A Critical Examination of Abortion Terminology

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Today we are reviewing a new document from SMFM’s Reproductive Health Committee regarding the vocabulary surrounding abortion. Joining us are two of the paper’s lead authors: Dr. Cara Heuser, an associate professor of OB/GYN at University of Utah; and Dr. Sarah Horvath, an assistant professor of OB/GYN at Penn State University.

Their paper and their comments in today’s podcasts are really worth listening to. We also recommend some additional resources or guides for reproductive health advocacy:

SMFM: a number of resources and ways to get involved are here.

ACOG: the ACOG IMPACT project on abortion care training can be reviewed here.

SFP: SFP regularly updates clinical guidance and educational material surrounding abortion care, best practices, and data.

Espresso: Update to the Mifespristone REMS Requirements

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Reading: ACOG Practice Advisory: Updated Mifepristone REMS Requirements

Background 

  • What is mifepristone? 

    • As you probably know, mife is used in combination with misoprostol as part of medication abortion 

    • This method is safe, effective, and FDA-approved 

    • Can also be used for early pregnancy loss 

    • Check out our medication abortion and telehealth abortion episodes! 

    • However: 

      • Starting in 2011, the FDA implemented the Mifepristone REMS (risk evaluation and mitigation strategy) Program placed several restrictions on mifepristone distribution 

      • There needed to be an in-person dispensing requirement 

        • Needed to be dispensed in a clinic, medical office, or hospital by or under direct supervision of a certified clinician 

        • So patients could not get the mifepristone in a retail pharmacy or by mail 

    • ACOG has long advocated for removal of this restriction 

      • Doesn’t make care safer 

      • Not based on medical evidence 

      • Creates barriers to clinician and patient access to medication abortion and medical management of early pregnancy loss 

      • Disproportionately burdens communities already facing structural barriers to care 

Why are we making this episode? 

  • Timeline 

    • During COVID-19, with advocacy, the FDA halted enforcement of the REMS in-person dispensing requirement due to public health emergency

      • This allowed telehealth provision of mifepristone and also by mail in some states  

    • December 2021 - FDA completed a review of the Mifepristone REMS Program and determined that modifications were warranted to reflect long-standing safety data, improve patient access, and reduce burden on health care delivery 

    • January 3, 2023 - Drug manufacturer’s submission of updated prescribing information, etc. and was approved by FDA 

  • Updates 

    • Permanent removal of in-person dispensing requirement 

      • So in addition to clinics, medical offices, hospital: certified pharmacies can now dispense mifepristone to patients with prescription from certified prescriber 

      • Mifepristone can be dispensed in-person or by mail 

    • Addition of a pharmacy certification requirement 

      • Retail pharmacies that meet certain requirements and complete a Pharmacy Agreement Form can now dispense mifepristone to patients to patients who have a prescription from a certified prescriber 

    • Find the documents can be found on the FDA website.

What does this mean for us and for our patients? 

  • Increase access to medication abortion 

    • Maybe – can still be dependent on state-specific laws and ability and willingness of retail pharmacies to achieve REMS certification 

      • Some states restrict abortion

      • Some states restrict telehealth access, may still require in-person dispensing of mifepristone, and regulation of medications by mail 

    • So… the REMS requirements still remain as a medically unnecessary barrier to obtaining this medication 

Abortion: Telemedicine and Self-Management

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Today we’re joined by Dr. Sarah Gutman, who is an assistant professor of OB/GYN at the University of Pennsylvania, and a recent graduate of their fellowship in complex family planning. She’s joining us today to talk about some of the most important and interesting topics trending in the weeks after the Dobbs vs Jackson Women’s Health: self-managed abortion and telemedicine abortion.

What is telemedicine abortion?

  • Provision of medication abortion care using telemedicine services, typically fully remote but can involve some degree of in-person contact for part of the process, under the supervision of a medical provider.

  • Who are the appropriate candidates for telemedicine abortion?

    • Eligibility criteria for studies evaluating telemedicine abortion have typically included:

      • Pregnancy less than 10 weeks gestation,

      • No contraindications to mifepristone or misoprostol and

      • The ability to receive mife/miso by mail

  • What are the steps of a typical telemedicine abortion visit?

