Understanding First Trimester Abortion Care: Aspiration and Medication Methods
An important first step in advocating for NPs, midwives, and PAs as abortion providers involves education about the abortion procedure itself. Although there are multiple types of abortion procedures, this article focuses on the two methods most commonly used during the first trimester of pregnancy: aspiration and medication. The vast majority of patients seeking abortion care do so in the first trimester, the time when NPs, midwives, or PAs are most likely to provide abortion care.
The Importance of Accurate Terminology
We use the term aspiration abortion when discussing first-trimester abortion care because it more accurately depicts a first-trimester abortion than does surgical abortion. Surgical implies incision, excision and suturing and is associated with the physician subpopulation of surgeons. Aspiration abortion is not surgery. Using the term surgical abortion to describe both less invasive aspiration procedures as well as more invasive procedures blurs the boundary between these very different types of procedures. Use of the term aspiration–rather than surgical–abortion is a small but important step that all of us can take to help de-mystify early abortion techniques.
Medication Abortion
Medication abortion is a method of pharmacologic termination of the early first trimester of pregnancy. Depending on the agent(s), the regimen, and the provider, medication abortion may be initiated as soon as a patient finds out she is pregnant, through 70 days of gestation (via menstrual dating). Medication abortion is an extremely safe and effective procedure.
The procedure typically involves the following medications:
- Mifepristone: Blocks the uptake of progesterone by receptor cells in the uterus. Without this essential hormone, the lining of the uterus begins to break down, and the cervix softens.
- Misoprostol: A prostaglandin analogue that stimulates uterine contractions and softens the cervix, facilitating uterine emptying.
In March 2016, the FDA-approved updated labeling for mifepristone (Mifeprex®), bringing the label in alignment with what had been proven safe and effective and was standard medical practice recommended in the American Congress of Obstetricians and Gynecologists (ACOG) practice bulletin. The percentage of cases in which the medications do not successfully terminate the pregnancy and an aspiration procedure is necessary is less than 5% of medication abortions.
Aspiration Abortion
In the first trimester, abortion can be performed as a simple office procedure using a vacuum aspirator. Most abortions performed during the first trimester use electric or manual suction to empty the uterus. These simple procedures require only local or oral analgesics and can easily be performed in a primary care setting.
During the procedure, the cervix usually is gradually stretched with tapered rods. After the cervix is dilated sufficiently, a plastic cannula attached to the suction apparatus is inserted into the uterus. Gentle suction (<60 mmHg) is applied to empty the contents of the uterus. Aspiration abortion is highly effective, with success rates (complete abortion) at 99%. It is also one of the safest medical procedures and carries minimal risk.
Comparison of First Trimester Methods
| Feature | Medication Abortion | Aspiration Abortion |
|---|---|---|
| Method | Pharmacologic (Mifepristone & Misoprostol) | Manual or electric vacuum aspiration |
| Gestation Period | Up to 70 days | First trimester |
| Success Rate | Greater than 95% | 99% |
| Setting | Initiated by provider, completed at home | Simple office procedure |
The Role of NPs, Midwives, and PAs
Politicians, regulators, and clinicians are often unaware of the basic training required to become a provider of medication or early aspiration abortion. This lack of understanding can lead to misinformed decisions that unduly restrict training and access. Primary care providers, including NPs, midwives, and PAs, provide a wide range of procedures, including intrauterine device (IUD) insertion, endometrial biopsy, management of early pregnancy loss, and abortion. Its use can assist efforts to challenge the thinking that only physicians should provide abortion care.