Medical abortion - induced termination of pregnancy

Abortions are not prohibited in Ukraine. The possibility of terminating a pregnancy is defined in the Civil Code of Ukraine (Article 281) and in the Law of Ukraine "Fundamentals of the Legislation of Ukraine on Health Care" (Article 50). Artificial termination of pregnancy, the term of which does not exceed 12 weeks, can be carried out at the request of the woman. From 12 to 22 weeks of pregnancy, a medical abortion can be performed only if there are indications established by law (Resolution of the Cabinet of Ministers of Ukraine No. 144 dated 15.02.06).

For patients undergoing an artificial termination of pregnancy, pre-abortion and post-abortion counseling is provided regarding the specific features of a particular method of medical abortion and the possible consequences.

Counseling is provided on a voluntary basis. The issue is especially acute for HIV-infected women. This category of the population is provided with information regarding the available options for preventing mother-to-child HIV transmission, as well as the possible specific risk of infection of the fetus and newborn.

When consulting regarding the procedure for a medical abortion, the following information is provided:

• what actions will be performed during the termination of pregnancy;
• what inconveniences may arise during and after termination of pregnancy;
• what painkillers and methods can be used before performing an abortion (it is important to remember that frequent use of painkillers reduces the effectiveness of pain relief during a medical abortion);
• what is the risk of complications with this method of medical abortion;
• after what period of time can a woman return to her normal lifestyle and resume sexual relations;
• the need and frequency of post-abortion monitoring in order to reduce the risk of complications;
• contraceptive methods that a woman can use after an abortion.

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Methods of performing medical abortion

1. Method of using mifepristone, misoprostol and prepidiaa

The patient takes 200 mg (1 tablet) of mifepristone orally in the presence of a doctor. 22-26 hours after taking mifepristone, the doctor administers 3 g of gel containing dinoprostone (0.5 mg) endocervically to the pregnant woman.

After the next 22-26 hours, the patient, in the presence of a doctor, takes 800 mcg of mizolostol (4 tablets): 2 tablets orally and 2 intravaginally.

2. In case of late-term frozen pregnancy, it is necessary to use only misoprostol - 2 tablets orally, 2 tablets intravaginally. 3.
3. Method of intra-amniotic administration of dinoprost. By transabdominal amniocentesis (puncture of the amniotic sac), at least 1 ml of amniotic fluid is removed. It is necessary to check for the absence of blood in the amniotic fluid (there should be no color).

After this, 40 mg (8 ml) of sterile dinoprost solution is very slowly injected into the amniotic sac. The first 5 mg (1 ml) is injected over 5 minutes, the remaining dose over the next 5-10 minutes.

In case of strict adherence to the noted technique, the probability of anaphylaxis, arterial hypertension, bronchospasm, and vomiting is reduced. 4.

4. A technique of intracervical administration of a gel containing dinoprost followed by induction of uterine contractions by intravenous administration of a dinoprostone solution.

In order to prepare the cervix, 3 g of gel containing dinoprost (0.5 mg) is injected into the endocervix every 6 hours until the cervical canal is opened using a Hegar dilator No. 12.

Induction of uterine contractions is performed by intravenous drip administration of 0.75 mg dinoprost in the form of a sterile solution (0.75 mg in 500 ml of isotonic sodium chloride solution). The vial with the solution is shaken to ensure homogeneity. The initial infusion rate, which is maintained for the first 30 minutes, is 0.25 mcg/min, after which the rate of administration is either left the same or increased to 50 mcg/min in each individual case (from 6-8 to 35-40 drops/min). The average infusion rate is from 20 to 25 drops/min, the infusion time is about 3.5-4 hours.

5. Method of intra-amniotic injection of hypertonic solution. Amniocentesis is performed by transabdominal, transvaginal or transcervical access. The puncture site is determined depending on the location of the placenta and the height of the presenting part of the fetus, which are specified using ultrasound.

Anesthesia is performed locally. The skin of the anterior abdominal wall is treated with a 5% alcohol solution of iodine or another antiseptic. After infiltration anesthesia (10.0 ml of 0.25-0.5% novocaine solution), a puncture is made in the anterior abdominal wall or vaginal vault, uterine wall and fetal membranes with a thick needle 10-12 cm long.