    • Initial consult – confirmation of dating, review of medical history/risks factors, discussion of how medication should be used and expectations for abortion process.

    • Patients should be certain of their LMP within one week, and it should be <77days before anticipated start of mifepristone

    • Evaluate for symptoms or risk factors for ectopic pregnancy, including vaginal bleeding, pelvic pain, prior ectopic, current IUD use, prior tubal surgery

      • Interestingly, the rate of ectopic pregnancy among patients seeking abortion is lower than the general population – between 1.5 – 6 per 1,000 pregnancies compared to about 20 per 1,000 pregnancies in the general population

    • Ensure no contraindications for medication abortion

      • RH type and hemogloblin are not needed

    • Receipt of medications – due to restrictions in mifepristone accessibility, typically this has been through the mail

  • Medication abortion has been covered by the podcast in the past, but as a reminder: the two medications used for medication abortion are mifepristone and misoprostol.

    • Mifepristone is a taken orally as a one-time 200mg dose

    • Misoprostol can be used vaginally, sublingually, or buccally, 800mcg are given initially with the option to repeat a dose if needed.

      • Patients are informed to take within 48h of mifepristone administration.

      • Consider a second dose if GA >63 days or no bleeding in 24 hours.

    • Analgesics, antiemetics – many providers give ibuprofen and Zofran

  • When to seek help:

    • Heavy bleeding soaking >2 pads/hour for more than 2 hours,

    • Passing blood clots larger than a lemon, or

    • Symptoms of blood loss such as feeling dizzy/lightheaded.

  • Follow up

    • Symptoms – can be assessed at 7-14 days through a text, secure messaging, telephone all, or video.

      • Patients are counseled to expect bleeding heavier than a period, and that they may pass blood clots and see some tan/pink tissue.

    • Urine pregnancy tests – given 4 to 6 weeks following the abortion

What is the evidence behind telemedicine abortion?

  • Efficacy is very high – around 95% of abortions are completed without needing a procedure.

  • Complications are exceedingly rare.

    • Around 6% of patients visit an ER or urgent care center related to the abortion

    • The rate of adverse events is less than 1%, with hospitalization <0.5%, transfusion 0.4%, infection <0.1%

What is self-managed abortion?

  • Self-managed abortion has also been referred to as self-sourced medication abortion (SSMA)

  • Society of Family Planning definition:

    • “It refers to any action taken to end a pregnancy outside of the formal healthcare system, and includes self-sourcing mifepristone and/or misoprostol, consuming herbs or botanicals, ingesting toxic substances, and using physical methods.”

  • Historically, people fearing criminalization or unable to access abortion care often turned to unsafe or invasive methods of self-managing their abortion – think of the abortion scene in ‘Dirty Dancing’ and the use of a coat-hanger as a sign of an unsafe abortion.

    • However, increased access to the medications used for abortion, in particular misoprostol, had made self-managed abortion much safer and more effective.

    • Other reasons besides access that people may choose self-managed abortion, including privacy, discomfort with the available medical services, and person safety.

What are the components of SMA?

  • Similar to telemedicine abortion, SMA includes assessment of eligibility, administration of abortion medications, management of the abortion process, and assessment of abortion completion.

    • These actions are all taken without the formal guidance of a healthcare provider.

    • People who self-manage their medication abortions should be able to estimate their gestational age using their last menstrual period and be aware of their cycle regularity and any contraception use.

  • There are many clinical resources available online, including through the Reproductive Health Access Project, Doctors without Borders, and Aid Access.

  • The WHO recommends mifepristone followed by misoprostol.

    • However, if mifepristone is not accessible, misoprostol can be used alone, typically 800 mcg used vaginally, sublingually, or buccally repeated every 3 hours or up to 3 doses until expulsion occurs.

  • How common is SMA?

    • Recent cross-sectional data suggests 7% of individuals in the US attempt SMA at some point in their lifetime, and this is likely growing due to increased restrictions on abortion access.

