Sexually Transmitted Diseases Overview (STDs)
Sexually transmitted diseases (STDs, venereal diseases) are among the most common infectious diseases in the United States today. STDs are sometimes referred to as sexually transmitted infections, since these conditions involve the transmission of an infectious organism between sex partners. More than 20 different STDs have been identified, and about 19 million men and women are infected each year in the United States, according to the CDC (2010).
Depending on the disease, the infection can be spread through any type of sexual activity involving the sex organs, the anus, or the mouth; an infection can also be spread through contact with blood during sexual activity. STDs are infrequently transmitted by any other type of contact (blood, body fluids or tissue removed from an STD infected person and placed in contact with an uninfected person); however, people that share unsterilized needles markedly increase the chance to pass many diseases, including STD's (especially hepatitis B), to others. Some diseases are not considered to be officially an STD (for example, hepatitis types A, C, E) but are infrequently noted to be transferred during sexual activity. Consequently, some authors include them as STD's, others do not. Consequently, lists of STD's can vary, depending on whether the STD is usually transmitted by sexual contact or only infrequently transmitted.
• STDs affect men and women of all ages and backgrounds, including children. Many states require that Child Protective Services be notified if children are diagnosed with an STD.
• STDs have become more common in recent years, partly because people are becoming sexually active at a younger age, are having multiple partners, and do not use preventive methods to lessen their chance of acquiring an STD.
• People can pass STDs to sexual partners even if they themselves do not have any symptoms.
• Frequently, STDs can be present but cause no symptoms, especially in women (for example, chlamydia, genital herpes or gonorrhea). This can also occur in some men.
• Health problems and long-term consequences from STDs tend to be more severe for women than for men. Some STDs can cause pelvic infections such as pelvic inflammatory disease (PID), which may cause a tubo-ovarian abscess. The abscess, in turn, may lead to scarring of the reproductive organs, which can result in an ectopic pregnancy (a pregnancy outside the uterus), infertility or even death for a woman.
• Human papillomavirus infection (HPV infection), an STD, is a known cause ofcancer of the cervix.
• Many STDs can be passed from a mother to her baby before, during, or immediately after birth.
• Because the method of becoming infected is similar with all STDs, a person often obtains more than one pathogenic organism at a time. For example, many people (about 50%) are infected at a single sexual contact with both gonorrhea and chlamydia.
Sexually Transmitted Diseases (STDs) Causes
Depending on the disease, STDs can be spread with any type of sexual activity. STDs are most often caused by viruses and bacteria. The following is a list of the most common STDs, their causes and other infections (see STDs with asterisk mark*) that may be transmitted on occasion by sexual activity, but are frequently not considered primarily to be an STD by many investigators:
STDs caused by bacteria
• Chancroid (Haemophilus ducreyi)
• Chlamydia (Chlamydia trachomatis)
• Gonorrhea (Neisseria gonorrhea)
• Granuloma inguinale (Calymmatobacterium granulomatis)
• Lymphogranuloma venereum (Chlamydia trachomatis)
• Syphilis (Treponema pallidum)
STDs caused by viruses
• Genital herpes (herpes simplex virus)
• Genital warts (human papillomavirus virus [HPV])
• Hepatitis B and D, and infrequently, A*,C*,E* (hepatitis viruses, types A-E)
• HIV/AIDS (human immunodeficiency virus [HIV virus])
• Molluscum contagiosum* (poxvirus)
STD caused by protozoan
• Trichomoniasis (Trichomonas vaginalis)
STD's* caused by fungi
• Jock itch (Tenia cruris)*
• Yeast infections* (Candida albicans)
STD's caused by parasites
• Pubic lice or crabs (Pediculosis pubis)
• Scabies* Sarcoptes scabiei
For details about the pathogens that cause the diseases, the reader is urged to search the specific disease by simply clicking on it.
Sexually Transmitted Diseases (STDs) Symptoms
Common STDs have a variety of symptoms (if symptoms develop at all) and many different complications, including death.
Symptoms of STDs caused by bacteria
Chancroid Symptoms
• Are not common in the United States but common in developing countries.
• Symptoms include painful ulcers on the genitals.
• Can be confused with syphilis or herpes
• Is treatable with antibiotics
Chlamydia symptoms
• Most common of all STDs caused by bacteria.
• Cause no symptoms in about 80% of women and 50% of men
• When symptoms are present, commonly there is discharge from the vagina or the penis, and burning or pain during urination.
• Is transmitted through vaginal, oral, or anal sexual contact
• Ectopic pregnancy and infertility for women are potential serious complications.
• Is treatable with antibiotics
Gonorrhea symptoms
• Discharge from the vagina or the penis
• Over 50% of infected women have no symptoms, but they can still transmit the disease to others.
• Painful urination
• Ectopic pregnancy, pelvic inflammatory disease (PID), infertility for women, Fitzhugh-Curtis syndrome (perihepatitis) and death are potential serious complications.
• Is treatable with antibiotics
Granuloma inguinale (donovanosis) symptoms
• Not common in the U.S.
• Symptoms are painless genital ulcers in the groin area.
• Is treatable with antibiotics, usually for three or more weeks
Lymphogranuloma venereum
• Not common in the U. S.
• Symptoms are abscesses (buboes) in the groin, rectum or other areas; fistulas that drain pus may occur and are treatable with antibiotics.
Syphilis
• Symptoms are mild and often go undetected initially
• Starts with a painless genital ulcer that goes away on its own
• Rash, fever, headache, achy joints
• Is treatable with antibiotics
• More serious complications associated with later stages of the disease if undetected and untreated
Symptoms of STDs caused by viruses
Genital herpes
• Recurring outbreaks of blister-like sores on the genitals
• Can be transmitted from a mother to her baby during birth
• Reduction in frequency and severity of blister outbreaks with treatment but not complete elimination of infection.
• Can be transmitted by a partner who has herpes even if no blisters are present.
Genital warts
• Caused by a virus related to skin warts, human papillomavirus (HPV)
• Small, painless bumps in the genital or anal areas (sometimes in large clusters that look like cauliflower)
• Various treatments available (for example, freezing or painting the warts with medication)
• Vaccines are available against the most common types of HPV
Hepatitis
• Hepatitis B and D are most often associated with sexual contact, hepatitis A, C, E are less frequently transmitted by sexual contact.
• Both may be transmitted via contact with blood; for hepatitis B, sexual transmission is believed to be responsible for 30% of the cases worldwide.
• The hepatitis B virus can cause both an initial (acute) and a chronic form of liver inflammation. Only 50% of acute infections with the hepatitis B virus produce symptoms. The initial phase of infection lasts a few weeks, and in most people (90%-95%), the infection clears.
• Acute infection can cause yellowish skin and eyes, fever, achy, tired (flu-like symptoms).
• Severe complications in some people, including cirrhosis and liver cancer may occur in a small percent of individuals infected with HBV.
• Treatments are available and remission is possible with some aggressive medications.
• Immunizations are available to prevent hepatitis B.
HIV/AIDS
• Spread primarily by sexual contact and from sharing IV needles
• Can be transmitted at the time a person becomes infected with other STDs
• No specific symptoms or physical signs confirm HIV infection.
• The average time from infection to the development of symptoms related to immunosuppression (decreased functioning of the immune system) is 10 years.
• Fatigue, night sweats, chills, or fever lasting several weeks, headaches, andcough may occur a few weeks after contracting the virus initially.
• Serious complications of AIDS include unusual infections or cancers, weight loss, intellectual deterioration (dementia), and death.
• No current cure but medications are available to slow disease progression.
Molluscum contagiosum
• Small (2-5mm) raised areas (papules) on the skin
• Contagious, usually by direct skin to skin contact
• Self-limited over months to years; treated with some topical creams
• Often cryotherapy (freezing) or surgical removal is performed
Symptoms of STDs caused by protozoan
Trichomonas
• Frothy vaginal discharge with a strong odor
• Treated with antibacterial/antiprotozoal medicines
Symptoms of STDs* caused by fungi
Jock itch (genital itching or Tenia cruris)* (not always an STD)
• Itchy groin skin, sometimes has a reddish color
• Is treated with topical antifungal medicines
Yeast infection (Candidiasis)* (not always an STD)
• Cheese-like vaginal discharge or whitish exudates sometimes with a reddish hue to the skin; it may occur around the foreskin of infected males; common symptoms are itching and burning sensation of the vagina or penis.
• Is treated with topical antifungal medicines in most cases
Symptoms of STDs caused by parasites
Pubic lice
• Very tiny bugs that are found in pubic hair, sometimes referred to as "crabs"
• Can be picked up from clothing or bedding
• First noticed as itching in the pubic area
• Are treatable with creams, anti-lice agents, and combing
Scabies
• Skin infestation caused by a tiny mite
• Highly contagious
• Intense itching is the primary symptom, which worsens at night
• Spread primarily by sexual contact or from contact with skin, infested sheets, towels, or furniture
• Is treated with creams
When to Seek Medical Care
A medical examination may be necessary if a person believes he or she may have an STD or if he or she may have been exposed to someone with an STD. Being seen by a doctor as soon as possible after exposure to an STD is important; these infections can easily spread to others and can have serious complications.
Go to a hospital's emergency department in these circumstances if:
• an STD problem worsens;
• a fever develops with other symptoms; or
• if it will be a couple of days before the individual can be evaluated by a doctor.
Exams and Tests
Some STDs can be diagnosed without any tests at all (for example, pubic lice). Other STDs require a blood test or a sample of any unusual fluid (such as an abnormal discharge from the vagina or the penis for gonorrhea or chlamydia) to be analyzed in a lab to help establish a diagnosis. Some tests are completed while a person waits; other tests require a few days before a person may obtain the results (for example, syphilis).
Sexually Transmitted Diseases (STDs) Treatment
Self-Care at Home
Home treatment of STDs is not recommended because prescription medications are usually necessary.
Medical Treatment
The treatment of an STD varies depending on the type of STD. Some STDs require a person to take antibiotic medication either by mouth or by injection; other STDs require a person to apply creams or special solutions on the skin. Often, reexamination by a doctor is necessary after the treatment to confirm that the STD is completely gone.
Some STDs, such as genital herpes and HIV (which leads to AIDS), cannot be cured, only controlled with medication.
For treatment of individual STD types, the reader is urged to click on the individual disease listed above.
Next Steps
Follow-up
Sometimes people with STDs are too embarrassed or frightened to ask for help or information. However, most STDs are easy to treat. The sooner a person seeks treatment and warns sexual partners about the disease, the less likely the disease will do permanent damage, be spread to others, or be passed to a baby.
If diagnosed with an STD, follow these guidelines:
• Seek treatment to stop the spread of the disease.
• Notify sexual contacts and urge them to have a checkup.
• Take all of the prescribed medication, even if symptoms stop before all of the prescribed medication(s) are taken.
• Sometimes, follow-up tests are important so comply with the instructions given by the health care practitioner.
• Consult a doctor with specific needs and any questions about reinfection, sexual partner notification, and prevention.
• Avoid sexual activity while being treated for an STD.
Prevention
The best way to prevent STDs is to avoid sexual contact with others. If people decide to become sexually active, they can reduce the risk of developing an STD in these ways:
• Practice abstinence (refrain from sex entirely) or be in a monogamous relationship (both sexual partners are each other's only sexual partner).
• Delay having sexual relations as long as possible. The younger people are when they become sexually active, the higher the lifetime risk for contracting an STD. The risk also increases with the number of sexual partners.
• Correctly and consistently use a male latex condom. The spermicide nonoxynol-9, once thought to protect against STDs as well as to prevent pregnancy, has been proven to be ineffective for disease prevention. Do not rely on it. In addition, condoms are only about 90% effective in preventing STDs
• Have regular medical checkups even if you do not have symptoms of an STD.
• Learn the symptoms of STDs.
• Avoid douching because it removes some of the natural protection in the vagina.
• Vaccines against HPV and hepatitis B are available and effective.
Outlook
Most of the common STDs can be cured with treatment.
• In addition to the discomfort of the infection, some STDs can cause other, more serious, long-term problems, including infertility and problems in newborns infected by their mothers during pregnancy such as blindness, bone deformities, mental retardation, and infrequently, death.
• HIV can only be slowed, not eliminated, and may cause death.
Tuesday, April 19, 2011
ABORTION
Abortion is one of the most common medical procedures performed in the United States each year.More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives.
While women of every social class seek terminations, the typical woman who ends her pregnancy is either young, white, unmarried, poor, or over the age of 40.
In the United States and worldwide, abortion (known also as elective termination of pregnancy) remains common.
• The US Supreme Court legalized abortion in the well-known Roe v Wadedecision in 1973; currently, there areabout 1.2 million abortions are performed each year in the United States.
• Worldwide, some 20-30 million legal abortions are performed each year, with another 10-20 million abortions performed illegally. Illegal abortions are unsafe and account for 13% of all deaths of women because of serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
In spite of the introduction of newer, more effective, and more widely available birth control methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these unplanned pregnancies, about half end in abortion.
