There are two primary methods for early abortions: medical (drug-induced) abortions and surgical abortions. The choice depends on your preference, the length of time you have been pregnant, and the availability of medical abortion. The nearest Planned Parenthood site is the best source of information on what is available in your area.

A surgical abortion is similar to a D&C, with vacuum or suction aspiration of the contents of the uterus. Some physicians perform menstrual extractions, which also use vacuum or suction aspiration but take place very early in the pregnancy. Mifepristone, a drug originally used in Europe and Canada for medical abortions, has recently become available in this country. Medical abortion with methotrexate is a little-known procedure that uses a readily available drug to produce much the same results as mifepristone.

Menstrual Extraction

A menstrual extraction, sometimes also called a miniabortion or a minisuction, is a procedure for suctioning out the contents of the uterus without dilating the cervix. It was quite popular a number of years ago and was often performed by midwives.

Menstrual extractions, often done before a test has established the fact of pregnancy (between four and five weeks gestational age), must be performed when there is very little fetal tissue. Requesting this procedure, it seems to me, involves self-deception and denial, since the woman asking for menstrual extracting is seeking a way of terminating a possible pregnancy “without having an abortion.”

How is menstrual extraction performed?

Menstrual extractions are just like suction D&Cs performed slightly later in the pregnancy, except that there is no need to dilate the cervix. A thin tube, or cannula, maybe 3-4 mm wide (about as thick as a piece of spaghetti), is inserted through the cervix. The contents of the uterus are suctioned out with a small pump or a bulb syringe. The procedure takes only a few minutes and may not require any anesthesia.

What are its advantages and disadvantages?

The advantages are several: it is easy to perform and does not usually require anesthesia. It is very low risk and low cost. But it also has a high failure rate. Because the dividing egg is so small, it is easy to miss during the suction procedure.

Sherry, the girlfriend of a medical student I was teaching some years back, asked whether I would do a menstrual extraction for her. When I asked Sherry how long it had been since she had missed her period, she said that she was only a week late but she just “knew” she was pregnant and was very anxious to have an abortion.

This was early in my career and I agreed to do the procedure, though I explained that there was a risk I might not end the pregnancy. My concern was well founded. Three weeks later Sherry had to have a D&C, a repeat of an uncomfortable procedure.

Medical Abortion with Methotrexate

Methotrexate is a drug used for treating cancer, especially tumors of the placenta. Like other chemotherapeutic agents, methotrexate attacks cells that are dividing rapidly, which includes not only cancer cells but also the cells of the placenta.

Because it kills rapidly dividing cells and destroys the placenta, methotrexate terminates a pregnancy, whether it is in the uterus or in the fallopian tube. Methotrexate has also been used quite frequently in this country during the past five years to terminate ectopic pregnancies without surgery, and similar drugs have been used in China for many years for the same purpose. In addition, methotrexate is sometimes prescribed for treating psoriasis and rheumatoid arthritis.

How is methotrexate given for purposes of abortion?

This is a treatment that requires a doctor’s care and supervision. First, you are given a quantitative pregnancy test to measure the amount of human chorionic gonadotropin in your blood. When this baseline level is established, you are given methotrexate as an injection in the muscles of the arm or the buttocks. A week later, another quantitative blood test will show whether the amount of human chorionic gonadotropin is decreasing. If it is, then the placenta is degenerating and the fetus will miscarry. If not, a second shot can be given. Some physicians will follow up the methotrexate with a prostaglandin, which stimulates uterine contractions. If the methotrexate still does not work, a D&C can serve as a backup procedure.

How effective is methotrexate in inducing an abortion?

Since the drug has not been widely used in this country, reliable statistics have not been gathered. In one experimental study where methotrexate was followed by a prostaglandin to stimulate uterine contractions, 96 percent of the women in the study group did have successful abortions.

Does methotrexate have side effects?

If taken in large doses and for extended periods, as it is for people with arthritis or psoriasis, methotrexate can be toxic to the liver. This does not seem to be a danger for women getting a one- or two-shot dose of the drug for abortion purposes.

Medical Abortion with Mifepristone

The drug mifepristone (formerly known as RU-486, the “French abortion pill”) is widely used in Canada, the United Kingdom, and Sweden as well as France, where it has been shown to be generally safe and effective. For many years it was used only experimentally in the United States, because the antichoice lobby effectively prevented any pharmaceutical company from marketing it for the purpose of abortion.

Clinical trials began here in 1994 and lasted about a year. The drug received FDA approval in 2000, and today is manufactured under the trade name Mifeprex.

How does mifepristone work?

It blocks the production of progesterone, the hormone necessary for sustaining early pregnancy. It can be used for abortions before the ninth week of pregnancy, but is most effective when used during the first forty-nine days or seven weeks of pregnancy (counting from the beginning of the last menstrual period).

What are the advantages and disadvantages of this procedure?

Mifepristone offers more privacy than other methods because it requires visits only to a doctor’s office, not to a surgicenter or abortion clinic. In parts of the country where it is difficult to get a surgical abortion, women may be able to find physicians close to their homes who are able to provide this procedure. It is less invasive than a surgical abortion. Women who took part in the clinical trials suggested that it was more “natural,” because it resembled a spontaneous miscarriage, and therefore was less frightening.

