Induced Abortion & Pregnancy Options Counseling
Counsel neutrally, exclude ectopic, pick the method, and spot the rare killer
Options counseling and evaluation
Nondirective counseling. A patient with an unintended pregnancy should hear all three options presented neutrally and accurately: continuing the pregnancy and parenting, continuing and placing the infant for adoption, or abortion. Answer her questions, screen privately for coercion and intimate partner violence, and support the decision she makes with timely referral.
Before any method. Confirm the pregnancy, estimate gestational age from the last menstrual period with or without ultrasound, and exclude ectopic pregnancy. Ultrasound is needed when dating is uncertain or when bleeding, pain, or risk factors (prior ectopic, PID, tubal surgery) are present. Check Rh type and, if anemia is suspected, hemoglobin.
Medication abortion
Regimen and mechanism. Mifepristone 200 mg orally blocks the progesterone receptor, causing decidual breakdown, cervical softening, and increased uterine sensitivity to prostaglandins. Misoprostol 800 μg buccally, taken 24–48 hours later, is a prostaglandin E1 analog that produces contractions and expulsion. The regimen is used up to 10–11 weeks (70–77 days) and completes about 95–98% of abortions. Cramping and bleeding heavier than a period follow within hours of misoprostol, often with transient nausea, diarrhea, or chills.
Contraindications. Confirmed or suspected ectopic pregnancy; an IUD in place (remove it first); chronic adrenal failure or long-term systemic corticosteroids, because mifepristone also blocks glucocorticoid receptors; inherited porphyria; a bleeding disorder or anticoagulant therapy; severe anemia; and allergy to either drug.
Follow-up. Completion is confirmed by serial serum hCG (a fall of at least 80% about 1 week later), ultrasound, or symptom review with a urine pregnancy test at about 4 weeks, since residual hCG keeps sensitive urine tests positive for several weeks. An ongoing pregnancy is managed with vacuum aspiration (most definitive) or a repeat misoprostol dose; retained tissue with bleeding is treated with repeat misoprostol or aspiration.
Misoprostol is teratogenic (Möbius sequence, limb defects), so a pregnancy that continues after a failed regimen is usually completed rather than carried.
Procedural abortion
Vacuum aspiration. After cervical dilation, usually under a paracervical block, manual or electric suction empties the uterus in minutes, with more than 99% effectiveness throughout the first trimester. Prophylactic antibiotics (typically doxycycline) reduce postabortal infection. The aspirate is examined for chorionic villi or a gestational sac; if none is found, ectopic pregnancy must be excluded with serial hCG and ultrasound.
Second trimester. Dilation and evacuation (D&E), preceded by cervical preparation with osmotic dilators, misoprostol, or mifepristone, is the most common method in the US. Induction with mifepristone followed by repeated misoprostol doses is the alternative; it takes longer and resembles labor.
| Feature | Medication | Vacuum aspiration | D&E |
|---|---|---|---|
| Timing | Up to 10–11 weeks | First trimester | Second trimester |
| Efficacy | About 95–98% | More than 99% | Very high |
| Setting | Home; bleeding over hours to days | Clinic; minutes | Clinic or hospital after cervical preparation |
| Key caveats | Remove IUD; exclude ectopic; follow-up needed | Antibiotic prophylaxis; inspect tissue | Perforation risk rises with gestation |
Complications
Common problems. Serious complications are uncommon, and legal abortion carries far lower risk than childbirth. Hemorrhage arises from atony, retained products, cervical laceration, or perforation. Endometritis presents with fever, uterine tenderness, and foul discharge and is treated with broad-spectrum antibiotics plus evacuation of retained tissue. Uterine perforation is more likely at later gestations and with difficult dilation.
Clostridium sordellii toxic shock. This rare, frequently fatal infection appears days after medication abortion, childbirth, or miscarriage. Its exotoxin causes capillary leak, so patients have little or no fever, tachycardia, refractory hypotension, edema, a leukemoid reaction, and hemoconcentration with a rising hematocrit. Treatment is aggressive resuscitation, broad-spectrum antibiotics, and often hysterectomy.
Asherman syndrome. Intrauterine adhesions follow instrumentation, especially with infection or repeated curettage, causing hypomenorrhea or amenorrhea, infertility, and recurrent loss. Hormone levels are normal and an estrogen–progestin challenge produces no bleeding. Hysteroscopy both diagnoses and treats the adhesions.
Aftercare, ethics, and law
Contraception. Ovulation can return within about 2 weeks, so any method can start immediately: an IUD at the aspiration procedure, an implant or injectable on the day of mifepristone, and an IUD after medication abortion once expulsion is confirmed.
Rh immune globulin. Rh(D)-negative patients receive anti-D immune globulin at 12 weeks or later; current guidance allows it to be omitted before 12 weeks.
Minors. Parental consent or notification requirements vary by jurisdiction, and many allow judicial bypass. Encourage, but do not force, involvement of a trusted adult, and protect confidentiality.
A clinician with a conscientious objection may decline to perform an abortion but must inform the patient, refer promptly, and still manage emergencies; refusal without referral or misleading counseling abandons the patient.