, Georgia§ (PA), Kazakhstan§, Kyrgyzstan§, Tajikistan§, Tunisia§, Turkey‡ (PA/SA), Turkmenistan§, Uzbekistan§

EAST AND SOUTH ASIA AND THE PACIFIC Cambodia**,China (SS/L),  Democratic People’s Republic of Korea (L), Mongolia§, Nepal§ (SS), Singapore‡‡, Vietnam(L) 

EUROPE Albania§, Austria**,  Belarus§,  Belgium**, Bosnia/Herzegovina§ (PA), Bulgaria§, Croatia§ (PA), Czech Rep.§ (PA), Denmark§ (PA), Estonia§, Former Yugoslav Republic of  Macedonia§ (PA), France**, Germany**, Greece§(PA), Hungary§, Italy§§ (PA),  Latvia§ (PA),  Lithuania§,  Moldova§, Montenegro§ (PA),  Netherlands*†,  Norway§ (PA),  Portugal‡ (PA), Romania**, Russian Federation§ , Serbia§ (PA), Slovak Republic§ (PA), Slovenia§ (PA), Sweden††, Switzerland§, Ukraine§

SUB-SAHARAN AFRICA Cape Verde§, South Africa§  

----------------------------------------------------------

*Federal system; abortion law determined by states. In Australia and Mexico, state laws fall into different categories of restrictiveness. Classification reflects law affecting largest number of people. †Gestational limit is 8 weeks. ‡Gestational limit is 10 weeks. §Gestational limit is 12 weeks. **Gestational limit is 14 weeks. ††Gestational limit is 18 weeks. ‡‡Gestational limit is 24 weeks. §§Gestational limit is 90 days. *†Law does not limit previability abortions. Notes The countries listed include independent states and, where populations exceed one million, semi-autonomous regions, territories and jurisdictions of special status. The table therefore includes Hong Kong, Northern Ireland, Puerto Rico, Taiwan and the West Bank and Gaza Strip. For gestational limits, duration of pregnancy is calculated from the first day of the last menstrual period, which is generally considered to occur 2 weeks prior to conception. Thus, statutory gestational limits calculated from the date of conception have been extended by 2 weeks. F, abortion allowed in cases of fetal impairment; I, abortion allowed in cases of incest; R, abortion allowed in cases of rape; RM, abortion allowed in cases of rape of a mentally disabled woman; X, abortion allowed on additional enumerated grounds relating to such factors as the woman’s age or capacity to care for a child; PA, parental authorization required; SA, spousal authorization required; SS, sex-selective abortion prohibited; L, law does not indicate gestational limit; ND, existence of defense of necessity is in question; U, law unclear.

 

Indications for abortion where abortion is not restricted

 

The abortion decision may be influenced by medical considerations for the woman. At one extreme are conditions when abortion is strongly recommended, even when the pregnancy is highly desired. A woman who has pulmonary hypertension or Eisenmenger's syndrome faces a mortality of 50% for each pregnancy.7 Such a woman would be strongly advised to consider abortion. Table 2 lists examples of medical situations in which abortion of a desired pregnancy should be considered and discussed. In many more situations, medical considerations exist but are not immediately life threatening, and the woman's wishes strongly influence the course that is taken. Thus, a woman with mitral stenosis faces a greater-than-average risk of serious illness or death during pregnancy, but might decide to accept these risks and continue the pregnancy if she strongly wants a child. Another woman with similar medical circumstances could appropriately refuse to accept the risk, and seek abortion on legitimate medical grounds.

 

Table 2. Maternal indications for termination of a desired pregnancy


Category

Examples

Cardiovascular disease

 

 

 

 

Pulmonary hypertension

Eisenmenger's syndrome

History of myocardial infarction

History of pregnancy cardiomyopathy

Severe hypertensive disease

Genetic disease

Marfan's syndrome

Hematologic disease

Thrombotic thrombocytopenic purpura

Neurologic disease

Untreated cerebrovascular malformation such as aneurysm or arteriovenous malformation

Renal disease

Deterioration of renal function in early pregnancy

Neoplastic disease

 

Invasive carcinoma of the cervix

Any neoplastic disease in which maternal survival depends on prompt treatment with

 chemotherapy or radiation in teratogenic doses

Metabolic disease

Proliferative diabetic retinopathy

Terminal maternal disease

End-stage cancer, end-stage AIDS

Disorders of the current pregnancy

 

Intrauterine infection

Rupture of the fetal membranes before fetal viability

Severe pre-eclampsia or eclampsia

Pregnancies that present a high risk of uterine injury

 

Conjoined twins

Placenta accreta

Prior catastrophic uterine rupture

Neoplastic pregnancy

Trophoblastic disease

Nonviable pregnancy

 

 

Fetal death in utero

Anembryonic pregnancy (“empty sac” or “blighted ovum”)

