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1 : Abortion
2 : The Supreme Court’s Wisdom “ . . . we need not resolve the difficult question of when life begins. When those trained in the respective disciplines of medicine, philosophy, and theology are unable to arrive at any consensus, the judiciary, at this point in the development of man’s knowledge, is not in a position to speculate as to the answer.”
3 : Early “Life” Intercourse Fertilization Implantation Pre-embryo Embryo Fetus Viability Birth
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6 : Fertilization complex process which takes 24 hours after penetration of the oocyte (egg) by the sperm occurs in fallopian tube complete when pronuclei (23 chromosomes) of sperm and oocyte fuse to form a new cell called a zygote (46 chromosomes)
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8 : Stages of the pre-embryo . . . Zygote: one cell Blastomere: 2-8 cells, it takes 20 hours for the first cell division Morula: 8-16 cells. The morula travels out of the fallopian tube and reaches the endometrial cavity Blastocyst: multicellular mass of cells with a fluid filled center
9 : Implantation Process of blastocyst adhering to the uterine wall. Slow process occurring 5 - 9 days after the beginning of fertilization. Three cell layers are formed: Ectoderm brain, nerves, skin Mesoderm cartilage, muscle, blood vessels, heart, kidneys Endoderm: digestive tract, respiratory tree, liver, pancreas
10 : Embryo and Fetus Embryo 16 days after the beginning of fertilization until 8 weeks after after fertilization. Organogenesis is complete Fetus Completion of organogenesis until delivery
11 : Pregnancy Dating Days, weeks LMP Human gestation Conception Trimesters
12 : Viability Survival by Gestational age at DHMC Weeks % survival 22 0 23 25 24 55 25 65 26 75 27 90 28 92
13 : Definitions Abortion Complete Abortion Incomplete Abortion Threatened Abortion Inevitable Abortion Missed Abortion Septic Abortion Induced
14 : Abortion Termination of pregnancy before 20 weeks gestation calculated from date of onset of last menses Early Abortion: before 12 weeks Late Abortion: from 12-20 weeks Delivery of a fetus of weight less than 500 grams
15 : Definitions . . . Induced Abortion: intentional medical or surgical termination of a pregnancy Elective: if performed for a woman’s desires Therapeutic: if performed for reasons of maintaining health of the mother
16 : Induced abortion: statistics . . . 1,180,000 abortions are reported to the CDC in 1997. This is constant since 1980 305 abortions/1000 live births National abortion rate: 20/1000 women aged 15-44 79.7% of women obtaining abortions are unmarried 21 % of women obtaining abortions are younger 19 years old 55.2 % are younger than 24 years old
17 : Statistics, continued 53% of women in the United States having abortions have never had one before 88% of women who abort are in the first trimester of pregnancy 97% of women having first trimester abortions have no complications or post abortion complaints 2.5 % have minor complaints that are handled in a physicians office <0.5% require additional surgery
18 : Induced abortion: safety Risk of death from a legal abortion is 0.4/100,000 Risk of death from a term pregnancy is 9/100,000
19 : Induced Abortion: safety Risk of death for being an abortion provider 20/100,000
20 : Historical Perspective “(T)here is every indication that abortion is an absolutely universal phenomenon, and that it is impossible even to construct an imaginary social system in which no woman would ever feel at least compelled to abort” Devereux G. A typological study of abortion in 350 primitive, ancient, and pre-industrial societies.
21 : Historical perspective cont . . . Abortion legal in US from Puritan settlement till mid 1800’s 1840: Eastman Everett Act, State of Maine 1 year in jail, $1000, loss of license 1846: abortion illegal nationally
22 : Roe vs. Wade 1/22/73 “We recognize the right of the individual, married or single, to be free from unwanted governmental intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child. That right necessarily includes the right of a woman to decide whether or not to terminate her pregnancy.”