The amniotic fluid is evacuated (150-250 ml depending on the gestational age), then a 20% sodium chloride solution is slowly introduced into the amnion cavity in an amount 30-50 ml less than the volume of amniotic fluid removed. The latent period from the moment of instillation of the solution until the onset of contractions ranges from 17 to 21 hours. Spontaneous abortion usually occurs after 24-26 hours.

In order to facilitate the process of expanding the cervical canal while using all the above-mentioned methods, it is possible to use 6 to 20 laminaria sticks.

After the expulsion of the fertilized egg, it is necessary to perform curettage of the walls of the uterine cavity.

After an artificial termination of pregnancy between 12 and 22 weeks, in the event of congenital malformations of the fetus that are incompatible with life, an autopsy of the fetus is mandatory. The results of the pathological examination are filed in the "Medical Record of the Inpatient" and entered into the discharge summary.

Methodology for performing medical abortion

A medical abortion may be performed in an accredited healthcare institution of any form of ownership and departmental subordination, where emergency medical care can be provided.

Medical abortion is performed exclusively in a gynecological or day hospital by an obstetrician-gynecologist.

Medical termination of pregnancy is performed at the request of a woman up to 49 days into pregnancy from the first day of her last menstrual period.

Medical abortion is performed in the absence of medical contraindications.

Contraindications to medical abortion:

• lack of reliable data on the presence of pregnancy;
• suspected ectopic pregnancy;
• pregnancy period more than 49 days from the first day of the last menstrual period;
• allergy, hypersensitivity to mifepristone or misoprostol;
• adrenal insufficiency;
• long-term glucocorticoid therapy;
• damage to coronary or cerebral vessels;
• renal failure;
• severe liver damage and liver failure;
• porphyry;
• violation of the hemostasis system (including previous treatment with anticoagulants);
• uterine leiomyoma;
• scars on the uterus;
• breastfeeding a child;
• the woman's age is over 35 years;
• active smoking (more than 10 cigarettes per day);
• severe form of bronchial asthma;
• cardiovascular diseases.

Medical Abortion: Using Mifepristone and Misoprostol

The patient takes 200 mg (1 tablet) of mifepristone in the presence of a doctor.

36-48 hours after taking mifepristone, the pregnant woman, in the presence of a doctor, takes 2 tablets orally (400 mcg) or 800 mcg of misoprostol intravaginally and remains in the hospital all day until the termination of pregnancy, which usually occurs within 3-6 hours.

On the 7th-10th day, the obstetrician-gynecologist examines the patient and makes an entry in form No. 025/o “Medical record of an outpatient”, approved by order of the Ministry of Health of Ukraine No. 302 dated 12/27/99.

An ultrasound scan is required to confirm the absence of a fertilized egg in the uterine cavity.

In case of incomplete removal of the fertilized egg, bleeding, diagnostic curettage of the uterine cavity is performed, followed by sending the obtained material for histological examination.

Medical abortion by vacuum aspiration

Vacuum aspiration is the safest of surgical methods of pregnancy termination. The vacuum aspiration method is used instead of the uterine cavity curettage method, which is traumatic and most dangerous for a woman's health.

Medical abortion by vacuum aspiration is performed in day hospitals of women's consultations and gynecological departments of healthcare institutions by an obstetrician-gynecologist.

Vacuum aspiration of the uterine cavity is performed at a pregnancy period of no more than 8 weeks.

The women's consultation center is assigned a gynecological hospital for the hospitalization of women with complications after artificial termination of pregnancy and ensures their timely delivery by ambulance.

Medicinal pain relief is used in all cases of surgical abortion. Three types of medications are used for this purpose - separately or in combination: analgesics, tranquilizers, anesthetics. The question regarding the method of pain relief for the operation is decided individually. 

It is not advisable to perform a medical abortion under general anesthesia (narcosis), since this increases the clinical risk; anesthesia is used only in complex cases, according to indications.

Non-narcotic analgesics - non-steroidal anti-inflammatory drugs - help reduce pain.

When performing vacuum aspiration of the uterine cavity, the following is used for pain relief:

1. local anesthesia;
2. analgesia;
3. light sedation.

Manual vacuum aspiration technique

In the case of manual vacuum aspiration, the required negative pressure is created using a 60 ml plastic aspirator, which is operated manually. Most models of such aspirators are reusable, provided they are washed and disinfected or sterilized.

In pregnancy up to 2 weeks, the vacuum aspiration operation is performed in compliance with the rules of asepsis and antisepsis, without dilating the cervical canal, by inserting a plastic cannula with a diameter of 4-6 mm for vacuum aspiration into the uterine cavity, connected to a special syringe for manual vacuum aspiration.

