Unintended Pregnancy

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

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II. Epidemiology

  1. Unintended Pregnancy accounts for 43% of the approximately 5.3 Million pregnancies per year in U.S.
  2. Elective pregnancy termination varies by year in U.S. by is roughly 600,000 per year
  3. Costs in U.S (2020)
    1. Vaginal Delivery costs $15,000
    2. Cesarean Section costs $29,000

III. Risk Factors: Unintended Pregnancy

  1. Difficult access to Contraception
    1. No Contraception or inconsistent Contraception accounts for 95% of unintended pregnancies
  2. Age 20-24 years old
  3. Less social support
  4. Unmarried
  5. Income below poverty line
    1. Women ages 15 to 44 years old with incomes below poverty line (RR 5)
  6. Non-hispanic Black
  7. Major Depression symptoms
  8. Emotional stress
  9. Childhood Sexual Assault
  10. Intimate Partner Violence
  11. 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. Contrast with unsafe abortion practices when legal abortion services are not available
      1. Highly toxic chemicals have been used (e.g. Chloroquine, detergents, kerosene, turpentine)
      2. Foreign body insertion and intentional abdominal or back Trauma may also result in serious complications
      3. Haddad (2009) Rev Obstet Gynecol 2(2):122-6 +PMID: 19609407 [PubMed]
    4. No longterm psychological impact from elective termination
    5. 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]
    6. Pregnancy termination may fail in some cases
      1. If this occurs, pregnancy care should continue with a high risk obstetrician (e.g. maternal fetal medicine)
  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
      1. Vacuum aspiration
      2. Dilation and Curettage
  4. Second-Trimester regimens
    1. Medical induction (admit for delivery)
      1. Efficacy and safety
        1. Success rate: 91%
        2. Retained Placenta in 21% of cases
      2. Primary protocol
        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. Other medications
        1. Oxytocin
    2. Surgical Methods (preferred)
      1. Efficacy and Safety
        1. Overall preferred by patients over medical induction
        2. Faster than medical induction
        3. Lower complication rate than medical induction (4%)
          1. Cervical Laceration
          2. Uterine perforation
      2. Procedures
        1. 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. Ultrasound is not needed in regular Menses, LMP within 56 days and no Ectopic Pregnancy risks or symptoms
      4. Ultrasound may be required by local law before Termination of Pregnancy
    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 and other symptoms 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. See Postabortion Hemorrhage
        2. Pelvic Ultrasound
        3. Consider Suction Dilation and Curettage
  4. Red Flag findings prompting medical evaluation after self-medicated termination
    1. See bleeding management as above
    2. Severe, unrelenting Pelvic Pain
      1. Patients should expect pelvic cramping that is more intense than a typical menstrual period
    3. Severe persistent Nausea and Vomiting (e.g. failed termination)
    4. Fever (e.g. Endometritis, Septic Abortion)
  5. References
    1. Wetterer (2023) Am Fam Physician 108(5): 519-22 [PubMed]

VIII. Resources

  1. Comprehensive Options Counseling (Provider education)
    1. https://www.reproductiveaccess.org/resource/options-counseling/
  2. All-Options Counseling (patient and provider education)
    1. https://www.all-options.org/
  3. Pregnancy Options Counseling (ACOG, Patient Education)
    1. https://www.acog.org/womens-health/faqs/pregnancy-choices-raising-the-baby-adoption-and-abortion

IX. Prevention

  1. See Contraception

X. References

  1. (2014) Obstet Gynecol 123(3): 676-92 [PubMed]
  2. Finer (2014) Am J Public Health 104(suppl 1): S43-8 [PubMed]
  3. MacNaughton (2021) Am Fam Physician 103(8) 473-80 [PubMed]
  4. Moss (2015) Am Fam Physician 91(8): 544-9 [PubMed]
  5. Valerio (2025) Am Fam Physician 111(4): 352-60 [PubMed]
  6. Wildschut (2011) Cochrane Database Syst Rev (1): CD005216 [PubMed]

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