Abortion is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability.
An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy.
Abortion, when induced in the developed world in accordance with local law, is among the safest procedures in medicine.
However, unsafe abortions result in approximately 70,000 maternal deaths and 5 million hospital admissions per year globally.
An estimated 44 million abortions are performed globally each year, with slightly under half of those performed unsafely.
The incidence of abortion has stabilized in recent years, having previously spent decades declining as access to family planning education and contraceptive services increased.
Forty percent of the world's women have access to induced abortions (within gestational limits).
Induced abortion has a long history and has been facilitated by various methods including herbal abortifacients, the use of sharpened tools, physical trauma, and other traditional methods.
Contemporary medicine utilizes medications and surgical procedures to induce abortion. The legality, prevalence, cultural and religious status of abortion vary substantially around the world.
Its legality can depend on specific conditions such as incest, rape, fetal defects, a high risk of disability, socioeconomic factors or the mother's health being at risk.
In many parts of the world there is prominent and divisive public controversy over the ethical and legal issues of abortion
A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses.
Specific procedures may also be selected due to legality, regional availability, and doctor or patient
preference.
Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; prevent harm to the woman's physical or mental health; terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.
An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons.
Confusion sometimes arises over the term "elective" because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not.
A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth".
When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".
Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.
Only 30 to 50% of conceptions progress past the first trimester. The vast majority of those that do not progress are lost before the woman is aware of the conception, and many pregnancies are lost before medical practitioners can detect an embryo.
Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman.
The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus, accounting for at least 50% of sampled early pregnancy losses.
Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus.
Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion.
A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.
The most common early first-trimester medical abortion regimens use mifepristone in combination with a prostaglandin analog (misoprostol or gemeprost) up to 9 weeks gestational age, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone.
Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone.
This regime is effective in the second trimester. In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue.
Early medical abortion regimens using mifepristone, followed 24–48 hours later by buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age. If medical abortion fails, surgical abortion must be used to complete the procedure.
Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain, France, Switzerland, and the Nordic countries. In the United States, the percentage of early medical abortions is far lower.
Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second-trimester abortions in Canada, most of Europe, China and India, in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.
Up to 15 weeks' gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion.
Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) uses an electric pump.
These techniques differ in the mechanism used to apply suction, in how early in pregnancy they can be used, and in whether cervical dilation is necessary.
MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation.
Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion.
Curettage refers to cleaning the walls of the uterus with a curette. The World Health Organization recommends this procedure, also called sharp curettage, only when MVA is unavailable.
From the 15th week of gestation until approximately the 26th, other techniques must be used. Dilation and evacuation (D&E) consists of opening the cervix of the uterus and emptying it using surgical instruments and suction.
Premature labor and delivery can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with hypertonic solutions containing saline or urea.
After the 16th week of gestation, abortions can also be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called "partial-birth abortion," which has been federally banned in the United States.
In the third trimester of pregnancy, abortion may be performed by IDX as described above, induction of labor, or by hysterotomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy.
First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require deep sedation or general anesthesia.
The use of herbs in such a manner can cause serious—even lethal—side effects, such as multiple organ failure, and is not recommended by physicians.
Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.
In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage.
One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld.
Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where surgical abortion is legal and available.
Legal abortions performed in the developed world are among the safest procedures in medicine.In the US, the risk of maternal death from abortion is 0.6 per 100,000 procedures, making abortion about 14 times safer than childbirth (8.8 maternal deaths per 100,000 live births).
The risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth through at least 21 weeks' gestation.
Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital.
Complications are rare and can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate.
Preventive antibiotics (such as doxycycline or metronidazole) are typically given before elective abortion, as they are believed to substantially reduce the risk of postoperative uterine infection.
Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen.
There is little difference in terms of safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 9 weeks gestation.
Medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion.
Some purported risks of abortion are promoted primarily by anti-abortion groups, but lack scientific support.
For example, the question of a link between induced abortion and breast cancer has been investigated extensively.
