Abortion

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Abortion Abortion is defined as the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo before it is viable. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy. Abortion, when induced in the developed world in accordance with local law, is among the safest procedures in medicine. However, unsafe abortions (those performed by persons without proper training or outside of a medical environment) result in approximately 70 thousand maternal deaths and 5 million disabilities per year globally. An estimated 42 million abortions are performed globally each year, with 20 million of those performed unsafely. The incidence of abortion has declined worldwide as access to family planning education and contraceptive services has increased. Forty percent of the world's women have access to induced abortions (within gestational limits).Induced abortion has a long history and has been facilitated by various methods including herbal abortifacients, the use of sharpened tools, physical trauma, and other traditional methods. Contemporary medicine utilizes medications and surgical procedures to induce abortion. The legality, prevalence, cultural and religious status of abortion vary substantially around the world. In many parts of the world there is prominent and divisive public controversy over the ethical and legal issues of abortion.

Types of Abortion A. Induced Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion. Most abortions result from unintended pregnancies. A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses. Specific procedures may also be selected due to legality, regional availability, and doctor or patient preference. Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; prevent harm to the woman's physical or mental health; terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy. An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for nonmedical reasons.
Induced abortion - this type of abortion uses drugs or instruments to stop the normal course of pregnancy. Different methods for performing abortions. • Menstrual Extraction (endometrial or vacuum aspiration). This method is used for most abortions performed during the first trimester. It is done by suctioning out the lining of the uterus (endometrium) through a thin opening of the undilated cervix. It is a method used after a woman has just missed a period, or anytime up to about the eight week or pregnancy. It can be performed safely in the doctor's office and has a very low rate of mortality. • Dilation and Evacuation (D & E) (also called vacuum suction or suction curettage) and Dilation and Curettage (D & C). This method is commonly used for late first trimester or early second trimester abortions. In this method suction is used to remove the fetus and placenta. The cervix is first dilated under local anesthesia using a suction tube that is firm, and a stronger suction is used than in menstrual extraction. Another way of dilating the cervix is the use of a type of dried seaweed, called laminaria, which expands as it absorbs moisture. Some doctors use a hollow, spoon-shaped knife, or curette, to ensure that all the placental tissues are removed by scraping the uterine walls. If curettes are used throughout the procedure instead of suction, the method is called dilation and curettage (D&C). Before the 12th week of pregnancy, D&E is preferred over D&C because it does not require general anesthesia, causes less discomfort and is less costly. D&C can be used up to the 12thweek of pregnancy. The mortality rate for both D&E and D&C is approximately 3 per 100,000 abortions.





Prostaglandin or Saline Administration. This method is done by injecting prostaglandins or saline solution through the uterine wall and into the amniotic sac holding the fetus to induce labor and delivery of a nonviable fetus. This procedure is commonly used for second trimester abortions. Prostaglandinsmay cause nausea, elevated temperatures, and vomiting but are safer than the saline solution. Mortality rate for second trimester abortions performed by this method is approximately 20 per 100,000 abortions. Hysterotomy. This method is similar to caesarian section, the uterus is opened through a small abdominal incision and the fetus is removed. Hysterotomy is usually performed only when other methods have failed repeatedly, it is performed under general anesthesia. It is used between the 12th and the 24th week of pregnancy. This method has the greatest risk of complications out of all the abortion procedures, maternal mortality rate is approximately 200 per 100,000 abortions.