Making abortion legal
Since the landmark 1973 US Supreme Court decision that made abortion legal, hundreds of federal and state laws have been proposed or passed. Abortion is one of the most visible, controversial, and legally active areas in the field of medicine. These laws address a variety of controversial questions including:
• The issue of parental notification. A number of state laws do require that some minors notify parents before obtaining an abortion, but what provisions are necessary to protect young women who feel they cannot notify their parents?
• Should spouses be notified before a woman has an abortion?
• Has the pregnancy progressed far enough that the fetus could live on its own before termination (termed viability)?
• Should there be mandatory waiting periods before an abortion can take place?
• What might be mandatory wording for counseling sessions or consent forms?
• Should public funds be used for abortions?
• What regulations if any should apply to abortion providers?
• What provisions might be made against specific abortion techniques?
• Should emergency contraception be allowed?
• Should the rules be different in cases of sexual assault and rape?
Before abortion was legal
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of medical personnel.
• Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion.
• The first US federal law on the subject was the Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception in order to suppress the circulation of "obscene" materials.
• From 1900 until the 1960s, abortions were prohibited by law. However, theKinsey report noted that premarital pregnancies were electively aborted, and public and physician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and ensured their right to choice in this process. No decision was more important than Griswold v Connecticut, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain birth control from their health care provider.
The Supreme Court decision: Roe v Wade
The Supreme Court case of Roe v Wade was the result of the work of a wide group of people who worked to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL).
• Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
• In 1973, the Roe v Wade law, in the opinion written by US Supreme Court justice Harry Blackmun, the court ruled that a woman had a right to an abortion during the first 2 trimesters (6 months) of pregnancy. He cited the safety of the procedures and the basic right of women to make their own decisions.
• Since this ruling, the states have regained much control. Serious restrictions have been placed on abortion services.Debate continues by federal and state lawmakers. The US Senate approved the first federal ban on a specific abortion procedure (called partial-birth abortion, defined later in this topic) in October 2003. The bill was signed byPresident George W. Bush.
Determining life
When does "life" begin?That is one of the issues surrounding the controversy about abortion. The legal issues are these:
• Loosely defined, the term viability is the ability of the fetus to survive outside the mother's womb without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation (gestation is the period of time a fetus develops in the mother's uterus, usually 40 weeks). However, there are no reliable or medically acceptable tests for viability prior to 28 weeks' gestation.
• The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (for example, a developing fetus with certain brain disorders will never live on its own). In Colautti v Franklin, the court overturned a Pennsylvania law requiring doctors to follow specific directives in certain medical cases and recognized the judgment of the doctor in these matters.
Parental consent
Various federal and state decisions have tried to require parental notification, waiting periods, informed consent, and abortion counseling.
People against abortion argue that parents need to be informed about and approve an abortion for a daughter younger than 18 years.Those supporting the rights of a woman to choose abortion say parental consent is not required for a woman to carry a pregnancy to term (the birth of a baby), nor do parents need to give permission for a woman seeking birth control such as pills or an intrauterine device (IUD). Parents are also not consulted when a woman seeks treatment for asexually transmitted disease.
Research shows that many young women younger than 18 yearsdo involve their parents in their decision to abort (45%). Laws requiring parental consent are forcing minors to obtain abortions much later in their pregnancies. Some minors must travel great distances to states with no such law.
Intact dilation and extraction
The recently crafted political term partial-birth abortion loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This definition broadly includes all methods of second-trimester abortion (done after the first three months of pregnancy. A 2007 Partial Birth Abortion ban was passed by the Supreme Court, and although its wording is open to interpretation, it essentially states that the act of termination of fetal life cannot occur in a partially extracted fetus.
Providers
Providers of abortions are generally specialists in women's health such as obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers (physicians, physician assistants, midwives, and nurse practitioners) to perform these procedures.
Various factors over the years have influenced the number of medical professionals available and trained to perform abortions:
• Medical student training in this procedure is limited or absent from many programs. Some students may opt not to be trained in the procedure. Pharmacists may decide not to dispense medical abortion medications.
• Increasing violence against providers and clinics has further decreased their willingness to provide abortion services.
• The US Food and Drug Administration (FDA) has approved Mifeprex (mifepristone, RU-486), a drug for medical abortions. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination.
• A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.
Abortion statistics
In the United States: In 2003, about 16 women for every 1,000 women aged 15-44 years had an abortion, and for every 1,000 live births, about 241 abortions were performed, according to the Centers for Disease Control and Prevention. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social issues surrounding abortion have led to more women seeking terminations later in pregnancy.
• Safety: Legal abortion is a safe procedure. Infection rates are less than one percent, and fewer than 1 in 100,000 deaths occurs from first-trimester abortions. Abortion is safer for the mother than carrying a pregnancy to term. Medical and surgical abortions are both safe and effective when performed by trained practitioners.
• Race: Most women seeking abortion are white (53%); 36% are black, 8% are of another race, and 3% are of unknown race.
• Age: Abortion rates are highest among 20- to 24-year-old women. Rates are lowest among women younger than 20 or older than 40 years but these women are far more likely to have an abortion if they become pregnant.
In the world: Abortion causes at least 13% of all deaths among pregnant women. New estimates are that 50 million abortions are performed world wide each year, with 30 million of them in developing countries. Approximately 20 million of these are performed unsafely because of conditions or lack of provider training.
Abortion is one of the most common medical procedures performed in the United States each year.More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives.
While women of every social class seek terminations, the typical woman who ends her pregnancy is either young, white, unmarried, poor, or over the age of 40.
In the United States and worldwide, abortion (known also as elective termination of pregnancy) remains common.
• The US Supreme Court legalized abortion in the well-known Roe v Wadedecision in 1973; currently, there areabout 1.2 million abortions are performed each year in the United States.
• Worldwide, some 20-30 million legal abortions are performed each year, with another 10-20 million abortions performed illegally. Illegal abortions are unsafe and account for 13% of all deaths of women because of serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
In spite of the introduction of newer, more effective, and more widely available birth control methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these unplanned pregnancies, about half end in abortion.
Making abortion legal
Since the landmark 1973 US Supreme Court decision that made abortion legal, hundreds of federal and state laws have been proposed or passed. Abortion is one of the most visible, controversial, and legally active areas in the field of medicine. These laws address a variety of controversial questions including:
• The issue of parental notification. A number of state laws do require that some minors notify parents before obtaining an abortion, but what provisions are necessary to protect young women who feel they cannot notify their parents?
• Should spouses be notified before a woman has an abortion?
• Has the pregnancy progressed far enough that the fetus could live on its own before termination (termed viability)?
• Should there be mandatory waiting periods before an abortion can take place?
• What might be mandatory wording for counseling sessions or consent forms?
• Should public funds be used for abortions?
• What regulations if any should apply to abortion providers?
• What provisions might be made against specific abortion techniques?
• Should emergency contraception be allowed?
• Should the rules be different in cases of sexual assault and rape?
Before abortion was legal
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of medical personnel.
• Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion.
• The first US federal law on the subject was the Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception in order to suppress the circulation of "obscene" materials.
• From 1900 until the 1960s, abortions were prohibited by law. However, theKinsey report noted that premarital pregnancies were electively aborted, and public and physician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and ensured their right to choice in this process. No decision was more important than Griswold v Connecticut, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain birth control from their health care provider.
The Supreme Court decision: Roe v Wade
The Supreme Court case of Roe v Wade was the result of the work of a wide group of people who worked to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL).
• Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
• In 1973, the Roe v Wade law, in the opinion written by US Supreme Court justice Harry Blackmun, the court ruled that a woman had a right to an abortion during the first 2 trimesters (6 months) of pregnancy. He cited the safety of the procedures and the basic right of women to make their own decisions.
• Since this ruling, the states have regained much control. Serious restrictions have been placed on abortion services.Debate continues by federal and state lawmakers. The US Senate approved the first federal ban on a specific abortion procedure (called partial-birth abortion, defined later in this topic) in October 2003. The bill was signed byPresident George W. Bush.
Determining life
When does "life" begin?That is one of the issues surrounding the controversy about abortion. The legal issues are these:
• Loosely defined, the term viability is the ability of the fetus to survive outside the mother's womb without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation (gestation is the period of time a fetus develops in the mother's uterus, usually 40 weeks). However, there are no reliable or medically acceptable tests for viability prior to 28 weeks' gestation.
• The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (for example, a developing fetus with certain brain disorders will never live on its own). In Colautti v Franklin, the court overturned a Pennsylvania law requiring doctors to follow specific directives in certain medical cases and recognized the judgment of the doctor in these matters.
Parental consent
Various federal and state decisions have tried to require parental notification, waiting periods, informed consent, and abortion counseling.
People against abortion argue that parents need to be informed about and approve an abortion for a daughter younger than 18 years.Those supporting the rights of a woman to choose abortion say parental consent is not required for a woman to carry a pregnancy to term (the birth of a baby), nor do parents need to give permission for a woman seeking birth control such as pills or an intrauterine device (IUD). Parents are also not consulted when a woman seeks treatment for asexually transmitted disease.
Research shows that many young women younger than 18 yearsdo involve their parents in their decision to abort (45%). Laws requiring parental consent are forcing minors to obtain abortions much later in their pregnancies. Some minors must travel great distances to states with no such law.
Intact dilation and extraction
The recently crafted political term partial-birth abortion loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This definition broadly includes all methods of second-trimester abortion (done after the first three months of pregnancy. A 2007 Partial Birth Abortion ban was passed by the Supreme Court, and although its wording is open to interpretation, it essentially states that the act of termination of fetal life cannot occur in a partially extracted fetus.
Providers
Providers of abortions are generally specialists in women's health such as obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers (physicians, physician assistants, midwives, and nurse practitioners) to perform these procedures.
Various factors over the years have influenced the number of medical professionals available and trained to perform abortions:
• Medical student training in this procedure is limited or absent from many programs. Some students may opt not to be trained in the procedure. Pharmacists may decide not to dispense medical abortion medications.
• Increasing violence against providers and clinics has further decreased their willingness to provide abortion services.
• The US Food and Drug Administration (FDA) has approved Mifeprex (mifepristone, RU-486), a drug for medical abortions. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination.
• A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.
Abortion statistics
In the United States: In 2003, about 16 women for every 1,000 women aged 15-44 years had an abortion, and for every 1,000 live births, about 241 abortions were performed, according to the Centers for Disease Control and Prevention. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social issues surrounding abortion have led to more women seeking terminations later in pregnancy.
• Safety: Legal abortion is a safe procedure. Infection rates are less than one percent, and fewer than 1 in 100,000 deaths occurs from first-trimester abortions. Abortion is safer for the mother than carrying a pregnancy to term. Medical and surgical abortions are both safe and effective when performed by trained practitioners.
• Race: Most women seeking abortion are white (53%); 36% are black, 8% are of another race, and 3% are of unknown race.
• Age: Abortion rates are highest among 20- to 24-year-old women. Rates are lowest among women younger than 20 or older than 40 years but these women are far more likely to have an abortion if they become pregnant.
In the world: Abortion causes at least 13% of all deaths among pregnant women. New estimates are that 50 million abortions are performed world wide each year, with 30 million of them in developing countries. Approximately 20 million of these are performed unsafely because of conditions or lack of provider training.
Abortion Preparation
History
Most abortions are performed after your health care provider takes a brief and targeted medical history. You will be asked questions about prior pregnancies and any treatment or care during the current pregnancy. You will be asked about any diseases or conditions that affect your reproductive organs, such as sexually transmitted infections.
The provider will ask whether you have a history of diabetes, high blood pressure, heart disease,anemia, bleeding disorders, or surgery (on your ovaries or uterus, for example). If you have active medical problems, you may need to be stabilized before an abortion or have the procedure performed in a facility that can handle special medical problems.
• If there are known problems with the fetus, such as severe brain abnormalities that will either not allow the fetus to live, and if these problems are known through diagnostic testing, the woman may choose to end the pregnancy with abortion.
• The most common problems with the fetus encountered in abortion counseling include major system development failures and problems that cannot be repaired dealing with the heart, nervous system, spine, brain, abdomen, kidneys, and breathing and digestive systems.
Physical
A brief physical examination is usually performed before an abortion. The focus is on determining when your pregnancy began and checking for sexually transmitted disease and whether you are healthy enough to undergo the procedure.
Lab tests
Pregnancy tests are used to confirm that you are pregnant. Home tests are reliable, so providers will accept these results in some cases. Blood will be tested for sexually transmitted diseases and for hepatitis. Urine may be checked to see if you have a urinary tract infection.
Imaging studies
An ultrasound is virtually always dome for pregnancy confirmation and dating. Doctors are looking for how many fetuses may be developing, the size of the fetus or fetuses, a picture of the uterus and ovaries, and to rule out a problem such as an ectopic pregnancy (a life-threatening condition in which the fetus develops outside the uterus).
Medications
Your health care provider may give you antibiotics as a precaution against infection. Antibiotic use for the procedure is usually given the day of the procedure and for the next day or two.