  • What is the safety and efficacy of SMA?

    • Data is limited: it’s difficult to study something that is outside the healthcare system.

    • However, from the data we have available and by extrapolating data from the telemedicine abortion models with lowest amount of supervision, self-managed abortion using mifepristone and misoprostol appears to be as safe and effective as medication abortion within a clinical setting.

    • A meta-analysis of misoprostol alone regimens used <91 days gestation found a 6.8% ongoing pregnancy rate

      • Serious adverse events occur <1% of the time.

  • How can providers support patients who have chosen self-managed abortion?

    • When people are criminalized for abortion, it is often due to a healthcare provider reporting them to the police.

    • Currently, there are no mandated reporting laws for healthcare providers.

    • There is legal help available for patients concerned about their options and criminalization, such as If/When/How

      • People of color and low-income individuals are most likely to be targeted and disproportionately criminalized.

Summary

  • Telemedicine abortion is the provision of medication abortion through telehealth under a healthcare providers supervision. Self-managed abortion is actions taken outside the formal healthcare setting to end a pregnancy.

  • Both telemedicine abortion and self-managed abortion using mifepristone and misoprostol are remarkably safe and effective.

  • While protocols vary, typically patients receiving telemedicine abortion should be at or below 10 weeks gestation, should not have any risk factors or symptoms concerning for ectopic pregnancy, and should not have any contraindications to taking mifepristone or misoprostol. After taking their medications, they should be able to monitor their vaginal bleeding and cramping and take a home urine pregnancy test in 4-6 weeks to confirm completion of the abortion.

  • Importantly, there are no laws mandating that healthcare providers report patients for suspected self-managed abortion. If patients are concerned about criminalization there are legal resources available such as If/When/How.

Additional Resources

Special Episode: Abortion Rights in the USA

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In light of this week’s events, Fei and Nick sit down to talk through abortion rights in the US and evaluate the place of abortion as healthcare in the US.

The Current State of Abortion in the USA

  • Earlier this week: leaked Supreme Court document to overturn Roe v. Wade 

    • If you have not: https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473

    • Just so we are clear, this does not mean that Roe V. Wade is overturned 

      • Per Politico: “Deliberations on controversial cases have in the past been fluid. Justices can and sometimes do change their votes as draft opinions circulate and major decisions can be subject to multiple drafts and vote-trading, sometimes until just days before a decision is unveiled. The court’s holding will not be final until it is published, likely in the next two months.” 

  • Roe V Wade has not yet been overturned, so in the US, technically abortion is still legal 

Where Things Stand if Roe is Overturned

  • There are multiple states that have restrictions in some way or other. So for example, only 6 states have no restrictions on abortion: 

    • Oregon, Colorado, New Mexico, New Jersey, Vermont and New Hampshire 

    • Most states have limitations at viability, and certain states have limitations at 24-25 weeks

      • 24-25 week limitation: Nevada, PA, FL, Massachusetts, and Virginia 

      • Still others state “viability” but individual institutions limit the gestational ages, effectively making the limitation less than viability (AHEM RI, Women and Infants ← don’t have to actually call them out)  

    •  Some states have 22 week limits (North Dakota, South Dakota, Nebraska, Kansas, Oklahoma, Iowa, Wisconsin, Indiana, Ohio, West Virginia, Georgia, South Carolina, Alabama, Louisiana, Arkansas 

    • Others have limitation at 15 or 20 weeks (Mississipi, Kentucky) 

    • Most restrictive: Texas, at 6 weeks 

  • And still more restrictions exist beyond gestational age:

    • In the setting of minors, parental consent or inform laws exist for all but 7 states 

    • There is also a mandatory waiting period for 24 hours or more in 24 states 

    • State constitutional protection of abortion exist in only 14 states 

    • No government funding for abortion (US government insurance will not fund it) 

      • First trimester abortions can cost $500-$1000 out of pocket 

  • Currently, should Roe v. Wade get overturned, legislatures in 22 states said they would move to ban or further restrict abortion laws 

US Case Law Regarding Abortion Rights

  • Roe V. Wade (1973)

