Therapeutic and induced abortions: Clinical sciences

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Introduction 0:00–0:46

Therapeutic abortion refers to termination of pregnancy for medical indications; while an induced abortion, also known as an elective abortion, is performed because an individual chooses to end a pregnancy.
Be sure to differentiate these two from pregnancy loss, which includes missed, threatened, inevitable, complete, incomplete, and septic abortion.
Both therapeutic and induced abortions are extremely safe, especially in the first trimester when the vast majority of them occur.
In fact, in the United States over 90% of induced abortions occur in the 1st trimester; fewer than 10% occur between 13 to 20 weeks, and fewer than 1% occur after 20 weeks gestation.
Before jumping into management, let’s review abortion care keeping reproductive rights in mind. These are focused on the understanding that all people have a fundamental right to decide whether to have children, the number and spacing of their children, and to have the information, education, and access to health services to make these choices.

Reproductive Rights 0:46–2:19

Across the United States, reproductive rights vary in legality and accessibility, particularly for adolescents, people of color, individuals living in rural areas, those with low incomes, and incarcerated individuals.
Many factors influence the decision to obtain an abortion including contraceptive failure, barriers to contraceptive access and use, sexual assault, incest, intimate partner violence, fetal anomalies, and exposure to teratogenic medications.
There are also scenarios where severe pregnancy complications can be life-threatening, in which case an abortion is safer than a continued pregnancy.
These include hemorrhage from placental abruption, placenta previa, or inevitable abortions; preeclampsia and eclampsia; chorioamnionitis causing sepsis; and underlying cardiac or renal conditions in the pregnant patient.
Here’s a clinical pearl! Strict abortion laws do not eliminate the occurrence of abortions; however, they create unsafe environments in which abortions are performed thereby increasing the rates of preventable maternal morbidity and mortality.
Okay, when a patient presents for a therapeutic or induced abortion, start by obtaining a focused history and physical exam; you might also need to get some labs like hCG and blood type.

H&P and Labs 2:19–3:30

History might reveal a medical indication for a therapeutic abortion; or, in some cases, the patient might express a desire for an induced abortion.
If performing your exam in person, confirm the pregnancy with a positive hCG. Alternatively, if you’re seeing your patient via telemedicine, their report of a positive pregnancy test is sufficient for confirmation.
Here’s a clinical pearl! Consider obtaining a type and screen to assess your patient's Rh status.
Rh-negative pregnant individuals are at risk of forming antibodies against fetal Rh-positive antigens, which can lead to isoimmunization or fetal anemia in future pregnancies.
This can be prevented by administering Rh immunoglobulin to Rh-negative individuals. However, if your patient is less than 8 weeks gestation, it’s very unlikely these antibodies have formed, so in situations where Rh testing and Rh immunoglobulin are not available or would significantly delay access to abortion, shared decision-making is recommended.
Alright, your next step is to counsel the patient on their options, which include either a medical or procedural abortion.