Inevitable abortion


Fetal anomalies, illnesses, and exposures may also be indications for abortion or for discussion of abortion as an option (Table 3). At one extreme are situations in which the fetus has no chance of survival, such as fetal anencephaly or Potter's syndrome. On occasion, continued fetal development may endanger the woman's well being without any benefit to the fetus, such as conjoined twins with poor prognoses. A woman exposed to 5 rad of pelvic irradiation in early pregnancy might either seek abortion or continue the pregnancy, depending on her willingness to accept some fetal risk from this borderline dose of ionizing radiation.8

 

Table 3. Fetal indications for termination of a desired pregnancy


Category

Examples

Known major fetal malformation

 

 

 

 

Anencephaly

Myelomeningocele

Severe hydrocephaly

Severe cardiac anomaly

Renal agenesis

Chromosomal abnormality

 

 

Down's syndrome and other trisomies

Fragile X

X-linked recessive disease such as hemophilia

Inherited metabolic defect

 

Duchenne muscular dystrophy

Tay-Sachs disease

Fetal exposure to known teratogen

 

 

 

Warfarin

Thalidomide

Isotretoin

Cancer chemotherapy

Radiation exposure

 

15 rad or more total

Radioactive iodine in ablative doses

Maternal infection

 

 

Rubella

Cytomegalovirus

Toxoplasmosis


Sometimes the woman or her advisers overestimate the medical indications for abortion. The lay public and many physicians currently believe that almost any drug taken in early pregnancy can be harmful to the fetus and that any diagnostic radiology procedure is an indication for abortion. The physician's job in such circumstances is not easy. The usual rate of malformations is variously quoted as from 2% to 4% of all pregnancies.9 The majority of these malformations are unexplained, and many have minor effects. No one can guarantee in advance that any pregnancy will be normal. It may be helpful to the woman to present the risk of malformation after the exposure in comparison to her background risk of fetal malformation.10 For example, a dose of 5 rads to the maternal pelvis in early pregnancy is considered to be the least dose that might represent a risk to the fetus.8 An intravenous pyelogram would be an exposure of 600 mrad, well below 5 rad; hence, the risk of fetal harm is low. The physician can assess details of the specific exposure and then consult the literature to assess the risk of fetal malformation. Resources such as ReproTox (www.reprotox.org) are available to both providers and patients. Consultation with a genetic counselor should be offered. Ultimately, the woman whose medical condition is not so severe as to indicate abortion of a desired pregnancy may decide to abort the pregnancy anyway for personal reasons. She may be reassured that the decision can be made based on her own feelings about the pregnancy and her willingness to accept some risk.

 

Indications for abortion in countries that restrict access

Since the health risk of safe abortion is so very much less than the risks of either continuing pregnancy or of unsafe abortion, the health professional working in countries that restrict access should feel a duty to "put health first" and assess whether a woman with an undesired pregnancy has an indication that would allow for legal abortion, and to tell the patient the truth regardless of their own feelings about abortion.11   

COUNSELING

Counseling and referral

Abortion counseling has several purposes: to provide information, to help the woman understand and cope with her feelings, to allay anxiety, to provide information, to help the woman understand and cope with her feelings, to help prevent future unplanned pregnancies and to screen for serious psychopathology.12, 13, 14, 15, 16 Ideally, the woman should have access to a knowledgeable, sympathetic, skilled person who will help her understand the pregnancy in the context of her life and future, review her options for dealing with the pregnancy, provide information about the abortion procedure and possible complications, and provide contraceptive information. As a special discipline that combines education, advice, care taking, and therapy, abortion counseling borrows from the techniques of interviewing and of short-term crisis intervention that have been developed for wider application.17 In a medical office, the clinician, nurse, or lay or professional counselor may assume these duties. However, organized abortion services make use of abortion counselors, a new professional role that began when the first abortion clinics were founded in the United States.13 Thus, under many circumstances, the clinician working in an abortion service will not do much, if any, of the primary counseling. By the time the woman meets the clinician, much of the counseling has been done. If there is a presumed medical indication for the abortion, then the clinician may need additional information to advise the woman properly.

Some women will have other special needs: a safe home for women who are victims of physical violence from their mates, rape crisis intervention, or referral to a drug detoxification program. Some women will have obvious psychiatric problems or extreme ambivalence that will require further evaluation, and a referral source must be available to meet this need at short notice. Special legal issues may arise, and the service must be prepared to consult lawyers and court clerks as necessary to deal with minors or mentally incompetent women who seek abortion services.

