Unintended Pregnancy

Aka: Unintended Pregnancy, Unwanted Pregnancy, Unplanned Pregnancy, Termination of Pregnancy

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II. Epidemiology

  1. Elective pregnancy termination is sought in 43% of unintended pregnancies
  2. Unintended Pregnancy accounts for 50% of approximately 6.6 Million pregnancies per year
    1. Approximately 3.3 Million unintended pregnancies per year (2008)
  3. Risks
    1. Women ages 15 to 44 years old with incomes below poverty line have a 5 fold increased Unintended Pregnancy rate
    2. No Contraception or inconsistent Contraception accounts for 95% of unintended pregnancies
  4. Costs
    1. Vaginal Delivery costs $30,000 and Cesarean Section costs $50,000 (as of 2010)
  5. References
    1. Finer (2014) Am J Public Health 104(suppl 1): S43-8 [PubMed]

III. Risk Factors

  1. Difficult access to Contraception
  2. Age 20-24 years old
  3. Less social support
  4. Major Depression symptoms
  5. Emotional stress
  6. Childhood Sexual Assault
  7. Intimate Partner Violence
  8. Decreased social support

IV. Evaluation

  1. See Pregnancy Dating

V. Management: Counseling

  1. Approach
    1. Offer assistance in non-judgemental manner
  2. Counseling regarding options
    1. Carry fetus to delivery and raise the child
      1. Offer to connect the mother to social services and public health resources
    2. Carry fetus to delivery and offer child for adoption (less commonly chosen in U.S.)
      1. https://www.childwelfare.gov/topics/adoption/
    3. Elective pregnancy termination
      1. Medical providers may conscientiously refuse to perform certain procedures if not consistent with their principles
      2. However, in these cases AAFP and ACOG recommend providers offer safe referrals for these services

VI. Management: Elective Termination

  1. General
    1. Guttmacher Institute Summary of Elective Termination laws
      1. http://www.guttmacher.org/statecenter/
  2. Safety
    1. First trimester termination does not appear to increase risk of Ectopic Pregnancy, preterm birth or Miscarriage
      1. Virk (2007) N Engl J Med 357(7): 648-53 [PubMed]
    2. Legal pregnancy termination appears safe (mortality 0.6 per 100,000 live births compared with 8.8 per 100,000)
      1. Raymond (2012) Obstet Gynecol 119(2 pt 1): 215-9 [PubMed]
    3. No longterm psychological impact from elective termination
    4. Clostridial Toxic Shock Syndrome
      1. Associated with vaginal Misoprostol protocols without Antibiotic prophylaxis (regimens before 2006)
      2. Rare now with newer regimens that use oral or buccal Misoprostol and Antibiotic prophylaxis
      3. Fjerstad (2009) N Engl J Med 361(2): 145-51 +PMID:19587339 [PubMed]
  3. First Trimester regimens (<77 days gestation)
    1. Mifrepristone 200 mg and Misoprostol 800 mcg (preferred)
      1. See Mifepristone and Misoprostol Protocol for Termination of Pregnancy
    2. Other medication options include Methotrexate/Misoprostol and Misoprostol alone
      1. However, combined Mifepristone and Misoprostol is preferred for its effectiveness in 98% of cases
      2. Misoprostol 800 mcg orally alone has an efficacy of 85 to 95% in Termination of Pregnancy
      3. Zhang (2022) Cochrane Database Syst Rev (5): CD002855 [PubMed]
    3. Surgical methods (vacuum aspiration or Dilation and Curettage)
  4. Second-Trimester regimens
    1. Medical induction (admit for delivery)
      1. Mifrepristone 200 mg and Misoprostol 400 mcg
        1. Start: Mifrepristone 200 mg orally
        2. Next: Misoprostol 400 mcg sublingual, buccal starting in 24-48 hours, every 3 hours for up to 5 doses
      2. Misoprostol alone
        1. 400 mcg vaginal or sublingual every 3 hours for up to 5 doses
      3. Oxytocin
    2. Dilation and Evacuation
  5. Additional measures
    1. RhoGAM (if Rh Negative)
    2. Obstetric Ultrasound
      1. Typically used to confirm Early Pregnancy Loss and assess Gestational age
      2. Also obtain for risk of Ectopic Pregnancy (e.g. Adnexal Mass, PID history, IUD pregnancy, Adnexal Mass)
    3. Quantitative bhCG
      1. Obtained to monitor serially to confirm completed Miscarriage

