Abortion has been practiced for centuries, often utilizing various methods, some of which were unsafe and posed significant health risks to women. The societal and legal attitude towards abortion have varied throughout history and across different cultures.

Abortion procedures vary based on the stage of pregnancy. Early-stage abortions (within the first trimester) are often performed using medication (medical abortion), while later-stage abortions might involve surgical procedures such as aspiration or dilation and evacuation (D&E).

The incidence of abortion refers to the number of new abortions that occur within a specific time frame, often reported as the number of abortions per 1,000 women of reproductive age (typically 15-49 years). This statistic helps provide insight into the rate of unintended pregnancies resulting from abortions. Globally, the estimated abortion rate was around 39 abortions per 1,000 women of reproductive age in 2014.

However, rates can vary significantly between regions and countries. Countries with more restrictive abortion laws may have higher rates of unsafe abortions. Abortion-related mortality refers to deaths caused by complications arising from unsafe abortions. When safe and legal abortion services are not readily available, individuals might resort to unsafe methods, leading to serious health risks and even death.

Unsafe abortions are a significant contributor to maternal mortality, especially in regions where abortion laws are restrictive. The World Health Organization estimated that unsafe abortions accounted for about 13% of maternal deaths globally in 2017. However, these figures can vary widely by region.

Medical abortion, also known as medication abortion or non-surgical abortion, involves using medications to terminate a pregnancy. The most common medications used for medical abortion are a combination of mifepristone and misoprostol. The process involves several stages of pathophysiological changes within the body. Mifepristone is an anti-progestin medication that works by blocking the action of progesterone.

By inhibiting progesterone’s effects, mifepristone causes the uterine lining to break down, decreasing the pregnancy-sustaining environment. As progesterone levels decline due to mifepristone, the uterine lining becomes less capable of supporting the implanted embryo. This results in a detachment of the embryo from the uterine wall, leading to the beginning of the process of abortion. After taking mifepristone, misoprostol is typically administered within 24 to 48 hours. Misoprostol is a prostaglandin analogue that causes uterine contractions and cervical dilation.

These contractions help expel the uterine contents, including the detached embryo and the remaining uterine lining. Misoprostol also helps soften and dilate the cervix, facilitating the passage of the uterine contents. This dilation is important for the successful completion of the abortion process. The combined effects of mifepristone and misoprostol lead to the termination of the pregnancy. The expelled tissue is examined to ensure that the abortion has been completed successfully. In some cases, additional medical attention might be required if the abortion is not complete.

Fetal Abnormalities: Detecting fetal abnormalities or congenital disabilities can lead some individuals to opt for medical abortion. Learning that the fetus has a severe health issue that might result in a poor quality of life, or an early death can be a significant factor in this decision.

Access to Abortion Services: In areas where surgical abortion services are limited or unavailable, medical abortion might be the more accessible. This is particularly relevant in regions with legal restrictions on abortion.

Contraceptive Failure: Despite the use of contraception, unintended pregnancies can occur due to contraceptive failure. In such cases, individuals might choose medical abortion to address the unintended pregnancy.

Age Group: 

• Adolescents: Adolescents may present concerns about confidentiality, fear of parental or societal judgment, and emotional distress. 
• Young Adults: Young adults may present concerns about future fertility, relationship dynamics, and financial considerations. 
• Older Adults: Older adults may present with concerns about health risks associated with pregnancy, existing health conditions, and family planning decisions. 

Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and temperature can provide important information about the patient’s overall health and any signs of potential complications. Vaginal bleeding is a common outcome of medical abortion. The healthcare provider will ask about the amount and characteristics of the bleeding to ensure it is within the expected range.

Excessive bleeding might suggest complications like incomplete abortion or hemorrhage. If the patient is experiencing ongoing uterine contractions, the healthcare provider might observe the frequency, duration, and intensity of the contractions. Monitoring for signs of hemodynamic instability, such as pallor, sweating, dizziness, or fainting, is crucial to detect any signs of severe bleeding or shock.

• Medical Conditions: Women with pre-existing medical conditions or autoimmune disorders may have additional concerns about the impact of pregnancy on their health. 
• Mental Health: Women with mental health conditions such as depression or anxiety may experience heightened emotional distress surrounding the decision to have an abortion. 
• Substance Use: Women who engage in substance use may face challenges related to addiction treatment and concerns about the impact of substance use on pregnancy. 

