|
Abortion can best be defined as the expulsion
of the products of conception, i.e. a fetus or embryo with
associated placenta and membranes, prior to viability. There
is no uniform agreement as to the point in pregnancy at
which a fetus ought to be considered viable or capable of
living outside the uterus. Generally, it is felt to be between
24 and 26 weeks from a standard last menstrual period, even
though survival does not become a probability until 28 weeks.
If the products of conception are expelled spontaneously,
as is frequently the case in nature, the process is referred
to as a spontaneous abortion. When the pregnancy is surgically
removed for the purpose of terminating a pregnancy, the
process is known as an induced abortion. Induced abortion
is the subject of this discussion.
In most states, including the state of Florida, a qualified
physician may electively induce an abortion until viability.
Beyond that stage, abortion is generally permitted only
for severe fetal abnormality or to preserve the life of
the mother. Because most women recognize pregnancy and make
their decision for abortion early, most pregnancy terminations
are performed in the first trimester, i.e. at 12 weeks or
less of pregnancy.
Luteal Phase Pregnancy Termination
"Morning After Pill" (Termination prior to a Missed
Period)
Women are frequently aware of pregnancy and seek termination
prior to missing a menstrual period. This stage of pregnancy
is known as the "Luteal phase" which refers to the
portion of the cycle that follows ovulation or release of
an egg; and precedes menses. This is generally the second
two weeks of the menstrual cycle.
An egg is generally fertilized within 24 hours of release.
This occurs roughly 2 weeks after the onset of the menstrual
period. The use of the "Morning After Pill” a high
dose of oral contraceptives, will generally prevent pregnancy
if used within 48 hours of fertilization.
The fertilized egg develops as a free floating cluster of
growing cells for the next week then implants in the cavity
of the uterus. At this stage, a trans-vaginal ultrasound test
will usually reveal the pregnancy as a fluid filled sac. Once
this sac is visible (one week after conception and one week
before a missed period) we feel it is appropriate to perform
pregnancy termination and have been doing so since 1995.
The advantage is avoiding the anxiety of waiting until 6-7
weeks of pregnancy as was previously customary. This is particularly
important if severe pregnancy symptoms are present. In addition,
less cervical dilation is required. The disadvantage is that
confirmation of successful termination may require follow-up
pregnancy testing because visual inspection of tissue may
not be adequate due to the small size.
First
Trimester Pregnancy Termination
With few exceptions, surgically (as opposed to medically)
induced abortions are performed by a procedure generally known
as Dilation and Aspiration (“D&A”). Typically,
this procedure is performed in a physicians office or abortion
clinic. It may also be performed in an out patient surgical
center or hospital.
The procedure may safely be performed using local anesthesia
with reasonable comfort, but in recent years it has become
common practice to provide various levels of sedation or "twilight
sleep" using intravenous drugs in the category of narcotics
and tranquilizers. Once a satisfactory level of sedation and
local anesthesia is achieved, the cervix or neck of the uterus
(womb) must be opened to remove the contents of the uterus.
In the first 12 weeks of pregnancy this is generally accomplished
by sequentially inserting tapered rods of increasing width
called "dilators". Usually, the cervix needs to
be opened no more than 1/4" - 1/2" in the first
trimester. This can be done with anywhere between 1 and 8
dilator insertions, depending on the stage of pregnancy and
the resistance of the individual cervix.
Once the cervix has been adequately dilated, the products
of conception are removed by inserting a hollow plastic tube
called a "vacurette" and applying negative pressure
(suction/ vacuum). Generally, the vacurette is moved in a
series of in and out strokes or is rotated to enhance the
traction forces at the tip of the vacurette. This is sometimes
followed by curetting (scraping) the walls of the uterus to
ensure that no tissues are remaining that might cause subsequent
problems.
It is appropriate immediately following surgery to examine
the tissues to assure compatibility between what was removed
and what was expected based on pre-oprerative evaluation.
D&A in reasonably experienced hands is one of the safest
surgical procedures performed today, the mortality being 80
times less than child birth which is quite low. The most common
complications involve excessive bleeding and infection that
sometimes require recuretting (repeat suctioning) of the uterus.
Infrequently, D&A may result in injury to the uterus or
surrounding internal organs, e.g. intestines, bladder or major
blood vessels which requires opening the abdomen to surgically
repair. The aftermath of D&A typically consists of bleeding
which is similar in degree to a normal menstrual period and
menstrual-like cramps which are similar in severity to a "bad
menstrual period". These symptoms tend to subside rapidly
but persist to some degree for as long as 2 weeks.
Emotional reactions to surgery are common. Mild depression
associated with low hormone levels and a feeling of loss is
usually brief. The emotionally healthy individual will generally
rationalize the situation as they do with other life stresses
and quickly put their experience in perspective. On rare occasion,
counseling or drug therapy may be required. Long range concerns
usually center about future fertility. If there have been
serious complications from surgery such as severe infection
or excessive bleeding that required vigorous scraping, fertility
may be affected.
Obviously, complications, which result in hysterectomy, will
result in sterility. These problems are rare. The issue of
an increased risk of breast cancer has received wide publicity.
