Elective Abortion
Updated: Nov 03, 2025
- Author: Frances E Casey, MD, MPH; Chief Editor: Michel E Rivlin, MD
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Elective termination of pregnancy remains common in the United States and worldwide; however, controversy and debate about abortion are ongoing. After the 1973 US Supreme Court's Roe v Wade decision legalized abortion, the number of these procedures performed annually in the United States increased, with a peak of 1.6 million in 1990. The number of terminations decreased steadily over the following decades but started to increase after 2017. []
More than 1 million abortions were provided by clinicians in states without total bans in 2023, according to estimates from the Guttmacher Institute. That number represented an 11% increase from 2020. Much of the rise was due to increases in states without bans that border states with bans; these states reported a 38% increase in the number of abortions between 2020 and 2023. []
Worldwide, some 20-30 million legal abortions and an estimated 25 million unsafe abortions are performed annually. Unsafe abortions cause about 39,000 deaths each year, and most of these deaths (97%) occur in lower-income countries. [, ]
In 2022, the US Supreme Court’s Dobbs v Jackson Women’s Health Organization (Dobbs) decision overturned Roe v Wade. This ruling returned regulatory authority over abortion to individual states.
State laws vary drastically, which can create significant legal ambiguity and risk for healthcare providers. Forty-one states now ban abortion altogether or at varying gestational ages and with varying exceptions. Clinicians must be aware of their specific state's restrictions, which may include the following [] :
Criminalization of abortion care
Gestational limits or near-total bans on the procedure
Mandatory waiting periods - These require that a patient seeking to terminate a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives anywhere from 24 to 72 hours before the procedure
State-mandated counseling scripts - These may include misinformation about future fertility or unreferenced information on topics such as fetal pain and the psychological effects of abortion
Parental consent or notification requirements for minor patients - These laws often include waiting periods and fairly limited provisions for judicial bypass
Targeted Regulation of Abortion Providers (TRAP) laws, such as facility structural requirements (eg, specifications for procedure room size and corridor width) that have little to no impact on patient safety
Public funding restrictions, with most states banning the use of public funds (eg, Medicaid) for abortion services
In the context of international laws, restrictive regulations and laws do more to increase the morbidity and mortality associated with abortions and do not present alternatives to obtaining abortions.
Providers of elective induced abortions have generally been obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other healthcare providers—physicians in other specialties, physician assistants, nurse practitioners, and certified nurse midwives—to perform these procedures. Various factors over the years have reduced the overall number of providers.
It has been shown that the availability and type of abortion training is independently associated with abortion procedural experience. The number of abortion providers in the United States has declined because of the aging population of providers and the lack of training during residency. []
Abortion is the only common surgical procedure that is elective in obstetric and gynecologic residencies. Students are able to opt out of the training if they are morally opposed to abortion. Thus, few board-certified gynecologists are qualified to perform the procedure. Violence against providers and clinics has further decreased providers' willingness to provide abortion services.
A survey study found that following the Dobbs decision, approximately 1 in 6 clinicians who provide abortion care said they had relocated to a new state to practice. About 42% of those previously practicing in a state with an abortion ban said they had moved to a state without such rules. []
The lack of abortion providers is underscored by the fact that 90% of counties in the United States have no abortion services. [] As the number of providers has decreased and abortion restrictions have increased, patients are traveling farther to obtain abortions and thus may present later in pregnancy; they are often unable to obtain services if they are poor and live in rural areas.
Medication abortion protocols have the potential to expand the number of available providers because they require significantly less infrastructure and staffing than are needed for procedural abortion. Additionally, a study showed that healthcare providers who do not perform procedural pregnancy terminations have indicated a willingness to provide medication abortions. [] Finally, the increase in nurse practitioners with prescribing privileges and the growth of telemedicine can also expand access to abortion care.