• Early Gestation: Women presenting in early gestation may be seeking elective abortion for personal or socioeconomic reasons. They may be more likely to opt for medical abortion (using medication) rather than surgical procedures. 
• Late Gestation: Women presenting in later stages of pregnancy may face additional legal and ethical considerations. Late-term abortions are typically associated with fetal abnormalities or maternal health risks. 

Medical Care

After confirming pregnancy and determining gestational age, the chosen abortion procedure typically corresponds to the stage of gestation. Early pregnancies can be terminated either through medical or surgical means. Research has indicated that abortions are notably safer than continuing a pregnancy to full term. Ending a pregnancy can avoid the associated risks of conditions such as pregnancy-induced hypertension and the considerable complications of cesarean delivery.

Guiding individuals through the risks and benefits of abortion has become a multifaceted and contentious process, often deviating from typical medical procedures. In Texas, for instance, there’s a requirement to provide patients with a pamphlet that emphasizes a higher number of complications from surgical and medical abortion compared to childbirth, which contradicts established data.

The predominant method for medical termination in the first trimester involves a combination of mifepristone and misoprostol. While alternative methods like methotrexate-misoprostol or misoprostol alone exist, they are less efficient and lead to more side effects. Different prostaglandins are utilized in countries beyond the United States. The most straightforward and successful approaches involve the combined use of mifepristone and misoprostol.

For women carrying pregnancies of 14-21 weeks gestation, administering mifepristone prior to treatment doubled the likelihood of achieving a complete abortion within fewer than 15 hours. Importantly, this combined approach also notably reduced the duration between induction and abortion without a corresponding increase in side effects compared to using misoprostol alone.

Surgical Care

In the case of women undergoing first-trimester terminations, especially those within the initial 10 weeks of gestation, the necessity for preoperative cervical preparation is quite rare. However, for individuals in the later stages of the first trimester, it can be beneficial to consider preoperative measures such as cervical dilatation using laminaria or medical intervention involving prostaglandins. The decision to implement such measures should be made by the healthcare provider who is conducting the abortion.

As the pregnancy progresses into the second trimester or beyond, preparing the cervix becomes essential. Aggressive dilation of the cervix carries the risk of causing cervix lacerations, which can result in significant bleeding or, in unusual instances, contribute to cervical incompetence. Administering misoprostol orally, buccally, or vaginally in doses ranging from 200 to 800 mcg can aid in readying the cervix. Situations where cervical preparation might be advantageous include cases involving uterine irregularities or a history of cesarean delivery.

Psychiatry/Mental Health

Counseling and Therapy: 

• Individual Counseling: People can share their feelings, ideas, and worries about abortion in a safe setting by seeking the advice of a qualified counselor or therapist. 
• Couple or Family Counseling: Involving partners or family members in counseling can facilitate communication and mutual understanding during a challenging time. 

Support Groups: 

• Associating with others in a support group who have gone through comparable experiences helps foster a feeling of empathy and compassion. Sharing experiences in a supportive environment can help reduce feelings of isolation. 

Education and Information: 

• Providing comprehensive information about the abortion process, potential emotional reactions, and available support resources can empower individuals to make informed decisions and cope better with the experience. 

Mindfulness and Relaxation Techniques: 

• Stress and anxiety can be controlled with the use of methods like progressive muscle relaxation, deep breathing techniques, and mindfulness meditation. Mindfulness can assist in staying present and focused on one’s emotional well-being. 

Art and Expressive Therapies: 

• Using creative mediums like writing, music, or painting may be a therapeutic approach to process and express thoughts that can be hard to say out loud.  

Spiritual Support: 

• For those with religious or spiritual beliefs, seeking guidance from a spiritual leader or participating in spiritual practices can provide comfort and solace. 

Exercise and Physical Activity: 

• Exercise regularly has been demonstrated to improve mental wellness. Physical activity has been shown to lower stress and enhance general well-being. 

Emergency Medicine

Antiprogesterones, also known as progesterone receptor antagonists, are medications that interfere with the action of progesterone, a hormone crucial for maintaining the uterine lining during pregnancy. 

Mifepristone (RU-486): 

It is a synthetic steroid that competitively binds to the progesterone receptor, disrupting progesterone’s effects. This leads to the cervix softening, uterine lining collapse, and greater susceptibility to the uterotonic side effects of misoprostol and other drugs. 