Abortion Counseling
Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing the pregnancy to deliver a baby, information and options for the abortion procedure, and, finally, information regarding a birth control decision. The risks and benefits of both medical and surgical abortions are often reviewed.
• The counseling process is aimed primarily at the woman herself but may also include other people she chooses to be involved. Studies indicate that men are involved in more than 40% of the decisions, but only scant research has been performed on male involvement in the process. Some women can reach a decision quickly. Others take longer to decide. The counseling process may provide referrals if you need ongoing support.
• You should not feel pressured to make a decision. Take time to consider your options.
• During the counseling, you may be asked questions designed to encourage meaningful discussion of the issues as they pertain to you. You will have many emotions.Counseling may take a day or longer.
Some state laws may apply to the counseling process. Some states have mandatory waiting times between the information session and the actual abortion. Other states require family or parental notification, and some states mandate that certain subjects be covered during abortion counceling.
Explanation of the Procedures
Once your pregnancy has been confirmed, and the doctor knows how many weeks along the pregnancy is, and you have decided to end the pregnancy, the procedure offered typically reflects your stage of gestation. Early abortions can be accomplished medically or surgically, but most facilities do not have the protocols established or personnel with the technical ability to offer medical abortions (with pills). Therefore, most abortions are performed surgically.
• Women often travel far for their abortion procedure and feel comfortable completing the preoperative preparation in a short office visit. In states where laws require waiting periods, this can be done in stages.
• The assessment process involves only a targeted history, physical examination, laboratory work, and ultrasound (including dating of the pregnancy, if indicated) followed by a counseling session.
• Second-trimester abortion preparation is more difficult. Preparing the cervix in less than 24 hours is almost impossible, but the basic assessment process is identical.
• Ultrasound examinations may be used to look specifically for obvious problems with the fetus.
• Some centers also offer an intra-amniotic injection of the drug digoxin, which stop heart activity in the fetus before a second-trimester abortion.
Medical abortion
• First- and second-trimester medical abortion
o First-trimester (first three months of a pregnancy) terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or Mifeprex (RU-486) with or without misoprostol. Other prostaglandins are used in other countries.
o Medical abortions are indicated for women who consent to a medical abortion but are also willing to undergo a surgical abortion if the medical abortion fails. Gestational age is usually less than 42-49 days, but many protocols can be used, including for gestations up to 63 days from the last menstrual period.
o The Mifeprex/misoprostol drugs are given as follows:
On day one, Mifeprex (200mg or 600mg) as pills are taken by mouth in the doctor's office.
On day two or three, misoprostol (800mcg is taken as pilsl or inserted vaginally) or in an office setting with four hours of observation.
Between days 7 and 10, you return to the office to determine if the abortion has been completed.
If it has not, a repeat dose of misoprostol is given or you may undergo a surgical abortion.
About 50% will abort in the first three days, about 80% of patients by the next day, and only about 5% of patients will need a surgical abortion.
o The methotrexate/misoprostol regimen is similar, as follows:
Methotrexate is injected on day one.
On days six to seven, misoprostol is taken at home vaginally, and you return to the office on day eight to determine if the abortion has taken place. Misoprostol can be repeated with monitoring, or surgical abortion may be completed.
• Prostaglandin-induced second-trimester abortion: Medication can be given vaginally, orally, or injected into the fetus. The most typical regimen is usually 200mcg vaginally every four hours until the process is complete.
• Saline-induced abortion:A long process that was used 20 years ago is not often performed but is safe.
Surgical abortion
• Cervical dilatation and preparation
o For a first-trimester termination, particularly at less than 10 weeks' gestation, rarely do you need to have your cervix dilated (enlarged so the contents of the uterus can pass through and out of your body). If you are in the latter part of the first trimester (first three months), you may have a small sterilized stick called a laminaria japonica (or more than one) placed in your cervix to open it. These laminaria take about four hours to be useful and may be placed overnight.
o Before inserting the stick, your cervix may be swabbed with Betadine, a cleaning solution. You may be given an injection of numbing solution into the cervix. This is the beginning of the abortion procedure. Please understand your risks, and they should have been explained in the counseling process, before you start the dilatation process.
• Sedation during abortion
o Most women are coached through an abortion as the health care provider explains each step. Some women prefer to have some numbing in their cervix. Most do not require IV sedation.
o If heavy sedation is selected, then IV fluids will be used.
• First-trimester surgical abortion
o Early terminations are performed with little cervical dilatation and using a hand-held syringe or a small-bore cannula (a tube) attached to a suction machine. Abortions performed with a syringe are referred to as manual aspirations (or menstrual extractions). Those performed with the suction generated by a vacuum aspirator are referred to as a vacuum aspiration. Both procedures take only a few minutes.
o Tools are used to grasp the cervix after it has been prepared with Betadine and possibly numbed. The cannula is carefully inserted through the cervix into your uterus. The actual evacuation is performed by applying suction to the syringe or via the machine. The procedure takes a few minutes to complete. There is a small amount of blood loss.
o The doctor will check the tissue to make sure it has all been taken out.
• Dilatation and curettage (D&C)
o This specifically is a term that is usually applied to a diagnostic procedure or the treatment of an incomplete abortion.
o The procedure is usually accomplished with similar dilatation procedures, but the uterus is emptied with a sharp metal curette. These curettes are more dangerous than the flexible or rigid plastic devices, which are used in the suction procedures, and are not recommended for abortion procedures.
• Second-trimester dilatation and evacuation
o Dilatation and evacuation is the safest and most common method of second-trimester termination used by experienced health care professionals. Dilation takes place over hours and possibly days with the sticks to enlarge the cervix.
o Once the cervix is enlarged enough, the procedure is accomplished using a combination of suction curettage and manual evacuation of the fetus and placenta. Ultrasound may be used to guide the tools.
o The procedure is longer and more uncomfortable than a first-trimester procedure, but many women can comfortably go through the procedure with local anesthesia.
• Dilatation and extraction
o This procedure is accomplished by cervical preparation similar to cases of dilatation and evacuation, but the fetus is removed in a mostly intact condition. The fetal head s able to be collapsed after the contents are evacuated so that it may pass through the cervix.
o Very few providers perform the procedure. It is usually reserved for cases of maternal medical complications or serious medical problems with the fetus.
o The procedure, referred to as intact dilatation and extraction, called partial-birth abortion, has now been banned by a 2007 Supreme Court ruling.
o To avoid performing a partial birth abortion while performing a legal dilatation and extraction, digitalis or potassium chloride may be injected onto the fetus to induce preoperative fetal death. Fetal cord cutting may accomplish this as well.
o Research has not firmly established at what age a healthy fetus can feel pain, but generally it is thought that this occurs around 24-28 weeks.
• Induction of labor
o Most doctors have experience with the standard drugs used to induce labor for birth. These can be used in the second trimester of pregnancy.
o Premature rupture of membranes is one indication for this method.
o o Cervical ripening agents are typically necessary with either laminaria or misoprostal.
After the Procedure
• Activity: You may be referred for ongoing counseling and support after an abortion. You may eat a regular diet and resume normal activity. Avoid heavy activity or lifting for a few days. Do not use tampons,douche, or have sexual intercourse for one week.
• Medications: You may be given medication for pain, but these are usually not necessary. Your doctor may prescribe medications for painful contractions and cramping of your uterus, but with a first-trimester procedure, none are usually needed. f you have pain, your doctor may suggest acetaminophen (such as Tyleno)l or ibuprofen (such as Advil) and similar pain relievers.
Follow-up
Abortion does not require a stay in the hospital unless you have a medical condition that requires you to be monitored or if you have a complication with the surgical procedure.
• Medical care after a surgical abortion
o Your health care provider will watch you for at least 30 minutes after the surgery, checking for abdominal painand unusual bleeding.
o If you have decided to use an IUD for birth control, it will be inserted. If you have decided to use a hormonal injection form of birth control, you may receive your injection on this day.
o You will be asked to return to the clinic in one to three weeks to make sure the pregnancy has been terminated and to check for any medical complications.
o If you have these symptoms, you should see your health care provider:
Severe pain
Fever of 100.4°F or higher
Bleeding through more than four or five pads per hour or more than 12 pads in 24 hours
o You may be given pain relievers during the first 24 hours after surgery, such as acetaminophen (Tylenol). After that time you can switch to a pain reliever such as ibuprofen (Advil) or aproxen.
o You should make sure you have been given emergency contact numbers and instructions regarding where to go if you have an emergency and cannot reach your health care provider. You may bleed very little, if at all. The most common bleeding pattern is bleeding the day of the procedure, then not much until the fifth day after surgery, when heavier cramping and clotting occurs.
o You should not use tampons for five days and should not have intercourse until bleeding has stopped for a week or you have been cleared by your doctor at your appointment after the surgery.
• Psychological effects of abortion
o You may feel normal emotions such as sadness and grief after an abortion. You may also feel depression. 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, and these feelings usually pass within days to weeks in most cases and do not lead to mental health problems. One study showed that women who had abortions had mental health issues such as depression 1% of the time, compared with 10% of women who gave birth who experienced depression.
o How you feel may be affected by your emotional status during the decision making, your relationships, religion, age, social support networks, and whether you have had mental health issues before If you were a victim of rape or incest, you may have entirely different feelings and emotions undergoing an abortion.
o Counseling may help you work through your emotions and cope with your feelings.
Abortion Rights in the United States
The abortion ethics debate has kept termination of pregnancy in the courts and media since the landmark decision in Roe v Wade. The original ruling was fairly straightforward, legally confirming a woman's right to a private medical decision when selecting a medical procedure (abortion).
As the debate has raged and the medical issues have become more complex, rulings in the courts and in the legislatures have extended beyond this simplistic question to restrictions on gestational age, viability determinations, spousal and parental consents, enforced waiting periods, enforced language in consents, enforcement of provider qualifications, the right to use fetal tissue for research or medical treatments, the rights of providers and patients to be shielded from overt protest, and, finally, on access to birth control.
In a typical year, hundreds of laws and rulings are proposed, and some even specifically criminalize performing abortions. Current laws are difficult to follow, but a summary is available in the State Policies in Brief section on The Alan Guttmacher Institute Web site.
Prior to the 1960s, an estimated nine of 10 out-of-wedlock pregnancies were electively aborted. These procedures were performed in a variety of medical and nonmedical settings, and almost 20% of all pregnancy-related complications were due to illegal abortions.
• Roe v Wade
o An important early decision by the US Supreme Court constitutionally establishing a woman's right to privacy was Griswold v Connecticut in 1965.
o In the early 1970s, political support was overwhelmingly in support of legalized abortion, and activists for abortion rights specifically sought a plaintiff so that a legal challenge to abortions could be argued in court. The plaintiff, Norma McCorvey, was the "Jane Roe" for whom the decision is named. The Centers for Disease Control and Prevention define aninduced abortion as "a procedure intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age."
• Late-term abortions
o Although only 2% of people express opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, another divisive factor has crept into the debate. Abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.
o By 1998, 28 states had passed bans on this procedure, referred to as a partial-birth abortion, which is the medical procedure called intact dilatation and extraction.
o o In November, 2003, President George Bush signed a partial birth abortion ban. This Act was not in effect because of a court order, and in 2007 the Supreme Court passed the Partial Birth Abortion Ban.
• Parental consent
o Most young women have parents or family involvement in their decision to have an abortion. Adolescents who are older, especially those living independently, often do not. In spite of ample scientific evidence that many teens seek parental involvement and widespread legal concern that young women who do not seek parental involvement may be at risk physically or emotionally, a barrage of legislation mandates that all minors seek parental consents or that the parents be notified in advance of a minor child having an abortion.
o The laws that have enabled this to occur legally are backed by the US Supreme Court. As of 2007, 35 states require some sort of parental involvement in a minor's decision to have an abortion. Twentytwo states require parental consent only, 11 states require parental notification only, and two states require both parental consent and parental notification. Currently, only Connecticut, Hawaii, Maine, New York, Oregon, Vermont, and Washington do not require parental involvement. For a summary of laws, see Parental Involvement in Minors' Abortions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents who may travel hundreds of miles to seek an abortion.
o Patient rights bills have been developed by a variety of groups, including the Consumers' Bill of Rights and Responsibilities that has been developed by a presidential task force. These bills specifically state that patients have a right to access knowledge and that providers have a right to discuss care they think is medically appropriate regardless of the source of that care.
• Mandatory waiting periods
o Mandatory waiting periods mandate by law that the woman seeking to end a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives.
o In spite of the fact that these laws typically only mandate a short 24-hour waiting period, they have the effect of increasing the percentage of second-trimester abortions in states with these laws.
• Special concerns
o Advances in neonatal medicine leading to improved survival by babies born very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on when life begins.
o Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments continues. These potential therapies may be indicated for the treatment of diabetes,Parkinson's disease, kidney disease, and cartilage diseases, among others.
o Current national regulations prohibit most fetal tissue research, but theNational Institutes of Health revealed late in 2000 that it will allow stem cell research. In June 2002, President Bush enacted a law restricting stem cell research to only preexisting cell lines and embryos "left over" from in vitro fertilization procedures.
o Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface.
