Termination of pregnancy

Abortion, VIP, Pregnancy Termination, Voluntary Interruption of Pregnancy

What is an induced abortions?

An induced abortion is the intentional termination of a pregnancy. The procedure removes a fetus and placenta from a woman’s uterus. The vast majority of abortions performed in the United States are accomplished through surgery, but recent advances have also made abortion possible through medication.

In 1973, the landmark Roe v. Wade Supreme Court ruling stated that women in the United States have a constitutionally protected right to have an abortion during the early stages of pregnancy. The court ruling guaranteed that unrestricted abortion would be available to all women before the viability of the fetus, which is the time when the fetus can exist on its own outside the uterus.

A later Supreme Court ruling gave states the right to restrict abortions as long as it does not create an “undue burden” for women seeking abortion. In the United States, federal law had prohibited any restrictions on abortion during the first trimester of pregnancy until a recent law was passed in South Dakota in February 2006. This is the only state where any abortions had become prohibited in an attempt to counteract the previous federal ruling. Later that year, however, South Dakota voters overturned their state’s abortion ban. There was an effort to reintroduce the South Dakota abortion law in January 2007 with provisions that would allow abortion for rape and incest victims, but the bill was once again overturned the following month. During the second trimester, states may regulate abortion services, but only in regard to preserving a woman’s health.

Abortions may be performed for several reasons. Most often, abortions are performed because a woman does not wish to be pregnant. In the majority of cases, such abortions are performed to terminate a pregnancy after a woman fails to use contraception or the method of birth control has failed. Abortions are also performed to terminate pregnancies that are the result of acts of rape or incest, to prevent the birth of a child with birth defects or because a woman’s health is endangered by the pregnancy.

According to statistics released in 2018 by the Centers for Disease Control and Prevention (CDC), there were approximately 638,169 legal abortions performed in the United States in 2015. Abortion rates have declined over time due to a number of factors, such as fewer cases of unintended pregnancies and more restricted laws for adolescents. The majority of reported abortions occurred in unmarried women under the age of 25 years.

There are two principal types of elective abortions performed in the United States. They include surgical abortions, which make up the vast majority of abortions in the United States, and nonsurgical abortions.

In surgical abortions, the cervical canal is dilated (enlarged) and a hollow tube is inserted into the uterus. A vacuum machine is then used to suction the tissues of the fetus and placenta from the uterus. In cases of more advanced pregnancy, forceps (instrument resembling pincers or tongs used for extracting tissue) may be used to remove the fetus, and the uterus may be gently scraped.

Surgical abortions can be performed in several different ways. The choice of technique often depends on how far along the pregnancy is at the time of the abortion.

For example:

  • Six to 12 weeks. These abortions are often performed while the woman is awake. In most cases, the woman has the option of being sedated by medications, or having an injection of local anesthetic that numbs her cervix.
  • More than 12 weeks. These abortions are usually, but not always, performed while the woman is under general anesthesia, which means she will be asleep during the procedure.

Nonsurgical methods, which include medication, interfere with the development of the placenta and force the uterus to contract, which eventually causes its contents to be expelled. These methods can be used in a pregnancy of 16 weeks or more. Newer protocols for nonsurgical or medical abortions can be used through the first 60 days of a pregnancy.

Almost 90 percent of abortions occur in the first trimester, according to the Alan Guttmacher Institute, a private, nonprofit organization that focuses on sexual and reproductive health research, policy analysis and public education. Fewer than 2 percent are performed after 20 weeks of pregnancy, and just 0.08 percent are performed after 24 weeks.

Controversy has grown over a rarely performed procedure commonly known as partial-birth abortion (clinically referred to as intact dilation and extraction). In this procedure, the physician delivers a baby to the point where only the head remains inside the womb. The physician then punctures the back of the skull and removes the brain before completing delivery. This procedure was banned in 2003. A year later the ban was declared unconstitutional and was heavily appealed until April 2007 when the Supreme Court upheld the banning of partial-birth abortions.

Abortion remains an intensely controversial issue in the United States. Currently, 28 U.S. states require women who want to have an abortion to undergo counseling prior to the procedure, and 24 states require women to wait a specified period of time, usually 24 hours, between the time they receive the counseling and time the procedure is performed. During abortion counseling, women typically receive information to discourage them from having the procedure (e.g., health risks, mental health consequences). As a result, women who consider having this procedure may want to seek outside support from sympathetic family and friends or support groups.

