Melody Y. Hou

Therapeutic abortion is defined as the intended interruption of an established pregnancy. Under the landmark 1973 Roe vs. Wade decision, the United States Supreme Court ruled that abortion is a legal procedure up until the point when the fetus becomes viable, or “has the capability of meaningful life outside the mother’s womb.” Although individual States may regulate or prohibit abortion after viability, these actions are not permitted if abortion is deemed medically necessary to preserve the life or health of the woman seeking abortion. Prior to viability, States may enact restrictions if they do not create “undue burden” on the woman.

Abortion is an important issue in reproductive health, historically and worldwide, and few other topics in medicine have attracted as much debate. Some people feel that therapeutic abortion should be illegal because it destroys a developing human life. However, history has shown that a woman who has an undesired pregnancy will seek abortion despite the legal or social restrictions in her society, and that maternal mortality rate decreases significantly whenever and wherever abortion is safe and legal.

Abortion has been described as early as 2737 Bc, and found in civilizations as diverse as the Chinese, Greek and Roman Empires. With the rise of Christianity, abortion and contraception became more controversial, culminating in the criminalization of abortion throughout the United States by the 1870s. Over the next century, thousands of women died or sufered serious injuries due to “back alley” abortions, and caring for women sick or dying from sepsis caused by these illegal and unregulated procedures became a common experience for medical trainees. By 1970, the American Medication Association (AMA), which had originally supported the criminaliza-tion of abortion in order to establish physician dominance over nonphysician clinicians, reversed its stance on abortion and called for its legalization. Three years later, the US Supreme Court recognized the need for safe and legal abortion with its landmark decision in Roe vs. Wade. Since then, there has been an opposing movement in the United States to repeal or limit the abortion rights granted by this decision.

Unintended pregnancy and abortion are important public health issues worldwide. The majority of the world’s population lives in countries where abortion is restricted or generally prohibited. In 2008, 26% of all people resided in countries where abortion was permitted only to save a woman’s life or is prohibited altogether, whereas 35% lived in countries where abortion was permitted only to preserve either physical or mental health or for socioeco-nomic grounds. The remaining 39% resided in countries where there were no restrictions as to reason for the procedure.

In the United States, nearly half of all pregnancies are unintended. Four in 10 of these unintended pregnancies end in abortion, accounting for 22% of all pregnancies, excluding miscarriage. Half of all American women have had an unintended pregnancy, and 35% are estimated to have had an abortion before age 35 years.

Counseling

It is important not to assume that a positive pregnancy test is good news for a patient. Any woman who tests positive for an unplanned pregnancy should be counseled on all options, including abortion, adoption, or parenting the resulting child. The information must be handled sensitively and empathetically, since this decision is personal and may be extremely difficult for a patient. Efforts should be made to ensure that the patient’s choice is not coerced. As abortion laws vary from State to State, these restrictions, such as 24-hour waiting periods, spousal notification, and mandatory ultrasound-viewing, must also be considered during counseling.

If the patient elects termination, she must be informed regarding the nature of the procedure and its risks. Legal abortion in the United States is among the safest of medical procedures, with less than 0.3% of abortion patients experiencing a complication requiring hospitalization. Abortion risk increases with gestational age. Based on the most recently published national review of mortality risk from 1988 to1997, mortality risk was determined to be 0.1 per 100 000 abortions done at or before 8 weeks, 3.4 in 100 000 between 16 weeks and 20 weeks, and 8.9 in 100 000 at 21 weeks or more. However, timely access to abortion services may be difficult since 87% of counties in the United States have no abortion providers, and 35% of American women live in those counties. Access to abortion services becomes more difficult with increasing ges-tational age, since there is a shortage of providers trained to do abortions in later gestations.

Patient History, Physical and Laboratory Tests

A careful history should be taken, which includes documenting the patient’s last menstrual period (LMP) and any pregnancy symptoms she may be experiencing. (In this chapter, all gestational ages will refer to menstrual weeks, with the woman’s LMP as the reference point.) If the pregnancy has not been confirmed, a urine pregnancy test should be done. On physical exam, assess the size of the uterus and its position (ante- or retroverted, ante- or retrofexed), as well as any tenderness or masses in the adnexa. A preprocedure ultrasound will confirm the ges-tational age and help exclude the presence of an ectopic pregnancy or any pathology that may complicate the procedure, such as fibroids, müllerian duct anomalies, or a multiple pregnancy. Since abortions carry a 5% risk of rhesus (Rh) D alloimmunization in susceptible patients, Rh antigen status should also be determined and Rh negative patients treated with D immunoglobulin.

Most procedures are performed under local anesthesia, such as a paracervical block, but this may not be completely effective. Local anesthesia may be augmented with sedation for patient comfort, particularly in later gestational ages. Prophylactic antibiotics are also recommended since a meta-analysis showed that antibiotics reduced the rate of postoperative endometritis by half, including women in low-risk groups.

Methods for First Trimester Abortion