 

Abortion decision

Most women who request abortion have considered their options and have made up their minds before they see a clinician. However, women who are considering abortion need some time with a nonjudgmental, informed counselor to review the options and the decision. Even when the decision appears clear, some ambivalence may be present. There is reason to believe that thorough exploration of the alternative choices allows a “higher quality” decision, in which conflict is resolved as much as possible and the least regret will follow.17 The woman who has not yet reached a decision needs help to explore her options and her feeling about each. To facilitate this process, the counselor needs to assess the following factors:5

  1. Her current situation (e.g., living arrangement, finances, important relationships, future goals, religious or ethical orientation);
  2. The circumstances resulting in this pregnancy and her feelings about the circumstances;
  3. Her reasons for wanting to terminate the pregnancy and her feelings about them;
  4. Any history relevant to her decision;
  5. Her knowledge of the alternatives available to her and her feelings about them;
  6. Her understanding of the effect this decision will have on her current situation and her future plans;
  7. Any pressures she may be feeling, arising from either the nature of her circumstances or the influence of other people;
  8. Her expectations of how she will feel in the future;
  9. Her need for secrecy.

For most women, the abortion decision is carefully decided and is seldom taken lightly. In most cases, her decision to terminate the pregnancy is based on an accurate assessment of her circumstances. For example, she perceives that the price of continuing the pregnancy would be dropping out of school, forced marriage under bad circumstances, or welfare dependency. Abortion, conversely, offers a way out, a second chance to finish education, achieve independence, pursue a career, and then marry and bear children when the prospects for her future and theirs are improved.

The counselor should seek to know who wants the abortion. That is to say, does the patient herself wish to abort, or is abortion the choice of her partner or her parents? Experienced abortion counselors have learned to expect a problem when the patient says that she wants to continue the pregnancy but feels pressured by external forces toward abortion.12, 15 In such cases, if the conflict cannot be resolved in one session, it is best to arrange further counseling and delay the decision about abortion.

In the years before abortion was legalized in the US, psychiatrists were frequently the gateway to a safe “therapeutic abortion.” The patients and the psychiatrist had a need to maximize emotional symptoms so that abortion could be allowed. Freed of this need by the legalization of abortion on personal grounds, it is apparent that few women need psychiatric evaluation before abortion. However, some do, and the counselor must, while facilitating decision making, also screen the patient for signs of more severe disturbance.18 Is there extreme anxiety and agitation? Are the patient's thoughts jumbled and disorganized? Are there signs of serious depression or suicidal ideation? If so, then expert psychiatric evaluation should be promptly sought, so as to not delay the abortion more than several days. A history of significant mental illness in the past in itself is not a reason to delay abortion any more than past mental illness would be a reason to delay or deny other medical care. In countries were abortion is restricted but available for health indications, the role of the counselor should include documentation of mental and physical symptomatology that would justify providing safe abortion.   

Women referred for abortion on medical grounds deserve special consideration. Although most women do not experience serious psychological problems after abortion,18, 19, 20 it has been documented that when a desired pregnancy is aborted for genetic reasons, both the woman and her partner are at increased risk for depression.21, 22 Other patients for whom special consideration is necessary include the very young woman, the woman who appears overtly hostile, the woman concerned because of religious conflict, and a woman in her second trimester.15, 16

Landy13 has proposed that for very young women, counseling should include separate sessions for the girl and for the girl together with her mother (or father) if they are supportive, bearing in mind the need to respect the young woman's right to privacy. Younger women, particularly those younger than 15 years of age, almost always involve parents in the abortion decision process.23 In states in which parental consent is required for minors, many women younger than 18 years of age choose to request judicial bypass and complete the abortion without parental involvement.

Anger often indicates a patient who feels trapped by her circumstances. Extra patience is required, and the counselor and medical personnel must refrain from acting defensively. The patient in religious conflict may benefit from encouragement to explicitly state her feelings, and from reading information available through the Religious Coalition for Abortion Rights and from Catholics for Choice. It is extremely helpful if the office can identify sympathetic clergy of appropriate denominations, so that women who are suffering because of this issue can be referred. Women who belong to anti-abortion groups are at risk for emotional isolation; they may be unwilling to accept support from abortion staff and cannot obtain support from their social group.

Anti-abortion demonstrations can increase the anxiety level for all women.24 Unfortunately, counseling has to include a realistic description of likely demonstrations and ways to preserve safety.

Medical personnel dealing with women considering abortion must be aware of their own feelings and the possible impact of these feelings on patient care. Repeat abortion is an area of special concern. Forty-five per cent of women seeking abortion have had one or more previous induced abortions.25 The reasons for them are various but in most cases involve failure of effective contraceptive methods. Pregnancy rates of contraceptive methods, other than long-acting injectable and intrauterine devices, are higher in the general population than the rates seen in controlled research settings with a selected population and intensive follow-up.25 Despite this, it is difficult to avoid blaming the patient requesting repeat abortion. What is needed is a careful exploration of the patient's previous contraceptive experience and her special circumstances to help her develop a plan that may be successful.

Requests for abortion from a woman who has not been using contraception can be frustrating for staff. Reasons for not using contraception include a perception of infertility, which may have been indicated by medical staff.26 Emergency contraception could decrease the abortion rate substantially, but lack of knowledge and lack of access remain barriers. Finally, some women expect their pregnancy to result in improvement of their life, such as family support, marriage, or improvement in personal relationships. When the situation worsens instead, they need to reassess their situation.26 In the authors' institution, one of the situations that occurs on a regular basis, and frequently results in abortion, is the diagnosis of a sexually transmitted disease at the first prenatal visit.

