Unintended Pregnancy

Aka: Unintended Pregnancy, Unwanted Pregnancy, Unplanned Pregnancy, Termination of Pregnancy

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II. Epidemiology

  1. Elective pregnancy termination is sought in 43% of unintended pregnancies
  2. Unintended Pregnancy accounts for 50% of approximately 6.6 Million pregnancies per year
    1. Approximately 3.3 Million unintended pregnancies per year (2008)
  3. Risks
    1. Women ages 15 to 44 years old with incomes below poverty line have a 5 fold increased Unintended Pregnancy rate
    2. No Contraception or inconsistent Contraception accounts for 95% of unintended pregnancies
  4. Costs
    1. Vaginal Delivery costs $30,000 and Cesarean Section costs $50,000 (as of 2010)
  5. References
    1. Finer (2014) Am J Public Health 104(suppl 1): S43-8 [PubMed]

III. Risk Factors

  1. Difficult access to Contraception
  2. Age 20-24 years old
  3. Less social support
  4. Major Depression symptoms
  5. Emotional stress
  6. Childhood Sexual Assault
  7. Intimate Partner Violence
  8. Decreased social support

IV. Evaluation

  1. See Pregnancy Dating

V. Management: Counseling

  1. Approach
    1. Offer assistance in non-judgemental manner
  2. Counseling regarding options
    1. Carry fetus to delivery and raise the child
      1. Offer to connect the mother to social services and public health resources
    2. Carry fetus to delivery and offer child for adoption (less commonly chosen in U.S.)
      1. https://www.childwelfare.gov/topics/adoption/
    3. Elective pregnancy termination
      1. Medical providers may conscientiously refuse to perform certain procedures if not consistent with their principles
      2. However, in these cases AAFP and ACOG recommend providers offer safe referrals for these services

VI. Management: Elective Termination

  1. General
    1. Guttmacher Institute Summary of Elective Termination laws
      1. http://www.guttmacher.org/statecenter/
  2. Safety
    1. First trimester termination does not appear to increase risk of Ectopic Pregnancy, preterm birth or Miscarriage
      1. Virk (2007) N Engl J Med 357(7): 648-53 [PubMed]
    2. Legal pregnancy termination appears safe (mortality 0.6 per 100,000 live births compared with 8.8 per 100,000)
      1. Raymond (2012) Obstet Gynecol 119(2 pt 1): 215-9 [PubMed]
    3. No longterm psychological impact from elective termination
    4. Clostridial Toxic Shock Syndrome
      1. Associated with vaginal Misoprostol protocols without antibiotic prophylaxis (regimens before 2006)
      2. Rare now with newer regimens that use oral or buccal Misoprostol and antibiotic prophylaxis
      3. Fjerstad (2009) N Engl J Med 361(2): 145-51 +PMID:19587339 [PubMed]
  3. First Trimester regimens (<77 days gestation)
    1. Mifrepristone 200 mg and Misoprostol 800 mcg (preferred)
      1. See Mifepristone and Misoprostol Protocol for Termination of Pregnancy
    2. Other medication options include Methotrexate/Misoprostol and Misoprostol alone
      1. However, combined Mifepristone and Misoprostol is more effective than Misoprostol alone
      2. Zhang (2022) Cochrane Database Syst Rev (5): CD002855 [PubMed]
    3. Surgical methods (vacuum aspiration or Dilation and Curettage)
  4. Second-Trimester regimens
    1. Medical induction (admit for delivery)
      1. Mifrepristone 200 mg and Misoprostol 400 mcg
        1. Start: Mifrepristone 200 mg orally
        2. Next: Misoprostol 400 mcg sublingual, buccal starting in 24-48 hours, every 3 hours for up to 5 doses
      2. Misoprostol alone
        1. 400 mcg vaginal or sublingual every 3 hours for up to 5 doses
      3. Oxytocin
    2. Dilation and Evacuation
  5. Additional measures
    1. RhoGAM (if Rh Negative)
    2. Obstetric Ultrasound
      1. Typically used to confirm Early Pregnancy Loss and assess Gestational age
      2. Also obtain for risk of Ectopic Pregnancy (e.g. Adnexal Mass, PID history, IUD pregnancy, Adnexal Mass)
    3. Quantitative bhCG
      1. Obtained to monitor serially to confirm completed Miscarriage

VII. Prevention

  1. See Contraception

VIII. References

  1. (2014) Obstet Gynecol 123(3): 676-92 [PubMed]
  2. Moss (2015) Am Fam Physician 91(8): 544-9 [PubMed]
  3. Wildschut (2011) Cochrane Database Syst Rev (1): CD005216 [PubMed]
  4. MacNaughton (2021) Am Fam Physician 103(8) 473-80 [PubMed]

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