Pregnancy OptionsPregnancy Options

Julie Moldenhauer, MDReproductive Genetics

Maternal Fetal MedicineObstetrics and Gynecology

ObjectivesObjectives

Review background information relating to

pregnancy options

Discuss management options for pregnancy

Review timing, benefits and risks of various

options

Review options in multiple gestations

In the U.S. 47% of pregnancies are In the U.S. 47% of pregnancies are unplanned. unplanned.

Finer 2006, Perspectives on Sexual and Reproductive Health Henshaw SK: Family Planning Perspectives 1998;30:24-29.

• Pregnancy intendedness is associated with adverse obstetric, neonatal and parenting outcomes

Every woman who is diagnosed with an Every woman who is diagnosed with an unplanned pregnancy should be made unplanned pregnancy should be made

aware of all of her options.aware of all of her options.

• Continuation of pregnancy

Termination

Adoption

Hacker, Moore and Gambone. Essentials of Obstetrics and Gynecology, 4th Ed.

BackgroundBackground

• 1973 Roe v. Wade Supreme Court decision legalized abortion in the U.S.

• Abortion laws vary state by state• Gestational age limits• 24 hour wait time prior to procedure• Teens and parental notification

Pregnancy TerminationPregnancy Termination

• Language:

• Termination

• Abortion

• Elective abortion

• Therapeutic abortion

• Interruption of pregnancy

• Definition: The removal of a fetus or embryo from the uterus before the stage of viability

• Indications

• Personal choice

• Medical recommendation

• Anomalous fetus

• Intrauterine infection or

Septic abortion

• Methods

• Dependent upon gestational

age and provider abilities

Medications Used in Medical AbortionsMedications Used in Medical Abortions

• Medical abortions are performed early in gestation – typically < 9 weeks (63 days) from LMP (Last Menstrual Period)

• Mifepristone – progestin analogue that binds to the progesterone receptor and acts as an antiprogestin. Results in separation of the trophoblast from the endometrial wall, increases endogenous prostaglandin release, sensitizes the myometrium to exogenous prostaglandins, and softens the cervix. Administered orally. Side effects: abdominal pain, nausea, vomiting, diarrhea, dizziness, fatigue, and fever.

• Misoprostol – prostaglandin E1 analogue that causes uterine contractions resulting in cervical softening and dilation. Administered orally and vaginally. Side effects: nausea, vomiting, fevers, chills.

• Methotrexate – antimetabolite that inhibits the enzyme dihydrofolate reductase interfering with DNA production. It targets rapidly dividing cells and interferes with implantation. Contraindicated in women with kidney disease, liver dysfunction or anemia. Administered orally or intramuscularly. Side effects: nausea, vomiting, diarrhea, fever, chills, headache, dizziness, and oral ulcers.

Termination in Early Gestation: Termination in Early Gestation: Medical AbortionMedical Abortion

• < 49 days from LMP

• Mifepristone followed 2 days later by misoprostol orally

• FDA approved: 600 mg mifepristone/400micrograms misoprostol

• 92-99% complete abortion

• Most effective method of termination < 49 days from LMP

• Variation on dosing and route

• Studies validate this regimen up to 63 days from LMP

• Performed as outpatient, readily available and pain managed with

NSAIDS

• Proportion of women will require surgical procedure to evacuate

contents of uterus if incomplete. Recommend follow-up visit to check

for negative pregnancy test or ultrasound.

• Bleeding occurs for about 14 days after procedure

Termination in Early Gestation: Termination in Early Gestation: Medical AbortionMedical Abortion

• Methotrexate followed by misoprostol

• < 49 days from LMP

• ~ 95% complete abortion

• Misoprostol alone

• Typically used <63 days from LMP

• Varying doses and routes of administration

• > 85% effective

Termination in Early Gestation:Termination in Early Gestation:Surgical – Vacuum AspirationSurgical – Vacuum Aspiration

• Up to 12 completed weeks

• Suction procedure

• Manual vacuum aspiration

• Electric vacuum aspiration

• 95-100% effective

• < 0.1% complication rate

• Inexpensive

• Typically done as outpatient with local

anesthesia or premedication

• When performed <6 weeks more

• likelihood of retained products

http://www.who.int/reproductive-health/impac/Procedures/Manual

www.ipas.org/Library/News/News

World Health Organization.Safe abortion : technical and policy guidance for health systems. 2003.