 

Abortion procedure

In situations were both medication induced abortion and surgical abortion are available, the patient needs information as to the advantages and disadvantages of each. A brief, step-by-step description of the abortion procedure often allays anxiety and improves patient understanding. For first-trimester surgical abortion, the explanation might include the pelvic examination, speculum insertion, the paracervical block, cervical dilation, uterine aspiration or suction, a possible check with a sharp curette, and a final suctioning, and the physician's inspection of the tissue. A description of the patient's expected sensation with each step is also helpful. Use of a plastic pelvic model and demonstration of an actual speculum, dilator, and plastic vacuum cannula facilitate the explanation. Some women are very apprehensive about the amount of pain. It may be helpful to describe the length of the procedure, which is typically less than 5 minutes in the first trimester. A review of pain during first-trimester abortion showed that most women feel it is less painful than a toothache or labor pain. For early surgical or early medical abortion, the steps described might include ultrasound dating of the pregnancy, the medications used, and the follow-up schedule. In addition, women choosing medical abortion need information about surgical techniques that might be used should the medication fail to induce complete abortion. Available methods for pain management should be described.

For both surgical and medical abortion procedures, there are many variations of technique and the counseling will describe the technique used at the facility. In addition to the procedure itself, there may be other visits for osmotic dilator insertion, amniocentesis, amnioinfusion, or ultrasonographically directed procedures or medications for cervical priming.

 

Describing the pregnancy

In the authors' experience, few women inquire about the physical characteristics of the fetus before abortion, and those who do seem primarily concerned with fetal size at the gestational age in question. If such information is requested, it should be provided. Many women are relieved when they find that in early first trimester, no fetus is visible either sonographically or on tissue inspection. However, in a supposed effort to guarantee informed consent for abortion, some states require that a detailed (and sometimes inaccurate) description of the fetus be given to each woman considering abortion. The apparent intent of such legislation is to discourage abortion. The actual effect of requiring unwanted fetal description or pictures of fetuses on women considering abortion has not been systematically studied, but certainly could be expected to increase the emotional burden of the decision and, hence, the patient's anxiety.

 

Describing the risks of the procedure

A part of informed consent is a presentation of the possible risks of abortion choices. One approach that has been used is to list virtually all possible complications of abortion and then attempt to put them in perspective by pointing out that serious complications are rare. Abortion, at least in the first trimester, is clearly less dangerous than continuing the pregnancy to term. However, it is impossible to list all possible complications. Information is appropriately presented with a discussion of the most common complications, the most serious complications, and information that additional, less-frequent complications are possible.

At minimum, the patient must be told about the possibility of a failed procedure, hemorrhage, infection, and perforation, and how each might be treated: repeat procedure, transfusion, antibiotics, and major surgery, respectively. The triad of pain, bleeding, and low-grade fever is the most common postabortion complication; it occurs in 1– 2% of surgical abortions.27 This should be described to the woman along with the treatment that would be necessary: antibiotics, uterotonic medications, and possible repeat curettage. Finally, the woman should be encouraged to report any postabortion symptoms to the abortion facility promptly, because early treatment minimizes the chance of complication.

The possibility of sequelae in a later pregnancy is an issue of great concern. A single abortion by vacuum curettage, as presently provided in the United States, has no demonstrable risk for future reproduction.28, 29, 30, 31, 32 Severe postabortion infection or a major perforation that requires hysterectomy are obvious exceptions, but fortunately are extremely rare in current practice.33 Whether multiple induced abortions convey some risk for later pregnancy loss remains unresolved; at this point, there are no studies to support this fear with first-trimester abortion.

 

Selection of abortion procedure

Under certain circumstances, there may be a choice of abortion procedures. Women in first trimester may have a choice of medical and surgical procedures. Medical procedures are typically done until the 9th menstrual week. 

Confidentiality may play a major role in procedure selection. If the pregnancy itself is secret, then a surgical procedure may involve a single visit, with little chance of repeat visits. However, many women prefer medication abortion because they feel it is more natural. Medication abortion may appear to family or friends to have been spontaneous.

In middle and late second trimester, women may have a choice of induction or surgical techniques. Local availability and the need for travel, personal preference, medical concerns, confidentiality, and finances may influence the choice. Induction procedures require a hospital stay and may be more expensive, whereas surgical techniques may be entirely outpatient but require daily visits.