• Provider issues
o Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (such as family practitioners and nurses) can be taught to perform abortions safely. Physicians are generally receptive to the concept of legal abortions being available in the United States. Research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.
o Keeping abortions safe, legal, and rare are the goals of abortion providers.
o As providers have decreased in number, women are traveling farther to obtain abortions, seeking abortions later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.
o Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.
• Insurance Coverage
o While few state public funding sources cover abortions except in cases of jeopardy to maternal life, many private health care plans do cover abortion counseling and procedures.
While women of every social class seek terminations, the typical woman who ends her pregnancy is either young, white, unmarried, poor, or over the age of 40.
In the United States and worldwide, abortion (known also as elective termination of pregnancy) remains common.
• The US Supreme Court legalized abortion in the well-known Roe v Wadedecision in 1973; currently, there areabout 1.2 million abortions are performed each year in the United States.
• Worldwide, some 20-30 million legal abortions are performed each year, with another 10-20 million abortions performed illegally. Illegal abortions are unsafe and account for 13% of all deaths of women because of serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
In spite of the introduction of newer, more effective, and more widely available birth control methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these unplanned pregnancies, about half end in abortion.
Making abortion legal
Since the landmark 1973 US Supreme Court decision that made abortion legal, hundreds of federal and state laws have been proposed or passed. Abortion is one of the most visible, controversial, and legally active areas in the field of medicine. These laws address a variety of controversial questions including:
• The issue of parental notification. A number of state laws do require that some minors notify parents before obtaining an abortion, but what provisions are necessary to protect young women who feel they cannot notify their parents?
• Should spouses be notified before a woman has an abortion?
• Has the pregnancy progressed far enough that the fetus could live on its own before termination (termed viability)?
• Should there be mandatory waiting periods before an abortion can take place?
• What might be mandatory wording for counseling sessions or consent forms?
• Should public funds be used for abortions?
• What regulations if any should apply to abortion providers?
• What provisions might be made against specific abortion techniques?
• Should emergency contraception be allowed?
• Should the rules be different in cases of sexual assault and rape?
Before abortion was legal
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of medical personnel.
• Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion.
• The first US federal law on the subject was the Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception in order to suppress the circulation of "obscene" materials.
• From 1900 until the 1960s, abortions were prohibited by law. However, theKinsey report noted that premarital pregnancies were electively aborted, and public and physician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and ensured their right to choice in this process. No decision was more important than Griswold v Connecticut, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain birth control from their health care provider.
The Supreme Court decision: Roe v Wade
The Supreme Court case of Roe v Wade was the result of the work of a wide group of people who worked to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL).
• Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
• In 1973, the Roe v Wade law, in the opinion written by US Supreme Court justice Harry Blackmun, the court ruled that a woman had a right to an abortion during the first 2 trimesters (6 months) of pregnancy. He cited the safety of the procedures and the basic right of women to make their own decisions.
• Since this ruling, the states have regained much control. Serious restrictions have been placed on abortion services.Debate continues by federal and state lawmakers. The US Senate approved the first federal ban on a specific abortion procedure (called partial-birth abortion, defined later in this topic) in October 2003. The bill was signed byPresident George W. Bush.
Determining life
When does "life" begin?That is one of the issues surrounding the controversy about abortion. The legal issues are these:
• Loosely defined, the term viability is the ability of the fetus to survive outside the mother's womb without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation (gestation is the period of time a fetus develops in the mother's uterus, usually 40 weeks). However, there are no reliable or medically acceptable tests for viability prior to 28 weeks' gestation.
• The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (for example, a developing fetus with certain brain disorders will never live on its own). In Colautti v Franklin, the court overturned a Pennsylvania law requiring doctors to follow specific directives in certain medical cases and recognized the judgment of the doctor in these matters.
Parental consent
Various federal and state decisions have tried to require parental notification, waiting periods, informed consent, and abortion counseling.
People against abortion argue that parents need to be informed about and approve an abortion for a daughter younger than 18 years.Those supporting the rights of a woman to choose abortion say parental consent is not required for a woman to carry a pregnancy to term (the birth of a baby), nor do parents need to give permission for a woman seeking birth control such as pills or an intrauterine device (IUD). Parents are also not consulted when a woman seeks treatment for asexually transmitted disease.
Research shows that many young women younger than 18 yearsdo involve their parents in their decision to abort (45%). Laws requiring parental consent are forcing minors to obtain abortions much later in their pregnancies. Some minors must travel great distances to states with no such law.
Intact dilation and extraction
The recently crafted political term partial-birth abortion loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This definition broadly includes all methods of second-trimester abortion (done after the first three months of pregnancy. A 2007 Partial Birth Abortion ban was passed by the Supreme Court, and although its wording is open to interpretation, it essentially states that the act of termination of fetal life cannot occur in a partially extracted fetus.
Providers
Providers of abortions are generally specialists in women's health such as obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers (physicians, physician assistants, midwives, and nurse practitioners) to perform these procedures.
Various factors over the years have influenced the number of medical professionals available and trained to perform abortions:
• Medical student training in this procedure is limited or absent from many programs. Some students may opt not to be trained in the procedure. Pharmacists may decide not to dispense medical abortion medications.
• Increasing violence against providers and clinics has further decreased their willingness to provide abortion services.
• The US Food and Drug Administration (FDA) has approved Mifeprex (mifepristone, RU-486), a drug for medical abortions. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination.
• A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.
Abortion statistics
In the United States: In 2003, about 16 women for every 1,000 women aged 15-44 years had an abortion, and for every 1,000 live births, about 241 abortions were performed, according to the Centers for Disease Control and Prevention. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social issues surrounding abortion have led to more women seeking terminations later in pregnancy.
• Safety: Legal abortion is a safe procedure. Infection rates are less than one percent, and fewer than 1 in 100,000 deaths occurs from first-trimester abortions. Abortion is safer for the mother than carrying a pregnancy to term. Medical and surgical abortions are both safe and effective when performed by trained practitioners.
• Race: Most women seeking abortion are white (53%); 36% are black, 8% are of another race, and 3% are of unknown race.
• Age: Abortion rates are highest among 20- to 24-year-old women. Rates are lowest among women younger than 20 or older than 40 years but these women are far more likely to have an abortion if they become pregnant.
In the world: Abortion causes at least 13% of all deaths among pregnant women. New estimates are that 50 million abortions are performed world wide each year, with 30 million of them in developing countries. Approximately 20 million of these are performed unsafely because of conditions or lack of provider training.
Abortion is one of the most common medical procedures performed in the United States each year.More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives.
While women of every social class seek terminations, the typical woman who ends her pregnancy is either young, white, unmarried, poor, or over the age of 40.
In the United States and worldwide, abortion (known also as elective termination of pregnancy) remains common.
• The US Supreme Court legalized abortion in the well-known Roe v Wadedecision in 1973; currently, there areabout 1.2 million abortions are performed each year in the United States.
• Worldwide, some 20-30 million legal abortions are performed each year, with another 10-20 million abortions performed illegally. Illegal abortions are unsafe and account for 13% of all deaths of women because of serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
In spite of the introduction of newer, more effective, and more widely available birth control methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these unplanned pregnancies, about half end in abortion.
Making abortion legal
Since the landmark 1973 US Supreme Court decision that made abortion legal, hundreds of federal and state laws have been proposed or passed. Abortion is one of the most visible, controversial, and legally active areas in the field of medicine. These laws address a variety of controversial questions including:
• The issue of parental notification. A number of state laws do require that some minors notify parents before obtaining an abortion, but what provisions are necessary to protect young women who feel they cannot notify their parents?
• Should spouses be notified before a woman has an abortion?
• Has the pregnancy progressed far enough that the fetus could live on its own before termination (termed viability)?
• Should there be mandatory waiting periods before an abortion can take place?
• What might be mandatory wording for counseling sessions or consent forms?
• Should public funds be used for abortions?
• What regulations if any should apply to abortion providers?
• What provisions might be made against specific abortion techniques?
• Should emergency contraception be allowed?
• Should the rules be different in cases of sexual assault and rape?
Before abortion was legal
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of medical personnel.
• Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion.
• The first US federal law on the subject was the Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception in order to suppress the circulation of "obscene" materials.
• From 1900 until the 1960s, abortions were prohibited by law. However, theKinsey report noted that premarital pregnancies were electively aborted, and public and physician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and ensured their right to choice in this process. No decision was more important than Griswold v Connecticut, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain birth control from their health care provider.
The Supreme Court decision: Roe v Wade
The Supreme Court case of Roe v Wade was the result of the work of a wide group of people who worked to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL).
• Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
• In 1973, the Roe v Wade law, in the opinion written by US Supreme Court justice Harry Blackmun, the court ruled that a woman had a right to an abortion during the first 2 trimesters (6 months) of pregnancy. He cited the safety of the procedures and the basic right of women to make their own decisions.
• Since this ruling, the states have regained much control. Serious restrictions have been placed on abortion services.Debate continues by federal and state lawmakers. The US Senate approved the first federal ban on a specific abortion procedure (called partial-birth abortion, defined later in this topic) in October 2003. The bill was signed byPresident George W. Bush.
Determining life
When does "life" begin?That is one of the issues surrounding the controversy about abortion. The legal issues are these:
• Loosely defined, the term viability is the ability of the fetus to survive outside the mother's womb without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation (gestation is the period of time a fetus develops in the mother's uterus, usually 40 weeks). However, there are no reliable or medically acceptable tests for viability prior to 28 weeks' gestation.
• The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (for example, a developing fetus with certain brain disorders will never live on its own). In Colautti v Franklin, the court overturned a Pennsylvania law requiring doctors to follow specific directives in certain medical cases and recognized the judgment of the doctor in these matters.
Parental consent
Various federal and state decisions have tried to require parental notification, waiting periods, informed consent, and abortion counseling.
People against abortion argue that parents need to be informed about and approve an abortion for a daughter younger than 18 years.Those supporting the rights of a woman to choose abortion say parental consent is not required for a woman to carry a pregnancy to term (the birth of a baby), nor do parents need to give permission for a woman seeking birth control such as pills or an intrauterine device (IUD). Parents are also not consulted when a woman seeks treatment for asexually transmitted disease.
Research shows that many young women younger than 18 yearsdo involve their parents in their decision to abort (45%). Laws requiring parental consent are forcing minors to obtain abortions much later in their pregnancies. Some minors must travel great distances to states with no such law.
Intact dilation and extraction
The recently crafted political term partial-birth abortion loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This definition broadly includes all methods of second-trimester abortion (done after the first three months of pregnancy. A 2007 Partial Birth Abortion ban was passed by the Supreme Court, and although its wording is open to interpretation, it essentially states that the act of termination of fetal life cannot occur in a partially extracted fetus.
Providers
Providers of abortions are generally specialists in women's health such as obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers (physicians, physician assistants, midwives, and nurse practitioners) to perform these procedures.
Various factors over the years have influenced the number of medical professionals available and trained to perform abortions:
• Medical student training in this procedure is limited or absent from many programs. Some students may opt not to be trained in the procedure. Pharmacists may decide not to dispense medical abortion medications.
• Increasing violence against providers and clinics has further decreased their willingness to provide abortion services.
• The US Food and Drug Administration (FDA) has approved Mifeprex (mifepristone, RU-486), a drug for medical abortions. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination.
• A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.
Abortion statistics
In the United States: In 2003, about 16 women for every 1,000 women aged 15-44 years had an abortion, and for every 1,000 live births, about 241 abortions were performed, according to the Centers for Disease Control and Prevention. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social issues surrounding abortion have led to more women seeking terminations later in pregnancy.
• Safety: Legal abortion is a safe procedure. Infection rates are less than one percent, and fewer than 1 in 100,000 deaths occurs from first-trimester abortions. Abortion is safer for the mother than carrying a pregnancy to term. Medical and surgical abortions are both safe and effective when performed by trained practitioners.
• Race: Most women seeking abortion are white (53%); 36% are black, 8% are of another race, and 3% are of unknown race.
• Age: Abortion rates are highest among 20- to 24-year-old women. Rates are lowest among women younger than 20 or older than 40 years but these women are far more likely to have an abortion if they become pregnant.
In the world: Abortion causes at least 13% of all deaths among pregnant women. New estimates are that 50 million abortions are performed world wide each year, with 30 million of them in developing countries. Approximately 20 million of these are performed unsafely because of conditions or lack of provider training.
Abortion Preparation
History
Most abortions are performed after your health care provider takes a brief and targeted medical history. You will be asked questions about prior pregnancies and any treatment or care during the current pregnancy. You will be asked about any diseases or conditions that affect your reproductive organs, such as sexually transmitted infections.
The provider will ask whether you have a history of diabetes, high blood pressure, heart disease,anemia, bleeding disorders, or surgery (on your ovaries or uterus, for example). If you have active medical problems, you may need to be stabilized before an abortion or have the procedure performed in a facility that can handle special medical problems.
• If there are known problems with the fetus, such as severe brain abnormalities that will either not allow the fetus to live, and if these problems are known through diagnostic testing, the woman may choose to end the pregnancy with abortion.