    • Court case involving Norma McCorvey (Jane Roe) who became pregnant in 1969 with her third child 

    • She could not have an abortion as she wanted because in Texas it was illegal 

    • Her attorneys filed a lawsuit on her behalf in the US federal court, alleging that the Texas abortion laws were unconstitutional

    • The US District Court ruled in her favor and the state appealed to the Supreme Court 

    • In 1973, the Supreme Court Ruled in a 7-2 decision that per the Due Process Clause of the Fourteenth Amendment, this provides a “right to privacy” that protects a woman’s right to choose 

    • However, there were clauses: 

      • Right is not absolute and must be balanced against governments’ interests in protecting women’s health and prenatal life 

      • Tied state regulation to the three trimesters of pregnancy: during first trimester, government could not prohibit abortion at all; second trimester, government could require reasonable health regulations; during third trimester, abortion could be prohibited entirely so long as the laws contained exceptions for cases when they were necessary to save the life or health of the mother 

    • What this means: yes, abortion was now legal, but it left a lot up for interpretation 

      • States could still enact other provisions that would make it difficult to get an abortion (ie. long waiting periods, informed consent laws, spousal or parental consent) 

  • Planned Parenthood vs. Casey (1992) 

    • Another landmark trial where the Court upheld the right to have an abortion that was established in Roe v. Wade 

    • The case arose from a challenge to 5 provisions of the Pennsylvania Abortion Control Act of 1982

      • The provisions included (not limited to) requirements for waiting period unless there was a “medical emergency,” spousal notice, and parental consent for minors (other two were informed consent and reporting requirements or record keeping for abortion service facilities) 

    • The court upheld Roe and also overturned the original trimester framework in favor a viability analysis  

      • While this is typically seen at 24 weeks, but since Casey, states have enacted laws to restrict abortion, including abortions earlier than the general standard of 24 weeks 

      • Also replaced the strict scrutiny standard of review required by Roe with the “undue burden” standard, under which abortion restrictions would be unconstitutional when they were enacted for “the purpose or effect of placing a substancial obstacle in the path of a woman seeking an abortion of a nonviable fetus” 

      • The court upheld 4 provisions of the PA law, but invalidated the requirement of the spousal notification 

  • Dobbs v. Jackson Women’s Health Organization (2022)

    • Pending US supreme court case dealing with the constitutionality of the 2018 Mississippi state law that bans abortions after 15 weeks 

    • In March 2018, Mississippi passed the Gestational Age Act 

    • Within a day, the remaining abortion clinic in MS (Jackson Women’s Health Organization) sued the state challenging the constitutionality of the bill 

    • In the district court for southern MS, the judge ruled for the clinic and placed an injunction on the state enjoining them from enforcing the Act 

    • State appealed to the Fifth Circuit → upheld the judge’s ruling

    • The state then petitioned their act to the Supreme Court in June 2020 - case was heard on December 2021

    • Which then leads us to our leaked Politico draft that appears to overturn Roe v. Wade on May 2, 2022! 

What about other countries / guidelines?

  • WHO guidelines - recently updated on 3/9/2022: https://srhr.org/abortioncare/

    • It’s very long, but some important points as below: 

      • WHO recommends against mandatory waiting periods

      • Recommend that abortion be available on request of the woman/pregnant person without authorization of any other individual, body, or institution 

      • Recommend against laws and other regulations that prohibit abortion based on gestational age limits 

      • Recommend the full decriminalization of abortion

      • Recommend against the use of ultrasound scanning as a prerequisite for providing abortion services 

  • Other countries

    • Canada - no laws or restrictions regulating abortion

    • In most countries (other than the US and Australia) - right to abortion has been legalized by respective parliament/government instead of by state 

    • Legal in all European nations, though some gestational age limits apply 

      • Usually up to 16 weeks

Why is abortion healthcare? 

