**Medical and Surgical Induced Abortion**

Dennis G. Chambers

*Queen Elizabeth Hospital Pregnancy Advisory Centre, Adelaide, Australia* 

#### **1. Introduction**

100 From Preconception to Postpartum

Zeimet AG, Offner FA, Muller-Holzner E. etal. Peritoneum and tissues of the female

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reproductive tract as physiological sources of Ca-125. Tumor boil 1998 ;19:275-

reproductive tract and in serum during the normal menstrual cycle. Fert.Steril

No method of contraception is 100% effective; over half the women seeking an abortion are using contraception (Jones et al., 2002). It has been estimated that 42 million abortions are carried out every year, and half of these are illegal and unsafe (Sedgh et al., 2007). A proportion of women of all backgrounds with an unintended pregnancy are going to seek an abortion, legal or illegal, irrespective of the risks involved (Rosenfield, 1994) . Unplanned pregnancies are a problem that faces all societies; the Guttmacher Institute in New York determined that 49% of all pregnancies occurring in the USA in 1994 were unintended, 54% of these ending in abortion, and 48% of women aged 15-44 had had at least one unintended pregnancy at some point in their lives (Henshaw, 1998). The United Nations estimated that in 2008 of the 208 million pregnancies worldwide 41% were unintended (Singh et al., 2010). The Guttmacher Institute estimates that 30% of American women will have an abortion by the age of 45 (Jones & Kavanagh, 2011).

Access to abortion varies around the world from completely free access in some developed countries to total prohibition in some undeveloped countries. In developing countries there is often a lack of training and equipment that leads to termination of pregnancies by the outdated procedure of sharp curettage, with consequent higher injury and complication rates (Henshaw, 1990). Rehan, (2011) states that the treatment of unsafe abortion complications consumes a large portion of O&G hospital budgets in developing countries. Shah & Ahman (2010) reported estimates from the World Health Organisation that there were 21.6 million unsafe abortions worldwide in 2008. Rasch (2011) in an overview found that globally an estimated 66,500 women die every year as a result of unsafe abortions, and in Sub-Saharan African states unsafe abortion rates are 18-39 per 1,000 women. Srinil (2011) surveyed complication rates in 170 women treated for unsafe abortion and found incidences of haemorrhage requiring blood transfusion 66.6%, shock 63%, acute renal failure 22.2%, sepsis with disseminated intravascular coagulation 7.4%, and 2 deaths. Shaw (2011) highlighted the dilemma facing many Muslim women because of the fact that there was little knowledge or open discussion of the view that Islam permits the termination of pregnancy for serious abnormality within 120 days of conception.

Where women have no access to legal abortion self administration of misoprostol commonly occurs with women accessing misoprostol from a pharmacy or through the internet. A Google search of "buy mifepristone and/or misoprostol online" produces over 2,000 hits. Before 1970 when the legalisation of abortion began to spread around the world menstrual extraction by manual vacuum aspiration was used to circumvent abortion prohibition (Potts

Medical and Surgical Induced Abortion 103

at the level of the progesterone receptor being a competitive progesterone antagonist, and in combination with a prostaglandin is effective for medical abortion at all gestations (Ashok et al., 2002). The effects of mifepristone on the pregnant uterus are induced contractility, decidual necrosis with bleeding (Garfield et al., 1988), and cervical softening. Oral mifepristone achieves peak serum concentrations in pregnant women in 2 hours, with a half life of 24-29 hours (Heikinheimo, 1989). Contraindications to the use of mifepristone are adrenal failure and hereditary porphyria. Misoprostol is a synthetic prostaglandin E1 analog which regulates various immunologic cascades (Davies et al., 2001). It is a potent uterotonic drug, but its use in obstetrics and gynaecology is in all countries apart from France an offlabel use as it is only marketed for the prevention and treatment of peptic ulcer disease. It has been used widely in obstetrics and gynaecology practice because of its effectiveness, low cost, stability in light and hot climate conditions, and ease of administration compared with its licensed counterparts dinoprostone and gemeprost (Song, 2000). Misoprostol is marketed as a 200 mcg tablet that is rapidly absorbed by the vaginal, rectal, oral, sublingual and buccal routes. The sublingual route results in the highest serum peak concentration levels and the highest bioavailability; the vaginal route has the lowest peak concentrations, but the longest duration of peak levels (Tang et al., 2002; 2009). Nevertheless measures of uterine

contractility have shown similar effects for both routes (Tang et al., 2007).

mild 3.8%, moderate 0.2%, severe 0% (Fig. 2).

