II. Epidemiology
- Unintended Pregnancy accounts for 43% of the approximately 5.3 Million pregnancies per year in U.S.
- Elective pregnancy termination varies by year in U.S. by is roughly 600,000 per year
- Costs in U.S (2020)
- Vaginal Delivery costs $15,000
- Cesarean Section costs $29,000
III. Risk Factors: Unintended Pregnancy
- Difficult access to Contraception
- No Contraception or inconsistent Contraception accounts for 95% of unintended pregnancies
- Age 20-24 years old
- Less social support
- Unmarried
- Income below poverty line
- Women ages 15 to 44 years old with incomes below poverty line (RR 5)
- Non-hispanic Black
- Major Depression symptoms
- Emotional stress
- Childhood Sexual Assault
- Intimate Partner Violence
- Decreased social support
IV. Evaluation
- See Pregnancy Dating
V. Management: Counseling
- Approach
- Offer assistance in non-judgemental manner
- Counseling regarding options
- Carry fetus to delivery and raise the child
- Offer to connect the mother to social services and public health resources
- Carry fetus to delivery and offer child for adoption (less commonly chosen in U.S.)
- Elective pregnancy termination
- Medical providers may conscientiously refuse to perform certain procedures if not consistent with their principles
- However, in these cases AAFP and ACOG recommend providers offer safe referrals for these services
- Carry fetus to delivery and raise the child
VI. Management: Elective Termination
-
General
- Guttmacher Institute Summary of Elective Termination laws
- Safety
- First trimester termination does not appear to increase risk of Ectopic Pregnancy, preterm birth or Miscarriage
- Legal pregnancy termination appears safe (mortality 0.6 per 100,000 live births compared with 8.8 per 100,000)
- No longterm psychological impact from elective termination
- Clostridial Toxic Shock Syndrome
- Associated with vaginal Misoprostol protocols without Antibiotic prophylaxis (regimens before 2006)
- Rare now with newer regimens that use oral or buccal Misoprostol and Antibiotic prophylaxis
- Fjerstad (2009) N Engl J Med 361(2): 145-51 +PMID:19587339 [PubMed]
- Pregnancy termination may fail in some cases
- If this occurs, pregnancy care should continue with a high risk obstetrician (e.g. maternal fetal medicine)
- First Trimester regimens (<77 days gestation)
- Mifrepristone 200 mg and Misoprostol 800 mcg (preferred)
- Other medication options include Methotrexate/Misoprostol and Misoprostol alone
- However, combined Mifepristone and Misoprostol is preferred for its effectiveness in 98% of cases
- Misoprostol 800 mcg orally alone has an efficacy of 85 to 95% in Termination of Pregnancy
- Zhang (2022) Cochrane Database Syst Rev (5): CD002855 [PubMed]
- Surgical Methods
- Vacuum aspiration
- Dilation and Curettage
- Second-Trimester regimens
- Medical induction (admit for delivery)
- Efficacy and safety
- Success rate: 91%
- Retained Placenta in 21% of cases
- Primary protocol
- Mifrepristone 200 mg and Misoprostol 400 mcg
- Start: Mifrepristone 200 mg orally
- Next: Misoprostol 400 mcg sublingual, buccal starting in 24-48 hours, every 3 hours for up to 5 doses
- Misoprostol alone
- 400 mcg vaginal or sublingual every 3 hours for up to 5 doses
- Mifrepristone 200 mg and Misoprostol 400 mcg
- Other medications
- Efficacy and safety
- Surgical Methods (preferred)
- Efficacy and Safety
- Overall preferred by patients over medical induction
- Faster than medical induction
- Lower complication rate than medical induction (4%)
- Cervical Laceration
- Uterine perforation
- Procedures
- Dilation and Evacuation
- Efficacy and Safety
- Medical induction (admit for delivery)
- Additional measures
- RhoGAM (if Rh Negative)
- Obstetric Ultrasound
- Typically used to confirm Early Pregnancy Loss and assess Gestational Age
- Also obtain for risk of Ectopic Pregnancy (e.g. Adnexal Mass, PID history, IUD pregnancy, Adnexal Mass)
- Ultrasound is not needed in regular Menses, LMP within 56 days and no Ectopic Pregnancy risks or symptoms
- Ultrasound may be required by local law before Termination of Pregnancy
- Quantitative bhCG
- Obtained to monitor serially to confirm completed Miscarriage
VII. Management: Self-Medicated Termination of Pregnancy
- Background
- In the U.S. since 2018, there has been a significant decrease in access to services for Termination of Pregnancy
- This has resulted in an increase in self-medicated Termination of Pregnancy (unsupervised)
- National resources have developed to assist patients self-medicated termination
- Examples include Plan C, Mayday Health, Miscarriage and Abortion Hotline
- Most commonly used agent for self-Medication is Misoprostol (Cytotec) alone
- In the U.S. since 2018, there has been a significant decrease in access to services for Termination of Pregnancy
- Confirmation of completion
- Resolution of Pregnancy Symptoms (e.g. Breast fullness, Nausea)
- Qualitative and Quantitative hCG tests may be positive for up to 4 to 6 weeks after abortion (EAB or SAB)
- Serial Quantitative hCG (48 to 72 hours apart) may be useful in establishing a trend
- Consider pelvic Ultrasound (esp. if intrauterine pregnancy has not been confirmed)
- Protocol for patients reporting bleeding and other symptoms after self-medicated termination
- Background
- Heavier bleeding and passage of clots is more common after termination at >=10 weeks gestation
- Bleeding in first 24 hours after taking Misoprostol
- Light bleeding may be offered reassurance
- Heavy bleeding (e.g. 2 large soaked pads in 2 hours)
- Take a second dose Misoprostol 800 mcg (or Ibuprofen 800 mg orally once if not available)
- If heavy bleeding persists >1 hour, patient should be seen in the Emergency Department (or office)
- If bleeding decreases, patient should have follow-up within 1 week
- Spotting periodically for 2 to 3 weeks after taking Misoprostol
- Otherwise asymptomatic patients may be offered reassurance
- Persistent bleeding (more than spotting) for >1 month after taking Misoprostol
- Non-orthostatic patients with normal Hemoglobin
- Consider repeat Misoprostol 800 mcg dose
- Iron Supplementation as needed
- Less reassuring findings (e.g. Orthostasis, significant Anemia)
- Pelvic Ultrasound
- Consider Suction Dilation and Curettage
- Non-orthostatic patients with normal Hemoglobin
- Background
- Red Flag findings prompting medical evaluation after self-medicated termination
- See bleeding management as above
- Severe, unrelenting Pelvic Pain
- Patients should expect pelvic cramping that is more intense than a typical menstrual period
- Severe persistent Nausea and Vomiting
- Fever
- References
VIII. Resources
- Comprehensive Options Counseling (Provider education)
- All-Options Counseling (patient and provider education)
- Pregnancy Options Counseling (ACOG, Patient Education)
IX. Prevention
- See Contraception
X. References
- (2014) Obstet Gynecol 123(3): 676-92 [PubMed]
- Finer (2014) Am J Public Health 104(suppl 1): S43-8 [PubMed]
- MacNaughton (2021) Am Fam Physician 103(8) 473-80 [PubMed]
- Moss (2015) Am Fam Physician 91(8): 544-9 [PubMed]
- Valerio (2025) Am Fam Physician 111(4): 352-60 [PubMed]
- Wildschut (2011) Cochrane Database Syst Rev (1): CD005216 [PubMed]