Abortion Complications

Excerpt

Elective abortion is a common medical procedure in the United States and worldwide. Around 1 million legal abortions are performed in the United States every year, with over 90% occurring in the first trimester. When performed according to current guidelines, abortion is approximately 14 times safer than childbirth. However, complications can and do occur. To understand abortion complications and their management, it is important to outline how elective abortions are performed.

Elective abortions can be performed in 2 ways—surgically and medically. Surgical abortions involve the evacuation of the products of conception through a dilated cervix. In contrast, medical abortions use a combination of mifepristone and misoprostol. In the United States, medical abortions are typically offered up to 70 days (10 weeks) of gestation due to reduced efficacy and higher complication rates beyond that point. In contrast, procedural abortions are effective at any gestational age.

Patients undergoing procedural abortions typically receive several medications to optimize safety and comfort, including analgesia, conscious sedation, and, depending on the gestational age, medications and osmotic dilators to soften the cervix. Following the procedure, which is typically vacuum aspiration with or without dilation and evacuation, the clinician inspects the retrieved material to confirm completion. In the case that fetal tissue is not visible on manual inspection (a common occurrence for abortions performed at very early gestations), quantitative serum beta-human chorionic gonadotropin (β-hCG) levels are measured at baseline and again several days later to rule out ongoing pregnancy, including ectopic pregnancy. Patients rarely require a scheduled follow-up visit after a procedural abortion, and typically experience cramping and bleeding similar to a normal menses that tapers down over 1 to 3 weeks.

For first-trimester medical abortion, the most common regimen is oral mifepristone followed 24 hours later by misoprostol, which may be administered vaginally, sublingually, or buccally. Mifepristone is a progesterone receptor blocker that enhances the efficacy of misoprostol, a synthetic prostaglandin that induces uterine contractions, softens the cervix, and facilitates the expulsion of the pregnancy within 8 hours of administration. Analgesics and antiemetics, such as ibuprofen and ondansetron, are often administered prophylactically in anticipation of the predictably strong cramping, moderate to heavy bleeding, and nausea that occur during 1 to 2 hours in which the pregnancy is expelled.

Similar to procedural abortions, medical abortions do not require routine follow-up unless serial β-hCG values are needed to confirm completion. Once the pregnancy is expelled, patients can expect cramping and bleeding similar in volume to normal menses, which tapers over 1 to 4 weeks.

Over the past 2 decades, medical abortions have seen a general trend toward fewer diagnostic tests and fewer (or no) required clinic visits. Telehealth abortions are safe, effective, provide better access to care, and are supported by current guidelines. Nevertheless, clinicians need to recognize that telehealth abortions are initiated without a baseline ultrasound. As a result, patients presenting with complications may require closer evaluation for conditions such as ectopic pregnancy or gestational age significantly exceeding estimates based on the reported last menstrual period.