**4. Postabortion care**

penicillin: *Clostridium perfringens* and *Clostridium sordellii*; group A streptococcus; and also

In addition to the complications of anesthesia or intravenous sedation, D&C may result in adhesions (Asherman's syndrome). Intrauterine adhesion increases the risks of future ectopic pregnancy, miscarriage, or abnormal placentation (placenta previa and accreta) [34]. The risk of preterm birth after induced abortion is higher than that in a first pregnancy or after a previous live birth. Surgical but not medical abortion appears to be associated with an increased risk of spontaneous preterm birth [34]. These data warrant caution in the use of surgical uterine evacuation and should encourage safer surgical techniques as well as medical methods [34, 35].

Whenever surgical abortion is difficult or unacceptable, medication abortion should be considered. Mifepristone (RU 486) is a 19-norsteroid that specifically blocks receptors for progesterone and glucosteroids. Acting as a competitive inhibitor of the progesterone receptor, mifepristone is used as a pretreatment 24–48 h before inducing first-trimester abortion with a prostaglandin analog. Misoprostol, a synthetic prostaglandin E1 analog, has been proven effective for pregnancy termination at various gestational ages, cervical ripening, labor induction in term pregnancies, and incomplete abortion treatment. The combination of a mifepristone and a prostaglandin derivative was the most effective regimen for medical pregnancy termination [36].

Mifepristone is approved by FDA for medical abortion up to 49 days of estimated gestational age. However, mifepristone is commonly used in combination with vaginal or buccal misoprostol at higher gestational ages based on studies demonstrating safety and efficacy up to 9 weeks [36]. Recent data support the use of mifepristone for outpatient abortion through 70 days of gestation, since similar safety and effectiveness as those used at 63 days of gestation have been demonstrated [37]. Mifepristone and misoprostol may also be used from 10 to 13 weeks [39]. This will require a setting whereby patients' condition can be monitored and a repeated dose of misoprostol administered given the potential risk of excessive bleeding at this later gestational age. Depending on the local regulations, the candidate setting could be a

The combined use of mifepristone and misoprostol for second-trimester termination has a shorter induction time and lower misoprostol dose compared with misoprostol alone [39]. Both sublingual and vaginal routes of misoprostol administration resulted in a shorter abortion duration than the oral route [40]. The differences in duration or side effects between sublingual and vaginal routes of misoprostol administration were not significant. However, sublingual administration may be preferred by patients over vaginal administration due to

It is effective and feasible to prevent unintended pregnancy with low-dose mifepristone combined with misoprostol before expected menstruation or menstruation regulation after missed period. The success rate of abortion for mifepristone-misoprostol regimen is 95–98%. [41], while 78–90% for misoprostol only [42]. Despite highly restrictive abortion laws in LAC, access

labor and delivery unit or gynecology inpatient department [37–39].

some toxin-producing strains of *E. coli* [32, 33].

*3.3.3.6. Anesthesia and late complications*

**3.4. Medical termination**

176 Family Planning

ease of use [39].

Postabortion care is part of the reproductive health care in women after induced abortions. Extreme urgent demand in LMICs is understandable given that, in most of them, induced abortion is either completely illegal or legal but with limited access by women who need it. In such settings, the only option for women wishing to end their pregnancies is to procure clandestine, usually unsafe abortions—with substantial negative consequences for themselves, their families, and their societies [44]. It has been shown that comprehensive family planning would reduce unintended pregnancies and therefore the incidence of unsafe abortions [45].

All women seeking an abortion should be offered a contraceptive method. Long-acting reversible contraceptives, such as the intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA), have been found to statistically significantly decrease abortion incidence [46]. IUDs placed immediately after an abortion lower the rate of repeat abortions from 34.6 per 1000 woman-years to 91.3 per 1000 woman-years in controls [47]. Immediate postabortal IUDs are safe and effective, although they have a slightly higher expulsion, ranging from 3 to 5% immediately after an abortion compared with 0–2.7% in interval groups [48]. However, at 6 months postabortion, IUD use is higher following immediate insertion compared to delayed insertion [49]. Women interested in progestin or combined hormonal contraceptives can be given a prescription before leaving the clinic to be started immediately after the procedure [50].