The use of self-managed abortion appears to be increasing among US females of reproductive age, from 2.4% before the Dobbs decision to 3.3% afterward. [] Most self-managed medication abortions are performed safely with misoprostol, either in combination with mifepristone or alone. []
The ability to define therapeutic abortion performed for maternal indications is difficult because of the subjective nature of decisions made about potential morbidity and mortality in pregnant women. A variety of medical conditions in pregnant women have the potential to affect health and cause complications that may be life-threatening.
Prenatal screening in the form of prenatal diagnostic testing continues to improve the antepartum diagnosis of fetal anomalies. The decision to continue or terminate a pregnancy complicated by fetal anomalies is a difficult decision. The most difficult decisions are associated with anomalies that are unpredictable or highly variable in their expression.
The increase in the use of assisted reproductive technologies has been associated with an enormous increase in multifetal pregnancies. Twins have increased in frequency from 1 set per 90 pregnancies to 1 set per 45 pregnancies. Higher-order multifetal pregnancies have quadrupled in recent decades. These pregnancies are complicated by increased fetal morbidity and mortality rates, which are largely caused by prematurity and growth restriction. Selective reduction has been introduced as a technology to improve perinatal outcomes in these pregnancies and has been successful in reducing preterm deliveries and associated perinatal morbidity and mortality.
Indications for pregnancy termination
There are medical factors both maternal and fetal that contribute to the decision. These factors have been termed therapeutic abortion, defined as the termination of pregnancy for medical indications.
Medical illness in the mother in which continuation of the pregnancy has the potential to threaten the patient's life or health is a factor. The maternal medical condition and a reasonable prediction of future circumstances as well as the consequences of the pregnancy as it progresses must be considered.
The total incidence of malignancy during pregnancy is estimated at 1 case per 1000 pregnancies. The most common cancers found in pregnant women mirror those found in their nonpregnant counterparts, to include the following:
Cervical cancer (1 case per 2200 pregnancies)
Breast cancer (1 case per 3000 pregnancies)
Melanoma (0.14-2.8 cases per 1000 pregnancies)
Ovarian cancer
Thyroid cancer
Leukemia (rare)
Lymphoma
Colorectal carcinoma (0.10-1.0 cases per 1000 pregnancies)
Rape or incest and fetal anomalies when pregnancy outcome is likely to be the birth of a child with significant mental or physical defects or high likelihood of intrauterine or neonatal death are also considered.
Approximately 3-5% of all newborns have a recognizable birth defect. The suggested causes of fetal anomalies are as follows [] :
Genetic (ie, chromosomal) (20-25%)
Fetal infection (3-5%)
Maternal disease (4%)
Drugs/medications (< 1%)
Unknown (65-70%)
The data that indicate increased maternal risk from fetal demise primarily date from the pre-ultrasonography era, when prolonged retained products of conception put the patient at risk of coagulopathies. Current management thus centers on prompt diagnosis and uterine evacuation, particularly in the second trimester.
The development of accurate over-the-counter pregnancy tests allows for the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in this very early time frame have been termed menstrual extractions, a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed extremely early suction evacuations without histologic tissue confirmation, allowing for maximum confidentiality for both patient and provider.
Abortions performed prior to 9 weeks from the last menstrual period (LMP) (7 weeks from conception) are performed either surgically or medically. Most procedural abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.
The following methods are available for procedural abortion (also referred to as surgical abortion):
Manual vacuum aspiration (menstrual extraction) is used at 4-10 weeks' gestation and is 99.2% effective
Suction curettage is used at 6-14 weeks' gestation
Sharp curettage alone is not recommended owing to risk of increased blood loss, adhesive disease, and retained products of conception (POC) compared with suction
Dilation and evacuation (D&E) is used at 14-24 weeks' gestation
Intact dilation and extraction (D&X) is used at more than 18 weeks' gestation but is not performed in the United States without prior feticide treatments due to current laws.