 

Consent

The elements of informed consent are a description of the procedure and alternatives, possible risks, complications, and benefits. In the United States, written informed consent is obtained for every patient undergoing abortion. Although some abortion providers have a detailed consent that is specific to their abortion procedure or procedures, many providers use a generic medical consent and provide detailed information in another format, such as that provided by the American College of Obstetricians and Gynecologists.33 Either approach is appropriate as long as the information has been provided. Williamson34 has collected representative consent, information, and patient record forms. Some states have requirements for a specific mandatory written consent; this consent may replace or augment the provider's usual consent, depending on content of the state consent and circumstances. The distributor of mifepristone has a detailed consent form, which is mandatory for women receiving mifepristone.35

 

Contraception

Preabortion counseling includes a discussion of contraception. Women need to know that fertility returns within a few weeks of abortion. Some women do not want contraception. For instance, if there is a fetal indication for abortion, the woman may desire another pregnancy immediately. However, most women dealing with a fetal loss because of anomaly have a grieving period of variable length, and often choose to wait several months before seeking another pregnancy. They may choose to use a short-term method while they are grieving.

Most women are interested in contraception, and many are motivated to seek a highly effective method. Available methods, their effectiveness, and their main advantages and disadvantages should be discussed. The woman's experience with contraceptive methods should be reviewed. Some women, especially adolescents, state that they do not plan to have intercourse again for a long time. At minimum, these women can be encouraged to use foam and condoms, and should be reminded that these are readily available in any pharmacy without prescription. Advance provision or prescription of emergency hormonal contraception is also appropriate for women who are uncertain about contraceptive method. The final decision about contraceptive method can be left until after the abortion, but it is a serious mistake to leave the contraception discussion for the postabortion visit. In many settings only a minority of patients have a postabortion examination. Hence, women should be provided with contraceptive supplies at the time of their abortion procedure.

 

Confidentiality

Women requesting pregnancy termination, regardless of the reason for the termination, need the option and the presumption of confidentiality. Although confidentiality should be the rule for all medical services, a breach of confidentiality concerning abortion can result in serious consequences for the woman. Pregnancy and abortion are intensely personal subjects for most women, and revealing a pregnancy termination can result in embarrassment and humiliation. Once information is circulated, the circumstances may be distorted: a suction curettage for a nonviable pregnancy may be considered the same as a therapeutic abortion for personal reasons. Women may find themselves ostracized by family, employers, or shunned in certain religions. Loss of confidentiality can stress the relationship with a partner if the pregnancy is suspected of resulting from another partner or if the partner opposes abortion. Most seriously, women may be at risk for abuse, injury, or death from partner or family.

To safeguard confidentiality, medical record information should not be released to anyone without the woman's consent. The chart should record people who can receive information about the woman; this might be one or two specific people or might indicate that no one should be contacted or receive information about the woman. Emergency contact information should include specific instructions about acceptable and safe contact people, if any. When a woman is in the office or facility, her presence should not be disclosed to anyone. In the authors' facility, if someone asks whether a patient is there, her presence is not confirmed, but the caller is asked for a name and telephone number and told that the name and number will be given to the woman if she is there.

Telephone messages to patients should not disclose the source of the message. A common practice is to assign the same name for all telephone calls. For instance, a typical message from the office might be, “This is Mary. Please call me back.” The woman can then return the call to a previously arranged number. Given the prevalence of caller identification, blocking caller identification on the return telephone line is prudent. The return telephone line should be answered in a way that does not identify the facility; simply saying “hello” or “Mary's Place” is safer.

Finally, anti-abortion extremists can harass women thought to have had, or be considering, an abortion. As mentioned, the exact diagnosis may not be of interest to an extremist. Information about the identity of patients cannot be disclosed, even accidentally. Charts should be secured when the office is closed. Waste paper that might contain information should be shredded or destroyed promptly.

 

SERVICES

Telephone counseling

For most patients, the initial contact with an abortion provider is by telephone. The person who answers the telephone call must be knowledgeable, informative, and sympathetic. The abortion provider needs to know the patient's last menstrual period, whether pregnancy has been confirmed, and whether there are any medical problems or allergies that might complicate the abortion. If the service offers only first-trimester abortion, then patients whose last menstrual period indicates their pregnancy may be beyond the cutoff point must be so informed. Some of these women will wish to come in for confirmation of pregnancy, estimation of gestational age, and appropriate referral. Similarly, if the abortion service is a freestanding, out-of-hospital unit, women with medical problems that are beyond the scope of the service should be referred to a unit able to handle the problem.

After informing the patient of the clinic procedure and obtaining the information above, the telephone counselor answers any specific questions. Women often want to know what types of pain relief are available. Many US clinics offer conscious sedation in addition to paracervical block. Some offer general anesthesia. If the clinic does not offer general anesthesia, this should be stated at the outset. Patients who insist that they wish to be “asleep” should be informed of alternative services in the community, if these exist.


Reception and registration

The complexity of this function depends on whether the abortion unit is an office, a free-standing clinic, or part of a hospital, but the essential tasks are similar. They include greeting the patient and obtaining or confirming identification, address, telephone number, and a procedure for contacting the patient while maintaining confidentiality, if that will be necessary. Financial matters, insurance coverage, and referrals are usually discussed at this time.