Surgical Procedures: D&C and D&ESurgical Procedures: D&C and D&E

• Require accurate determination of gestational age

• Involve manual dilation of cervix and removal of intrauterine contents

• Require anesthesia and typically more expensive

• Destructive procedures requiring both aspiration and sharp curettage

• D&C: Dilation and Curettage – “Sharp curettage”

• Up to 12 weeks

• Can typically be done with minimal anesthesia as outpatient

• D&E: Dilation and Evacuation

• 12+ weeks

• Typically done in an OR setting using heavy sedation/anesthesia

• Requires more operator skillWorld Health Organization.

Safe abortion : technical and policy guidance for health systems. 2003.

Barcointernational.se

Cookmedical.com

www.berkeleymedevices.com/dispbles.html

thomasmedical.com

LaminariaDilipan

Cervical DilatorsCurettes

Second Trimester Medical ManagementSecond Trimester Medical Management

• Typically used > 14 weeks

• Similar to an induction of labor – many options for management

• Cervical ripening

• Misoprostol

• Foley bulb

• Laminaria

• Multiple agents

• Pitocin

• Misoprostol**

• Inpatient procedure – expensive

• Pain management

• Most women will deliver within 24 hours

• Fetus delivered intact – autopsy available

• Risk of failure/retained products of conception and the need for D&C or D&E

World Health Organization RecommendationsWorld Health Organization Recommendations

World Health Organization. Safe abortion : technical and policy guidance for health systems. 2003.

Maternal Mortality in the United States: Maternal Mortality in the United States: 12.1 deaths per 100,000 live births12.1 deaths per 100,000 live births

Hoyert DL. Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 3(33). 2007.

SafetySafety

Grimes DA et al. Lancet 2006;368:1908-1919

According to WHO an unsafe abortion is defined as: A procedure for terminating an unintended pregnancy carried out either by persons lacking the

necessary skills or in an environment that does not conform to minimal medical standards, or both.

SafetySafety

Grimes DA et al. Lancet 2006;368:1908-1919

• Morbidities associated

with unsafe abortion:

• Bleeding

• Infection

• Poisoning

• Damage to vagina,

cervix, uterus, and

other abdominal

organs

• Death

SafetySafety• Approximately 20 million unsafe abortions take

place annually worldwide– 97% of these occur in developing nations– 68,000 women die – Case-fatality rate 367 deaths/100,000 unsafe abortions

• In the United States the case-fatality rate is < 1 death per 100,000 procedures

• Overall complication rate:– 0.7/1000 procedures requiring hospitalization– 8/1000 procedures less serious complications

Grimes DA et al. Lancet 2006;368:1908-1919

Grimes DA and Creinin MD. Ann Int Med 2004;140:620-626.

Hakim-Elahi et al. Obstet Gynecol 1990;76:129-135.

Special Consideration: MultiplesSpecial Consideration: Multiples

• Higher order multiples – triplets, quads,etc

• High risk pregnancy category with

outcomes dependent upon gestational age

at delivery

• Option of MultiFetal Pregnancy Reduction

(MFPR)

• Ultrasound guided needle technique to

deliver cardiotoxic agent to fetus(es) to

reduce the overall number

Special Consideration: MultiplesSpecial Consideration: Multiples

• Selective Reduction of an

abnormal co-twin to optimize

survival or outcome for normal

twin

• Procedure dependent upon

placentation, clinical picture and

practitioner skill

• Cardiotoxic agents cannot be used

in monochorionic cases

• Options for monochorionic:

• Umbilical cord ligation

• Radiofrequency Ablation

• Alcohol/Sclerosing Agents http://www.chop.edu/consumer/jsp/division/generic.

http://fetus.ucsfmedicalcenter.org/twin/trap_sequence.asp

AdoptionAdoption

• Open Adoption

• Birth parent(s) choose adoptive parents and are involved

after adoption completed.

• Semi-Open Adoption

• Birth parent(s) choose adoptive parents, but are not involved

after birth/adoption completed.

• Closed Adoption

• No identifying information is known on either side of the

adoption. Typically medical history is shared.

AdoptionAdoption

• Birth records can also be “sealed”

• Legal agreements between adoptive adults

are void once the child reaches the age of

majority, typically 18

• Laws vary state by state

• Adoptions can be arranged privately or

through governmental programs

SummarySummary

• Options are available to women/couples diagnosed with unplanned

pregnancies and they should be counseled about these options.

• Pregnancy prevention is preferred.

• Routine prenatal care should occur in continuing pregnancies.

• Termination of pregnancy is a safe option.

• Method is dependent upon gestational age and patient preference.

• Laws vary state by state.

• Adoptions can be set up to meet the expectations of both the

biological and adoptive parents.