Abortion ends a pregnancy before birth takes place. When an embryo or fetus dies in the uterus and is expelled by the body, it is called a spontaneous abortion. After 20 weeks of pregnancy a spontaneous abortion is also called a “miscarriage.” When a woman decides to end her pregnancy voluntarily, she has an induced abortion.

Approximately 88 percent of all induced abortions are performed during the first trimester — the first three months of pregnancy. In fact, more than half are performed within the first two months of pregnancy (CDC, 2002). These abortions are usually performed at a clinic, health center, or in a doctor’s office, and women are usually able to return home an hour or so later.

Medical Abortion

In some clinics, women can choose to use a combination of drugs to end their pregnancies. This is called medical abortion. Medical abortion does not require surgery. The medications used are prescribed by a clinician.

A small percentage of medical abortions fail. In these cases, surgical procedures are required to end the pregnancy.

Medical abortion is not available from all abortion providers.

Follow-up visits are important for women seeking medical abortions. Candidates for medical abortion must be able to complete the regimen of drugs and to make between one and three visits to the medical provider.

Two combinations of medications can be used for medical abortion:

The Methotrexate-Misoprostol Method

These two medications, approved by the U.S. Food and Drug Administration (FDA) for other uses, can be used for medical abortion. Studies have shown this method to be effective up to 49 days after the first day of the last menstrual period.

A woman receives an injection of methotrexate from her clinician. About five days later she inserts misoprostol tablets into her vagina. The pregnancy usually ends at home within a day or two, although 15–20 percent of women undergoing this procedure require up to four weeks to terminate their pregnancies successfully (ACOG, 2001). The pre-embryo or embryo and other products of conception that develop during pregnancy are passed out through the vagina. Complete abortion will occur in 92–96 percent of women receiving this regimen (ACOG, 2001).

The Mifepristone-Misoprostol Method

Mifepristone was approved by the FDA on September 28, 2000 for use as an abortifacient. Studies have shown this method to be effective up to 63 days after the first day of the last menstrual period (Schaff, et al., 2000).

A woman swallows a dose of mifepristone under the guidance of her clinician. In a few days she uses the second medication, misoprostol. The pregnancy usually ends within four hours after taking the misoprostol. The pre-embryo or embryo and other products of conception that develop during pregnancy are passed out through the vagina. Complete abortion will occur in 96–97 percent of women receiving this regimen (ACOG, 2001; Schaff, et al., 2000).

Surgical Abortion

Women who choose to end their pregnancies may also have surgical abortions. Surgical abortions can be done with the gentle suction of a syringe, which is called manual vacuum aspiration (MVA); with gentle suction curettage; with dilation and evacuation; or with induction, depending on the length of the pregnancy. Surgical abortion is nearly 100 percent effective — 99 percent of procedures are complete.

Manual Vacuum Aspiration

MVA can be done from the time when a woman suspects pregnancy up to about 10 weeks from her last period. The cervix is dilated, and the uterus is emptied with a handheld syringe. If a definitive gestational sac is not identified within the removed tissue, the woman is tested for possible ectopic pregnancy. MVA takes about 10 minutes.

Suction Curettage

The usual method of early abortion is suction curettage. It is performed from about six to 14 weeks after the last period. The procedure takes about 10 minutes:

• The vagina is washed with an antiseptic. Usually, a local anesthetic is injected into or near the cervix. Injectable painkillers or general anesthesia can also be used.
• The opening of the cervix is gradually stretched. One after the other, a series of increasingly thick rods (dilators) is inserted into the opening. The thickest may be the width of a fountain pen. As an alternative, absorbent dilators can be used to stretch the cervical opening. The dilators absorb fluids from the cervical area and stretch the opening of the cervix as the dilators expand. If the woman is to go home with the dilators in place, she will be given instructions for care until she returns for the abortion. She may be given antibiotics to prevent infection. She will also be given a 24-hour telephone number so she can contact the clinic staff should any problem arise. Some women may feel pressure or cramping while the dilators are in place. Medication may also be given to help dilate and soften the cervix. Misoprostol is commonly used alone or in combination with dilators for cervical preparation. Misoprostol has not been approved by the FDA for cervical softening and dilation — nor has the FDA been asked to approve the drug for this purpose. However, studies have shown it to be an effective way to prepare the cervix for abortion (Goldberg, 2001).
• After the opening is stretched, a tube, attached to a suction machine, is inserted through it into the uterus.
• The suction machine is turned on and the uterus is gently emptied.
• To be sure that the uterus has been completely emptied after the suction tube has been removed, a curette (narrow metal loop) may be used to gently scrape the walls of the uterus.
• Suction curettage takes about 10 minutes.

Abortion After the First Trimester

Abortions performed after about 14 weeks from the last period can be performed using a variety of methods. The type of procedure used depends on different factors, such as the length of the pregnancy and what is best suited to the individual situation. Abortions after 14 weeks of pregnancy are available in some clinics and certain hospitals.

Dilation and Evacuation

Dilation and evacuation (D&E) is performed in two steps.

The first step of a D&E involves cervical preparation (softening and dilation).

• The vagina is washed with an antiseptic.
• Absorbent dilators may be put into the cervix, where they remain for several hours, sometimes overnight. Misoprostol may also be used to facilitate dilation of the cervix.

During the second step of a D&E

• The woman may be given medication to ease pain and/or prevent infection.
• A local anesthetic is injected into or near the cervix. General anesthesia can also be used.
• The dilators are removed from the cervix.
• The fetus and other products of conception are removed from the uterus with surgical instruments and suction curettage. This procedure takes about 10–20 minutes.

Induction

The induction procedure is rarely performed. For an induction the doctor may insert a medication called prostaglandin into the vagina or give the medication in the form of an injection to start contractions that will expel the fetus. Or, urea or salt solution may be injected into the uterus to start contractions and cause a stillbirth. The discomfort from the contractions, which usually last from six to 24 hours, may be relieved with oral medication. Induction is usually done in a hospital and usually requires staying overnight or longer.

Bibliography
ACOG —American College of Obstetricians and Gynecologists.
(2001, April). “Medical Management of Abortion.” ACOG
Practice Bulletin, 26, 1–13.
CDC — Centers for Disease Control and Prevention. (2002,
June 7). “Abortion Surveillance — United States, 1998.”
Morbidity and Mortality Weekly Report, 51(SS-3).
Goldberg, Alisa, et al. (2001, January 4). “Misoprostol and
Pregnancy.” New England Journal of Medicine, 344, 38–47.
Schaff, Eric, et al. (2000). “Low-Dose Mifepristone Followed by
Vaginal Misprostol at 48 Hours for Abortion up to 63 Days.”
Contraception, 61(1), 41–6.

Unless otherwise indicated, procedures described in this fact sheet are based upon practices outlined in:

Paul, Maureen, et al. (1999). A Clinician’s Guide to Medical and
Surgical Abortion. New York: Churchill Livingstone.
PPFA — Planned Parenthood Federation of America. National
Medical Committee. (2000). Manual of Medical Standards and Guidelines, 2000 revision. New York: PPFA.