 

Pregnancy detection

Pregnancy must be confirmed either by pregnancy testing or by ultrasound before an abortion is started. Modern urine pregnancy tests are specific to human chorionic gonadotropin (hCG) and are extremely sensitive, detecting as little as 20–50 mlU of hCG per milliliter. This is an advantage in the diagnosis of abnormal pregnancy in which low levels of hCG would not have been detected by older, less-sensitive urine pregnancy tests. However, the use of sensitive tests means that, somewhat, women presenting for early abortions who have normal, very early pregnancies cannot be distinguished from women who have early missed abortions or ectopic pregnancies. Many US clinics use ultrasound routinely to confirm intrauterine gestation. In a normal pregnancy, a urine pregnancy test will become positive by 22–26 days after the last menstrual period in a 28-day cycle. This is 8–12 days after fertilization, assuming that fertilization occurred on day 14. Ultrasound examination may show thickening of the endometrium from days 24 to 28 of the menstrual cycle, but the gestational sac does not become visible until day 30 or several days later depending on the resolution of the ultrasound equipment.36 Thus, there is a period of up to 10 days when a pregnancy test is positive, but the pregnancy is not visible on ultrasound. Even when a gestational sac seems to be present, it can be confused with a pseudosac of fluid in the endometrium. A pseudosac may be present with a normal pregnancy, and abnormal pregnancy, or an ectopic pregnancy. When a yolk sac appears at 35–38 days, an intrauterine pregnancy is certain.


Laboratory tests

It is best that the basic laboratory tests are available on the premises. In addition to pregnancy testing, the only other essential test is Rh determination or knowledge of Rh status. Anemia screening by hematocrit or hemoglobin testing is usual, but the usual blood loss with first-trimester abortion is very small and testing policy can be individualized according to the woman's history and the community. In some states or localities, additional tests are customary or required: cervical cytology, cervical culture for gonorrhea, tests for chlamydia, serologic test for syphilis, and rubella titer. Any or all of these tests may be appropriate from the point of view of health screening. However, their mandatory performance for all women who seek abortion adds to the cost, and this cost is usually borne by the patient. Because in many areas, third-party payers do not cover abortion services, the routine use of tests that do not contribute importantly to the safety of the abortion procedure must be questioned.

Rates of cervical chlamydial colonization vary according to population and may be as low as 1% or up to 5–10% in some series.37 In most populations, the incidence of positive gonorrhea test results in an abortion service is much lower than the incidence of chlamydia and is less than 1%. In the authors' inner-city service, the rate of gonorrhea among abortion patients is 0.4%, whereas the incidence of chlamydia is 6%. Postabortal endometritis and salpingitis are more likely if either organism is present, so screening should be based on incidence in the community as well as individual risk factors. Another approach is to give all abortion patients treatment for chlamydia; treatment is often less expensive than screening and ensures that all colonized women are treated. It does not, however, allow identification of women who might be infectious or who are at risk for reinfection from an infected partner. If treatment is given at the time of abortion, rates of postabortal infection decrease to close to those of uninfected women.37, 38 Therefore, abortion should not be delayed until a negative screen is obtained.

In the population using abortion services, Papanicolaou (Pap) smears will indicate abnormality in 2–3% of patients (personal communication). Most of the abnormal cytology will be diagnosed as only mild-to-moderate dysplasia, although some may have more serious lesions. Screening with cervical cytology is an excellent idea for all women, but if the patient has had a Pap smear performed within the past year, there is no reason to insist that she obtain another prior to abortion.

The time of induced abortion is an opportunity to screen for rubella-negative patients and to vaccinate them against this disease; however, both cost and time constraints may be limitations. Discussion of pregnancy, abortion, and contraception also provides an opportunity to offer testing for human immunodeficiency virus (HIV).

Prophylaxis against Rh sensitization deserves special mention. All Rh-negative women who have abortions and who have not been sensitized previously should be given Rh immune globulin.39 Obtaining an Rh titer is unnecessary, adds expense, and imposes a delay that may result in some women failing to receive Rh immune globulin. No harm is done if women who are already Rh sensitized are given Rh immune globulin, and very few of the young women who seek abortion will be already Rh sensitized. Although sensitization in pregnancy is less frequent than in midtrimester, at this point the age below which sensitization is absent is unknown; several studies suggest that maternal exposure can occur as early as 6 weeks.40 If all Rh-negative women are given Rh immune globulin before they leave the abortion service, virtually 100% can be protected.

 

Abortion procedures

Abortion providers must decide which procedures will be offered: very early surgical procedures including manual vacuum aspiration, standard first-trimester vacuum curettage, midtrimester curettage, or midtrimester induction abortion by amnioinfusion, or vaginal, intravenous, or intramuscular medication. Currently, the term manual vacuum aspiration encompasses the technique described for menstrual regulation but includes appropriate cervical dilation if needed, and use of rigid or flexible cannulae. It may be used at higher gestational ages. From the point of view of counseling, medical services, and staffing, manual vacuum aspiration and first-trimester electric vacuum curettage are similar.