Types and differences of induced abortion

There are several methods that can be used to perform an abortion. These include:

Surgical methods

Involves removing tissue from the uterus with a surgical instrument. Surgical methods used in abortion include:

  • Vacuum aspiration. The most common method of performing abortions in the United States, it involves withdrawing the contents of the uterus through a narrow, flexible tube that is inserted through the cervix and into the uterine cavity. Very early in the pregnancy, this procedure may be performed without dilation (expanding) of the cervix or use of general anesthesia. However, abortions performed when the gestational age is eight weeks or more generally require dilation of the cervix. Vacuum aspiration is usually used in pregnancies of 12 weeks or less.
  • Dilation and curettage (D&C). The most common method of abortion used beyond the first 8 weeks of a pregnancy, it usually involves suction and use of a curette (a surgical instrument commonly shaped like a spoon or scoop) to remove the fetus. Dilation and curettage has several advantages. These include greater convenience, lack of need for hospitalization and lower cost than other second-trimester procedures (such as induction of uterine contractions).
  • Dilatation and evacuation (D&E). This procedure is performed for later second trimester abortions. It may require the additional use of forceps to remove fetal tissue from the uterus. The progression of the pregnancy at this point creates several disadvantages associated with this technique. Dilation and evacuation requires great technical expertise to perform the procedure effectively. It also comes with the risk of possible long-term damage to the cervix.

Medication-induced methods

These can be used in early first-trimester abortions and are sometimes used in second-trimester abortions, especially after 16 weeks, when dilation and evacuation carries a high surgical risk, or if the physician is not skilled in performing dilatation and evacuation. This method can be performed in several ways. For example, a woman may receive an injection of hypertonic saline into the amniotic cavity to force uterine contractions that result in an aborted pregnancy. In other cases, a woman may receive doses of prostaglandins (hormone-like substances) either orally or as vaginal suppositories to induce abortion.

In recent years, the antiprogesterone medication mifepristone, also known as RU 486, has been used in these types of abortions. The Food and Drug Administration (FDA) has approved the use of a single dose of mifepristone, followed by a dose of a prostaglandin analogue known as misoprostol two days later. This technique is used more often in Europe than in the United States. However, it does not always remove all retained products of conception, and additional suction and curettage may be required. Mifepristone and misoprostol are increasing in use to terminate a pregnancy that is less than 7 weeks old. Women may safely and effectively take dosages of mifepristone and misoprostol at the same time, rather than up to 48 hours apart, as is typically done, according to a new study. In addition, a second study found the drugs to be safe for late first-trimester abortions. Both studies appear in the April 2007 issue of Obstetrics & Gynecology.

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Major surgery

In rare cases, hysterectomy or hysterotomy (surgical incision of the uterus, such as in a Caesarean section) may be used to perform an abortion. However, these methods are considered to have a higher risk of mortality than other procedures, and usually are not used unless other gynecological conditions (such as cancer of the cervix or uterine fibroids) exist.

Some people mistakenly believe that emergency contraceptive pills (e.g., morning-after pill) – which may be taken after sexual intercourse when other contraceptive methods failed or no contraception was used – are a form of induced abortion. However, emergency contraceptive pills do not terminate a pregnancy, but instead prevent it from occurring in the first place.

Before, during and after the procedure

Some states require that a woman who wishes to have an abortion receive counseling and wait a specified period of time, usually 24 hours, after receiving counseling before having the abortion. Women should follow their physician’s recommendations regarding any preparatory steps that should be taken before the abortion procedure. These may include dietary restrictions or changes in their medication regimen.

Prior to a vacuum aspiration procedure, a woman may need to have her cervix dilated, particularly if the abortion is happening in the eighth week of pregnancy or later. For women having first-trimester abortions, sponge-like devices called osmotic dilators may be inserted into the cervical canal overnight or several hours prior to the procedure to ensure slow dilation. This helps prevent perforation of or injury to the cervix, especially in women who have not previously given birth.

Women having second-trimester abortions usually require a greater amount of cervical dilation. As a result, osmotic dilators may be inserted up to several days prior to the procedure.

A surgically induced abortion will unfold in different ways depending on the procedure being used. In some cases, general anesthesia will be used whereas in others, a local anesthetic or no anesthetic will be needed.

A nonsurgical abortion performed with medication therapy will be administered in a physician’s office after a complete physical examination and thorough medical history have been performed.

In most cases, physical recovery from abortion occurs within a few days. A small amount of vaginal bleeding and mild uterine cramping is not unusual during this time. Use of a heating pad or hot water bottle on the abdomen may relieve these symptoms.

Women should avoid strenuous activity for a few days following an abortion. Tampons may be used after three days, and sexual intercourse may be resumed after two to three weeks. Normal menstrual periods should resume four to six weeks after the operation. The physician may have additional recommendations based on the specific woman and procedure.