Disadvantages include the fact that a medical abortion lengthens the period of cramping while the fetus is expelled. There is a period of waiting and uncertainty before the abortion takes place. The abortion happens at home (or at work or somewhere else), where there is no immediate access to professional help or intravenous pain control. Although mifepristone is relatively safe and has been used by millions of European women, no long-term safety statistics are available for the United States. The method must be used before the ninth week of pregnancy and preferably before the seventh, which means within the first month after you have missed a period. Mifepristone is said to be dangerous for smokers.

What is the regimen for taking mifepristone?

Using mifepristone effectively is a multistep process, requiring three or more visits to a doctor’s office. The first step is a dose of mifepristone, taken orally. The second step, three days later, is the administration of a prostaglandin, either as an injection or as a vaginal suppository. The prostaglandin causes the uterus to contract and expel the fetus, which has been weakened by depriving the uterus of progesterone. After the miscarriage has taken place, a follow-up exam is scheduled to make sure that all the fetal tissue has been expelled.

How effective is mifepristone?

European studies have suggested that it is 95 percent effective when used in conjunction with a prostaglandin. Clinical studies in the United States returned a figure of 92 percent, with the success rate declining as pregnancy advanced.

What are its side effects?

The side effects, common to almost all women who use mifepristone, are like those of a natural miscarriage — cramping and bleeding. The actual amount of blood lost is about the same as for other kinds of early abortions, whether medical or surgical. Bleeding or spotting lasted an average of thirteen days. A few women, roughly 2 in 1,000, have heavy bleeding and require transfusion. About 5 percent of women need a D&C to complete the procedure because their bleeding continues. Other side effects include nausea, diarrhea, and vomiting, but these take place mostly within four hours of taking the second drug, the prostaglandin.

Dilation and Curettage

This kind of first-trimester abortion is not very different from a D&C performed for other purposes, for example to help with heavy menstrual bleeding. The contents of the uterus can be removed via a vacuum procedure, curettage (scraping with a sharp tool, called a curette), or both. Most doctors do the vacuum procedure first and follow it with curettage. This procedure is usually performed after the sixth or seventh week of pregnancy and before the thirteenth. Most doctors do not advocate a D&C earlier than about seven weeks after your last menstrual period (five weeks after conception); before that the fetal sac is so tiny that there is a significant chance of missing it.

How long does a D&C take?

This depends on several factors, the most important being the duration of the pregnancy: the more advanced the pregnancy the more difficult, and therefore the longer, the procedure. The actual D&C takes somewhere between five and fifteen minutes. After resting for about an hour in a setting where you can be observed for pain or bleeding, you can usually go home.

Is a D&C done with anesthesia?

Again, this depends on how far the pregnancy is advanced. Dilating the cervix can be painful, so sometimes you will have intravenous tranquilizers that make you sleepy and reduce anxiety. D&Cs can be done with either local anesthesia or with a general anesthetic, which puts you to sleep. Many women prefer this for emotional as well as physical reasons. Even with general anesthesia, the procedure can be done in a surgicenter or other outpatient facility.

How is the actual D&C performed?

Because the length of the pregnancy will determine how far the cervix must be dilated, your doctor may use an ultrasound image to check duration of the pregnancy. The D&C is done while you are in the dorsal lithotomy position — on your back with your feet elevated in stirrups, the same position as for a pelvic exam. Your vagina is washed out with an antiseptic solution, perhaps iodine. When the anesthetic has taken hold, the physician gradually stretches your cervix using dilators, tapered metal rods of increasing diameter: the smallest are as narrow as a piece of wire, the later ones are considerably thicker.

Once the cervix has been dilated, the doctor introduces a little tube or hose called a cannula into your uterus. The cannula is attached to a pump that makes enough vacuum pressure to suction out the embryo, the placenta! tissue, and the lining of the uterine cavity. Most, though not all, doctors will follow the suction procedure by scraping the uterine lining with a sharp curette. This helps to ensure that no fetal tissue remains inside the uterus to cause infection or bleeding later on.

How painful is a D&C?

This varies from woman to woman, depending on how far the pregnancy has advanced, her anxiety about the procedure, and her pain threshold. During the suction phase some women feel only mild cramping, something similar to a menstrual period; others feel more intense pain. The same variation is true of the scraping procedure, if the surgeon chooses to use it.

Are there any medical conditions that would rule out an outpatient D&C during the first trimester of pregnancy?

Women with heart disease, high blood pressure, asthma, lupus, fibroids, clotting disorders, diabetes, or epilepsy that are not well under control may have to be hospitalized and take special precautions. Most women tolerate the procedure well.

How much does a D&C cost?

Depending on where you live, where the procedure takes place, whether or not you have anesthesia, a first-trimester D&C can cost anywhere from two hundred to eight hundred dollars. Your insurance may pay for it, but this varies from company to company. Check with your carrier.

 

Selections from the book: “The Yale Guide to Women`s Reproductive Health: From Menarche to Menopause”, 2003.

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