Menstrual regulation refers to very early abortion performed within 6–7 weeks of last menses without confirmation of the pregnancy and using small flexible Karman cannulas without additional cervical dilatation and using a manual uterine aspirator. When menstrual regulation was first described, neither sensitive pregnancy tests nor transvaginal ultrasound was available. Some women were either not pregnant or had extremely early pregnancies. Menstrual regulation was reported as more likely than standard first-trimester curettage to be associated with complications, such as failed abortion, ectopic pregnancy, and incomplete abortion. When ultrasound or tissue examination is included, the risk of failed or incomplete abortion for pregnancies less than 6 weeks is no higher than abortion later in first trimester.41 Those facilities that offer early surgical abortion need the ability to take appropriate precautions; the basic requirement is careful follow-up of all patients not shown to have an intrauterine pregnancy by either ultrasound or tissue examination.

Midtrimester curettage usually requires cervical preparation prior to uterine evacuation. Cervical ripening can also be done with misoprostol or mifepristone; or by placement of osmotic dilators (laminaria or Dilapan(TM) some hours in advance.42, 43 Surgical skill required for safe midtrimester abortion unquestionably is greater than that needed for first-trimester procedures, and the potential for major complications is greater. Therefore, if midtrimester curettage is to be offered, the abortion facility must have access to hospital services if complications ensue.

Some basic decisions about the way in which services will be offered are important. Out-of-hospital abortion services generally have favored local paracervical block as opposed to general anesthesia. This choice has undoubtedly contributed to the safety of out-of-hospital abortions. Intravenous sedation/analgesia offers improved pain relief and is safe, provided modest doses are used and patients are properly selected and monitored.

The abortion provider must decide whether certain patients will be excluded on a medical basis. Because out-of-hospital services lack the emergency facilities present in the hospital, most freestanding abortion clinics exclude patients with significant medical problems that might increase the likelihood of complication during or after the abortion procedure. These policies clearly protect the clinics from having to deal with some complications. However, in some cases, these policies act to the detriment of patients. For example, the patient with stable juvenile diabetes would be better served by an abortion performed while she is under local anesthesia in a free-standing clinic, with no disruption of her usual pattern of eating and insulin use. In contrast, a hospital abortion is usually performed under general anesthesia after overnight fasting. A reasonable policy for out-of hospital facilities would be to accept those patients with chronic medical conditions that are well controlled and refer patients with acute illnesses not yet stabilized for hospital care.

 

THE PHYSICAL PLANT

First-trimester vacuum abortion and manual vacuum aspiration can be provided in a doctor's office setting, with no additional personnel or facilities beyond those necessary for the very similar procedure of endometrial biopsy. Medical abortion can also be conducted in an office setting. On-site ultrasound for those women who require ultrasound is more efficient. Women who have had a surgical abortion may need from 10 to 30 minutes or more to recover, and a busy waiting room full of other patients is far from ideal for this purpose. An adjacent examining room with the door ajar so that the office staff can frequently check the patient would suffice. For offices performing enough abortions to have several women recovering at once or where other minor surgical procedures are performed, a dedicated recovery area may be more pleasant and allow more frequent monitoring if needed. Recliner chairs are more comfortable than examination tables.

At the other extreme, there are many freestanding clinics that perform 60 or more first-trimester procedures per day. Such a facility would obviously need more extensive space. Rooms are required for the following: telephone counseling and scheduling, reception and registration, examination rooms for preoperative screening, private counseling, drawing blood, the laboratory, a preoperative holding area for patients, the abortion procedure (four or five rooms), a central nurses' station, a recovery room, a staff lounge, male and female staff change areas, suitable toilet facilities, clean supply storage, instrument cleanup and autoclave, and administrative offices.

 

Postabortion recovery

In US clinics were only local anesthesia or low dose conscioius sedation is used, patients are typcially moved into recliner chairs for recovery rather than beds as the chairs take up less space and contribute to a more home-like setting. Trained personnel observe the patients, monitoring symptoms and vital signs until the patient is comfortable and able to ambulate. The addition of general anesthesia adds the need for pulse oximetry and closer observation during recovery.

The recovery area can be another opportunity to review contraception with the women and review postabortion care. Written instruction should be provided, and, if appropriate, the patient should be given a form to return to her referring physician. The form should list the abortion procedure provided, any complications, any medications given, Rh prophylaxis if given, and the contraceptive selected and whether it was supplied.

 

Instruments and supplies

A supply system must be designed to maintain inventories, order, and restock supplies. A partial list includes paper sheets and drapes for the examination tables, examination and sterile gloves, transport media for gonorrhea and chlamydia testing, cartons and formaldehyde solution for pathologic specimens, local anesthetic and disposable needles, medicines, and contraceptive supplies.

A sterile instrument pack must be prepared for each patient. The pack should contain an indicator paper to confirm sterility. Facilities that provide more than a small number of abortions per day will need their own central sterile processing area and personnel specifically trained for the task.