B. Spontaneous Main article: Miscarriage Spontaneous abortion, also known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 20th to 22nd week of gestation. A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth". When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn". Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.
Spontaneous abortion or miscarriages - is a type of abortion that occur without medical or other intervention. About 25% of all pregnancies result in miscarriages, women older than 35 or younger than 17 years old and couples who have difficulty in achieving pregnancy; and women who have had at least two miscarriages has a higher chance of experiencing miscarriage. About 90% of miscarriages occur during the first trimester (first three months, or 12 weeks of pregnancy). Some cases of miscarriages happen even before a woman realizes that she is pregnant, and she even may not realize that she has aborted. Symptoms of Miscarriage: • A typical 10th week miscarriage is characterized by a very heavy menstrual period. A pregnant woman may experience several days of bleeding and cramps before the contents of the uterus are removed, followed by a short period of bleeding until the lining of the uterus heals. • Miscarriage after the 12th week is like a mild version of the labor of during childbirth, with strong contractions that dilate the cervix and expel the fetus. • Miscarriages between the 13th and 24th weeks (second trimester) are most often caused by faulty attachment of the placenta to the walls of the uterus or from a weak cervix that dilates too soon. Medical names of the various stages of actual or possible miscarriages: • Threatened abortion is a condition of pregnancy, occurring before the 20thweek of gestation, the patient usually experiences vaginal bleeding with or without some cramps, and the cervix is closed. Bed rest is usually the only treatment needed. In a few cases the symptoms disappear and the rest of the pregnancy is normal. • Inevitable abortion is when the bleeding continues and becomes heavy, it usually means that the cervix is dilating and the contents of the uterus are being expelled. Pregnant women will experience lower abdominal cramping and bleeding. • Complete abortion is when all the contents are expelled. There is no treatment other than rest is usually needed. All of the tissues that came out should be saved for examination by a doctor to make sure that the abortion is complete. The laboratory examination of the saved tissue may determine the cause of abortion. • Incomplete abortion is a name given to abortion where the uterus retains part or all of the placenta. Bleeding may occur because part of the placenta may adhere to the uterine wall and the uterus does not contract to seal the large blood vessels that feed the placenta. The usual treatment is a drug that induces labor by stimulating uterine contractions, a surgical procedure called curettage can also be done to remove the remaining material from the uterus, the goal of this treatment is to prevent prolonged bleeding or infection. • Missed abortion - is a case in which an intrauterine pregnancy is present but is no longer developing normally. Before widespread use of ultrasonography, the term missed abortion was applied to pregnancies with no uterine growth over a prolonged period of time, typically 6 weeks after its (fetus) death. A missed abortion is usually indicated by the disappearance of the signs of pregnancy except for the continued absence of menstrual periods. Missed abortions are usually treated by induction of labor by dilation (or dilatation) and curettage (D & C).

Only 30 to 50% of conceptions progress past the first trimester. The vast majority of those that do not progress are lost before the woman is aware of the conception, and many pregnancies are lost before medical practitioners have the ability to detect the presence of an embryo. Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman. The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo/fetus, accounting for at least 50% of sampled

early pregnancy losses. Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus. Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion. A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.

Induction methods

Surgical

A vacuum aspiration abortion at eight weeks gestational age (six weeks after fertilization). 1: Amniotic sac 2: Embryo 3: Uterine lining 4: Speculum 5: Vacurette 6: Attached to a suction pump In the first 15 weeks, suction-aspiration or vacuum abortion is the most common method. Manual vacuum aspiration (MVA) abortion consists of removing the fetus or embryo, placenta and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) abortion uses an electric pump. These techniques are comparable, and differ in the mechanism used to apply suction, how early in pregnancy they can be used, and whether cervical dilation is necessary. MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation.Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. Curettage refers to cleaning the walls of the uterus with a curette. The World Health Organization recommends this procedure, also called sharp curettage, only when MVA is unavailable.[24]

From the 15th week until approximately the 26th, other techniques must be used. Dilation and evacuation (D&E) consists of opening the cervix of the uterus and emptying it using surgical instruments and suction. Premature labor and delivery can be induced with prostaglandin; this can be coupled with injecting theamniotic fluid with hypertonic solutions containing saline or urea. After the 16th week of gestation, abortions can also be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called "partial-birth abortion," which has been federally banned in the United States. In the third trimester of pregnancy, abortion may be performed by IDX as described above, induction of labor, or by hysterotomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy.
[25]