Potential risks with induced abortions

All abortion procedures come with some risk of side effects and complications, although most women do not experience physical complications. In general, complications are least likely during first trimester abortions and become more likely in later stages of pregnancy.

Infection is the most common complication associated with an induced abortion. Symptoms that may indicate the presence of an infection include fever, pain, mild bleeding and a tender uterus. Oral antibiotics and drugs that reduce fever are usually effective in controlling such infections. In some cases, suction curettage may be necessary to remove tissue that remains in the uterus that may be causing the complications.

In rare cases, patients may experience a severe infection called a septic abortion. This rarely occurs in legal abortions and is more commonly associated in abortions performed illegally and in unsterile conditions.

Symptoms include:

  • Sepsis (pus-forming bacteria or other toxins in the blood or tissues)
  • Shock
  • Hemorrhage
  • Potential renal (kidney) failure

Septic abortions can be treated with parenteral antibiotics (taken through injection or intravenously), fluid therapy and removal of the uterus (hysterectomy).

Bleeding is the second most common complication associated with an induced abortion.

Sources of bleeding include:

  • Remains of the placenta left behind in the uterus
  • Infections
  • Blood clots in the legs

Postabortal syndrome occurs when the uterus fails to remain contracted after an induced abortion. It can result in an open cervix or a large uterus that appears softer than expected upon examination. Women who develop this syndrome may experience cramps and bleeding. Postabortal syndrome is usually treated with suction curettage and antibiotic therapy.

Other general risks associated with surgically induced abortions include:

  • Risks associated with any surgery, such as general bleeding and infection
  • Reactions to medication
  • Breathing problems
  • Infection or puncture of the uterus
  • Infection of the fallopian tubes, resulting in scarring and infertility
  • Damage to the cervix
  • Scarring of the uterine cavity (Asherman’s syndrome)

Abortions performed through medication may result in pain, nausea, vomiting, diarrhea or prolonged bleeding. In addition, the abortion may not be complete, requiring possible surgical intervention.

Induced abortions may or may not affect a woman’s future ability to have children, depending on circumstances. First- or second-trimester abortions performed without complication do not appear to impact future pregnancies. However, there is a slight increased risk of premature delivery for women who have had more than three first-trimester induced abortions.

Some women who have an abortion experience emotional trauma as a result of the procedure. Mental health professionals (e.g., psychiatrist, psychologist) and support groups may help women who experience such feelings.

Common misconceptions about abortion

There are many myths and misconceptions regarding abortion. The following statistics come from the Alan Guttmacher Institute, a nonprofit organization that focuses on sexual and reproductive health research, policy analysis and public education:


MythReality
Abortion is generally dangerous.Abortion is among the safest surgical procedures. The risk of death is approximately 0.6 per 100,000 abortions. The risk of major complications is less than 0.3 percent. By contrast, the risk of death following a pregnancy carried to term is 12 times higher.
Abortion is on the rise in the United States.Abortion rates have been declining since the 1990s.
Abortions frequently occur late in a woman’s pregnancy.Almost 90 percent of abortions occur in the first trimester. Fewer than 2 percent are performed after 20 weeks, and just 0.08 percent are performed after 24 weeks.
The majority of women who have abortions have terminated multiple pregnancies.More than half (52 percent) of women having abortions had no prior abortion.
Abortion is available in most counties in the United States.About 87 percent of U.S. counties had no abortion provider in 2000.
There is a link between abortion and some diseases.To date, there is no credible link between abortion and diseases such as endometriosis and breast cancer or other types of cancer.


Questions for your doctor on induced abortion

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about induced abortion:

  • Will I be able to have an induced abortion?
  • What method of abortion is best for my case?
  • Where will the procedure be performed?
  • What type of anesthesia will be used in my procedure?
  • What are the risks associated with the procedure?
  • How long will it take for me to recover following surgery?
  • What restrictions will I have following the procedure?
  • How will this procedure affect my ability to become pregnant and the birth of my children?
  • Am I at greater risk for other gynecological conditions if I have an abortion?
  • Can you refer me to support groups to help me with any emotional issues I may have?
  • After my abortion, what are my contraceptive options to prevent an undesired pregnancy from occurring again?

  • Jatlaoui TC, Boutot ME, Mandel MG, et al. Abortion Surveillance — United States, 2015. MMWR Surveill Summ 2018;67(No. SS-13):1–45. DOI: http://dx.doi.org/10.15585/mmwr.ss6713a1
  • Jerman J, Jones RK and Onda T, Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014.