  • Abortion History in the US 

    •  1973 - Roe V. Wade; abortion is a constitutional right 

      • Three years later: Hyde Amendment; block federal funds from being used to pay for abortion outside of narrow scope of rape, incest, or life endangerment 

    • Prior to this: 

      • Until the early 1800s, abortion was legal until “quickening” 

      • Shift toward banning abortion was born from racism, misogyny, and desire to control pregnant people’s bodies

        • In mid 1800s: US shifted toward criminalizing abortion 

        • Black midwives and healers were condemned for performing abortions and care of pregnant people 

        • Motivated potentially by declining birthrates of white Protestant American women in the 1800s and increased migration 

Safe Abortion Care and Why It is Needed

  • It will occur whether or not it is prohibited

    • The Guttmacher Institute reports that in 2017 the abortion rate in countries that prohibit or limit abortion was 37/1000 people and the abortion rate was 34/1000 people in countries that broadly allow for abortion 

    • Unsafe abortion leads to 4.7-13.2% of maternal deaths  

  • Most abortions occur early on and is safe when there is good healthcare

    • According to the CDC, in 2016, 65.5% of abortions occurred at 8 weeks or less 

    • 91% occured before 13 weeks  

    • Only 1.2% of abortions are performed at 21 weeks or later 

  • For ways that abortions are done: look at our previous abortion episodes

  • Abortions are safer than pregnancy

    • Risk of death from abortion is <1/100,000; risk of dying in childbirth is 14xgreater than risk of dying from an early abortion 

    • Complications from medication abortion is <1% of patients 

    • Rate of complication in surgical abortion is 0.5-4% 

    • It does not increase your risk of future cancer and does not decrease your fertility

  • Who gets abortions?

    • Guttmacher Institute in 2014: 

      • 39% white, 28% black, 25% LatinX 6% Asian/PI, 3% other  

      • So the demographic is everyone 

    •  In addition:

      • 62% identified as religiously affiliated

      • 59% were people that had children 

      • 60% were people in their 20s  

    • Reasons for abortions

      • 74% state that having a child would interfere with education, work, or ability to care for dependents (so abortions decrease the risk that someone becomes unable to work, relies on the state for welfare – this is what conservatives want right??  ← don’t have to say this … it’s just my rage) 

      • 73% could not afford a baby (again, that person is being fiscally smart!) 

  • It is hard to get access to abortion care already, even in “liberal” states 

    • Among women seeking care for abortion in California, 11.9% traveled 50 miles or more 

    • Especially those who seek second trimester abortions or who live in rural areas 

    • One study of 6022 telemed requests: 76% of requests were from states with hostile restrictions

      • However, 60% reported a combination of barriers to clinic access and preference for self-management for privacy and convenience 

    • Why is this important to know? 

      • There are inevitably those that cannot travel 50 miles or more (and this is Cailfornia!) 

      • There are those who do not have $500-$1000 lying around for abortion 

      • What this means is that right now, safe, legal abortion is effectively unattainable for those people who are poor or do not have resources 

      • By further restricting abortion laws, we are going to inevitably make things worse for those who do not have resources (people with money and resources will always be able to get abortions) 

Call to Action: Based off the ACOG CO 815 Increasing Access to Abortion

  • The Hyde amendment and any law that restrict public or private insurance coverage of abortion should be eliminated 

  • There should not be undue barriers that restrict access to abortion including but not limited to: 

    • Bans by gestational age 

    • Requirements that only a physician or an Ob/Gyn give abortion care 

    • Telemedicine bans 

    • Restrictions on medication abortions (including mailing medication through the USPS) 

    • Requirement for mandatory counseling

    • Waiting periods before abortion 

    • Ultrasound requirements 

    • Mandatory parental consent/informing of parents 

    • Mandatory spousal consent or informing of spouse 

    • Faciliy and staffing requirements as outlined in the Targeted REgulations of Abortion Providers (TRAP) laws 

  • Ob/Gyn and family medicine practices will have opt-out abortion training for medical student, resident, and advanced-practice clinicians, and government funding will be ensured for these programs 

  • Obtaining an abortion or aiding another to obtain an abortion, or providing an abortion should not be considered criminal activities

  • Institutions should see abortion as healthcare and support it as such 

  • Any decision for abortion and method of abortion should be between the patient and her healthcare provider, and not be dictated by the government, healthcare facility, or ability to pay for abortion  

What can you do to help?