Hysterotomy is used at 12-24 weeks of gestation and is reserved for the rare instances in which all other methods of abortion have failed or are contraindicated
Hysterectomy is reserved for rare instances in which other gynecologic pathology dictates removal of the uterus
Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 92.8% of abortions are performed at or before 13 weeks’ gestation, and 78.6% are performed at or before 9 weeks’ gestation. []
In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. Hysterectomy/hysterotomy procedures have the highest risk of complications but may still have a role in very rare clinical situations (eg, stenotic cervical os, placenta accreta). D&E is considered the safest form of abortion in the second trimester. Little published data exist regarding the frequency or complication rates for D&X. A retrospective study showed comparable complication rates and obstetric outcomes between these two procedures when performed by experienced physicians. []
Labor induction methods have an increased risk of complications such as retained placenta as compared with D&E. [, ] Women with a history of prior cesarean delivery are at increased risk of morbidity/mortality when undergoing labor induction as a form of abortion. Labor induction has been associated with an increased odds ratio of uterine rupture and risk of blood transfusion in women with a history of prior cesarean delivery as compared with those without a uterine scar. Women with a history of a prior cesarean delivery may safely be offered D&E by a trained provider without increased risk.
The US Food and Drug Administration (FDA) approved mifepristone in combination with misoprostol for medication abortion at up to 70 days (10 weeks) of gestation. An estimated 63% of all abortions in the United States are medication abortions. [] Medical termination of pregnancy with mifepristone is used in nearly 100 countries worldwide.
Multiple regimens for medication abortion using drugs approved by the FDA for indications other than termination of pregnancy have come into use. Methotrexate and misoprostol are drugs approved for other indications that can also be used for medical termination of pregnancy.
Medication abortion (also referred to as medical abortion) can be accomplished with a variety of medications administered either singly or in succession. The combination of mifepristone and misoprostol has a success rate of about 95% at up to 63 days' gestation. [] If the gestational age is less than 7 weeks, the failure rate for mifepristone plus misoprostol is 2%. For misoprostol-alone regimens, a meta-analysis found the failure rate to be 11%. []
Ongoing pregnancy is rare, occurring in less than 0.4% of patients. It is more common, occurring in 3-5% of patients, to have retained products of conception, and these patients often require a suction procedure owing to ongoing symptoms. []
Medication abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Some patients require an emergency surgical abortion, and, for safety concerns, patients undergoing medication abortions need access to providers willing to perform an elective termination.
Medication abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed, the standard has been that the patient must be seen for evaluation of the completeness of the process. Many providers have also routinely used ultrasonography to assess abortion outcome. However, a study showed that use of a low-sensitivity pregnancy test and clinical examination are sufficient for completeness assessment. []
The medical regimens initiate the process with progesterone receptor blockage by mifepristone without activating the receptor. This leads to a progesterone effect withdrawal from the decidua with ensuing necrosis and eventual detachment of the placenta at its implantation site. Following this with a prostaglandin, usually misoprostol, then leads to uterine activity and expulsion of the products of conception. It works best up to day 49 of pregnancy and regimens up to day 63 are effective as well.
Clostridial sepsis has been reported after medication abortion. However, because current data do not support a specific link between clostridial infection and medication abortion, the American College of Obstetricians and Gynecologists (ACOG) does not recommend routine antibiotic prophylaxis. []
Nearly 25% of all US women will have an abortion at some point during their reproductive lives. [] In 2015-2019, 46% of all pregnancies in the United States were unintended, and 34% of those pregnancies ended in abortion. []
Globally, abortion-related mortality accounts for at least 13% of all maternal mortality. An estimated 50 million induced abortions are performed each year in developing countries, with approximately 25 million performed unsafely because of conditions or lack of provider training. While in the United States, only 1% of abortions are performed by induction, globally about 16% of all abortions, some as early as 12 weeks of gestation, are performed by labor induction.