Major medical and scientific bodies (including the World Health Organization, the US National Cancer Institute, the American Cancer Society, the Royal College of Obstetricians and Gynaecologists and the American Congress of Obstetricians and Gynecologists) have concluded that abortion does not cause breast cancer, although such a link continues to be promoted by anti-abortion groups.
Similarly, current scientific evidence indicates that induced abortion does not cause mental-health problems.
The American Psychological Association has concluded that a single abortion is not a threat to women's mental health, and that women are no more likely to have mental-health problems after a first-trimester abortion than after carrying an unwanted pregnancy to term.
Abortions performed after the first trimester because of fetal abnormalities are not thought to cause mental-health problems.
Some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called "post-abortion syndrome", which is not recognized by any medical or psychological organization.
They may attempt to self-abort or rely on another person who does not have proper medical training or access to proper facilities.
This has a tendency to lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.
Unsafe abortions are a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries.
Unsafe abortion is believed to result in millions of injuries and approximately 68,000 deaths annually, accounting for 13% of all maternal deaths.
Groups such as the World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.
The legality of abortion is one of the main determinants of its safety. Countries with restrictive abortion laws have significantly higher rates of unsafe abortion (and similar overall abortion rates) compared to those where abortion is legal and available.
For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications.
with abortion-related deaths dropping by more than 90%. In addition, a lack of access to effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by up to 75% (from 20 million to 5 million annually) if modern family planning and maternal health services were readily available globally.
Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits, while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria.
While maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year.
Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide, though this varies by region.
Secondary infertility caused by an unsafe abortion affects an estimated 24 million women. The rate of unsafe abortions has increased from 44% to 49% between 1995 and 2008.
Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address this phenomenon.
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An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy.
Abortion, when induced in the developed world in accordance with local law, is among the safest procedures in medicine.
However, unsafe abortions result in approximately 70,000 maternal deaths and 5 million hospital admissions per year globally.
An estimated 44 million abortions are performed globally each year, with slightly under half of those performed unsafely.
The incidence of abortion has stabilized in recent years, having previously spent decades declining as access to family planning education and contraceptive services increased.
Forty percent of the world's women have access to induced abortions (within gestational limits).
Induced abortion has a long history and has been facilitated by various methods including herbal abortifacients, the use of sharpened tools, physical trauma, and other traditional methods.
Contemporary medicine utilizes medications and surgical procedures to induce abortion. The legality, prevalence, cultural and religious status of abortion vary substantially around the world.
Its legality can depend on specific conditions such as incest, rape, fetal defects, a high risk of disability, socioeconomic factors or the mother's health being at risk.
In many parts of the world there is prominent and divisive public controversy over the ethical and legal issues of abortion
Types
Induced
Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion. Most abortions result from unintended pregnancies.A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses.
Specific procedures may also be selected due to legality, regional availability, and doctor or patient
preference.
Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; prevent harm to the woman's physical or mental health; terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.
An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons.
Confusion sometimes arises over the term "elective" because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not.
Spontaneous
Spontaneous abortion, also known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation.A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth".
When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".
Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.
Only 30 to 50% of conceptions progress past the first trimester. The vast majority of those that do not progress are lost before the woman is aware of the conception, and many pregnancies are lost before medical practitioners can detect an embryo.
Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman.
The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus, accounting for at least 50% of sampled early pregnancy losses.
Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus.
Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion.
A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.
Methods
Medical
Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone in the 1980s.The most common early first-trimester medical abortion regimens use mifepristone in combination with a prostaglandin analog (misoprostol or gemeprost) up to 9 weeks gestational age, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone.
Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone.
This regime is effective in the second trimester. In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue.
Early medical abortion regimens using mifepristone, followed 24–48 hours later by buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age. If medical abortion fails, surgical abortion must be used to complete the procedure.
Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain, France, Switzerland, and the Nordic countries. In the United States, the percentage of early medical abortions is far lower.
Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second-trimester abortions in Canada, most of Europe, China and India, in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.
