Last updated: 02/17/2009

Abortions are safest when performed within the first six to 10 weeks after the last menstrual period (LMP). This calculation is used by health care providers to determine the stage of pregnancy. About 90% of women who have abortions do so in the first...

trimester of pregnancy (before 13 weeks) and experience few complications. Abortions performed between 13 and 24 weeks (during the second trimester) have a higher rate of complications. Abortions after 24 weeks are extremely rare and are usually limited to situations where the life of the mother is in danger.

Although it is safer to have an abortion during the first trimester, some second trimester abortions may be inevitable. The results of genetic testing are often not available until 16 weeks gestation. In addition, women, especially teens, may not have recognized the pregnancy or come to terms with it emotionally soon enough to have a first trimester abortion. Teens make up the largest group having second trimester abortions.

Very early abortions cost between $200 and $400. Later abortions cost more. The cost increases about $100 per week between the thirteenth and sixteenth week. Second trimester abortions are much more costly because they often involve more risk, more services, anesthesia, and sometimes a hospital stay. Private insurance carriers may or may not cover the procedure. Federal law prohibits federal funds (including Medicaid) from being used to pay for an elective abortion.

Medical abortions

Medical abortions are brought about by taking medications that end the pregnancy. The advantages of a first trimester medical abortion are:

• The procedure is non-invasive; no surgical instruments are used.
• Anesthesia is not required.

• Drugs are administered either orally or by injection.
• The outcome resembles a natural miscarriage.

Disadvantages of a medical abortion are:

• The effectiveness decreases after the seventh week.
• The procedure may require multiple visits to the doctor.
• Bleeding after the abortion lasts longer than after a surgical abortion.
• The woman may see the contents of her womb as it is expelled.

As of 2003, two drugs were available in the United States to induce abortion: methotrexate and mifepristone.

METHOTREXATE. Methotrexate (Rheumatrex) targets rapidly dividing fetal cells, thus preventing the fetus from further developing. It is used in conjunction with misoprostol (Cytotec), a prostaglandin that stimulates contractions of the uterus. Methotrexate may be taken up to 49 days after the first day of the last menstrual period.

On the first visit to the doctor, the woman receives an injection of methotrexate. On the second visit, about a week later, she is given misoprostol tablets vaginally to stimulate contractions of the uterus. Within two weeks, the woman will expel the contents of her uterus, ending the pregnancy. A follow-up visit to the doctor is necessary to assure that the abortion is complete.

With this procedure, a woman will feel cramping and may feel nauseated from the misoprostol. This combination of drugs is approximately 92–96% effective in ending pregnancy. Approximately 50% of women will experience the abortion soon after taking the misoprostol; 35–40% will have the abortion up to seven days later.

Methotrexate is not recommended for women with liver or kidney disease, inflammatory bowel disease, clotting disorders, documented immunodeficiency, or certain blood disorders.

MIFEPRISTONE. Mifepristone (RU-486), which goes by the brand name Mifeprex, works by blocking the action of progesterone, a hormone needed for pregnancy to continue. It was approved by the Food and Drug Administration (FDA) in September 2000 as an alternative to surgical abortion. Mifepristone can be taken up to 49 days after the first day of a woman's last period.

On the first visit to the doctor, a woman takes a mifepristone pill. Two days later she returns and, if the miscarriage has not occurred, takes two misoprostol pills, which causes the uterus to contract. Approximately 10% will experience the abortion before receiving the dose of misoprostol.

Within four days, 90% of women have expelled the contents of their uterus and completed the abortion. Within 14 days, 95–97% of women have completed the abortion. A third follow-up visit to the doctor is necessary to confirm through observation or ultrasound that the procedure is complete. In the event that it is not, a surgical abortion is performed. Studies show that 4.5–8% of women need surgery or a blood transfusion after taking mifepristone, and the pregnancy persists in about 1%. Surgical abortion is then recommended because the fetus may be damaged. Side effects include nausea, vaginal bleeding, and heavy cramping. The bleeding is typically heavier than a normal period and may last up to 16 days.

Mifepristone is not recommended for women with ectopic pregnancy or an intrauterine device (IUD), or those who have been taking long-term steroidal therapy, have bleeding abnormalities, or on blood-thinners such as Coumadin.

Surgical abortions

MANUAL VACUUM ASPIRATION. Up to 10 weeks gestation, a pregnancy can be ended by a procedure called manual vacuum aspiration (MVA). This procedure is also called menstrual extraction, mini-suction, or early abortion. The contents of the uterus are suctioned out through a thin plastic tube that is inserted through the cervix; suction is applied by a syringe. The procedure generally lasts about 15 minutes.

A 1998 study of women undergoing MVA indicated that the procedure was 99.5% effective in terminating pregnancy and was associated with a very low risk of complications (less than 1%). Menstrual extractions are safe, but because the amount of fetal material is so small at this stage of development, it is easy to miss. This results in an incomplete abortion that means the pregnancy continues.

DILATATION AND SUCTION CURETTAGE. Dilation and suction curettage may also be called D & C, suction dilation, vacuum curettage, or suction curettage. The procedure involves gentle stretching of the cervix with a series of dilators or specific medications. The contents of the uterus are then removed with a tube attached to a suction machine, and walls of the uterus are cleaned using a narrow loop called a curette.

Advantages of an abortion of this type are:

• It is usually done as a one-day outpatient procedure.
• The procedure takes only 10–15 minutes.
• Bleeding after the abortion lasts five days or less.
• The woman does not see the products of her womb being removed.

Disadvantages include:

• The procedure is invasive; surgical instruments are used.
• Infection may occur.

The procedure is 97–99% effective. The amount of discomfort a woman feels varies considerably. Local anesthesia is often given to numb the cervix, but it does not mask uterine cramping. After a few hours of rest, the woman may return home.

DILATATION AND EVACUATION. Some second trimester abortions are performed as a dilatation and evacuation (D & E). The procedures are similar to those used in a D & C, but a larger suction tube must be used because more material must be removed. This increases the amount of cervical dilation necessary and increases the risk and discomfort of the procedure. A combination of suction and manual extraction using medical instruments is used to remove the contents of the uterus.

OTHER SURGICAL OPTIONS. Other surgical procedures are available for performing second trimester abortions, although are rarely used. These include:

• Dilatation and extraction (D & X). The cervix is prepared by means similar to those used in a dilatation and evacuation. The fetus, however, is removed mostly intact although the head must be collapsed to fit through the cervix. This procedure is sometimes called a partial-birth abortion. The D & X accounted for only 0.17% of all abortions in 2000.
• Induction. In this procedure, an abortion occurs by means of inducing labor. Prior to induction, the patient may have rods inserted into her cervix to help dilate it or receive medications to soften the cervix and speed up labor. On the day of the abortion, drugs (usually prostaglandin or a salt solution) are injected into the uterus to induce contractions. The fetus is delivered within eight to 72 hours. Side effects of this procedure include nausea, vomiting, and diarrhea from the prostaglandin, and pain from uterine contractions. Anesthesia of the sort used in childbirth can be given to reduce pain. Many women are able to go home a few hours after the procedure.
• Hysterotomy. A surgical incision is made into the uterus and the contents of the uterus removed through the incision. This procedure is generally used if induction methods fail to deliver the fetus.