 

FOLLOW-UP

Traditionally, women have been instructed to have a follow-up pelvic examination in 2–3 weeks. Preferably, the abortion provider should perform this examination. As an incentive for the patient to return, many clinics do not charge for the follow-up visit. The utility of the follow-up examination has not been documented. It is, however, an appropriate time for intrauterine contraceptive device insertion if not done during the time of abortion or for diaphragm fitting.

 

Emergency care

The most serious complications of abortion, such as perforations with major visceral injury or hemorrhage, are usually recognized at the time of the procedure, and abortion providers must make arrangements to deal appropriately with immediate complications. For out-of-hospital providers, arrangements should be made for a backup hospital to accept patients in transfer, with a specific physician or group of physicians to care for such patients on short notice. Ideally, the same physicians who staff the abortion facility would provide hospital care of women with complications. The care of women with complications can be seriously compromised by lack of communication between abortion facility and hospital or by lack of experience of hospital personnel in managing abortion complications.44 Office or clinic personnel must be familiar with the procedure for evacuating a patient quickly to the hospital service, even if the service is in the same building. An ambulance service or hospital transport procedure must be in place.

The later complications of abortion, incomplete abortion or infection, may not be as dramatic as perforation but can be potentially serious. The abortion service must have 24-hour, on-call coverage by staff knowledgeable in the abortion procedures. A qualified nurse or counselor can handle initial screening of calls. However, backup physician and hospital referral must be available. Abortion services that draw from a wide geographic area will need to identify hospitals and physicians in the various communities that refer to them who can be relied on to treat patients in an emergency. Often, the physician from a distant community who refers patients to an abortion facility is a good contact for emergency care of patients from his community who experience postabortion complications.

 

Contraceptive services

If the patient selects hormonal contraceptives, an initial supply of pills, patches or the rings should be provided and a prescription given for several months of refills, with appropriate contraceptive counseling for a same day or Sunday start. Limiting the contraceptive pills supplied by the abortion clinic to 1 or 2 months to encourage the patient's follow-up by another health provider is a form of coercion and not justified.

It is especially beneficial for patients to provide the long acting contraceptive methods, intrauterine devices, and subdermal implants at the time of abortion because these provide efficacy equivalent to sterilization yet are reversible. There is extensive literature that clearly justifies postabortion insertion of intrauterine devices.45, 46 Neither infectious complications nor the rate of perforation is increased with postabortion insertion more than with interval insertion. The expulsion rate is slightly higher for postabortion insertions. However, because not all eligible women will be able to return for insertion at 2–6 weeks, the practice of postabortion insertion is justified. Subdermal implants are easily inserted immediately after the abortion.

The first hour or 2 after an abortion is not a good time to fit a woman for a diaphragm. The diaphragm could be fitted before the abortion procedure and the patient instructed in its use at that time. However, most prefer to wait until the follow-up visit to fit the diaphragm.

Injectable contraceptives, depot medroxyprogesterone acetate (Depo-Provera), and estradiol cypionate-medroxyprogesterone acetate (Lunelle) provide extremely effective contraception and can be started at the time of surgical or medical abortion.

Patients who state that they will seek later tubal sterilization should always be offered an interim method of contraception, as many will not promptly obtain the procedure. Women may be able to obtain both tubal sterilization and abortion together and are obviously protected against pregnancy immediately.47, 48 There is no increase in morbidity for joint procedures. However, joint procedures may not be practical because of insurance or facility restrictions.

Women who do not elect an immediate postabortion contraceptive method should be instructed in the use of foam and condoms and emergency contraception. Advance prescription or provision of emergency contraception is appropriate and helpful and does not discourage the use of barrier methods. The reader is referred to several excellent reviews of postabortal contraception.49, 50

 

RESOURCES

Voluntary nonprofit associations have been of great importance to US abortion services by providing professional and patient education and support, and by setting standards and guidelines for care. These groups include the American College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, DC 20090-6920 www.acog.org; the American Medical Women's Association, 801 N. Fairfax Street, Suite 400, Alexandria, VA 22314 www.amwa-doc.org; the Association of Reproductive Health Professionals, 2401 Pennsylvania Avenue NW, Suite 350, Washington, DC 20037 www.arhp.org; Catholics for Choice, 1436 U Street, Suite 301, Washington, DC 20009 www.catholicsforchoice.org; the Center for Reproductive Law and Policy, 120 Wall Street, 18th floor, New York, NY 10005 Clrlp@echonyc.com; the National Abortion Federation, 1755 Massachusetts Avenue, NW, Washington, DC 20009 www.prochoice.org; Planned Parenthood Federation of America, 434 West 33rd Street, New York, NY 10001 www.plannedparenthood.org; Physicians for Reproductive Choice and Health, 55 West 39th Street,  New York, NY 10018 www.prch.org; and the Religious Coalition for Reproductive Choice, 1025 Vermont Avenue NW, Suite 1130, Washington, DC 20005 www.rcrc.org.

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