Medical abortion

 

A medical abortion, also known as medication abortion, occurs when medically prescribed drugs are used to bring about an abortion.

Medical abortions are an alternative to surgical abortions such as vacuum aspiration or dilation and curettage.

Medical abortions are more common than surgical abortions in most places, including Europe, India, China, and the United States.

Medical abortions as a percentage of all abortions

France 64% (2016)

Sweden 92% (2016)

UK: Eng. & Wales 62% (2016)

UK: Scotland 83% (2016)

United States 54% (2020)

Typically performed by administering a two-drug combination: mifepristone followed by misoprostol. 

Mifepristone, is a  progesterone antagonist that causes pregnancy tissue to detach from the endometrium.

Mifepristone blocks the hormone progesterone, causing the lining of the uterus to thin and preventing the embryo from staying implanted and growing. 

Misoprostol is a prostaglandin that induces cervical soften and uterine contractions.

Misoprostol alone may be used in some situations.

Medical abortion is both safe and effective throughout a range of gestational ages.

Medical abortion is both safe and effective, including the second and third trimester.

The combination of mifepristone and misoprostolhe is highly effective and safe method of first trimester induced abortion.

Medication abortion has the advantage that treatment and outcome assessment can be managed by the patient.

In the United States, the maternal mortality rate for medical abortion is 14 times lower than the mortality rate for childbirth.

Medical abortion can be administered safely by the patient at home, without assistance, in the first trimester.

Starting with the second trimester, it is recommended to take the second drug in a clinic or provider’s office.

Medical abortion should not be confused with emergency contraception, which typically involves drugs taken soon after intercourse to prevent a pregnancy from beginning.

200 mg mifepristone and 800 μg misoprostol, is the typical regimen for early medical abortion.

For medical abortion prior to 12 weeks’ gestation, the WHO recommends 200 milligrams of mifepristone by mouth followed one to two days later by 800 micrograms of misoprostol inside the cheek, vaginally, or under the tongue; misoprostol may be repeated to maximize success.

The success rate of mifepristone followed by one dose of misoprostol through 10 weeks’ pregnancy is 96.6%.

The National Abortion Federation (NAF) also recommends a mifepristone and misoprostol combination regimen. For medication abortion up to 10 weeks of pregnancy, 200 mg of mifepristone is taken followed in 24 to 48 hours by 800 μg of misoprostol. 

For pregnancies after 9 weeks, repeating the dose of misoprostol makes the treatment more effective.

Misoprostol is administered 24 to 48 hours after the mifepristone; taking the misoprostol before 24 hours have elapsed reduces the probability of success.

One study showed that the two drugs may be taken simultaneously with nearly the same efficacy.

Failure to take the misoprostol may result in : the fetus may be terminated, but not fully expelled from the uterus and may require surgical intervention to remove the fetus; or the pregnancy may be successfully aborted and expelled; or the pregnancy may continue with a healthy fetus. 

If the pregnancy involves twins, a higher dosage of mifepristone may be recommended.

Misoprostol alone, without mifepristone, may be used in some circumstances for medical abortion: more commonly available than mifepristone, and is easier to store and administer.

If misoprostol is used without mifepristone, the WHO recommends 800 μg of misoprostol inside the cheek, under the tongue, or in the vagina.

The success rate of misoprostol alone for first trimester abortion is 78%, lower than the mifepristone-misoprostol combination success rate.

Patients may opt to terminate an early pregnancy with medication rather than by surgical techniques because they perceive it as more private and less invasive. 

It allows patients to control the timing and setting of their abortion.

Though not a first line choice, a methotrexate-misoprostol combination regimen is appropriate. Methotrexate is given either orally or intramuscularly, followed by vaginal misoprostol 3–5 days later.

The WHO authorizes the methotrexate-misoprostol combination but recommends the mifepristone combination because methotrexate may be teratogenic to the embryo in cases of incomplete abortion. 

Methotrexate, which is sometimes used instead of mifepristone, stops the cytotrophoblastic tissue from growing and becoming a functional placenta.

Clinical trials indicate self-administered medical abortion is as effective as provider-administered abortion.

The pregnancy with embryo and placenta will be expelled through the vagina within 2 to 24 hours after taking misoprostol.

To avoid infection, the patient should not use tampons or engage in intercourse for 2 to 3 weeks.

Medical abortion is safe and effective in the second and third trimesters.

The WHO recommends that medical abortions performed after 12 weeks’ gestation be supervised by a medical practitioner, in contrast to first trimester, where the patient may safely take the drugs at home without supervision).

After 12 weeks’ gestation, the WHO recommends 200 mg of mifepristone by mouth followed one to two days later by repeat doses of 400 μg misoprostol under the tongue, inside the cheek, or in the vagina.

Misoprostol should be taken every 3 hours until successful abortion is achieved, the mean time to abortion after starting misoprostol is 6–8 hours, and approximately 94% will abort within 24 hours after starting misoprostol.

Both drugs, mifepristone and misoprostol,  are available as generic drugs.

Many countries make the medical abortion drugs available over the counter, without a prescription, such as China, and India.

Other countries require a prescription (Canada, most of Western Europe, the United States.

Some countries require a prescription but are lax about enforcing that requirement.

Misoprostol, is most commonly used for treating ulcers, and was never subject to the in-person dispensing constraints of mifepristone, and was always available from pharmacies with a prescription.

The FDA does not authorize the use of mifepristone for medical abortion after 70 days, unlike most other countries, which authorize medical abortion into the second trimester and even the third trimester.

Contraindications to mifepristone are inherited porphyria, chronic adrenal failure, and ectopic pregnancy.

Some consider an intrauterine device in place to be a contraindication as well.

Caution is required in a range of circumstances including:

long-term corticosteroid use, 

bleeding disorder, severe anemia.

Adverse effects:

Heavy bleeding 

Abdominal pain, 

nausea, vomiting, diarrhea (25-30%)

fever, chills (50%)

Most women will have cramping and bleeding heavier than a menstrual period.

Misoprostol taken vaginally tends to have fewer gastrointestinal side effects. 

Medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different. 

Vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion.

In occasional cases spotting can last up to 45 days.

Neither prolonged bleeding nor the presence of tissue in the uterus, as detected by ultrasonography is an indication for surgical intervention (that is, vacuum aspiration or dilation and curettage.

Remaining products of conception will be expelled during subsequent vaginal bleeding. 

Complications following medical abortion with mifepristone and misprostol under 10 weeks’ pregnancy are rare: bleeding requiring a blood transfusion occurred in 0.03–0.6% of women and serious infection in 0.01–0.5%.

Medication abortion before confirmed intriguing pregnancy is non-inferior to standard, delayed treatment with respect to complete abortion (VEMA study group).

Use of routine antibiotics is not recommended.recommend use of routine antibiotics.

Nonsteroidal anti-inflammatory drugs are effective for pain management.

The  mortality rate for medication abortion is half the mortality rate of abortion overall.

Fertility returns rapidly after a medication abortion. 

Any form of contraception except for IUD can be provided.