It is typically administered in combination with a prostaglandin analog, such as misoprostol, to induce a medical abortion. It is effective within the first 10 weeks of pregnancy. 

Mifepristone is usually taken orally in a clinic under medical supervision. A follow-up visit is necessary to ensure the completion of the abortion. 

Misoprostol: 

It is a prostaglandin E1 analog that stimulates uterine contractions and promotes cervical softening. When used in conjunction with mifepristone, it helps complete the abortion process by expelling the uterine contents. 

It is commonly used in combination with mifepristone for medical abortion. It is administered either orally or vaginally, typically within 24 to 48 hours after mifepristone. 

Depending on the healthcare provider’s recommendations and regional guidelines, misoprostol may be administered in a clinical setting or at home with appropriate instructions. 

Emergency Medicine

Antimetabolites are a class of drugs that interfere with the normal metabolic processes of cells by mimicking the structure of natural substances. In the context of elective abortion, certain antimetabolites, particularly antifolate drugs, can be used to interrupt the development of the embryo and induce abortion.  

Methotrexate: It is an antimetabolite that inhibits the enzyme dihydrofolate reductase, thereby interfering with the synthesis of DNA, RNA, and proteins. In the context of elective abortion, methotrexate primarily disrupts the rapidly dividing cells of the trophoblast, which is essential for the early development of the embryo. 

Methotrexate is used in combination with misoprostol for medical abortion. This combination is typically considered for pregnancies within the first seven weeks. It is administered either by injection or orally.  

Emergency Medicine

Local anesthetics play a crucial role in the treatment of elective abortion, particularly in the context of surgical abortion procedures. They are used to numb specific areas of the body, reducing or eliminating pain during the abortion procedure. Local anesthesia is commonly employed in various surgical techniques, such as dilation and evacuation or dilation and curettage. 

• Lidocaine: It is a commonly used local anesthetic. It works by blocking nerve signals in the body and is available in various formulations, including injectable forms for local anesthesia. 
• Bupivacaine: Bupivacaine is another local anesthetic used for longer-lasting pain relief. It is often chosen for procedures that may require an extended period of anesthesia. 
• Mepivacaine: Mepivacaine is a local anesthetic similar to lidocaine, and it is often used in various medical procedures, including abortions. 

Anesthesiology

Emergency Medicine

Uterotonics play a vital role in the treatment of elective abortion, particularly in medical abortion methods where medications are used to induce uterine contractions and facilitate the expulsion of the pregnancy. Uterotonics are essential for completing the abortion process. 

Oxytocin: It is a natural hormone that stimulates uterine contractions. It acts on the myometrium, promoting rhythmic contractions necessary for the expulsion of uterine contents. It is used in medical settings to induce labor and manage post-abortion bleeding. Oxytocin is typically administered through intravenous (IV) infusion under close medical supervision. 

Anesthesiology

Emergency Medicine

Ergot alkaloids work by inducing strong uterine contractions, helping to control bleeding and ensure the complete expulsion of uterine contents.  

Methylergometrine: 

It is an ergot alkaloid that acts on smooth muscle, including the uterine muscles. It stimulates strong and sustained contractions of the uterus. It is typically used to manage post-abortion hemorrhage or excessive bleeding after childbirth (postpartum hemorrhage). It is usually administered through intramuscular injection. 

While ergot alkaloids like methylergometrine have uterotonic effects and can induce powerful contractions of the uterus, they are not commonly used as the primary agents for elective abortion. These drugs may be reserved for managing complications, such as excessive bleeding, that can occur during or after an abortion procedure. 

Anesthesiology

Emergency Medicine

Sedatives may be used in the treatment of elective abortion to help manage anxiety, discomfort, or pain during the procedure. While sedation is not always required for all abortion procedures, it can be offered based on patient preference, medical considerations, and the complexity of the procedure. Sedatives can range from mild anxiolytics to more potent medications that induce varying degrees of relaxation and drowsiness.  

Midazolam: For individuals who need acute or brief sedation, shorter-acting benzodiazepine sedative-hypnotics are helpful. Its amnestic properties are also beneficial. 

Anesthesiology

Emergency Medicine

Antiemetics, medications that help prevent or alleviate nausea and vomiting, may be used in the treatment of elective abortion to manage potential side effects associated with certain medications or anesthesia. Nausea and vomiting can be common adverse effects during and after medical or surgical abortion procedures. 