• The most common problems with the fetus encountered in abortion counseling include major system development failures and problems that cannot be repaired dealing with the heart, nervous system, spine, brain, abdomen, kidneys, and breathing and digestive systems.
Physical
A brief physical examination is usually performed before an abortion. The focus is on determining when your pregnancy began and checking for sexually transmitted disease and whether you are healthy enough to undergo the procedure.
Lab tests
Pregnancy tests are used to confirm that you are pregnant. Home tests are reliable, so providers will accept these results in some cases. Blood will be tested for sexually transmitted diseases and for hepatitis. Urine may be checked to see if you have a urinary tract infection.
Imaging studies
An ultrasound is virtually always dome for pregnancy confirmation and dating. Doctors are looking for how many fetuses may be developing, the size of the fetus or fetuses, a picture of the uterus and ovaries, and to rule out a problem such as an ectopic pregnancy (a life-threatening condition in which the fetus develops outside the uterus).
Medications
Your health care provider may give you antibiotics as a precaution against infection. Antibiotic use for the procedure is usually given the day of the procedure and for the next day or two.
Abortion Counseling
Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing the pregnancy to deliver a baby, information and options for the abortion procedure, and, finally, information regarding a birth control decision. The risks and benefits of both medical and surgical abortions are often reviewed.
• The counseling process is aimed primarily at the woman herself but may also include other people she chooses to be involved. Studies indicate that men are involved in more than 40% of the decisions, but only scant research has been performed on male involvement in the process. Some women can reach a decision quickly. Others take longer to decide. The counseling process may provide referrals if you need ongoing support.
• You should not feel pressured to make a decision. Take time to consider your options.
• During the counseling, you may be asked questions designed to encourage meaningful discussion of the issues as they pertain to you. You will have many emotions.Counseling may take a day or longer.
Some state laws may apply to the counseling process. Some states have mandatory waiting times between the information session and the actual abortion. Other states require family or parental notification, and some states mandate that certain subjects be covered during abortion counceling.
Explanation of the Procedures
Once your pregnancy has been confirmed, and the doctor knows how many weeks along the pregnancy is, and you have decided to end the pregnancy, the procedure offered typically reflects your stage of gestation. Early abortions can be accomplished medically or surgically, but most facilities do not have the protocols established or personnel with the technical ability to offer medical abortions (with pills). Therefore, most abortions are performed surgically.
• Women often travel far for their abortion procedure and feel comfortable completing the preoperative preparation in a short office visit. In states where laws require waiting periods, this can be done in stages.
• The assessment process involves only a targeted history, physical examination, laboratory work, and ultrasound (including dating of the pregnancy, if indicated) followed by a counseling session.
• Second-trimester abortion preparation is more difficult. Preparing the cervix in less than 24 hours is almost impossible, but the basic assessment process is identical.
• Ultrasound examinations may be used to look specifically for obvious problems with the fetus.
• Some centers also offer an intra-amniotic injection of the drug digoxin, which stop heart activity in the fetus before a second-trimester abortion.
Medical abortion
• First- and second-trimester medical abortion
o First-trimester (first three months of a pregnancy) terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or Mifeprex (RU-486) with or without misoprostol. Other prostaglandins are used in other countries.
o Medical abortions are indicated for women who consent to a medical abortion but are also willing to undergo a surgical abortion if the medical abortion fails. Gestational age is usually less than 42-49 days, but many protocols can be used, including for gestations up to 63 days from the last menstrual period.
o The Mifeprex/misoprostol drugs are given as follows:
On day one, Mifeprex (200mg or 600mg) as pills are taken by mouth in the doctor's office.
On day two or three, misoprostol (800mcg is taken as pilsl or inserted vaginally) or in an office setting with four hours of observation.
Between days 7 and 10, you return to the office to determine if the abortion has been completed.
If it has not, a repeat dose of misoprostol is given or you may undergo a surgical abortion.
About 50% will abort in the first three days, about 80% of patients by the next day, and only about 5% of patients will need a surgical abortion.
o The methotrexate/misoprostol regimen is similar, as follows:
Methotrexate is injected on day one.
On days six to seven, misoprostol is taken at home vaginally, and you return to the office on day eight to determine if the abortion has taken place. Misoprostol can be repeated with monitoring, or surgical abortion may be completed.
• Prostaglandin-induced second-trimester abortion: Medication can be given vaginally, orally, or injected into the fetus. The most typical regimen is usually 200mcg vaginally every four hours until the process is complete.
• Saline-induced abortion:A long process that was used 20 years ago is not often performed but is safe.
Surgical abortion
• Cervical dilatation and preparation
o For a first-trimester termination, particularly at less than 10 weeks' gestation, rarely do you need to have your cervix dilated (enlarged so the contents of the uterus can pass through and out of your body). If you are in the latter part of the first trimester (first three months), you may have a small sterilized stick called a laminaria japonica (or more than one) placed in your cervix to open it. These laminaria take about four hours to be useful and may be placed overnight.
o Before inserting the stick, your cervix may be swabbed with Betadine, a cleaning solution. You may be given an injection of numbing solution into the cervix. This is the beginning of the abortion procedure. Please understand your risks, and they should have been explained in the counseling process, before you start the dilatation process.
• Sedation during abortion
o Most women are coached through an abortion as the health care provider explains each step. Some women prefer to have some numbing in their cervix. Most do not require IV sedation.
o If heavy sedation is selected, then IV fluids will be used.
• First-trimester surgical abortion
o Early terminations are performed with little cervical dilatation and using a hand-held syringe or a small-bore cannula (a tube) attached to a suction machine. Abortions performed with a syringe are referred to as manual aspirations (or menstrual extractions). Those performed with the suction generated by a vacuum aspirator are referred to as a vacuum aspiration. Both procedures take only a few minutes.
o Tools are used to grasp the cervix after it has been prepared with Betadine and possibly numbed. The cannula is carefully inserted through the cervix into your uterus. The actual evacuation is performed by applying suction to the syringe or via the machine. The procedure takes a few minutes to complete. There is a small amount of blood loss.
o The doctor will check the tissue to make sure it has all been taken out.
• Dilatation and curettage (D&C)
o This specifically is a term that is usually applied to a diagnostic procedure or the treatment of an incomplete abortion.
o The procedure is usually accomplished with similar dilatation procedures, but the uterus is emptied with a sharp metal curette. These curettes are more dangerous than the flexible or rigid plastic devices, which are used in the suction procedures, and are not recommended for abortion procedures.
• Second-trimester dilatation and evacuation
o Dilatation and evacuation is the safest and most common method of second-trimester termination used by experienced health care professionals. Dilation takes place over hours and possibly days with the sticks to enlarge the cervix.
o Once the cervix is enlarged enough, the procedure is accomplished using a combination of suction curettage and manual evacuation of the fetus and placenta. Ultrasound may be used to guide the tools.
o The procedure is longer and more uncomfortable than a first-trimester procedure, but many women can comfortably go through the procedure with local anesthesia.
• Dilatation and extraction
o This procedure is accomplished by cervical preparation similar to cases of dilatation and evacuation, but the fetus is removed in a mostly intact condition. The fetal head s able to be collapsed after the contents are evacuated so that it may pass through the cervix.
o Very few providers perform the procedure. It is usually reserved for cases of maternal medical complications or serious medical problems with the fetus.
o The procedure, referred to as intact dilatation and extraction, called partial-birth abortion, has now been banned by a 2007 Supreme Court ruling.
o To avoid performing a partial birth abortion while performing a legal dilatation and extraction, digitalis or potassium chloride may be injected onto the fetus to induce preoperative fetal death. Fetal cord cutting may accomplish this as well.
o Research has not firmly established at what age a healthy fetus can feel pain, but generally it is thought that this occurs around 24-28 weeks.
• Induction of labor
o Most doctors have experience with the standard drugs used to induce labor for birth. These can be used in the second trimester of pregnancy.
o Premature rupture of membranes is one indication for this method.
o o Cervical ripening agents are typically necessary with either laminaria or misoprostal.
After the Procedure
• Activity: You may be referred for ongoing counseling and support after an abortion. You may eat a regular diet and resume normal activity. Avoid heavy activity or lifting for a few days. Do not use tampons,douche, or have sexual intercourse for one week.
• Medications: You may be given medication for pain, but these are usually not necessary. Your doctor may prescribe medications for painful contractions and cramping of your uterus, but with a first-trimester procedure, none are usually needed. f you have pain, your doctor may suggest acetaminophen (such as Tyleno)l or ibuprofen (such as Advil) and similar pain relievers.
Follow-up
Abortion does not require a stay in the hospital unless you have a medical condition that requires you to be monitored or if you have a complication with the surgical procedure.
• Medical care after a surgical abortion
o Your health care provider will watch you for at least 30 minutes after the surgery, checking for abdominal painand unusual bleeding.
o If you have decided to use an IUD for birth control, it will be inserted. If you have decided to use a hormonal injection form of birth control, you may receive your injection on this day.
o You will be asked to return to the clinic in one to three weeks to make sure the pregnancy has been terminated and to check for any medical complications.
o If you have these symptoms, you should see your health care provider:
Severe pain
Fever of 100.4°F or higher
Bleeding through more than four or five pads per hour or more than 12 pads in 24 hours
o You may be given pain relievers during the first 24 hours after surgery, such as acetaminophen (Tylenol). After that time you can switch to a pain reliever such as ibuprofen (Advil) or aproxen.
o You should make sure you have been given emergency contact numbers and instructions regarding where to go if you have an emergency and cannot reach your health care provider. You may bleed very little, if at all. The most common bleeding pattern is bleeding the day of the procedure, then not much until the fifth day after surgery, when heavier cramping and clotting occurs.
o You should not use tampons for five days and should not have intercourse until bleeding has stopped for a week or you have been cleared by your doctor at your appointment after the surgery.
• Psychological effects of abortion
o You may feel normal emotions such as sadness and grief after an abortion. You may also feel depression. 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, and these feelings usually pass within days to weeks in most cases and do not lead to mental health problems. One study showed that women who had abortions had mental health issues such as depression 1% of the time, compared with 10% of women who gave birth who experienced depression.
o How you feel may be affected by your emotional status during the decision making, your relationships, religion, age, social support networks, and whether you have had mental health issues before If you were a victim of rape or incest, you may have entirely different feelings and emotions undergoing an abortion.
o Counseling may help you work through your emotions and cope with your feelings.
Abortion Rights in the United States
The abortion ethics debate has kept termination of pregnancy in the courts and media since the landmark decision in Roe v Wade. The original ruling was fairly straightforward, legally confirming a woman's right to a private medical decision when selecting a medical procedure (abortion).
As the debate has raged and the medical issues have become more complex, rulings in the courts and in the legislatures have extended beyond this simplistic question to restrictions on gestational age, viability determinations, spousal and parental consents, enforced waiting periods, enforced language in consents, enforcement of provider qualifications, the right to use fetal tissue for research or medical treatments, the rights of providers and patients to be shielded from overt protest, and, finally, on access to birth control.
In a typical year, hundreds of laws and rulings are proposed, and some even specifically criminalize performing abortions. Current laws are difficult to follow, but a summary is available in the State Policies in Brief section on The Alan Guttmacher Institute Web site.
Prior to the 1960s, an estimated nine of 10 out-of-wedlock pregnancies were electively aborted. These procedures were performed in a variety of medical and nonmedical settings, and almost 20% of all pregnancy-related complications were due to illegal abortions.
• Roe v Wade
o An important early decision by the US Supreme Court constitutionally establishing a woman's right to privacy was Griswold v Connecticut in 1965.
o In the early 1970s, political support was overwhelmingly in support of legalized abortion, and activists for abortion rights specifically sought a plaintiff so that a legal challenge to abortions could be argued in court. The plaintiff, Norma McCorvey, was the "Jane Roe" for whom the decision is named. The Centers for Disease Control and Prevention define aninduced abortion as "a procedure intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age."
• Late-term abortions
o Although only 2% of people express opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, another divisive factor has crept into the debate. Abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.
o By 1998, 28 states had passed bans on this procedure, referred to as a partial-birth abortion, which is the medical procedure called intact dilatation and extraction.
o o In November, 2003, President George Bush signed a partial birth abortion ban. This Act was not in effect because of a court order, and in 2007 the Supreme Court passed the Partial Birth Abortion Ban.
• Parental consent
o Most young women have parents or family involvement in their decision to have an abortion. Adolescents who are older, especially those living independently, often do not. In spite of ample scientific evidence that many teens seek parental involvement and widespread legal concern that young women who do not seek parental involvement may be at risk physically or emotionally, a barrage of legislation mandates that all minors seek parental consents or that the parents be notified in advance of a minor child having an abortion.
o The laws that have enabled this to occur legally are backed by the US Supreme Court. As of 2007, 35 states require some sort of parental involvement in a minor's decision to have an abortion. Twentytwo states require parental consent only, 11 states require parental notification only, and two states require both parental consent and parental notification. Currently, only Connecticut, Hawaii, Maine, New York, Oregon, Vermont, and Washington do not require parental involvement. For a summary of laws, see Parental Involvement in Minors' Abortions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents who may travel hundreds of miles to seek an abortion.
o Patient rights bills have been developed by a variety of groups, including the Consumers' Bill of Rights and Responsibilities that has been developed by a presidential task force. These bills specifically state that patients have a right to access knowledge and that providers have a right to discuss care they think is medically appropriate regardless of the source of that care.
