ABORTION
MEDICAL BACKGROUND
There are two types of abortions, medical abortions and surgical abortions. In medical abortions, the pregnancy is terminated with a set of medications, which are prescribed by a healthcare provider and which cause the embryo to disconnect from the uterine lining and be transported out of the body via the vagina (usually in a bleed resembling a stronger menstrual bleed). In surgical abortions, the embryo is removed from the uterus in a small surgical procedure, which can be done under general or local anesthesia. Aspiration abortions are a type of surgical abortion in which a small suctioning tube is inserted into the uterus vaginally to empty its contents. There are also dilation and evacuation abortions (another type of surgical abortion), for cases in which the pregnancy is further progressed, in which the cervix is relaxed (dilated) and surgical instruments are inserted into the uterus to empty it under ultrasound guidance. Which type of abortion is the better option depends on personal preference and each individual case, including questions such as how far along the pregnancy is, and whether there are any counter-indications to medical abortion, such as blood clotting, bleeding or other cardiovascular disorders. After abortion (whether medical or surgical), some bleeding and cramping is normal. Medical attention should be sought if bleeding is abnormally high. The risk of infection is very low. Abortion typically does not affect the ability to have a successful pregnancy at a later point, if desired. The success of an abortion can be confirmed with an at-home urine pregnancy test, a blood test or ultrasound.
Medical Abortion
A medical abortion is the termination of a pregnancy with prescription medicines. Specifically, these include two different medications. Mifepristone is a selective progesterone antagonist, which competitively binds to and thereby blocks progesterone receptors in the endometrium (uterine lining). As a result, the receptors can no longer bind to progesterone itself (because they are already occupied by mifepristone), causing the endometrium to become thinner until it can no longer hold the implanted embryo. At this point (usually 24-72 hours after mifepristone), a second medication is given, misoprostol (a synthetic prostaglandin analogue). Misoprostol attaches to prostaglandin receptors in the smooth muscle of the endometrium, thereby increasing the frequency and strength of muscle contractions. This causes the embryo to be expelled from the uterus (usually in a bleeding resembling a stronger menstrual bleed). While mifepristone is usually given orally, misoprostol tablets can be taken orally or vaginally (which may increase their efficiency).
Medical abortions are possible in pregnancies that are not very far along (usually 9 weeks or less). Moreover, there are certain counter-indications to medical abortions, including hemorrhagic (bleeding), thrombotic (clotting) or other cardiovascular disorders, having an IUD, a drug allergy, or some other chronic disorders. Medical abortions are about 95% effective. This means that in about 5% of cases, a medical abortion may not actually successfully terminate the pregnancy, thereby requiring further abortion (usually in the form of a surgical aspiration procedure).
Surgical Abortion
Surgical (aspiration) abortion is the removal of uterine contents with a suctioning device inserted vaginally. During this procedure, the cervix (the small passage dividing vagina and uterus) is accessed via the vagina, numbed with a topical and slowly dilated (relaxed, so it opens and becomes wider, improving access to the uterus). A small tube connected to a suctioning device is then inserted into the uterus (through the vagina and cervix) and the contents of the uterus are cleared with this device (sucked away). This type of abortion can usually be completed in one session under local anesthesia, and it is available for pregnancies up to 14 weeks of gestation.
​
Surgical (dilation and evacuation) abortion is the removal of the fetus from the uterus with surgical instruments (such as a curette, a small spoon-shaped instrument designed for scraping away tissue) and sometimes also suctioning. This procedure is typically done in pregnancies that are further along (15 to 23 weeks of gestation), over a period of 2-3 days (but without overnight hospital stay). On the first day, a counseling session is held with a doctor at the abortion center and sometimes also a psychologist. During this session, there is room for questions, and issues such as the timing of the procedure, possible medical risks and psychological consequences are discussed. On the second day (the pre-operative appointment), medication is applied to the cervix to start dilation (relaxation and opening of the cervix). If needed, thin dilation sticks (Laminaria, made from seaweed, or Dilapan, made synthetically) are inserted, which slowly absorb moisture and increase in diameter over the next hours to help with and maintain dilation. On the third day (the operative appointment), the uterus is accessed via the dilated cervix, and uterine contents are removed with surgical instruments and suctioning under ultrasound guidance. This procedure is usually performed under general anesthesia. It is believed that no more than 1% of all abortions in the US are later in pregnancy dilation and evacuation abortions.
​
Before, during and after each surgical procedure, antibiotics and pain medications are typically prescribed. If desired, after the removal of the fetal tissue (in the same procedure) an intra-uterine device (IUD) can be inserted for contraceptive purposes.
