Unintended Pregnancy

Epidemiology

Elective pregnancy termination is sought in 43% of unintended pregnancies
Unintended Pregnancy accounts for 50% of approximately 6.6 Million pregnancies per year
1. Approximately 3.3 Million unintended pregnancies per year (2008)
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
Costs
1. Vaginal Delivery costs $30,000 and Cesarean Section costs $50,000 (as of 2010)
References
1. Finer (2014) Am J Public Health 104(suppl 1): S43-8 [PubMed]

Risk Factors

Difficult access to Contraception
Age 20-24 years old
Less social support
Major Depression symptoms
Emotional stress
Childhood Sexual Assault
Intimate Partner Violence
Decreased social support

Evaluation

See Pregnancy Dating

Management
Counseling

Approach
1. Offer assistance in non-judgemental manner
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

Management
Elective Termination

General
1. Guttmacher Institute Summary of Elective Termination laws
  1. http://www.guttmacher.org/statecenter/
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]
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)
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
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

Management
Self-Medicated Termination of Pregnancy

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
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)
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
References
1. Wetterer (2023) Am Fam Physician 108(5): 519-22 [PubMed]

Prevention

See Contraception

References