• Mandatory waiting periods
o Mandatory waiting periods mandate by law that the woman seeking to end a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives.
o In spite of the fact that these laws typically only mandate a short 24-hour waiting period, they have the effect of increasing the percentage of second-trimester abortions in states with these laws.
• Special concerns
o Advances in neonatal medicine leading to improved survival by babies born very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on when life begins.
o Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments continues. These potential therapies may be indicated for the treatment of diabetes,Parkinson's disease, kidney disease, and cartilage diseases, among others.
o Current national regulations prohibit most fetal tissue research, but theNational Institutes of Health revealed late in 2000 that it will allow stem cell research. In June 2002, President Bush enacted a law restricting stem cell research to only preexisting cell lines and embryos "left over" from in vitro fertilization procedures.
o Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface.
• Provider issues
o Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (such as family practitioners and nurses) can be taught to perform abortions safely. Physicians are generally receptive to the concept of legal abortions being available in the United States. Research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.
o Keeping abortions safe, legal, and rare are the goals of abortion providers.
o As providers have decreased in number, women are traveling farther to obtain abortions, seeking abortions later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.
o Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.
• Insurance Coverage
o While few state public funding sources cover abortions except in cases of jeopardy to maternal life, many private health care plans do cover abortion counseling and procedures.
HIV AND AIDS INFECTION
HIV/AIDS Overview
HIV (human immunodeficiency virus) infection has now spread to every country in the world. Approximately 40 million people are currently living with HIV infection, and an estimated 25 million have died from this disease. The scourge of HIV has been particularly devastating in sub-Saharan Africa, but infection rates in other countries remain high. In the United States, approximately 1 million people are currently infected. Here are a few key points about the disease:
• Globally, 85% of HIV transmission is heterosexual.
• In the United States, approximately one-third of new diagnoses appear to be related to heterosexual transmission. Male-to-male sexual contact still accounts for approximately half of new diagnoses in the U.S. Intravenous drug use contributes to the remaining cases. Because the diagnosis may occur years after infection, it is likely that a higher proportion of recent infections are due to heterosexual transmission.
• Infections in women are increasing. Worldwide, 42% of people with HIV are women. In the United States, approximately 25% of new diagnoses are in women, and the proportion is rising.
• There is good news on one front. New HIV infections in U.S. children have fallen dramatically. This is largely a result of testing and treating infected mothers, as well as establishing uniform testing guidelines for blood products.
In order to understand HIV and AIDS, it is important to understand the meanings behind these terms:
• HIV stands for the human immunodeficiency virus. It is one of a group of viruses known as retroviruses. After getting into the body, the virus kills or damages cells of the body's immune system. The body tries to keep up by making new cells or trying to contain the virus, but eventually the HIV wins out and progressively destroys the body's ability to fight infections and certain cancers.
• AIDS stands for the acquired immunodeficiency syndrome. It is caused by HIV and occurs when the virus has destroyed so much of the body's defenses that immune-cell counts fall to critical levels or certain life-threatening infections or cancers develop.
HIV/AIDS Transmission
HIV is transmitted when the virus enters the body, usually by injecting infected cells or semen. There are several possible ways in which the virus can enter.
• Most commonly, HIV infection is spread by having sex with an infected partner. The virus can enter the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex.
• HIV frequently spreads among injection-drug users who share needles or syringes that are contaminated with blood from an infected person.
• Women can transmit HIV to their babies during pregnancy or birth, when infected maternal cells enter the baby's circulation.
• HIV can be spread in health-care settings through accidental needle sticks or contact with contaminated fluids.
• Very rarely, HIV spreads through transfusion of contaminated blood or blood components. Blood products are now tested to minimize this risk. If tissues or organs from an infected person are transplanted, the recipient may acquire HIV. Donors are now tested for HIV to minimize this risk.
• People who already have a sexually transmitted disease, such as syphilis,genital herpes, chlamydial infection, gonorrhea, or bacterial vaginosis, are more likely to acquire HIV infection during sex with an infected partner.
The virus does not spread through casual contact such as preparing food, sharing towels and bedding, or via swimming pools, telephones, or toilet seats. The virus is also unlikely to be spread by contact with saliva, unless it is contaminated with blood.
HIV/AIDS Symptoms and Signs
Many people with HIV do not know they are infected.
• Many people do not develop symptoms after they first get infected with HIV. Others have a flu-like illness within several days to weeks after exposure to the virus. They complain of fever, headache, tiredness, and enlarged lymph nodes in the neck. These symptoms usually disappear on their own within a few weeks. After that, the person feels normal and has no symptoms. This asymptomatic phase often lasts for years.
• The progression of disease varies widely among individuals. This state may last from a few months to more than 10 years.
o During this period, the virus continues to multiply actively and infects and kills the cells of the immune system.
o The virus destroys the cells that are the primary infection fighters, a type of white blood cell called CD4 cells.
o Even though the person has no symptoms, he or she is contagious and can pass HIV to others through the routes listed above.
AIDS is the later stage of HIV infection, when the body begins losing its ability to fight infections. Once the CD4 cell count falls low enough, an infected person is said to have AIDS. Sometimes, the diagnosis of AIDS is made because the person has unusual infections or cancers that show how weak the immune system is.
• The infections that happen with AIDS are called opportunistic infectionsbecause they take advantage of the opportunity to infect a weakened host. The infections include (but are not limited to)
o pneumonia caused by Pneumocystis, which causes wheezing;
o brain infection with toxoplasmosis which can cause trouble thinking or symptoms that mimic a stroke;
o widespread infection with a bacteria called MAC (mycobacterium avium complex) which can cause fever and weight loss;
o yeast infection of the swallowing tube (esophagus) which causes pain with swallowing;
o widespread diseases with certain fungi like histoplasmosis, which can cause fever, cough, anemia, and other problems.
• A weakened immune system can also lead to other unusual conditions:
o lymphoma in (a form of cancer of the lymphoid tissue) the brain, which can cause fever and trouble thinking;
o a cancer of the soft tissues called Kaposi's sarcoma, which causes brown, reddish, or purple spots that develop on the skin or in the mouth.
When to Seek Medical Care
If you have engaged in unprotected sex outside of a mutually monogamous relationship or shared needles while using drugs, you should have an HIV test. Early detection and treatment of the infection can slow the growth of HIV.
• If you are pregnant and infected with HIV, you may be able to reduce the risk to your unborn child by getting treatment early.
• You can also avoid infecting others if you know that you have the disease. Testing is available anonymously and confidentially. You can even test yourself at home.
People known to have HIV infection or AIDS should go to the hospital any time they develop high fever, shortness of breath, coughing up blood, severe diarrhea, severe chest orabdominal pain, generalized weakness, severe headache, seizures, confusion, or a change in mental status. These may be the indication of a life-threatening condition for which an urgent evaluation in the hospital's emergency department is recommended. All infected people should be under the regular care of a physician skilled in the treatment of HIV and AIDS.
HIV/AIDS Diagnosis
HIV infection is commonly diagnosed by blood tests. There are three main types of tests that are commonly used: (1) antibody tests, (2) RNA tests, and (3) a combination test that detects both antibodies and a piece of the virus called the p24 protein. In addition, a blood test known as a Western blot is used to confirm the diagnosis.
No test is perfect. Tests may be falsely positive or falsely negative. For example, it can take some time for the immune system to produce enough antibodies for the antibody test to turn positive. This time period is commonly referred to as the "window period" and may last six weeks to three months following infection. Therefore, if the initial antibody test is negative, a repeat test should be performed three months later. Early testing is crucial, because early treatment for HIV helps people avoid or minimize complications. Furthermore, high-risk behaviors can be avoided, thus preventing the spread of the virus to others.
Testing for HIV is usually a two-step process. First, an inexpensive screening test is done. If that test is positive, a second test (Western blot) is done to confirm the result. Antibody tests are the most common initial screening test used. There are different types of antibody screening tests available:
• Most commonly, blood is drawn for an enzyme immunoassay (EIA). The test is usually run in a local laboratory, so results can take one to three days to come back.
• Other tests can detect antibodies in body fluids other than blood such as saliva, urine, and vaginal secretions. Some of these are designed to be rapid tests that produce results in approximately 20 minutes. These tests have accuracy rates similar to traditional blood tests.
• HIV home-testing kits are available at many local drug stores. Blood is obtained by a finger prick and blotted on a filter strip. Other test kits use saliva or urine. The filter strip is mailed in a protective envelope to a laboratory to be tested. Results are returned by mail in one to two weeks.
• All positive antibody screening tests must be confirmed with a follow-up blood test called the Western blot to make a positive diagnosis. If the antibody test and the Western blot are both positive, the likelihood of a person being HIV infected is >99%. Sometimes, the Western blot is "indeterminate," meaning that it is neither positive nor negative. In these cases, the tests are usually repeated at a later date. In addition, an RNA test for the virus might be done.
Other tests, such as those that look for virus RNA and the combination test, are not commonly used for screening.
HIV/AIDS Treatment
Medications
Over the past years, several drugs have become available to fight both the HIV infection and its associated infections and cancers. These drugs are called highly active antiretroviral therapy (HAART) and have substantially reduced HIV-related complications and deaths. However, there is no cure for HIV/AIDS. Therapy is initiated and individualized under the supervision of a physician who is an expert in the care of HIV-infected patients. A combination of at least three drugs is recommended to suppress the virus from replicating and boost the immune system. The following are the different classes of medications used in treatment.
• Reverse transcriptase inhibitors: These drugs inhibit the ability of the virus to make copies of itself. The following are examples:
o Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs). These include medications such aszidovudine (AZT/Retrovir), didanosine (ddI/Videx), zalcitabine (ddC/Hivid),stavudine (d4T/Zerit), lamivudine (3TC/Epivir), abacavir (ABC/Ziagen),emtricitabine (FTC/Emtriva), and tenofovir (Viread).
o Non-nucleoside reverse transcriptase inhibitors (NNRTIS) are commonly used in combination with NRTIs to help keep the virus from multiplying. Examples of NNRTIs are efavirenz (Sustiva), nevirapine (Viramune), anddelavirdine (Rescriptor). Etravirine (Intelence), a newer member of this class of drugs, was approved by the U.S. FDA in 2008.
• Protease inhibitors (PIs): These medications interrupt virus replication at a later step in its life cycle, preventing cells from producing new viruses. These include ritonavir (Norvir), a lopinavir and ritonavir combination (Kaletra),saquinavir (Invirase), indinavir sulphate (Crixivan), amprenavir (Agenerase),fosamprenavir (Lexiva), darunavir (Prezista), atazanavir (Reyataz), tipranavir(Aptivus), and nelfinavir (Viracept). Using PIs with NRTIs reduces the chances that the virus will become resistant to medications.
• Fusion and entry inhibitors are newer agents that keep HIV from entering human cells. Enfuvirtide (Fuzeon/T20) was the first drug in this group. It is given in injectable form like insulin. Another drug called maraviroc (Selzentry) binds to a protein on the surface of the human cell and can be given by mouth. Both drugs are used in combination with other anti-HIV drugs.
• Integrase inhibitors stop HIV genes from becoming incorporated into the human cell's DNA. This is a newer class of drugs recently approved to help treat those who have developed resistance to the other medications.Raltegravir (Isentress) was the first drug in this class approved by the FDA in 2007.
Antiretroviral viral drugs stop viral replication and delay the development of AIDS. However, they also have side effects that can be severe. They include decreased levels of red or white blood cells, inflammation of the pancreas, liver toxicity, rash, gastrointestinal problems, elevated cholesterol level, diabetes, abnormal body-fat distribution, and painful nerve damage.
• Pregnant women who are HIV-positive should seek care immediately because HAART therapy reduces the risk of transmitting the virus to the fetus. There are certain drugs, however, that are harmful to the baby. Therefore, seeing a physician to discuss anti-HIV medications is crucial.
Follow-up
People with HIV infection should be under the care of a physician who is experienced in treating the infection. All people with HIV should be counseled about avoiding the spread of the disease. Infected individuals are also educated about the disease process, and attempts are made to improve the quality of their life.
HIV Prevention
Despite significant efforts, there is no effective vaccine against HIV. The only way to prevent infection by the virus is to avoid behaviors that put you at risk, such as sharing needles or having unprotected sex. In this context, unprotected sex means sex without a barrier such as a condom. Because condoms break, even they are not perfect protection. Many people infected with HIV don't have any symptoms. There is no way to know with certainty whether a sexual partner is infected. Here are some prevention strategies:
• Abstain from sex. This obviously has limited appeal, but it absolutely protects against HIV transmission by this route.
• Have sex with a single partner who is uninfected. Mutual monogamy between uninfected partners eliminates the risk of sexual transmission of HIV.
