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Deveber.orgWhen Abortion Fails
Occasionally abortion fails, especially when it is druginduced. When this happens, either a second D&C or a moreserious surgery may be attempted. The other alternative is adecision to continue the pregnancy and give birth to thebaby. In the case of “selective reduction” where only somefetuses are aborted from a multiple pregnancy (usually theresult of fertility treatments), the remaining fetuses can beendangered and the mother may be at risk of miscarrying.
Deciding after a failed abortion whether to continue or toterminate the pregnancy often results in feelings of grief andguilt for which a woman may need counseling. In the past45 years there have been only seven studies on failedabortion suggesting that there has probably been systemicunderreporting of its effects on women and their children.
Women’s Health after Abortion: The Medical and Psychological Evidence When Abortion Fails
In the vast majority of cases of surgical abortion, a failed
abortion – meaning that the fetus continues to survive or is
not fully expelled – leads to a second surgery which itself
raises the possibility of medical complications.
“…patient [who] had a D & C abortion at ten weeksgestation later presented to ER [Emergency Room] withfever and bleeding; ultrasound indicated retained partialfetal parts.” Survey of Canadian Physicians on Women’s Health after Induced Abortion Failed abortion is an extremely rare, but possible, result ofinduced surgical abortion. Nevertheless, in the United Statesalone, roughly 700 pregnancies a year continue followingan initial abortion procedure, and that over the past 25 yearsabout 17,500 women required either a second procedure,or a more serious surgery, or changed their mind andcontinued the pregnancy to term.1 A 1999 Canadian study by Hall reviewed the literature andfound that when abortion fails and women choose not toundergo a second procedure, the children born may have“limb or digit abnormalities and congenital contractures.” Thereview goes on to note, “However, it is likely there has been bias leading to the reporting of abnormal cases.” Given thefact that only seven studies in the past 45 years haveaddressed failed abortion, there may also be systemicunderreporting as well.
Holt, Daling and colleagues noted that for 3.4 per cent ofwomen in the study of ectopic pregnancy, the originalabortion procedure did not succeed and a D&C wasperformed. In these cases the abortion failed because theclinic did not test for ectopic pregnancy3 (see Chapter 4on “ectopic pregnancy”). This failure to test for ectopicpregnancy can be life-threatening.
Infants are also known to survive late-term abortions.4 Thisoutcome is now a less frequent occurrence with the use ofKCL injections (potassium chloride) in late-term abortion, toensure that a viable fetus does in fact die. As Ferguson andcolleagues state, “We use urea to be certain that we effectfetal death. It is unsettling to all personnel to deliver these fetuses when they are not stillborn”. In the Ferguson study,34 per cent of the abortions were on fetuses over 22 weeksgestation. (Fetal viability in premature birth is currently23-24 weeks, and rarely babies born at 21-22 weeks havebeen resuscitated.) A recent Canadian court case has drawn attention to theplight of a child who suffered cerebral palsy as an abortionsurvivor. The child was born alive and left without oxygenor medical treatment for 40 minutes until a nurse took her tothe neonatal intensive care unit. The hospital involved wasfound negligent and thus responsible for her disabilities, andwas ordered to pay the plaintiff $8,700,000.6 Holmes has alsoreported two known cases of infant malformation followingprenatal exposure to cervical dilation and uterine curettage.7 Abortion can also fail in cases where multiple pregnanciesare reduced to one or two desired fetuses. “Selectivereduction” is now a common practice in large teachinghospitals. Hall has documented cases in Canada where theprocedure killed the intended fetus but “puts the remainingfetus(es) at risk for vascular compromise” and elevates therisk of miscarriage (see also Chapter 13 on “MultifetalPregnancy Reduction”).
Failed Drug-Induced or “Medical” Abortion
Drug-induced or “medical” abortion has a higher failure rate
than surgical abortion. When abortion is induced by the use
of chemical prostaglandins or prostaglandin analogues, two
possible scenarios may lead to failed abortion.
The first is the actual failure of the drugs to complete theabortion. Grimes reports the overall complete abortion ratefrom his meta-analysis of seven chemical (drug-induced)abortion studies from 1991 to 1994 as 93.9 per cent.
Women’s Health after Abortion: The Medical and Psychological Evidence He goes on to say, “Failed abortion is an infrequent butimportant complication of medical abortion. These womenshould undergo suction curettage as soon as the diagnosis is made”. Similarly, Collins and Mahoney noted that“.prostaglandins and their analogues must be given in dosesyielding unacceptably high levels of side effects. [With a]lower dose.some failures will occur and these women will then need abortion by other methods”. Women may evenbe unaware that the abortion is incomplete and may onlylater seek medical help when infection develops.