**2.2 Preparation for abortion** 

Misoprostol has uterotonic and cervical priming actions; its advantage over other prostaglandins is that it is cheap, can be administered through any mucosal surface, can be used by asthmatics, and can be stored at room temperature for years. Misoprostol is a very safe and well tolerated drug. Pre-clinical toxicological studies indicate a safety margin of at least 500-1000 fold between lethal doses in animals and therapeutic doses in humans (Kotsonis et al., 1985). The misoprostol 200 mcg tablet is tolerated even in relatively high dosage; attempted suicide with high single dosage has failed with 30 tablets but succeeded with 60 tablets (Henriques et al., 2007). No clinically significant haematological, endocrine, biochemical, immunological, respiratory, ophthalmic, platelet, or cardiovascular effects have been found with misoprostol; diarrhoea is the major adverse reaction that has been reported consistently with misoprostol, but it is usually mild and self-limiting; nausea and vomiting may also occur and will resolve in 2-6 hours; fever and chills are common with high doses (Tang et al., 2007). Chambers et al., (2009) reported that in 1,000 women taking one misoprostol 200 mcg tablet orally three hours before suction termination of pregnancy the side effects were cramps: mild 52.2%, moderate 4%, severe 0.7%; nausea: mild 28.3%, moderate 4.9%, severe 1.4%; bleeding mild 8.6%, moderate 1.7%, severe 0.1%; diarrhoea:

A consultation requirement is the completion of a health check questionnaire by the woman of her present and past medical and surgical history including allergies. A health worker should then interview the woman alone, without the presence of her partner or friends, to determine that her decision to terminate her pregnancy is her own and that she is not being unduly influenced by others. If the health worker feels a woman has not made a clear decision she should be offered an appointment with a counsellor for supportive decision making counselling to assist her to clarify her ambivalence. Specialised genetic counselling should be offered to all women seeking termination of pregnancy (TOP) for foetal anomaly.

et al., 1977). Menstrual regulation continued to be used in government funded clinics in some developing countries where abortion has never been legalised because it occurs technically without verification of the presence of a pregnancy (Dixon-Mueller, 1988). A report on the menstrual regulation policy in Bangladesh states that the provision of menstrual regulation averts unsafe abortion and associated maternal morbidity and mortality, and on a per capita basis, saves scarce health system resources (Johnson et al., 2010).

Son preference and sex-selective abortion is another major problem found in some Asian countries. Zhou et al., (2011) report that in China the sex ratio at birth is 120 male births to 100 females. Jha et al., (2011) estimate that in China selective abortion of girls totalled about 4.2 -12.1 million per year from 1980-2010.

Women worldwide want to control the timing and number of their children, not just for personal and family reasons, but in the interest of being able to provide adequately for a child at the point in time in question. Whilst first trimester abortion is accessible to some degree in most western countries, access to second trimester abortion tends to be very restricted. This is despite there being a constant proportion over the years of approximately 12% of legal abortions occurring after 12 weeks gestation (Gamble et al., 2008), most of these being for psycho-social reasons, and a small but increasing proportion being for suspected or confirmed foetal anomaly. Teenagers in all countries seek abortions later; approximately 30% of abortions in girls under 15 years of age take place in the second trimester (Jones et al., 2002}. This delay is due to teenagers having little or no experience at recognising pregnancy symptoms, a lack of general knowledge, and the problems associated with emotional immaturity. At any age delay in seeking an abortion may be due to periods normally being irregular, bleeding during pregnancy being mistaken for periods, a past history of infertility, menopausal symptoms, having been conscientiously using contraception, ambivalence due to conflicting beliefs, sudden financial stress, breakdown of a relationship, domestic violence, disorganised or chaotic life associated with substance abuse, delaying by medical attendants with mis-diagnosis of the pregnancy, or obstruction by health advisers with anti-abortion views.