  • VOTE! 

  • Talk to your institutions – see if they will make a commitment to keeping abortion care as part of their practice 

  • Call your representatives

    • We know that you are all from different places, but we are especially talking to folks from the United States 

    • Find your senators here: https://www.senate.gov/senators/senators-contact.htm

    • Find your representatives here: https://www.house.gov/representatives

    • Let them know you are a constituent 

    • Here is a brief script from the ACLU that you can use. Know that there are Democratic Senators that are now working on protecting abortion rights, but there is nothing written/official as of yet 

      • Hi, my name is [SAY YOUR NAME] and my zip code is [SAY YOUR ZIP CODE]. [If you’d like, you can say that you are a physician, medical student, PA, healthcare provider of any type, etc.] I’m a constituent of [SAY SENATORS’ NAME] and I’m calling to urge the senator/representative to work with others to help codify abortion rights into law. 

  • Donate or volunteer for your local Planned Parenthood

  • Donate to the ACLU and join their mailing list: 

  • Familiarize yourself further with your state (and neighboring states’) laws and regulations for abortion via the Guttmacher institute 

  • Other things 

  • As a provider 

    • If you march, make sure to protect yourselves 

      • How to protest/attend a rally/march successfully 

        • Research what others are saying about the event/rally - is it safe to go? Will there likely be counterprotesters? Could things end with violence? 

        • Try not to go alone (esp if you are female, trans, BIPOC) - it’s safer to go in a group 

        • Wear a mask

        • Bring a pack and have with you water and snacks, medications, phone, phone charger and other essentials you may need (ie. pads, tampons, bandaids) 

        • Make sure your phone is only unlockable by password (police cannot force you to unlock, but they can unlock it with your face or fingerprint against your will) 

          • Consider turning it onto airplane mode while protesting 

        • Wear comfortable, close-toed shoes 

        • Write emergency contact information or emergency legal counsel numbers on your arm in permanent marker 

        • Stay vigilant. If arrested, demand legal representation before speaking to the police 

    • If you want to be seen in your white coats, that is ok, but make sure you are safe and go in a group 

      • If you don’t want to be recognized, make sure to wear your mask/goggles, cover tattoos that are recognizable.  

    • Educate your patients and hear what they have to say 

    • Prescribe refills on birth control pills, patches, contraceptive rings, etc. 

    • Place LARCs as desired by your patients 

    • Prescribe emergency contraception and tell patients to pick them up and keep it with them 

    • Compile a list of providers/places that provide abortion services and make them readily accessible to patient if they desire them 

Second Trimester Abortion

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Second Trimester Abortion: Legal Issues

  • In the US, 1.2 million abortions occured in 2008.

    • Of these, approximately 10% took place after 13 weeks, with more than half occurring between 13 and 15 weeks. 

    • Only 1.3% of abortions are performed at or after 21 weeks gestation.

  • There are varying state-level statutes that may limit the gestational age for obtaining an abortion, or the type of abortion treatment that can be offered.

  • The Guttmacher Institute maintains an overview of abortion laws by state. Some highlights from them:

    • 43 states have gestational age limits on when abortion can be performed. These range from 20 weeks to viability, with some statutes currently being challenged in court that could restrict access as early as 6-15 weeks.

    • 21 states prohibit “partial-birth” abortions, which is a misnomer that we will explain momentarily.

      • 2 states have standing bans on standard dilation and evacuation (Mississippi and West Virginia), with an additional 9 having some enjoinment on enforcement of a ban on D&E. 

    • 26 states require waiting periods between counseling and a procedure. 18 states require specific counseling which may include false or misleading information on:

      • Link between breast cancer and abortion (5 states).

      • The ability of a fetus to feel pain (13 states).

      • Long-term mental health consequences of abortion (8 states).

Methods of 2nd Trimester Abortion

Dilation and Evacuation

  • Use of medication or mechanical techniques to dilate the cervix, followed by the use of grasping forceps to remove the fetus.