The second scenario is the woman’s own decision-makingprocess: Drug-induced abortion requires at least twoinfusions of drugs at two separate office visits and mayrequire up to two weeks to complete. During this time awoman may change her mind and decide to continue withthe pregnancy. Holmes and Fonseca and colleagues havefound that “Exposure during pregnancy to the syntheticprostaglandin misoprostol has also been associated with theoccurrence of terminal transverse limb defects and scalp defects.” Likewise, Gonzalez identified Brazilian childrensuffering from limb deficiencies as a result of exposure tomisoprostol in early pregnancy.11 However, Grimes records that “. some women with a failedabortion choose to continue the pregnancy and a smallnumber of normal infants have been born after exposure to mifepristone in early pregnancy.” (For a fuller discussion ofdrug-induced or “medical” abortion, see Chapter 8.) Psychological Issues
The woman who seeks abortion is often promised a
relatively painless and simple procedure to eliminate a
pregnancy that she does not wish to carry to term. Failed
abortion may involve her in a number of unanticipated
outcomes. If she changes her mind about “medical” abortion
and a child is born with anomalies, maternal grief and guilt
may be anticipated and counseling may be necessary. If a
second abortion procedure is successful at a late stage of
fetal development, where the woman knows that procedures
are chosen to ensure that an anticipated live birth cannot
occur, grief and guilt may likewise ensue. (See Chapters 11
and 12 for more information.)
Though rare, there are some instances when both surgical
and drug-induced abortions do fail, putting a woman’s
health at risk (and, need we add, her child’s as well?) When
this happens, there are decisions to be made about what
alternative to pursue: continue the pregnancy or have a
second attempted abortion? There are both psychological
and ethical questions involved, in addition to purely medical
and scientific ones. More study needs to be done in this area
with its many medical and psychological implications for
both mother and child(ren).
Key Points Chapter 10
• Failure of abortion, though infrequent, is a complicationof the procedure.
• The woman can decide to attempt another abortion or tocontinue her pregnancy.
• Children born after a failed abortion may have limb ordigit abnormalities and other congenital problems, though anumber of infants with no defects are born.
• Drug-induced abortions are more likely to fail thansurgical abortions partly because drug dosages which wouldensure that the fetus is stillborn would yield in the mother“unacceptably high levels of side effects” (see note 9).
• Maternal grief and guilt are concerns after a failedabortion.
• More research is needed in this area.
Women’s Health after Abortion: The Medical and Psychological Evidence 1 Fielding WL, Lee SY, Friedman EA. Continued pregnancy after failedfirst-trimester abortion. Obstetrics & Gynecology 1978 July;52(2):56-8.
Steier A, Bergsjo P. [Failed induced abortion. Pregnancy continuing afterinduced abortion]. Tidsskr Nor Laegeforen. 1992 August 20;112(19):2538-40.
Hall JG. Arthrogryposis associated with unsuccessful attempts attermination of pregnancy. American Journal of Medical Genetics 1996May 3;63(1):293-300.
3 Holt VL, Daling JR, Voigt LF, McKnight B, Stergachis A, Chu J, et al.
Induced abortion and the risk of subsequent ectopic pregnancy.
American Journal of Public Health 1989 September;79(9):1234-8.
4 Shaver J. Gianna: Aborted…and Lived to Tell About It. Colorado Springs,CO: Focus on the Family Publishing, 1995.
5 Ferguson JE 2d, Burkett BJ, Pinkerton JV, Thiagarajah S, Flather MM,Martel MM, et al. Intraamniotic 15(s)-15-methyl prostaglandin F2 alpha andtermination of middle and late second-trimester pregnancy for geneticindications: A contemporary approach. American Journal of Obstetrics andGynecology 1993 August;169((2 Pt 1)):332-9;discussion 339-40, p. 340.
6 Hospital pays $8.7M settlement: Premature baby was abandoned withdead foetuses. The National Post 1999 July 31;Sect. A:1.
7 Holmes LB. Possible fetal effects of cervical dilation and uterinecurettage during the first trimester of pregnancy. Journal of Pediatrics1995 January;126(1):131-4.
8 Grimes D. Medical abortion in early pregnancy: A review of theEvidence [Review]. Obstetrics & Gynecology 1997 May;89(5 Pt 1):790-6, p. 793.
9 Collins FS, Mahoney MJ. Hydrocephalus and abnormal digits after failedfirst-trimester prostaglandin abortion attempt. Journal of Pediatrics 1983April;102(4):620-1, p. 621.
Fonseca W, Alencar AJ Pereira RM, Misago C. Congenital malformationof the scalp and cranium after failed first trimester abortion attempt withmisoprostol. Clinical Dysmorphology 1993 January;2(1)76-80.
11 Gonzalez CH, Vargas FR, Perez AB, Kim CA, Brunoni D,Marques-Dias MJ, et al. Limb deficiency with or without Mobius sequencein seven Brazilian children associated with misoprostol use in the firsttrimester of pregnancy. American Journal of Medical Genetics 1993 August1;47(1):59-64.
Estrategia Diagnóstica a Seguir en la Investigación de la Hipoacusia en la Infancia Este capitulo esta basado en 3 conjeturas: (1) la sordera es común, (2) la etiología básica varía alrededor de todo el mundo y (3) la estrategia diagnóstica debe ser secuencial tomando en cuenta la lateralidad y la severidad de la pérdida auditiva. 1) La sordera es frecuente La sordera es el défi