• Use a condom in other situations. Condoms offer some protection if used properly and consistently. Occasionally, they may break or leak. Only condoms made of latex should be used. Only water-based lubricants should be used with latex condoms.
• Do not share needles or inject illicit drugs.
• If you work in a health-care field, follow recommended guidelines for protecting yourself against needle sticks and exposure to contaminated fluids.
• If you have engaged in risky behaviors, get tested to see if you have HIV.
• The risk of HIV transmission from a pregnant woman to her baby is significantly reduced if the mother takes medications during pregnancy, labor, and delivery and her baby takes medications for the first six weeks of life. Even shorter courses of treatment are effective, though not as optimal. The key is to get tested for HIV as early as possible in pregnancy. In consultation with their physician, many women opt to avoid breastfeeding to minimize the risk of transmission after the baby is born
HIV/AIDS Prognosis
There is no cure for HIV infection. Before we had any treatment for the virus, people with AIDS lived only for a couple of years. Fortunately, medications have substantially improved the outlook and survival rates. Prevention efforts have sharply reduced HIV infection in young children and have the potential to sharply limit new infections in other populations.
• Medications have extended the average life expectancy, and many people with HIV can expect to live for decades with proper treatment. An increasing number have a normal life expectancy if they adhere carefully to medication regimens.
• Medications help the immune system recover and fight infections and prevent cancers from occurring. Eventually, the virus may become resistant to the available drugs, and the manifestations of AIDS may develop.
• Drugs used to treat HIV and AIDS do not eliminate the infection. It is important for the person to remember that he or she is still contagious even when receiving effective treatment.
• Intensive research efforts are being focused on developing new and better treatments. Although currently there is no promising vaccine, work continues on this front.
HIV (human immunodeficiency virus) infection has now spread to every country in the world. Approximately 40 million people are currently living with HIV infection, and an estimated 25 million have died from this disease. The scourge of HIV has been particularly devastating in sub-Saharan Africa, but infection rates in other countries remain high. In the United States, approximately 1 million people are currently infected. Here are a few key points about the disease:
• Globally, 85% of HIV transmission is heterosexual.
• In the United States, approximately one-third of new diagnoses appear to be related to heterosexual transmission. Male-to-male sexual contact still accounts for approximately half of new diagnoses in the U.S. Intravenous drug use contributes to the remaining cases. Because the diagnosis may occur years after infection, it is likely that a higher proportion of recent infections are due to heterosexual transmission.
• Infections in women are increasing. Worldwide, 42% of people with HIV are women. In the United States, approximately 25% of new diagnoses are in women, and the proportion is rising.
• There is good news on one front. New HIV infections in U.S. children have fallen dramatically. This is largely a result of testing and treating infected mothers, as well as establishing uniform testing guidelines for blood products.
In order to understand HIV and AIDS, it is important to understand the meanings behind these terms:
• HIV stands for the human immunodeficiency virus. It is one of a group of viruses known as retroviruses. After getting into the body, the virus kills or damages cells of the body's immune system. The body tries to keep up by making new cells or trying to contain the virus, but eventually the HIV wins out and progressively destroys the body's ability to fight infections and certain cancers.
• AIDS stands for the acquired immunodeficiency syndrome. It is caused by HIV and occurs when the virus has destroyed so much of the body's defenses that immune-cell counts fall to critical levels or certain life-threatening infections or cancers develop.
HIV/AIDS Transmission
HIV is transmitted when the virus enters the body, usually by injecting infected cells or semen. There are several possible ways in which the virus can enter.
• Most commonly, HIV infection is spread by having sex with an infected partner. The virus can enter the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex.
• HIV frequently spreads among injection-drug users who share needles or syringes that are contaminated with blood from an infected person.
• Women can transmit HIV to their babies during pregnancy or birth, when infected maternal cells enter the baby's circulation.
• HIV can be spread in health-care settings through accidental needle sticks or contact with contaminated fluids.
• Very rarely, HIV spreads through transfusion of contaminated blood or blood components. Blood products are now tested to minimize this risk. If tissues or organs from an infected person are transplanted, the recipient may acquire HIV. Donors are now tested for HIV to minimize this risk.
• People who already have a sexually transmitted disease, such as syphilis,genital herpes, chlamydial infection, gonorrhea, or bacterial vaginosis, are more likely to acquire HIV infection during sex with an infected partner.
The virus does not spread through casual contact such as preparing food, sharing towels and bedding, or via swimming pools, telephones, or toilet seats. The virus is also unlikely to be spread by contact with saliva, unless it is contaminated with blood.
HIV/AIDS Symptoms and Signs
Many people with HIV do not know they are infected.
• Many people do not develop symptoms after they first get infected with HIV. Others have a flu-like illness within several days to weeks after exposure to the virus. They complain of fever, headache, tiredness, and enlarged lymph nodes in the neck. These symptoms usually disappear on their own within a few weeks. After that, the person feels normal and has no symptoms. This asymptomatic phase often lasts for years.
• The progression of disease varies widely among individuals. This state may last from a few months to more than 10 years.
o During this period, the virus continues to multiply actively and infects and kills the cells of the immune system.
o The virus destroys the cells that are the primary infection fighters, a type of white blood cell called CD4 cells.
o Even though the person has no symptoms, he or she is contagious and can pass HIV to others through the routes listed above.
AIDS is the later stage of HIV infection, when the body begins losing its ability to fight infections. Once the CD4 cell count falls low enough, an infected person is said to have AIDS. Sometimes, the diagnosis of AIDS is made because the person has unusual infections or cancers that show how weak the immune system is.
• The infections that happen with AIDS are called opportunistic infectionsbecause they take advantage of the opportunity to infect a weakened host. The infections include (but are not limited to)
o pneumonia caused by Pneumocystis, which causes wheezing;
o brain infection with toxoplasmosis which can cause trouble thinking or symptoms that mimic a stroke;
o widespread infection with a bacteria called MAC (mycobacterium avium complex) which can cause fever and weight loss;
o yeast infection of the swallowing tube (esophagus) which causes pain with swallowing;
o widespread diseases with certain fungi like histoplasmosis, which can cause fever, cough, anemia, and other problems.
• A weakened immune system can also lead to other unusual conditions:
o lymphoma in (a form of cancer of the lymphoid tissue) the brain, which can cause fever and trouble thinking;
o a cancer of the soft tissues called Kaposi's sarcoma, which causes brown, reddish, or purple spots that develop on the skin or in the mouth.
When to Seek Medical Care
If you have engaged in unprotected sex outside of a mutually monogamous relationship or shared needles while using drugs, you should have an HIV test. Early detection and treatment of the infection can slow the growth of HIV.
• If you are pregnant and infected with HIV, you may be able to reduce the risk to your unborn child by getting treatment early.
• You can also avoid infecting others if you know that you have the disease. Testing is available anonymously and confidentially. You can even test yourself at home.
People known to have HIV infection or AIDS should go to the hospital any time they develop high fever, shortness of breath, coughing up blood, severe diarrhea, severe chest orabdominal pain, generalized weakness, severe headache, seizures, confusion, or a change in mental status. These may be the indication of a life-threatening condition for which an urgent evaluation in the hospital's emergency department is recommended. All infected people should be under the regular care of a physician skilled in the treatment of HIV and AIDS.
HIV/AIDS Diagnosis
HIV infection is commonly diagnosed by blood tests. There are three main types of tests that are commonly used: (1) antibody tests, (2) RNA tests, and (3) a combination test that detects both antibodies and a piece of the virus called the p24 protein. In addition, a blood test known as a Western blot is used to confirm the diagnosis.
No test is perfect. Tests may be falsely positive or falsely negative. For example, it can take some time for the immune system to produce enough antibodies for the antibody test to turn positive. This time period is commonly referred to as the "window period" and may last six weeks to three months following infection. Therefore, if the initial antibody test is negative, a repeat test should be performed three months later. Early testing is crucial, because early treatment for HIV helps people avoid or minimize complications. Furthermore, high-risk behaviors can be avoided, thus preventing the spread of the virus to others.
Testing for HIV is usually a two-step process. First, an inexpensive screening test is done. If that test is positive, a second test (Western blot) is done to confirm the result. Antibody tests are the most common initial screening test used. There are different types of antibody screening tests available:
• Most commonly, blood is drawn for an enzyme immunoassay (EIA). The test is usually run in a local laboratory, so results can take one to three days to come back.
• Other tests can detect antibodies in body fluids other than blood such as saliva, urine, and vaginal secretions. Some of these are designed to be rapid tests that produce results in approximately 20 minutes. These tests have accuracy rates similar to traditional blood tests.
• HIV home-testing kits are available at many local drug stores. Blood is obtained by a finger prick and blotted on a filter strip. Other test kits use saliva or urine. The filter strip is mailed in a protective envelope to a laboratory to be tested. Results are returned by mail in one to two weeks.
• All positive antibody screening tests must be confirmed with a follow-up blood test called the Western blot to make a positive diagnosis. If the antibody test and the Western blot are both positive, the likelihood of a person being HIV infected is >99%. Sometimes, the Western blot is "indeterminate," meaning that it is neither positive nor negative. In these cases, the tests are usually repeated at a later date. In addition, an RNA test for the virus might be done.
Other tests, such as those that look for virus RNA and the combination test, are not commonly used for screening.
HIV/AIDS Treatment
Medications
Over the past years, several drugs have become available to fight both the HIV infection and its associated infections and cancers. These drugs are called highly active antiretroviral therapy (HAART) and have substantially reduced HIV-related complications and deaths. However, there is no cure for HIV/AIDS. Therapy is initiated and individualized under the supervision of a physician who is an expert in the care of HIV-infected patients. A combination of at least three drugs is recommended to suppress the virus from replicating and boost the immune system. The following are the different classes of medications used in treatment.
• Reverse transcriptase inhibitors: These drugs inhibit the ability of the virus to make copies of itself. The following are examples:
o Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs). These include medications such aszidovudine (AZT/Retrovir), didanosine (ddI/Videx), zalcitabine (ddC/Hivid),stavudine (d4T/Zerit), lamivudine (3TC/Epivir), abacavir (ABC/Ziagen),emtricitabine (FTC/Emtriva), and tenofovir (Viread).
o Non-nucleoside reverse transcriptase inhibitors (NNRTIS) are commonly used in combination with NRTIs to help keep the virus from multiplying. Examples of NNRTIs are efavirenz (Sustiva), nevirapine (Viramune), anddelavirdine (Rescriptor). Etravirine (Intelence), a newer member of this class of drugs, was approved by the U.S. FDA in 2008.
• Protease inhibitors (PIs): These medications interrupt virus replication at a later step in its life cycle, preventing cells from producing new viruses. These include ritonavir (Norvir), a lopinavir and ritonavir combination (Kaletra),saquinavir (Invirase), indinavir sulphate (Crixivan), amprenavir (Agenerase),fosamprenavir (Lexiva), darunavir (Prezista), atazanavir (Reyataz), tipranavir(Aptivus), and nelfinavir (Viracept). Using PIs with NRTIs reduces the chances that the virus will become resistant to medications.
• Fusion and entry inhibitors are newer agents that keep HIV from entering human cells. Enfuvirtide (Fuzeon/T20) was the first drug in this group. It is given in injectable form like insulin. Another drug called maraviroc (Selzentry) binds to a protein on the surface of the human cell and can be given by mouth. Both drugs are used in combination with other anti-HIV drugs.
• Integrase inhibitors stop HIV genes from becoming incorporated into the human cell's DNA. This is a newer class of drugs recently approved to help treat those who have developed resistance to the other medications.Raltegravir (Isentress) was the first drug in this class approved by the FDA in 2007.
Antiretroviral viral drugs stop viral replication and delay the development of AIDS. However, they also have side effects that can be severe. They include decreased levels of red or white blood cells, inflammation of the pancreas, liver toxicity, rash, gastrointestinal problems, elevated cholesterol level, diabetes, abnormal body-fat distribution, and painful nerve damage.
• Pregnant women who are HIV-positive should seek care immediately because HAART therapy reduces the risk of transmitting the virus to the fetus. There are certain drugs, however, that are harmful to the baby. Therefore, seeing a physician to discuss anti-HIV medications is crucial.
Follow-up
People with HIV infection should be under the care of a physician who is experienced in treating the infection. All people with HIV should be counseled about avoiding the spread of the disease. Infected individuals are also educated about the disease process, and attempts are made to improve the quality of their life.
HIV Prevention
Despite significant efforts, there is no effective vaccine against HIV. The only way to prevent infection by the virus is to avoid behaviors that put you at risk, such as sharing needles or having unprotected sex. In this context, unprotected sex means sex without a barrier such as a condom. Because condoms break, even they are not perfect protection. Many people infected with HIV don't have any symptoms. There is no way to know with certainty whether a sexual partner is infected. Here are some prevention strategies:
• Abstain from sex. This obviously has limited appeal, but it absolutely protects against HIV transmission by this route.
• Have sex with a single partner who is uninfected. Mutual monogamy between uninfected partners eliminates the risk of sexual transmission of HIV.
