Of the 1.3 to 1.5 million legal abortions performed annually in the United States, 52% occur at less than or equal to 8 weeks' gestation and 30% at less than or equal to 7 weeks' gestation. Most clinicians do not perform a surgical abortion before the sixth or seventh week of gestation because of the perceived increased risk of continuing pregnancy. This further limits access above and beyond the problems associated with the lack of availability of abortion. Early surgical abortion and medical abortion are old ideas that have emerged as new technologies that may allow women to have more access to abortion very early in pregnancy. A protocol was developed at Planned Parenthood of Houston and Southeast Texas that allowed a woman access to surgical abortion as soon as her pregnancy test was positive. After vaginal ultrasonography was performed to confirm gestational age, a suction curettage was performed with a manual vacuum syringe and a 7 mm rigid suction cannula. The products of conception were immediately inspected under magnification to identify the gestational sac. If no gestational sac was visualized, appropriate follow-up of beta-hCG levels was performed. Of 2399 procedures, 2249 (93.7%) had verification of a gestational sac in the curettage specimen, and 2379 (99.2%) patients had a complete abortion; the other 20 patients were 14 ectopic pregnancies and 6 who required respiration procedures. The rate of ectopic pregnancy was 5.8 in 1000 procedures, and that of continuing pregnancy was 1.3 in 1000 procedures. All continuing pregnancies were detected by appropriate follow-up as dictated by the protocol, and repeat procedures were successful. Thus the availability and use of vaginal ultrasonography and manual vacuum aspiration allows for successful surgical abortion very early in pregnancy. Importantly, this procedure is not associated with a high risk of retained products of conception or need for respiration as had been previously described in the literature. Much focus has been placed over the past few years on the development of medical (nonsurgical) abortion techniques so that women would have access to abortion at a very early gestation. Although the potential reality of medical agents to effect abortion was first described in the modern literature almost 50 years ago, it has only been made realistically possible within the last 20 years because of the availability of prostaglandin analogs, mifepristone, and low-dose methotrexate. The overall effectiveness of mifepristone regimens is approximately 95%; most side effects are gastrointestinal (vomiting, diarrhea) and are usually a result of the prostaglandin analog. The gestational age limitation is dependent on the type of analog used; at present, 63 days' gestation is appropriate with gemeprost and 49 days' gestation with misoprostol. Alternatives to mifepristone were sought in the United States because of its lack of availability in the early 1990s. Low-dose methotrexate, commonly used for the treatment of early ectopic pregnancy, appeared to be a possible option. On the basis of the published literature intramuscular administration of 50 mg/m(2) methotrexate followed 5 to 7 days later by vaginal administration of 800 mu g in patients less than or equal to 49 days' gestation is 90% to 95% effective. Patients can self-administer the misoprostol and return approximately 1 week after receiving methotrexate for evaluation. Vaginal ultrasonography should be used to confirm the gestational age before treatment is begun and after misoprostol treatment to check for expulsion of the gestational sac. Appropriate follow-up is necessary because approximately one-third of women pass the pregnancy after a delay of 1 to 4 weeks after the methotrexate is administered. As with mifepristone regimens, side effects are limited and gastrointestinal in nature. Methotrexate has the advantage of being inexpensive and widely available throughout the United States and other countries. This monograph will review the history, study results, and protocols for use of early surgical and medical abortion.