This concern has been essentially put to rest by studies which
rather than relying on an individual recollection, reviewed
patient records.
Abortion performed in the middle months of pregnancy, i.e.
13-24 weeks is a significantly different procedure from the
first trimester. Although there are similarities, as pregnancy
progresses through the second trimester, the procedures used
require greater time, skill and entail somewhat greater risk,
though still significantly lower than carrying a pregnancy
to term.
The essential difference is that the cervix must be dilated
to increasing diameters with increasing stage of pregnancy.
The extent to which the cervix can be safely dilated with
dilators varies, generally being easier in women who have
delivered children previously. Most experienced physicians
will avoid the use of mechanical dilators beyond the 14th
week of pregnancy. Some will avoid them after the 10th week.
As a general rule, the method of choice for dilating the
cervix beyond the 12th week is osmotic dilators.
These are basically stalks of material that absorb water
and expand once placed inside the cervix. Once they have
been inserted they are left in place anywhere from six hours
to overnight. The result is that the cervix is both dilated
and softened with little risk of the damage that might occur
if wide dilation were to be attempted with mechanical dilators.
In more advanced stages of pregnancy, varying from 20-23
weeks and beyond, dilatation is generally accomplished in
a serial fashion. This involves the insertion of a number
of osmotic dilators for 6 or more hours to dilate the cervix
adequately to insert 10 to 20 or more osmotic dilators followed,
usually the next day with the Evacuation ("E")
of D&E of the uterus. This stage of surgery, as in the
first trimester procedure is usually performed under sedation
combined with local anesthesia. The fetus and placenta are
generally removed with forceps, usually followed with suction
curettage to remove debris. Sharp curettage may or may not
be performed as a final step.
An alternative to this procedure in the mid-trimester and
beyond is induction of labor. There are a variety of procedures
available to accomplish this end, but in general they all
involve stimulating the uterus to contract much the same
way as it does in a spontaneous term labor. This approach
would seem at first to be ideal, since it may involve no
instrumentation and is totally natural.
In reality, however, the uterus is frequently very much
disinclined to labor at these early stages, and even when
it does, the cervix may be very disinclined to dilate. There
are a variety of options for "induction".
The technique current in commonest use involves a group
of drugs called Prostaglandins. These are administered either
in the cavity of the uterus by injection or in the vagina
as a gel or suppository. These may be used in conjunction
with osmotic dilators as well.
There is some controversy as to which of these techniques
is the safest. Most available data suggest that prior to
20 weeks gestation, D&E offers greater safety and efficacy.
Beyond that stage, there is probably inadequate data to
prove either is superior. We believe that experience
is the primary determinant of safety in the later stage
procedures. In experienced hands, we believe that D&E
is preferable. It is more predictable and entails less serious
risk. The final alternative is "hysterotomy" which
is basically an early cesarean section.
This procedure is best reserved for situations where emptying
the uterus by the vaginal route is not possible. It has the
disadvantages of greater risk, greater pain, greater recuperation,
and higher cost and perhaps of greatest significance, it precludes
future vaginal birth.
Non-Surgical
(natural) Abortion with Mifepristone Mifepristone is a synthetic hormone originally developed
in Europe (the French abortion pill). It was used there
for many years where it provided to be safe and effective
alternative to surgical abortion. After years of delay because
of political controversy, it was approved by the FDA for
use in the United States in 2000. We have been using Mifepristone
since then with very satisfactory results. It has been our
experience, that up to the 8th week of pregnancy, Mifepristone
is a as safe and effective as surgical abortion. Although
it involves a longer process and increased pain, Mifepristone
is an important option for women whose priority is privacy,
autonomy or the comforts of their own home.
At BSSI, the process involves a preliminary screening by
Dr. Benjamin which includes pelvic ultrasound to insure
that the stage and location of the pregnancy are appropriate
for Mifepristone. If there are no medical issues, we administer
the Mifepristone table at the time of the initial visit.
We provide a second drug, Cytotec, as well as pain medication
of choice with instructions for use at home. We include
a 2 week follow-up visit to insure that the procedure is
complete.
How It Works
Mifepristone, once absorbed into they system, blocks the
"hormone of pregnancy", progesterone. This is
the hormone that maintains the lining membrane of the uterus.
Once deprived progesterone, the membrane disintegrates and
the pregnancy detaches. If no further action is taken, the
pregnancy will naturally miscarry. This may not occur, however,
for many days. To hasten the process, we have chosen to
administer Cytotec, a drug that is well established as a
safe and effective method of contracting the uterus. When
taken 6 hours after Mifepristone, it rapidly and reliably
causes the uterus to contract resulting in miscarriage.
Results
In our experience, Mifepristone followed by Cytotec has
been approximately 99% effective in terminating pregnancy
when used between the 4th and 8thf week of pregnancy. In
the 1% of failure to terminate the pregnancy, surgical termination
is strongly recommended and is provided at no additional
charge. An additional 1% of patients will require D&C
to remove tissue not completely expelled in the process
of miscarriage. In general, we have found a high percentage
of satisfaction in well selected patients who choose Mifepristone.
|