  • Most commonly achieved with osmotic dilators in combination with misoprostol for cervical ripening.

    • The success of cervical preparation at 18 weeks gestation and above may be improved with the use of mifepristone the night prior to the procedure in combination with osmotic dilators.

      • However mifepristone may also increase risk of pregnancy expulsion prior to the procedure, particularly if misoprostol is subsequently used for further dilation.

  • A variant of this technique is known by a variety of names such as “dilation and extraction” or “intact D&E,” in which further dilation is achieved which allows for removal of an intact fetus except for possible calvarial decompression. 

    • This has been labeled in some publications as partial-birth abortion and may be restricted to some degree in a number of jurisdictions. 

    • In order to avoid consequences associated with these laws, some experts advise preoperative feticidal injection with KCl or digoxin. 

Medical or Induction Abortion

  • Induction may also be used to achieve abortion, however this is less-cost effective, takes more time, and is more associated with complications.

  • Generally, this is achieved through similar techniques for cervical ripening to labor induction -- mechanical dilators or balloon catheters, misoprostol, and oxytocin. 

    • The most efficacious medical management is mifepristone administered 24-48 hours prior to misoprostol initiation, based on RCT evidence.

    • Osmotic dilators do not necessarily add benefit to misoprostol in this setting. 

  • Preoperative feticidal injection does not shorten the duration of induction, but may be used if preferable to the woman or provider to avoid transient fetal survival after expulsion. 

  • ACOG lists three primary techniques for medication abortion in the second trimester; ACOG and SFP note that the mife-miso regimen is the most efficacious for 2nd trimester induction abortion:

Hysterotomy or Hysterectomy

  • Abdominal surgery is rarely indicated for second-trimester abortion, but is occasionally indicated in the event other procedures fail or are contraindicated. 

  • A prior cesarean or uterine scar is not an indication for hysterotomy for abortion, or for the avoidance of misoprostol, at least up until about 28 weeks gestation.

    • Retrospective cohort studies have demonstrated an insignificantly increased risk of uterine rupture for women with one prior cesarean delivery around 0.28%, versus rupture risk for unscarred uteri around 0.04%.

      • There is insufficient data to guide management on women with 2+ CDs. 

    • However, this remains well below the established acceptable risk threshold with trial of labor after cesarean at term without misoprostol use (rupture risk for 1 prior CD at 0.5-0.7%). 

      • The risk of rupture is suspected to increase with misoprostol use at or after 28 weeks, based on TOLAC data.

Complications and Other Situations

  • Mortality is 0.6 / 100k legal, induced abortions, with that rate being tied to gestational age at the time of abortion.

    • At 21 weeks gestation or greater, the rate of mortality rises to 8.9 / 100k procedures.

    • Maternal mortality for live birth is 17.6 / 100k live births in USA (or double that for 21+wk abortion, by comparison).

  • Postabortion hemorrhage is defined as “blood loss > 500cc and/or bleeding requiring a clinical response such as transfusion or hospital admission.”

    • Rates of transfusion range from 0.1 - 0.7%, with higher rates seen for medical 2nd trimester abortion. 

    • Management is similar to hemorrhage after term vaginal delivery, ruling out retained products and uterine atony as primary causes.

      • Cervical laceration, uterine rupture, and abnormal placentation are also rarer but important concerns, particularly in more advanced gestational age and in women with prior cesarean delivery. 

  • Postabortion infection is uncommon, occurring in 0.1-4% of 2nd trimester abortions.

    • Antibiotic prophylaxis is indicated prior to dilation and evacuation.

      • SFP recommends 200mg doxycycline preoperatively.

      • The ACOG PB recommends use of 100mg doxycycline preoperatively and 200mg postoperatively

      • RCT methodologies on antibiotic use support solely preoperative antibiotic use as sufficient. 

  • Postabortion contraception placement in the form of IUDs additionally does not increase infection risk, but expulsion rates may be higher after abortion than with interval placement.

  • Reversible contraception of almost any kind (no diaphragms or cervical caps) can be initiated immediately post-abortion, and ovulation can resume as soon as 21 days post-procedure.