Surgical
1: Amniotic sac
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump
Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) uses an electric pump.
These techniques differ in the mechanism used to apply suction, in how early in pregnancy they can be used, and in whether cervical dilation is necessary.
MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation.
Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion.
Curettage refers to cleaning the walls of the uterus with a curette. The World Health Organization recommends this procedure, also called sharp curettage, only when MVA is unavailable.
From the 15th week of gestation until approximately the 26th, other techniques must be used. Dilation and evacuation (D&E) consists of opening the cervix of the uterus and emptying it using surgical instruments and suction.
Premature labor and delivery can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with hypertonic solutions containing saline or urea.
After the 16th week of gestation, abortions can also be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called "partial-birth abortion," which has been federally banned in the United States.
In the third trimester of pregnancy, abortion may be performed by IDX as described above, induction of labor, or by hysterotomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy.
First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require deep sedation or general anesthesia.
Other methods
Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine: tansy, pennyroyal, black cohosh, and the now-extinct silphium (see history of abortion).The use of herbs in such a manner can cause serious—even lethal—side effects, such as multiple organ failure, and is not recommended by physicians.
Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.
In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage.
One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld.
Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where surgical abortion is legal and available.
Safety
The health risks of abortion depend on whether the procedure is performed safely or unsafely. The World Health Organization defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities.Legal abortions performed in the developed world are among the safest procedures in medicine.In the US, the risk of maternal death from abortion is 0.6 per 100,000 procedures, making abortion about 14 times safer than childbirth (8.8 maternal deaths per 100,000 live births).
The risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth through at least 21 weeks' gestation.
Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital.
Complications are rare and can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate.
Preventive antibiotics (such as doxycycline or metronidazole) are typically given before elective abortion, as they are believed to substantially reduce the risk of postoperative uterine infection.
Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen.
There is little difference in terms of safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 9 weeks gestation.
Medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion.
Some purported risks of abortion are promoted primarily by anti-abortion groups, but lack scientific support.
For example, the question of a link between induced abortion and breast cancer has been investigated extensively.
Major medical and scientific bodies (including the World Health Organization, the US National Cancer Institute, the American Cancer Society, the Royal College of Obstetricians and Gynaecologists and the American Congress of Obstetricians and Gynecologists) have concluded that abortion does not cause breast cancer, although such a link continues to be promoted by anti-abortion groups.
Similarly, current scientific evidence indicates that induced abortion does not cause mental-health problems.
The American Psychological Association has concluded that a single abortion is not a threat to women's mental health, and that women are no more likely to have mental-health problems after a first-trimester abortion than after carrying an unwanted pregnancy to term.
Abortions performed after the first trimester because of fetal abnormalities are not thought to cause mental-health problems.
Some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called "post-abortion syndrome", which is not recognized by any medical or psychological organization.
Unsafe abortion
Women seeking to terminate their pregnancies sometimes resort to unsafe methods, particularly when access to legal abortion is restricted.They may attempt to self-abort or rely on another person who does not have proper medical training or access to proper facilities.
This has a tendency to lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.
Unsafe abortions are a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries.
Unsafe abortion is believed to result in millions of injuries and approximately 68,000 deaths annually, accounting for 13% of all maternal deaths.
Groups such as the World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.
The legality of abortion is one of the main determinants of its safety. Countries with restrictive abortion laws have significantly higher rates of unsafe abortion (and similar overall abortion rates) compared to those where abortion is legal and available.
For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications.
with abortion-related deaths dropping by more than 90%. In addition, a lack of access to effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by up to 75% (from 20 million to 5 million annually) if modern family planning and maternal health services were readily available globally.
Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits, while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria.
While maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year.
Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide, though this varies by region.
Secondary infertility caused by an unsafe abortion affects an estimated 24 million women. The rate of unsafe abortions has increased from 44% to 49% between 1995 and 2008.
Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address this phenomenon.
FOLLOW US ON FACEBOOK: http://www.facebook.com/PlaneHealth
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