Other methods

Bas-relief at Angkor Wat, Cambodia, c. 1150, depicting a demon inducing an abortion by pounding the abdomen of a pregnant woman with a pestle.[26][27] Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine: tansy,pennyroyal, black cohosh, and the nowextinct silphium (see history of abortion).[28] The use of herbs in such a manner can cause serious—even lethal—side effects, such as multiple organ failure, and is not recommended by physicians.[29] Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.[30] In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage.[26] One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to theunderworld.[26] Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where surgical abortion is legal and available.[31] Safety The health risks of abortion depend on whether the procedure is performed safely or unsafely. The World Health Organization defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities. [32] Abortion, when performed in the developed world in accordance with local law, is among the safest procedures in medicine.[1][33] In the US, the risk of maternal death from abortion in 1999 was 0.567 per 100,000 procedures, making abortion approximately 12.5 times safer than childbirth (7.06 maternal deaths per 100,000 live births).[34] The risk of abortion-related mortality increases with increasing gestational age, but remains lower than that of childbirth through at least 21 weeks' gestation.[35][36] Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital. Complications are

rare and can includeuterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate.[37] Preventive antibiotics (such as doxycycline or metronidazole) are typically given before elective abortion,[38] as they are believed to substantially reduce the risk of postoperative uterine infection. [39] Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen. A 2008 Cochrane Library review found that dilation and evacuation was safer than other means of second-trimester abortion.[40] Medical abortion with mifepristone and misoprostol is effective through 49 days of gestational age.[41] It has been used in women up to 63 days of gestational age, albeit with an increased risk of failure (requiring surgical abortion).[42] Medical abortion is generally considered as safe as surgical abortion in the first trimester, but is associated with more pain and a lower success rate (requiring surgical abortion).[43] Overall, the risk of uterine infection is lower with medical than with surgical abortion.[41] Unsafe abortion

Soviet poster circa 1925, warning against midwives performing abortions. Title translation: "Abortions performed by either trained or self-taught midwives not only maim the woman, they also often lead to death." Main article: Unsafe abortion In contrast, unsafe abortion is a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries. [1] Unsafe abortion is believed to result in approximately 68,000 deaths[44] and millions of injuries annually.[1] Groups such as the World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.[45] Women seeking to terminate their pregnancies sometimes resort to unsafe methods, particularly when access to legal abortion is restricted. They may attempt to self-abort or rely on another person who does not have proper medical training or access to proper facilities. This has a tendency to lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.[46] The legality of abortion is one of the main determinants of its safety. Restrictive abortion laws are associated with a high rate of unsafe abortions.[2][47][48][49][45] For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications,[50] with abortion-related deaths dropping by more than 90%.[51] In addition, a lack of access to effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by as much as 73% without any change in abortion laws if modern family planning and maternal health services were readily available globally.[52] Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits,[4] while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria. [53] While maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year.[2] Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide,[54] though this

varies by region.[55] Secondary infertility caused by an unsafe abortion affects an estimated 24 million women.[48] Although the global rate of abortion declined from 45.6 million in 1995 to 41.6 million in 2003, unsafe procedures still accounted for 48% of all abortions performed in 2003.[47] Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address this phenomenon. Breast cancer hypothesis Main article: Abortion–breast cancer hypothesis Some studies have suggested an association between abortion and breast cancer. Proponents of a causal link between the two suggest that the interruption of normal breast development during pregnancy leaves immature cells that are more cancerprone in the breasts. However, major medical bodies, including the World Health Organization, the US National Cancer Institute, the American Cancer Society, the Royal College of Obstetricians and Gynaecologists, and the American Congress of Obstetricians and Gynecologists, have all concluded on the basis of existing evidence that abortion does not cause breast cancer. The concept of a causal link between induced abortion and breast cancer is currently promoted primarily by pro-life groups. Mental health Main article: Abortion and mental health The current scientific consensus holds that there is no causal relationship between abortion and mental-health problems. Some factors in a woman's life, such as emotional attachment to the pregnancy, lack of social support, or pre-existing psychiatric illness increase the likelihood of experiencing negative feelings after an abortion. The American Psychological Association has concluded that a single abortion is not a threat to women's mental health, and that women are no more likely to have mental-health problems after a first-trimester abortion than after carrying an unwanted pregnancy to term. Similarly, abortions performed after the first trimester because of fetal abnormalities are not thought to cause mental-health problems. Some studies have disagreed with above conclusions; other researchers and professional organizations have noted that such studies typically fail to use appropriate comparison groups, do not adequately account for confounding variables, improperly account for pre-existing mental health complications or and their degree of severity. Some proposed negative psychological effects of abortion have been referred to by prolife advocates as a separate condition called "post-abortion syndrome", which is not recognized by any medical or psychological organization.

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