VII. Management: Self-Medicated Termination of Pregnancy

  1. Background
    1. In the U.S. since 2018, there has been a significant decrease in access to services for Termination of Pregnancy
      1. This has resulted in an increase in self-medicated Termination of Pregnancy (unsupervised)
    2. National resources have developed to assist patients self-medicated termination
      1. Examples include Plan C, Mayday Health, Miscarriage and Abortion Hotline
      2. Most commonly used agent for self-Medication is Misoprostol (Cytotec) alone
  2. Confirmation of completion
    1. Resolution of Pregnancy Symptoms (e.g. Breast fullness, Nausea)
    2. Qualitative and Quantitative hCG tests may be positive for up to 4 to 6 weeks after abortion (EAB or SAB)
      1. Serial Quantitative hCG (48 to 72 hours apart) may be useful in establishing a trend
    3. Consider pelvic Ultrasound (esp. if intrauterine pregnancy has not been confirmed)
  3. Protocol for patients reporting bleeding after self-medicated termination
    1. Background
      1. Heavier bleeding and passage of clots is more common after termination at >=10 weeks gestation
    2. Bleeding in first 24 hours after taking Misoprostol
      1. Light bleeding may be offered reassurance
      2. Heavy bleeding (e.g. 2 large soaked pads in 2 hours)
        1. Take a second dose Misoprostol 800 mcg (or Ibuprofen 800 mg orally once if not available)
        2. If heavy bleeding persists >1 hour, patient should be seen in the Emergency Department (or office)
        3. If bleeding decreases, patient should have follow-up within 1 week
    3. Spotting periodically for 2 to 3 weeks after taking Misoprostol
      1. Otherwise asymptomatic patients may be offered reassurance
    4. Persistent bleeding (more than spotting) for >1 month after taking Misoprostol
      1. Non-orthostatic patients with normal Hemoglobin
        1. Consider repeat Misoprostol 800 mcg dose
        2. Iron Supplementation as needed
      2. Less reassuring findings (e.g. Orthostasis, significant Anemia)
        1. Pelvic Ultrasound
        2. Consider Suction Dilation and Curettage
  4. References
    1. Wetterer (2023) Am Fam Physician 108(5): 519-22 [PubMed]

VIII. Prevention

  1. See Contraception

IX. References

  1. (2014) Obstet Gynecol 123(3): 676-92 [PubMed]
  2. Moss (2015) Am Fam Physician 91(8): 544-9 [PubMed]
  3. Wildschut (2011) Cochrane Database Syst Rev (1): CD005216 [PubMed]
  4. MacNaughton (2021) Am Fam Physician 103(8) 473-80 [PubMed]

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Related Studies

Ontology: Unwanted pregnancy (C0032995)

Definition (MSH) Pregnancy, usually accidental, that is not desired by the parent or parents.
Concepts Finding (T033)
MSH D011275
SnomedCT 160798004, 58532003
English Pregnancies, Unwanted, Pregnancy, Unwanted, Unwanted Pregnancies, Unwanted Pregnancy, Unwanted pregnancy, Unwanted child, PREGN UNWANTED, UNWANTED PREGN, current unwanted pregnancy (history), current unwanted pregnancy, pregnancy unwanted, unwanted pregnancies, unwanted pregnancy, Pregnancy unwanted, Unwanted pregnancy (finding), pregnancy; unwanted, unwanted; pregnancy
Italian Gravidanza non desiderata, Gravidanza indesiderata
Swedish Graviditet, oönskad
Japanese ﾉｿﾞﾏﾅｲﾆﾝｼﾝ, 望まない妊娠
Czech těhotenství nechtěné, Nechtěné těhotenství
Finnish Ei-toivottu raskaus
French Grossesse non souhaitée, Grossesse non désirée
Russian BEREMENNOST' NEZHELATEL'NAIA, БЕРЕМЕННОСТЬ НЕЖЕЛАТЕЛЬНАЯ
Polish Ciąża niepożądana
Hungarian Nem kívánt terhesség
Dutch ongewenst; zwangerschap, zwangerschap; ongewenst, ongewenste zwangerschap, Ongewenste zwangerschap, Zwangerschap, ongewenste
Spanish embarazo no deseado (hallazgo), embarazo no deseado, Embarazo no deseado, Embarazo no Deseado
Portuguese Gravidez não desejada, Gravidez não Desejada
German ungewollte Schwangerschaft, Schwangerschaft, unerwünschte
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Unplanned pregnancy (C0041747)