At 6-8 weeks of pregnancy, before inserting the cannula, dilation of the cervix is performed using Hegar dilators No. 8.

Electrovacuum aspiration technique of the uterine cavity

In pregnancy up to 20 days of delayed menstruation, the operation of electrovacuum aspiration of the uterine cavity (EVA) is performed in compliance with the rules of asepsis and antisepsis, without dilating the cervical canal by inserting a plastic or metal cannula with a diameter of 4-6 mm into the uterine cavity, connected to an apparatus for termination of pregnancy. In pregnancy of 6-8 weeks, before inserting the cannula, dilation of the cervix is performed with Hegar dilators No. 8.

EVA uses an electric vacuum pump. Aspiration is performed at negative pressure up to 0.8-1.0 atm.

Curettage of the uterine cavity after vacuum aspiration is not routinely performed. If there is no certainty that the ovum has been removed, the aspirate is sent for histological examination.

Methodology for performing a medical abortion operation up to 12 weeks using curettage of the uterine cavity

Medical abortion up to 12 weeks by curettage of the uterine cavity is performed in the gynecological department of an accredited healthcare institution by an obstetrician-gynecologist. 

Examination of the patient before performing an artificial termination of pregnancy up to 12 weeks by curettage of the uterine cavity is carried out in accordance with the “Standards for the provision of medical care to the female population in the specialty “Obstetrics and Gynecology” in outpatient and polyclinic medical institutions”, approved by order of the Ministry of Health of Ukraine No. 2 503 dated 12/28/02.

If necessary, the list of methods for examining a patient may be expanded in accordance with the medical indications found in the patient.

For each woman admitted for an artificial termination of pregnancy, a "Medical Card for Termination of Pregnancy" (form 003-1/0) is filled in. The card contains the specialist's advisory conclusion and examination data.

Information on the performance of a medical abortion is entered into the "Journal of recording surgical interventions in the hospital" (form 008/0), the form of which was approved by the order of the Ministry of Health of Ukraine No. 184 dated 26.07.94. Preparation of the cervix is mandatory for women under 18 years of age, for primigravidas, if the pregnancy period is 10 weeks or more, for women who have abnormalities in the development of the cervix, for women with a history of operations and interventions on the cervix.

Preparation of the cervix for surgical abortion can be carried out using the following methods:

• vaginal administration of 400 mcg misoprostol 3-4 hours before surgery;
• Oral administration of 400 mcg misoprostol 3-4 hours before the termination of pregnancy procedure;
• Oral administration of 200 mg mifepristone 36 hours before surgery.

Medical abortion is performed with mandatory pain relief (developed individually).

To reduce pain, the time period between the administration of the painkiller and the operation should not exceed 2 minutes.

Dilation of the cervix is performed mechanically using Hegar dilators or a complex of laminaria sticks for 6-16 hours.

After dilatation of the cervix with a metal curette, scraping of the uterine cavity is performed.

The procedure and methods for performing a medical abortion, the period of which is from 12 to 22 weeks.

Artificial termination of pregnancy, the term of which is from 12 to 22 weeks, is carried out in the gynecological department of a level III healthcare institution providing inpatient obstetric-gynecological and neonatological care, in accordance with the order of the Ministry of Health of Ukraine No. 620 dated 29.12.03.

Medical abortion, the term of which is from 12 to 22 weeks, is performed by an obstetrician-gynecologist of the first or highest qualification category.

What can happen after a medical abortion?

Every woman should be informed that the next ovulation occurs 2 weeks after an abortion, which may cause another unwanted pregnancy if contraception is not used.

After a medical abortion, a woman receives information on how to prevent unwanted pregnancy, including the location of family planning health facilities.

The doctor is obliged to explain to the patient in an accessible form the state of her health, and also to tell about the harmful effects of artificial termination of pregnancy on health, including the risk to life.

Medical abortion causes irreparable harm to the health of the woman, the reproductive health of both family members. The harmful effect on health is explained by the forced intervention in the hormonal state of the woman, and termination of pregnancy is an extreme stress for the hormonal and nervous systems of the body. Even the absence of tangible complications at first glance immediately after a medical abortion can cause miscarriage (spontaneous abortion and premature birth), as well as infertility, especially if the first pregnancy is terminated.