According to data from the Centers for Disease Control and Prevention (CDC), abortion rates by racial and ethnic group per 1000 US women aged 15-44 years are 28.6 for non-Hispanic Black women, 12.3 for Hispanic women, and 6.4 for non-Hispanic White women. []
Women in their 20s account for more than half (57%) of all abortions. Abortion rates are lowest among adolescents younger than 15 years and women aged 40 years or older. []
Fertility is not impaired, and the prognosis is excellent.
The safety of abortion is well established. From 2013 to 2020, the case-fatality rate for legal abortion in the United States was 0.45 deaths per 100,000 abortions. [] In contrast, the US maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births. [] The risk of death associated with childbirth is at least 14 times higher than that with abortion, and overall morbidity associated with childbirth exceeds that with abortion. []
Mortality rates are highest with the most invasive procedures and with increasing gestational age, as follows: 0.4 of 100,000 cases at less than 8 weeks of gestation, 3 of 100,000 cases at 13-15 weeks of gestation, and 12 of 100,000 cases at more than 21 weeks of gestation. Causes of death include infection, hemorrhage, pulmonary embolism, anesthesia complications, and amniotic fluid embolism. Death rates with hysterotomy/hysterectomy are 64.9 of 100,000 cases at 13-15 weeks of gestation and 123 of 100,000 cases at more than 21 weeks of gestation.
Complications of surgical abortion vary with the technique used, training of the provider, and the gestational age of the pregnancy. In general, the more advanced the gestational age at abortion, the higher the complication rate, and the more invasive the operative procedure, the higher the complication rate.
First-trimester abortion
Complication rates are low: 0.071% for hospitalization and 0.846% for minor complications. Abortion complications requiring hospitalization include incomplete abortion (0.028%), sepsis (0.021%), uterine perforation (0.009%), vaginal bleeding (0.007%), inability to abort (0.003%), and combined pregnancy (0.002%). Minor abortion complications include infection (0.46%), repeat suction (0.18%), cervical stenosis (0.016%), cervical tear (0.01%), seizure (0.004%), and underestimate of dates (0.006%).
Manual vacuum aspiration has the following complication rates: infection, 0.7%; perforation, 0.05%; retained products of conception, 0.5%; and repeat aspiration, 0.5-0.25%.
Second-trimester abortion
In D&E and D&X, the skill and experience of the physician are the most important factors in maintaining a low complication rate. Complication rates are low but increase with gestational age. Abortion complications requiring hospitalization include perforation, hemorrhage, infection, retained products of conception, and inability to complete abortion. Overall rates of hospitalization are 0.6% at 13 weeks of gestation and 1.4% at 20-21 weeks of gestation. Coagulopathy is a rare complication in D&E, occurring in 191 of 100,000 cases.
Avoid complications by obtaining adequate cervical dilatation through using passive dilators in abortions at 14 weeks of gestation and longer and by using double placement of passive dilators at longer than 20 weeks of gestation. Have appropriate instruments available for morbidly obese patients because standard instruments may not be long enough. Match the surgeon's skill and experience to the gestational age of the pregnancy to be terminated. Choose an inpatient setting for patients with severe medical conditions, anemia, placenta previa (or other abnormal placentation), pelvic masses or large leiomyomas, or vein problems (eg, no intravenous access).
Uterine hemorrhage
Hemorrhage can be caused by atony, retained products, or perforation. Hemorrhage has been defined in a variety of ways, and the need for transfusion is exceedingly rare. If uterine hemorrhage rates include hemorrhage immediately postabortion, uterine atony rates of hemorrhage are as low as 5%. Initial hemorrhage should be evaluated by ensuring complete uterine evacuation.
General anesthesia increases the risk of atony. Blood loss of more than 300 mL in the first trimester is considered excessive. The next steps are typically medical in nature (ie, the use of intramuscular methylergonovine at 0.2 mg, the use of misoprostol 800 μg placed rectally). Carboprost tromethamine is also helpful.