• Prochlorperazine: Prochlorperazine is a dopamine antagonist that is used to treat nausea and vomiting. It is available in oral, rectal, and injectable forms. 
• Promethazine: Inhibits the brain’s postsynaptic mesolimbic dopaminergic receptors, reducing inputs to the brainstem reticular system. 

Anesthesiology

Emergency Medicine

Antibiotics plays a major role in treating elective abortion to prevent and manage infections. Infections can occur because of the abortion procedure, whether it is a surgical or medical abortion. The administration of antibiotics helps reduce the risk of bacterial infections and associated complications. 

• Doxycycline: Doxycycline is a broad-spectrum antibiotic commonly used in abortion procedures. It belongs to the tetracycline class of antibiotics and is effective against many bacteria. 
• Azithromycin: It is a macrolide antibiotic that is also commonly used in abortion procedures. It has a wide range of activity and works against various bacteria. 
• Ceftriaxone: It is a third-generation cephalosporin antibiotic that may be used in combination with other antibiotics for prophylaxis against infection in abortion procedures. 

Anesthesiology

Emergency Medicine

The use of immune globulins, such as immunoglobulins or antibodies, is not a standard practice in the routine treatment of elective abortion. Immune globulins are typically administered to address specific immune-related conditions or deficiencies rather than for abortion procedures.  

Rh Immunoglobulin (RhIg): 

• RhIg is an example of an immune globulin that is relevant in the field of obstetrics and reproductive health but not specifically for elective abortion. 
• RhIg is commonly administered to Rh-negative pregnant individuals to prevent Rh isoimmunization. In this condition, an Rh-negative mother is exposed to Rh-positive fetal blood, leading to the development of antibodies that could affect future pregnancies. 
• RhIg is usually administered following procedures like surgical abortion or specific prenatal diagnostic testing that might mix the blood of the mother and fetus. 

Anesthesiology

Emergency Medicine

• Medical Abortion (Medication): This involves using medication, typically a combination of mifepristone and misoprostol, to induce abortion. It’s generally used in the early stages of pregnancy, typically up to 10 weeks gestation. 
• Surgical Abortion: Surgical procedures such as vacuum aspiration or dilation and evacuation (D&E) are commonly used for elective abortions. These procedures may involve local anesthesia, sedation, or general anesthesia depending on the circumstances and patient preference. 
• Counseling and Support Services: Emotional support and counseling are important aspects of abortion care. Patients may benefit from counseling before and after the procedure to address any emotional or psychological concerns. 
• Contraceptive Counseling: Providing information about contraceptive options and counseling on family planning is essential to help prevent unintended pregnancies in the future. 
• Follow-Up Care: Post-abortion care is crucial to monitor for any complications and ensure the patient’s well-being. This may include a follow-up appointment with a healthcare provider and access to resources for any needed emotional support. 

• Pre-Procedure Counseling: This phase involves comprehensive discussions between the patient and healthcare provider(s) about the decision to have an abortion. This phase also involves assessing the patient’s medical history to ensure the procedure can be performed safely. 
• Medical Evaluation: Before the abortion operation, a medical examination is performed to analyze the patient’s general health and choose the best type of abortion. This may include physical examinations, laboratory tests, and ultrasound imaging to confirm the gestational age of the pregnancy. 
• Informed Consent: The patient must give informed consent before to the operation, demonstrating that they are aware of the advantages, disadvantages, and available options about the abortion process. This includes discussing potential complications and side effects. 
• Procedure:The abortion technique might vary based on gestational age, patient desire, and healthcare professional skill. Common methods include medication abortion (using pills to induce abortion) or surgical abortion (such as vacuum aspiration or dilation and evacuation). 
• Post-Procedure Care: After the abortion, patients receive post-procedure care and instructions to manage any discomfort or side effects. This may include follow-up appointments to monitor recovery and address any complications. 
• Emotional Support: Elective abortion can be a complex and emotionally challenging experience for patients. Providing emotional support throughout the process is crucial, including access to counseling services or support groups for patients who may need additional assistance coping with their decision. 
• Contraceptive Counseling: Following an abortion, patients should receive counseling on contraceptive options to prevent unintended pregnancies in the future. This includes discussing the most suitable methods based on the patient’s preferences, medical history, and lifestyle.