• Use a condom in other situations. Condoms offer some protection if used properly and consistently. Occasionally, they may break or leak. Only condoms made of latex should be used. Only water-based lubricants should be used with latex condoms.
• Do not share needles or inject illicit drugs.
• If you work in a health-care field, follow recommended guidelines for protecting yourself against needle sticks and exposure to contaminated fluids.
• If you have engaged in risky behaviors, get tested to see if you have HIV.
• The risk of HIV transmission from a pregnant woman to her baby is significantly reduced if the mother takes medications during pregnancy, labor, and delivery and her baby takes medications for the first six weeks of life. Even shorter courses of treatment are effective, though not as optimal. The key is to get tested for HIV as early as possible in pregnancy. In consultation with their physician, many women opt to avoid breastfeeding to minimize the risk of transmission after the baby is born
HIV/AIDS Prognosis
There is no cure for HIV infection. Before we had any treatment for the virus, people with AIDS lived only for a couple of years. Fortunately, medications have substantially improved the outlook and survival rates. Prevention efforts have sharply reduced HIV infection in young children and have the potential to sharply limit new infections in other populations.
• Medications have extended the average life expectancy, and many people with HIV can expect to live for decades with proper treatment. An increasing number have a normal life expectancy if they adhere carefully to medication regimens.
• Medications help the immune system recover and fight infections and prevent cancers from occurring. Eventually, the virus may become resistant to the available drugs, and the manifestations of AIDS may develop.
• Drugs used to treat HIV and AIDS do not eliminate the infection. It is important for the person to remember that he or she is still contagious even when receiving effective treatment.
• Intensive research efforts are being focused on developing new and better treatments. Although currently there is no promising vaccine, work continues on this front.
Monday, April 4, 2011
Tuesday, January 18, 2011
ABDOMINAL PAIN ( INTERVENTION )
I. A 65- YEAR OLD MALE PRESENTS WITH GENERALIZE ABDOMINAL PAIN OF GRADUAL ONSET.
II. Immediate question:
A. ABCs/ Patients Stabilization
* - Is the air way intact?- manage appropriately.
* - What are the Vital sign?
- Does the patient looks acutely ill or toxic? Quick assessment of mental status. Is the patient OBTUNDED? Asses peripheral pulse. Initiate IV and administer fluid bolus if appropriate : CARDIAC MONITOR, PULSE OXIMETER, , SUPPLEMENTAL OXYGEN.
B. What was the timing of onset of symptoms?
- Sudden vs. Gradual, preceded bu anorexia,N/V, CONSTIPATION , diarrhea, fever waxing AND WANNING,OR STEADY.
C. WHERE DOES IT HURT? - Generalized pain, Peritonitis,ischemic bowel,Epi-gastric: Gastritis,duodenal/ gastric ulcer, pancreatitis,aortic pathology , early appendicitis, inferior MI, liver or biliary tract disease. RUQ- liver, or Biliary tract disease, inferior pneumonia or MI, occasionally renal. LUQ- SPLEEN ( SPECIALY IF TRAUMA) , sometimes RENAL,.. LLQ- Diverticular disease , colitis, gynecologic,or genitourinary. RLQ- Appendicitis or gynecologic source.Radiation from BACK/FLANK: RENAL SOURCE. Radiation from abdomen to back: PANCREATITIS /AORTIC ANEURYSM.
D. ARE THERE GENITOURINARY COMPLAINTS?
- Dysuria , Hematuria, Back pain, Penile discharge/ bleeding. sexual history,.
D. WHAT IS THE QUALITY OF THE PAIN?
- Burning/ Epigastric, consider gastritis or peptic ulcer, penetrating or boring, consider pancreatitis,. pain out of proportion to physical findingss, consider ischemic bowel. patient cant find comfortable position or withing on gourney,think colic,. patient avoiding movement, consider peritoneal irritation.
F. ARE THERE ARE GI COMPLAINTS?
- N/V, diarrhea, hematochezia, hamatemesis, prior history of same symptoms, any relation to food.
G. RESPIRATORY COMPLAINTS?
- COUGH, SOB, pleuritic pain.
H. ANY HISTORY OF TRAUMA OR PRIOR SURGERY?
I. OTHER PAST MEDICAL HISTORY? Ex. AAA, BOWEL OBSTRUCTION, CAD, DIABETES, INFLAMATORY BOWEL DISEASE etc.....
J. ADDITIONAL SOCIAL HISTORY.
- Foreign travel, recent questionable food sources, diet history,drug abnuse, possibility of accidental food poison / medicine ingestion.
III. DIFFERENTIAL DIAGNOSIS
A. GENDER / AGE- NEUTRAL
1. Appendicitis- pain preceded by nausea, anorexia, fever , pain open vague initially, then localized to RLQ.
2. BILIARY TRACT DISORDER - Cholelithiasis / cholecystitis , hepatitis,
3. PEPTIC ULCER- Think Viscus perforation or hemorrhage if completely ill.
4. GASTRITIS- Food or medication related: VIRAL
5. PANCREATITIS- ETOH/ Diabetes history: rule out gallstone.
6. BOWEL OBSTRUCTIONS- Distinguish from ILEUS.
7. GENITOURINARY OR RENAL DISORDER -calculi, pyelonephritis, infection of the urethra, bladder and reproductive organs.
8. THORACIC DISEASES- Inferior pneumonias pulmonary embolism, atypial cardiac angina/MI.
9. DIVERTICULITIS - Severe, cramping, LLQ, pain associated with bloody diarrhea.
10. INFLAMMATORY BOWEL DISEASE- Crohn`s disease , ulcerative colitis,( cramping episodic, recurrent pain associated with diarrhea, sometimes bloody).
11. SICKLE CELL CRISIS.
12. DIABETIC KETOACIDOSIS -
13. IRRITABLE BOWEL SYNDROME - Strictly a diagnosis of exclusion. symptoms often only briefly present : a variety of symptoms, often crampy, pain with intermittent diarrhea, and constipation.
14. MESENTERIC ADENITIS , GASTROENTERITIS, CONSTIPATION. DIAGNOSES OF EXCLUSION.....
---------- CONTINUE .........
II. Immediate question:
A. ABCs/ Patients Stabilization
* - Is the air way intact?- manage appropriately.
* - What are the Vital sign?
- Does the patient looks acutely ill or toxic? Quick assessment of mental status. Is the patient OBTUNDED? Asses peripheral pulse. Initiate IV and administer fluid bolus if appropriate : CARDIAC MONITOR, PULSE OXIMETER, , SUPPLEMENTAL OXYGEN.
B. What was the timing of onset of symptoms?
- Sudden vs. Gradual, preceded bu anorexia,N/V, CONSTIPATION , diarrhea, fever waxing AND WANNING,OR STEADY.
C. WHERE DOES IT HURT? - Generalized pain, Peritonitis,ischemic bowel,Epi-gastric: Gastritis,duodenal/ gastric ulcer, pancreatitis,aortic pathology , early appendicitis, inferior MI, liver or biliary tract disease. RUQ- liver, or Biliary tract disease, inferior pneumonia or MI, occasionally renal. LUQ- SPLEEN ( SPECIALY IF TRAUMA) , sometimes RENAL,.. LLQ- Diverticular disease , colitis, gynecologic,or genitourinary. RLQ- Appendicitis or gynecologic source.Radiation from BACK/FLANK: RENAL SOURCE. Radiation from abdomen to back: PANCREATITIS /AORTIC ANEURYSM.
D. ARE THERE GENITOURINARY COMPLAINTS?
- Dysuria , Hematuria, Back pain, Penile discharge/ bleeding. sexual history,.
D. WHAT IS THE QUALITY OF THE PAIN?
- Burning/ Epigastric, consider gastritis or peptic ulcer, penetrating or boring, consider pancreatitis,. pain out of proportion to physical findingss, consider ischemic bowel. patient cant find comfortable position or withing on gourney,think colic,. patient avoiding movement, consider peritoneal irritation.
F. ARE THERE ARE GI COMPLAINTS?
- N/V, diarrhea, hematochezia, hamatemesis, prior history of same symptoms, any relation to food.
G. RESPIRATORY COMPLAINTS?
- COUGH, SOB, pleuritic pain.
H. ANY HISTORY OF TRAUMA OR PRIOR SURGERY?
I. OTHER PAST MEDICAL HISTORY? Ex. AAA, BOWEL OBSTRUCTION, CAD, DIABETES, INFLAMATORY BOWEL DISEASE etc.....
J. ADDITIONAL SOCIAL HISTORY.
- Foreign travel, recent questionable food sources, diet history,drug abnuse, possibility of accidental food poison / medicine ingestion.
III. DIFFERENTIAL DIAGNOSIS
A. GENDER / AGE- NEUTRAL
1. Appendicitis- pain preceded by nausea, anorexia, fever , pain open vague initially, then localized to RLQ.
2. BILIARY TRACT DISORDER - Cholelithiasis / cholecystitis , hepatitis,
3. PEPTIC ULCER- Think Viscus perforation or hemorrhage if completely ill.
4. GASTRITIS- Food or medication related: VIRAL
5. PANCREATITIS- ETOH/ Diabetes history: rule out gallstone.
6. BOWEL OBSTRUCTIONS- Distinguish from ILEUS.
7. GENITOURINARY OR RENAL DISORDER -calculi, pyelonephritis, infection of the urethra, bladder and reproductive organs.
8. THORACIC DISEASES- Inferior pneumonias pulmonary embolism, atypial cardiac angina/MI.
9. DIVERTICULITIS - Severe, cramping, LLQ, pain associated with bloody diarrhea.
10. INFLAMMATORY BOWEL DISEASE- Crohn`s disease , ulcerative colitis,( cramping episodic, recurrent pain associated with diarrhea, sometimes bloody).
11. SICKLE CELL CRISIS.
12. DIABETIC KETOACIDOSIS -
13. IRRITABLE BOWEL SYNDROME - Strictly a diagnosis of exclusion. symptoms often only briefly present : a variety of symptoms, often crampy, pain with intermittent diarrhea, and constipation.
14. MESENTERIC ADENITIS , GASTROENTERITIS, CONSTIPATION. DIAGNOSES OF EXCLUSION.....
---------- CONTINUE .........
HEALTH PROMOTIONS AND ILLNESS PREVENTION
" Determining the Child`s Developmental stage is often the primary focus of a health interview. For instance, during her child`s 24 month check up a mother might ask if it is normal that her child cannot yet pedal a tricycle.This question, or any other questions about the child`s developmental progress, cannot be answered without a full understanding of the average ranges of motor coordination.
Parenting style and competence are major influences on the behavioral and mental health of children. In addition to reassurance that their child is doing well, parents also need periodic anticipatory guidance regarding their child`s development. For example, it would be important to discuss additional home safety with a parent when a child is approaching the age for creeping. Parent should be CAUTIONED to think about FENCING open stairways and clearing cleaning compounds out of bottom cupboards.Parents of a child who is almost 1 year old will appreciate being cautioned that their child`s appetite may decrease during the coming year: armed with this knowledge, they will not interpret a child`s rejection of food as a beginning of of a feeding problem but will it see it as a usual step in development. The parent of the child approaching the PUBERTY generally welcomes a discussion on how to prepare a child for this challenging growth phase.
If anticipatory guidance is not offered at appropriate time, it can be useless. Information given too early is forgotten by the time it is needed. Given too late, parent may have already addressed or ignored the issue, possibly not in the GROWTH enhancing way for their child. To be able to supply anticipatory guidance this way at the appropriate time or to plan nursing care to meet the need of the CHILDREN AND THE FAMILIES, you must be able to recognize the predictable stages of growth and development from NEW BORN TO YOUNG ADULT.., through which each child passes..... "
courtesy : (MATERNAL AND CHILD HEALTH NURSING BY ADELE P."
Parenting style and competence are major influences on the behavioral and mental health of children. In addition to reassurance that their child is doing well, parents also need periodic anticipatory guidance regarding their child`s development. For example, it would be important to discuss additional home safety with a parent when a child is approaching the age for creeping. Parent should be CAUTIONED to think about FENCING open stairways and clearing cleaning compounds out of bottom cupboards.Parents of a child who is almost 1 year old will appreciate being cautioned that their child`s appetite may decrease during the coming year: armed with this knowledge, they will not interpret a child`s rejection of food as a beginning of of a feeding problem but will it see it as a usual step in development. The parent of the child approaching the PUBERTY generally welcomes a discussion on how to prepare a child for this challenging growth phase.
If anticipatory guidance is not offered at appropriate time, it can be useless. Information given too early is forgotten by the time it is needed. Given too late, parent may have already addressed or ignored the issue, possibly not in the GROWTH enhancing way for their child. To be able to supply anticipatory guidance this way at the appropriate time or to plan nursing care to meet the need of the CHILDREN AND THE FAMILIES, you must be able to recognize the predictable stages of growth and development from NEW BORN TO YOUNG ADULT.., through which each child passes..... "
courtesy : (MATERNAL AND CHILD HEALTH NURSING BY ADELE P."
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