Treatment also can include uterine massage, removal of retained products of conception, and repair of perforation as indicated. In the past, uterine packing has been used, but this can be accomplished effectively with the intrauterine inflation of a Foley balloon. Balloons of 5 mL can be inflated with 30 mL, or 30-mL balloons can be inflated with up to almost 100 mL, of sterile saline. The inflation should correlate with uterine size. A Bakri balloon designed for post-abortion or postpartum hemorrhage can be used.
Uterine artery embolization can be used if placenta accreta is encountered, but very few of these procedures have been performed and statistical success rates are impossible to evaluate. If ineffective, hysterectomy should be performed as a life-saving measure.
Damage to cervix
The risk of cervical damage is increased with previous surgery to the cervix or laceration. Damage can be associated with forceful dilation with metal dilators and may be associated with damage to cervical vessels, with hemorrhage and parametrial hematoma formation. Repair damage using a transvaginal approach or laparoscopy/laparotomy. Prevent damage by avoiding forceful dilation. Passively dilate the cervix using passive dilators and/or prostaglandin analogues. Delay the procedure if adequate dilation is not achieved.
Uterine perforation
Perforation has been estimated to occur in 1 per 250 cases. The perforations are usually fundal and recognized by the provider at the time of the procedure. In a study of 13,907 women who underwent outpatient termination of pregnancy, the perforation rate was 0.05%; in the second trimester (ie, procedures from 13-20 weeks), the perforation rate was 0.32%. []
Risk factors for perforation are previous terminations of pregnancy, lower-segment cesarean deliveries, and loop electrosurgical excision procedures of the cervix. The common denominator is thought to be scarring of the internal cervical os.
Fundal perforations require only observation. If the extent of the perforation cannot be determined, if the patient is medically unstable, if the suction was applied at the time of the perforation, or if bowel or fat content was obtained by forceps at the time of a perforation, surgical evaluation of the patient is necessary. The surgical evaluation may be performed by an experienced laparoscopist or by laparotomy.
Perforation can occur with sound, dilators, curette, suction tip, forceps, or passive dilators. Increased risk is associated with previous surgery or laceration involving the cervix, previous uterine surgery, and grand multiparity. In the first trimester, most perforations are in the body of the uterus. Perforation can be recognized when an instrument passes endlessly, heavy or persistent vaginal bleeding occurs, signs of peritoneal irritation appear, or fat or other tissue appears in the specimen.
If perforation is made with the sound or dilator, stop the procedure and observe the patient for a minimum of 1 hour. Antibiotic prophylaxis and ultrasonography are options. Reschedule the procedure to be performed in 2-3 weeks. If perforation occurs with suction tip or curette, stop the procedure. Options include observation if the patient is stable and the abortion is complete, laparoscopy if hemorrhage is suspected or the abortion is incomplete, and laparotomy if the patient is unstable.
Retained products of conception
Evaluation of the obtained products of conception at the time of abortion and postabortion uterine scanning have reduced the retained products of conception rate to less than 1% of cases. In one series of 170,000 cases, only a 0.5% incidence was reported in the first trimester. [] In cases of second-trimester abortions, retained tissue rates are even lower, with rates ranging from 0.2% to 0.5%. []
Cases of delayed bleeding, even after a normal cycle, have been reported. Dilatation and curettage or hysteroscopy is necessary if bleeding is brisker or if the amount of tissue is determined by sonographic evaluation to warrant more extensive procedures.
Endometritis and pelvic inflammatory disease
Infections following abortion are rare, occurring in fewer than 1% of cases. They are usually due to preexisting infections, such as bacterial vaginosis, cervicitis or salpingitis, or a failure of antibiotic prophylaxis.
Fever greater than 102°F (39°C) within 72 hours of the abortion should be considered septic abortion due to retained products. Treatment requires reaspiration followed by intravenous antibiotics (cefoxitin, clindamycin, chloramphenicol, cephalosporin with ampicillin, or penicillinase-resistant penicillin). Fever less than 102°F (39°C) should be treated with reaspiration and oral antibiotics (doxycycline 100 mg bid for 10 d).