23 : Benefits of Legal Abortion Death from illegal abortion used to be a major component of maternal mortality Hospital wards were filled with patients suffering from septic “spontaneous abortion” In 1940, 1407 died from complications of induced abortion 1987 (last year of available data) 12 deaths from spontaneous abortion 6 deaths from legally induced abortion 2 deaths from illegally induced abortion
24 : Benefits of legal abortion Global perspective: WHO estimates 20,000,000 illegal abortion world wide annually 50,000-100,000 deaths annually 250-500/100,000 mortality rate (0.4/100,000 in United States)
25 : Gestational age and procedure 50% of abortion performed 8 weeks or earlier 12% of abortion performed past 12 weeks 1.4% of abortion performed past 20 weeks
26 : First Trimester Abortion Early Uterine Evacuation (EUE), Minisuction, Menstrual Regulation Suction Abortion, Vacuum Curettage Medical Abortion
27 : Minisuction Introduced in 1972 by Karman and Potts
28 : Minisuction Requires early recognition of pregnancy. Performs abortions up to 7-8 weeks from LMP Cervical dilation not required, 6 mm diameter cannula used Simplest, safest, least expensive examine aspirated tissue is essential
29 :
30 : Dilatation and curettage (D&C) Removal of pregnancy contents by some mechanical means Vacuum most commonly used 12-13 weeks is the upper limit of gestational age Usually performed in free standing clinics
31 : D&C (vacuum curettage) The cervix must be dilated to permit larger diameter suction curettes Premedication with NSAID Local (paracervical block), spinal, conscious sedation, or general anesthesia
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36 : Medical Abortion Mifepristone (RU486) analogue of progestin norethindrone strong affinity for the progesterone receptor, acting as an antagonist a single oral dose given to women 5 weeks or less produces abortion in 85% of cases
37 : Medical Abortion - politics RU486 - Mifepristone developed in 1980’s approved for use by French government 1988 one day later manufacturer withdrew it from the market succumbing to international boycott French government ordered redistribution Prohibited in US during Reagan and Bush Ban lifted by Clinton, clinical trials, preliminary FDA approval 9/96 Final approval stalled secondary to inability to manufacture and distribute until 9/2000
38 : Mifepristone protocol Women less than 49 days LMP with confirmed b-hCG 600mg mifepristone on day 1 On day three, return for prostaglandin, Misoprostil 400 mcg orally Patient remain in clinic four hours, during which time expulsion of pregnancy usually occurs
39 : Alternative Regimens 200 mg Mifepristone 800 mcg Mistoprostil vaginally
40 : Medical Abortion in the US Women less than 49 days LMP with confirmed pregnancy Methotrexate 50 mg/m2 on day 1 Misoprostol 800mg intravaginally on day 5,6, or 7, repeat x 1 in 48 hours if pregnancy persists Abortion off site in 1-5 days. Surgical intervention if pregnancy persists to day 29
41 : Surgical vs. Medical: pro vs. con Patient perspective: Private More sense of autonomy “More natural” Earlier intervention unwanted pregnancy Longer process with unclear endpoint More pain More bleeding Anxiety regarding abortion off site
42 : Surgical vs. Medical: pro vs. con Provider perspective: Less skill needed to provide Methotrexate also treats ectopic pregnancy Increased anxiety re: off site management More unscheduled care: calls, ER visits Need to guard against unnecessary intervention Limited to 49 days LMP
43 : Second Trimester Termination Dilatation and evacuation (D&E) Intrauterine injection of abortifacients Prostaglandin vaginal suppositories High dose oxytocin Hysterotomy
44 : D & E Mechanical and suction removal of formed pregnancy after cervical dilation Technically more difficult than earlier suction procedures Associated with fewer complications than instillation and suppository methods General anesthesia is not required
45 :
46 : Picture of laminaria
47 : Intrauterine injection of abortifacients Prostaglandin, hypertonic saline, hypertonic urea are introduced by amniocentesis Fetus and placenta are aborted vaginally Osmotic dilators are used to decrease time to delivery and decrease complications
48 : Prostaglandin suppositories 20 mg suppositories of PGE2 typically given q 3 hours mean time to induction 13.4 hours, with 90% aborting by 24 hours GI side effects: 39% vomiting, 25% diarrhea Fever: temperature elevation of 1 degree c Prostaglandin F2alpha 250 mg IM q 2 hours mean time to abortion 15-17 hours, with 80% aborting by 24 hours GI side effects: 83% vomiting, 71% diarrhea Misoprostil (PGE1)
49 : High Dose Oxytocin As effective as PGE2 when used in appropriate doses Risk of water intoxication
50 : Hysterotomy Surgical method to remove pregnancy abdominally (mini-cesarean section) Other methods are preferred
51 : Complications - rates Varies as a function of the gestational age they are performed Major complications: 0.25% < 7 weeks 1% < 12 weeks 2% over 12 weeks
52 : Complications - immediate Complications of local anesthetic Cervical shock Cervical lacerations Uterine perforation Hemorrhage Post abortal syndrome
53 : Complications - delayed Bleeding retained products Infection Continued pregnancy ectopic intrauterine


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