EARLY ABORTION - SURGICAL AND MEDICAL OPTIONS

Of the 1.3 to 1.5 million legal abortions performed annually in the Un ited States, 52% occur at less than or equal to 8 weeks' gestation and 30% at less than or equal to 7 weeks' gestation. Most clinicians do n ot perform a surgical abortion before the sixth or seventh week of ges tation because of the perceived increased risk of continuing pregnancy . This further limits access above and beyond the problems associated with the lack of availability of abortion. Early surgical abortion and medical abortion are old ideas that have emerged as new technologies that may allow women to have more access to abortion very early in pre gnancy. A protocol was developed at Planned Parenthood of Houston and Southeast Texas that allowed a woman access to surgical abortion as so on as her pregnancy test was positive. After vaginal ultrasonography w as performed to confirm gestational age, a suction curettage was perfo rmed with a manual vacuum syringe and a 7 mm rigid suction cannula. Th e products of conception were immediately inspected under magnificatio n to identify the gestational sac. If no gestational sac was visualize d, appropriate follow-up of beta-hCG levels was performed. Of 2399 pro cedures, 2249 (93.7%) had verification of a gestational sac in the cur ettage specimen, and 2379 (99.2%) patients had a complete abortion; th e other 20 patients were 14 ectopic pregnancies and 6 who required res piration procedures. The rate of ectopic pregnancy was 5.8 in 1000 pro cedures, and that of continuing pregnancy was 1.3 in 1000 procedures. All continuing pregnancies were detected by appropriate follow-up as d ictated by the protocol, and repeat procedures were successful. Thus t he availability and use of vaginal ultrasonography and manual vacuum a spiration allows for successful surgical abortion very early in pregna ncy. Importantly, this procedure is not associated with a high risk of retained products of conception or need for respiration as had been p reviously described in the literature. Much focus has been placed over the past few years on the development of medical (nonsurgical) aborti on techniques so that women would have access to abortion at a very ea rly gestation. Although the potential reality of medical agents to eff ect abortion was first described in the modern literature almost 50 ye ars ago, it has only been made realistically possible within the last 20 years because of the availability of prostaglandin analogs, mifepri stone, and low-dose methotrexate. The overall effectiveness of mifepri stone regimens is approximately 95%; most side effects are gastrointes tinal (vomiting, diarrhea) and are usually a result of the prostagland in analog. The gestational age limitation is dependent on the type of analog used; at present, 63 days' gestation is appropriate with gemepr ost and 49 days' gestation with misoprostol. Alternatives to mifeprist one were sought in the United States because of its lack of availabili ty in the early 1990s. Low-dose methotrexate, commonly used for the tr eatment of early ectopic pregnancy, appeared to be a possible option. On the basis of the published literature intramuscular administration of 50 mg/m(2) methotrexate followed 5 to 7 days later by vaginal admin istration of 800 mu g in patients less than or equal to 49 days' gesta tion is 90% to 95% effective. Patients can self-administer the misopro stol and return approximately 1 week after receiving methotrexate for evaluation. Vaginal ultrasonography should be used to confirm the gest ational age before treatment is begun and after misoprostol treatment to check for expulsion of the gestational sac. Appropriate follow-up i s necessary because approximately one-third of women pass the pregnanc y after a delay of 1 to 4 weeks after the methotrexate is administered . As with mifepristone regimens, side effects are limited and gastroin testinal in nature. Methotrexate has the advantage of being inexpensiv e and widely available throughout the United States and other countrie s. This monograph will review the history, study results, and protocol s for use of early surgical and medical abortion.