Medical abortion 3:30–9:05

Counseling should be viewed as an opportunity to review your patient's values, preferences, and experiences in an open and safe environment.
Additionally, take time to reflect and recognize any of your own unconscious or explicit biases that may influence the efficacy of your counseling.
Keep in mind that some states have additional requirements, such as requisite ultrasounds, mandatory waiting periods, and parental involvement, which are not generally based on medical recommendations and create additional barriers for people desiring abortion.
Okay, let’s first discuss medical abortion, which consists of administering medication to promote passage of pregnancy tissue from the uterus.
Medical abortions are available through 70 days or 10 weeks gestation. Use the first day of your patient's last menstrual period to calculate their gestational age or an ultrasound if one was performed.
Patients may choose a medical abortion because it allows for the pregnancy to pass at home with more privacy and does not involve an invasive procedure.
However, medical abortions take longer to complete and require active patient participation. Also, be sure to let your patient know that medical abortion might fail, or there might be an incomplete passage of products of conception, in which case they will need a surgical procedure.
Before administering medications, check for any contraindications to medical abortion including a confirmed or suspected ectopic pregnancy, current use of an intrauterine device or IUD, current long-term systemic steroid use, chronic renal fatigue, coagulopathy or anticoagulant treatment, and inherited porphyria.
A medical abortion involves either a regimen of mifepristone plus misoprostol or misoprostol alone. Mifepristone is a selective progesterone receptor modulator or antiprogestin.
It acts on the uterus during pregnancy to cause decidual necrosis, cervical softening, increased uterine contractility, and prostaglandin sensitivity.
Misoprostol is a prostaglandin E1 analogue that also causes cervical softening and uterine contractions. The combination of mifepristone and misoprostol is preferred, as it’s significantly more effective than misoprostol alone.
This regimen consists of taking mifepristone orally followed by misoprostol, which can be administered vaginally, buccally, orally, or sublingually, 24 to 48 hours later.
Both medications can be safely taken at home, with NSAIDs as needed for pain. Adverse effects are more common with misoprostol, but can occur with either medication, and include nausea, vomiting, dizziness, and fever.
Be sure to tell your patient that bleeding will be much heavier than their usual menses and potentially include severe cramping.
Let them know to call if they have heavy bleeding to the point of soaking more than two maxi pads per hour for 2 consecutive hours, as they may require evaluation in the emergency department and/or procedural intervention.
Here’s a clinical pearl! The FDA currently restricts mifepristone access, limiting its use to certain healthcare settings under the supervision of a provider.
This does not improve the safety of care, is not medically evidenced-based, and creates additional barriers to medical abortions.
Follow-up can be completed either in person or via phone call or telemedicine. If in person, a transvaginal ultrasound can be obtained to check for the absence of a gestational sac, which confirms a complete abortion.
If ultrasound is not available or preferred, a repeat serum hCG can be checked 1 week after medication administration. An 80% decrease from initial hCG levels indicates completion.
Alternatively, if follow-up is via phone or telemedicine, check in at 1 week to confirm passage of pregnancy tissue and advise your patient to take a home pregnancy test 4 weeks after medication administration to confirm the resolution of the pregnancy.
When it comes to contraception, all options can be initiated on the same day as mifepristone administration, except IUD and sterilization.
If using depot medroxyprogesterone for contraception, keep in mind that while still safe to administer, it does have a slightly increased risk of continued pregnancy.
This is because depot medroxyprogesterone is a progestin-based contraceptive, which could potentially out compete mifepristone, making it less effective.
Once a complete medical abortion is confirmed, all forms of contraception are safe. Here’s a clinical pearl!
While an IUD can be placed as early as 1 week after a completed medical abortion, the expulsion rate is slightly higher in the first 6 weeks following a medical abortion versus remote insertion.
Failure rates for medical abortions are low but increase as gestational age gets closer to 10 weeks. Rarely, there is an inadequate response to a medical abortion, including not passing pregnancy tissue; the presence of a gestational sac on follow-up ultrasound; or an hCG decrease of less than 80%.
If any of these occur, options for further management include repeating misoprostol, uterine aspiration, or expectant management.
If cardiac activity is noted on ultrasound, uterine aspiration is the recommended next step. Okay, let’s discuss procedural abortions.

Procedural abortion 9:05–10:07

A procedural abortion is a uterine aspiration either by dilation and curettage or D&C for short, or by dilation and evacuation or D&E, which is the procedure of choice for abortions completed after the first trimester.
Antibiotics, specifically doxycycline, are indicated prior to either procedure to prevent infection. Risks of procedural abortions include bleeding, infection, uterine perforation, damage to surrounding organs, inability to complete the procedure, and retained products of conception, as well as potential anesthesia-related complications.
Benefits include the relative quickness of the procedure as compared to medical abortions, the ability to receive anesthesia, and higher rates of complete uterine evacuation.
After a procedural abortion, all contraceptive options are available, including placement of an intrauterine system at the time of the procedure.
Alright, as a quick recap… Therapeutic and induced abortions are part of comprehensive reproductive healthcare. Be sure to counsel your patient on their options, including medical abortion with mifepristone and misoprostol, which are available through 10 weeks gestation, and procedural abortion with D&C or D&E, which is the procedure of choice for abortions completed after

Review 10:07–10:27