A significant challenge for a woman's body are inflammatory complications; they can occur immediately after a medical abortion and have an acute course, as well as a latent chronic course, which causes hormonal dysfunctions: the latter, in turn, can cause benign and malignant tumors of the reproductive organs in the future.

Surgical intervention during medical abortion is accompanied by trauma to the tissues of the cervix and body of the uterus. The technical features of medical abortion are that it is performed without visual control, so complications arise quite often and a pregnant woman who resorts to medical abortion should know about this in order to be personally responsible for the decision made.

Unfortunately, after a medical abortion, complications that are delayed in time and sometimes unexpected for the woman herself can often arise, with serious consequences, the treatment of which can be long-term and expensive, with a low degree of effectiveness.

Every pregnant woman should remember that a medical abortion can worsen the psychological climate in the family, as evidenced by scientific and sociological studies. Even short-term complications after an abortion negatively affect sexual relations and are associated with dysfunction of the reproductive organs. And complications such as miscarriage and infertility become factors of social tension in the family and divorce.

Another serious warning for a woman who has decided to have a medical abortion is the interruption of conceived intrauterine life, regardless of the pregnancy period. Ukraine has ratified the Universal Convention on the Rights of the Child, one of the requirements of which is the right to life of the future child. This must be remembered!

In exceptional cases, in accordance with the List of grounds (hereinafter referred to as the List), in the presence of which artificial termination of pregnancy is possible, the term of which is from 12 to 22 weeks. According to the Resolution of the Cabinet of Ministers of Ukraine No. 144 of 15.02.06, medical abortion can be performed up to 22 weeks of pregnancy with the informed consent of the patient or her legal representatives, in the case of minority and incapacity.

If a pregnant woman has medical circumstances that are not noted in the List, but in which prolongation of pregnancy and childbirth pose a threat to her health or life (urgent conditions), termination of pregnancy is carried out based on the conclusion of a council of doctors.

Medical abortion in pregnancy after 12 weeks (up to 22 weeks) in the presence of non-medical grounds specified in the List (age of the pregnant woman up to 15 years and over 45 years, pregnancy as a result of rape or the onset of disability during this pregnancy) is carried out upon the application of the pregnant woman or her legal representatives (in the case of minority, incapacity of the person) and the provided documents that confirm these circumstances.

In urgent cases, when there is a real threat to the life of an individual, medical assistance is provided without the consent of the individual or parents (adoptive parents), guardian, or trustee.

Parents (adoptive parents), guardians, trustees and the man (with the consent of the woman) have the right to receive information about the health of the fetus or ward.

Medical workers and other persons do not have the right to disclose information regarding the state of health and methods of treatment, except in cases provided for by law. When using information that constitutes a medical secret in the educational process, scientific and experimental work, including in the case of its publication in specialized literature, the anonymity of the patient must be ensured.

In connection with a medical abortion operation, at the request of the woman, a certificate of incapacity for work is issued for 3 days, taking into account the day of the operation. In the event of complications during the operation or in the post-abortion period, a certificate of incapacity for work is issued for the entire period of temporary incapacity.

An individual who is undergoing inpatient treatment at a healthcare facility has the right to be visited by other healthcare workers, family members, guardians, trustees, notaries and lawyers.

A woman after a medical abortion must follow the recommendations of doctors, which can prevent the occurrence of complications after a medical abortion. In accordance with current legislation, the doctor is not responsible for the patient's health in the event of failure to follow his recommendations and appointments.

You should come to the doctor for a follow-up examination in 7 days or earlier if you have complaints about bleeding, pain or an increase in body temperature.

After a medical abortion, the timely use of contraception methods is of great importance in preventing unwanted pregnancy. Today in Ukraine there is a network of centers, offices, family planning points, the main task of which is to provide spouses with the opportunity to give birth to desired children, adhering to the interval between births with the least harm to health.

Visiting family planning medical institutions or receiving consultation on these issues should indicate the general culture of the population.

Each woman should demand sufficient attention when a specialist prescribes a contraceptive based on an individual approach.

After providing information on all existing methods and means of preventing pregnancy, the doctor must prescribe a contraceptive in accordance with the woman's wishes, the age and health of her and the man (partner), their reproductive plans, as well as their financial capabilities. This approach increases its effectiveness

The modern range of contraceptive methods and means gives every woman or spouse the opportunity to use the most optimal of them and not violate the rights of the unborn child.