Definition (NCI) A pregnancy that was not desired or was timed incorrectly at the time that the conception occurred.
Definition (NCI_CTCAE) A disorder characterized by an unexpected pregnancy at the time of conception.
Definition (MSH) Unintended accidental pregnancy, including pregnancy resulting from failed contraceptive measures.
Concepts Finding (T033)
MSH D049168
SnomedCT 83074005, 169570005
English PREGNANCY UNEXPECTED, PREGNANCY UNINTENDED, Unplanned pregnancy, Unintended pregnancy, UNPLANNED PREGN, PREGN UNPLANNED, current unplanned pregnancy, current unplanned pregnancy (history), unplanned pregnancy, Pregnancy unexpected, Unexpected pregnancy, Pregnancy unintended, Unintended Pregnancy, pregnancies unintended, unintended pregnancies, unplanned pregnancies, pregnancy unintended, unintended pregnancy, pregnancy unplaned, unexpected pregnancy, accidental pregnancy, Unintended pregnancies, Unplanned pregnancy (situation), Accidental pregnancy, Unplanned pregnancy (finding), Pregnancies, Unplanned, Pregnancy, Unplanned, Unplanned Pregnancies, Unplanned Pregnancy, Pregnancy;unplanned
Spanish EMBARAZO NO DESEADO, Embarazo imprevisto, Embarazo inesperado, EMBARAZO INESPERADO, embarazo indeseado (hallazgo), embarazo indeseado, embarazo involuntario, Embarazo no intencionado, Embarazos no deseados, embarazo no planeado, Embarazo no Planeado
Italian Gravidanza involontaria, Gravidanze involontarie, Gravidanza inattesa, Gravidanza non voluta, Gravidanza non programmata
Dutch zwangerschap onverwacht, zwangerschap niet gepland, onverwachte zwangerschap, onbedoelde zwangerschappen, onbedoelde zwangerschap, Niet-geplande zwangerschap, Ongeplande zwangerschap, Zwangerschao, niet-geplande, Zwangerschap, ongeplande
French Grossesse non anticipée, Grossesse non voulue, Grossesse non planifiée, Grossesse imprévue, GROSSESSE INATTENDUE, GROSSESSE INVOLONTAIRE, Grossesse non programmée, Grossesses non intentionnelles
German Schwangerschaft unbeabsichtigt, Schwangerschaft unerwartet, unerwartete Schwangerschaft, SCHWANGERSCHAFT UNERWARTET, SCHWANGERSCHAFT UNGEWOLLT, Ungewollte Schwangerschaften, unbeabsichtige Schwangerschaft, Schwangerschaft, ungeplante, Schwangerschaft, ungewollte, Ungeplante Schwangerschaft
Portuguese Gravidez inesperada, Gravidez não planeada, GRAVIDEZ INESPERADA, GRAVIDEZ INVOLUNTARIA, Gravidez não prentendida, Gravidez não pretendida, Gravidez não Planejada
Japanese 予期外妊娠, ﾖﾃｲｶﾞｲﾆﾝｼﾝ, ﾖｷｶﾞｲﾆﾝｼﾝ, 妊娠-計画外, 妊娠-予定外, 予定外妊娠, 計画外妊娠
Swedish Graviditet, oplanerad
Czech těhotenství neplánované, Neočekávané těhotenství, Neplánovaná těhotenství, Neplánované těhotenství
Finnish Suunnittelematon raskaus
Russian BEREMENNOST' NEZAPLANIROVANNAIA, БЕРЕМЕННОСТЬ НЕЗАПЛАНИРОВАННАЯ
Polish Ciąża nieplanowana
Hungarian Véletlenszerű terhesség, Nem tervezett terhesség, Nem várt terhesség, Váratlan terhesség, Nem várt terhességek
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Antepartum Disorders

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