The usual criteria should be used for the diagnosis of pelvic inflammatory disease (PID).
Fatal toxic shock
Rapidly progressing toxic shock due to the endotoxins produced by Clostridia species bacteria has been reported in 7 patients (for a rate of 1 per 750,000).
Coexistent ectopic pregnancy
Residual positive human chorionic gonadotropin (hCG) titers are not uncommon, and clinicians need to be vigilant in their evaluation of persistent positive pregnancy test results to avoid missing an ectopic pregnancy.
Pelvic ultrasonography is the most helpful tool. The presence of significant tenderness during the postoperative examination, a history of continued pain, and the elevation or plateau of hCG titers should raise concern. Coexistent intrauterine and extrauterine pregnancies are observed only in extremely rare cases.
Asherman syndrome
Postabortion uterine synechiae (or adhesions) that can obliterate part or all of the endometrial cavity have been reported. This is thought to be more likely secondary to endometritis than to the instrumentation of the uterus, but sharp curetting after the abortion procedure should be avoided to prevent denuding the basal layer of the endometrium.
The diagnosis is made based on hysteroscopy or hysterosalpingogram findings in a patient who presents with postabortion amenorrhea.
Delayed sequelae
Abortion-related hemorrhage due to retained tissue can occur up to several weeks after the procedure. In general, blood loss in excess of that of a normal menstrual period is considered significant and should prompt reaspiration.
Few long-term sequelae of abortions have been documented. Both studies of first trimester procedural and medication abortion found that risks of ectopic pregnancies and spontaneous abortions in future pregnancies were not increased. Some studies have suggested an association between induced abortion and subsequent preterm birth and low birth weight. However, these studies have been retrospective and unable to adequately adjust for confounders also contributing to these outcomes. Although a syndrome of posttraumatic stress has been reported, the literature has not been able to separate the stressors of the patient's social situation that lead to the abortion from the abortion procedure itself.
Although initial studies indicated a greater risk of breast cancer with elective termination than with term birth, a prospective cohort study indicates that no link exists between induced abortion and breast cancer. A prospective study (the Nurses' Health Study II) examined the association between induced and spontaneous abortion and the incidence of breast cancer. Most of the early data have been refuted.
Psychologic consequences of abortion
Generally, the psychological health of the abortion patient parallels her psychologic health prior to seeking an abortion. If the woman needed to have the abortion in secrecy, then long-term psychologic sequelae, such as intrusive thoughts, are more common.
Many studies have actually demonstrated improved psychological well-being after abortion. For the studies that have shown this, the improvement in psychological health is suggested to be more reflective of the patient dealing with the social issues that led her to select abortion.
Sometimes, confusion over normal emotions, such as sadness and grief versus psychological illnesses (eg, depression), seems to occur. The most common feeling experienced after an abortion is that of relief and confidence in the decision. Few women may experience feelings of grief and guilt postabortion, and these feelings usually pass within days to weeks in most cases and do not lead to psychological sequelae. One study demonstrated that the risk for serious psychiatric illness postabortion was 1%, whereas with live birth it was 10%.
Many confounding factors are involved in a women's emotional status during the time of her abortion. Relationships, religion, age, social support, and previous psychological stability all play a part.
An entirely new set of circumstances and feelings exist in cases of rape and incest. These are often psychologically complex situations and unique to each case.
Providers can help women through abortions by presenting options and explaining the procedures. Counseling with a trained professional occurs before the abortion. This is a good time to identify factors that might lead to a patient having troubling feelings after the abortion. Some factors are low self-esteem, preexisting or past psychological illness, lack of emotional support, and past childhood sexual abuse. The counselor can then confront these issues before the procedure and help the patient assess specific needs and improve coping strategies.
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