Termination of first-trimester pregnancy is typically either done medically or via surgical methods. Although both methods are exceedingly safe, they both have their pros and cons. Approximately a million abortions were provided in the US in 2020, the overall rate has been steadily decreasing. Of note, first trimester abortions account for over 90% of all abortions. Surgical abortion is the most common method of abortion in the US however, the choice depends on the patient preferences, as well as clinician experience and legislative barriers to access.
Medical Abortion:
Medical abortion is the use of medications to terminate a pregnancy. The most common medications used for medical abortion are mifepristone and misoprostol. The procedure is usually performed in the first 10 weeks of pregnancy. Mifepristone is taken first and blocks the hormone progesterone, which is necessary for pregnancy to continue. Misoprostol is taken a 24-48 hours later and causes the uterus to contract and expel the pregnancy. This method is similar to a “miscarriage”. Medical abortion is exceedingly safe with an over 98% success rate and the rate of complications are exceedingly rare.
Benefits of Medical Abortion:
- Medical abortion is non-invasive and avoids surgical incisions or instruments as well as anesthesia. Thus, the risks from anesthesia are avoided.
- Medical abortion can be done at comfort of your home via telemedicine or in a private medical setting, making it more discreet than surgical abortion as well as providing women with a greater degree of control over the process, particularly avoiding travel issues that can rise due to ongoing legislative barriers.
- Medical abortion is usually less expensive than surgical abortion. This is because it does not require the use of surgical instruments or anesthesia and in most cases nothing more than a “telemedicine” visit.
- Since medical abortion does not involve surgical instruments, the risk of infection is lower than in surgical abortion and thus no antibiotics are needed routinely after the procedure.
- Patients undergoing medical abortion have reported that they felt more in control and that the procedure felt more natural. Furthermore, in studies more patients reported that if they had to get an abortion again, they’d choose a medical abortion compared to a surgical one. (63 vs 96%)
Limitations of Medical Abortion:
- Medical abortion is less effective than surgical abortion, meaning there’s an increased chance of a “failed abortion” or retained products of conception. This means that some women may require a second dose of medication or a surgical abortion to complete the termination of pregnancy in about 2-5% of the cases.
- Medical abortion involves taking medication over several days, which can be a longer process than surgical abortion.
- Patients may experience longer discomfort during a medical abortion due to the cramping and bleeding that can go on for several days and thus may also have greater recognition of level of blood loss as well as passage of pregnancy tissue.
- Patients with severe anemia or blood disorders may not be suitable candidates for medication abortion.
- Overall complications are more common with medication abortion then aspiration owing to higher risk of incomplete or failed abortion.
Surgical Abortion:
Surgical abortion is the use of surgical instruments to remove the pregnancy from the uterus. Termination of pregnancy by uterine aspiration is also known as aspiration curettage, dilation & curettage, or dilation and evacuation and is the most common method of abortion in the US.
This procedure is usually performed in a medical setting may it be a doctor’s office or an outpatient surgery center, and anesthesia (either general or local) is typically required. Surgical abortion, is more than 99% successful and can be safely provided as an outpatient. Antibiotic prophylaxis is also typically provided to help prevent infections and the most common side effects are either anesthesia or infection related.
Benefits of Surgical Abortion:
- Surgical abortion is highly effective, with a success rate of over 99%. This means that the procedure is less likely to require a second procedure to complete the abortion.
- Surgical abortion is a quick procedure that can be completed in as little as 10-15 minutes and the patients can leave as quickly as after 20-30 minutes of recovery, knowing that the abortion is complete.
- Uterine aspiration has a more predictable bleeding/recovery course post operation, thus maybe beneficial to those with particular socioeconomic requirements such as time off work, issues surrounding childcare or travel.
Limitations of Surgical Abortion:
- Owing to ever increasing legislative and regulatory barriers, access to surgical abortion has been curtailed around the US, thus access maybe ever costly and limited.
- Surgical abortion may be associated with an extremely slight risk of adverse pregnancy outcomes such as preterm birth or low birth weight; however, the data is not definitive and differing studies have found nonconclusive results.
- Contraindications to the procedure include anatomical conditions such as fibroids, which may also increase the risk of failure of abortions.
- Possibly owing to anesthesia, and the invasiveness of the procedure, there may be a risk of increased feelings of anxiety as well as stress.
The main factor affecting choice of procedure is patient experience. Ideally patients should be offered both medical abortion as well as surgical abortion as an option, particularly in the first trimester; however, owing to the legislative controversies in the US, this maybe progressively harder. Both abortion methods are extremely safe (statistically safer than driving to the appointment), as well as are not associated with any long-term negative outcomes, breast cancer nor increased risk of mental disorders. On the contrary, the most common long-term feeling associated with an abortion is “relief” and women denied abortion have higher rates of anxiety, lower levels of self-esteem as well as life satisfaction. While both procedures have their pros and cons, medical abortion is mainly more discreet, and more cost-effective as well as easily accessible owing to telehealth. Surgical abortion on the other hand almost 100% successful within minutes and has a lower risk of incomplete abortion. Ultimately, the decision to have a medical or surgical abortion lies with the patient.
Reference:
Guttmacher Institute Abortion Provider Census, 2022: https://www.guttmacher.org/article/2022/06/long-term-decline-us-abortions-reverses-showing-rising-need-abortion-supreme-court
How much does an abortion cost? Planned Parenthood, 2022:
Robson SC, Kelly T, Howel D, et al. Randomised preference trial of medical versus surgical termination of pregnancy less than 14 weeks’ gestation (Tops). Health Technol Assess. 2009;13(53):1-124, iii-iv.
Kortsmit K, Mandel MG, Reeves JA, et al. Abortion surveillance – united states, 2019. MMWR Surveill Summ. 2021;70(9):1-29.
Gatter M, Cleland K, Nucatola DL. Efficacy and safety of medical abortion using mifepristone and buccal misoprostol through 63 days. Contraception. 2015;91(4):269-273.
Jensen JT, Astley SJ, Morgan E, Nichols MD. Outcomes of suction curettage and mifepristone abortion in the United States. A prospective comparison study. Contraception. 1999;59(3):153-159.
Ireland LD, Gatter M, Chen AY. Medical compared with surgical abortion for effective pregnancy termination in the first trimester. Obstet Gynecol. 2015;126(1):22-28.
Hogue CJ, Cates W, Tietze C. Impact of vacuum aspiration abortion on future childbearing: a review. Fam Plann Perspect. 1983;15(3):119-126.
Saccone G, Perriera L, Berghella V. Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2016;214(5):572-591.
Robson SC, Kelly T, Howel D, et al. Randomised preference trial of medical versus surgical termination of pregnancy less than 14 weeks’ gestation (Tops). Health Technol Assess. 2009;13(53):1-124, iii-iv.
Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women’s mental health and well-being 5 years after receiving or being denied an abortion: a prospective, longitudinal cohort study. JAMA Psychiatry. 2017;74(2):169-178.
Beral V, Bull D, Doll R, Peto R, Reeves G, Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83?000 women with breast cancer from 16 countries. Lancet. 2004;363(9414):1007-1016.
