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Medical abortion

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Medical abortion

A medical abortion is a type of non-surgical abortion in which abortifacient pharmaceutical drugs are used to induce abortion. An oral preparation for medical abortion is commonly referred to as an abortion pill.

Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486)[1] in the 1980s.[2][3][4]

Medical uses

According to the 2006 WHO Frequently asked clinical questions about medical abortion, regarding factors that should be taken into account when counseling a woman about her choice between medical and surgical abortion:[5]

There is little, if any, difference between medical and surgical abortion in terms of safety and efficacy. Thus, both methods are similar from a medical point of view and there are only very few situations where a recommendation for one or the other method for medical reasons can be given.

Medical abortion may be preferred:
  • if it is the woman’s preference;
  • in very early gestation; up to 49 days of gestation, medical abortion is considered to be more effective than surgical abortion, especially when clinical practice does not include detailed inspection of aspirated tissue;
  • if the woman is severely obese (body mass index greater than 30) but does not have other cardiovascular risk factors, as surgical treatment may be technically more difficult;
  • if the woman has uterine malformations or a fibroid uterus, or has previously had cervical surgery (which may make surgical abortion technically more difficult);
  • if the woman wants to avoid a surgical intervention.
Surgical abortion may be preferred:
  • if it is the woman’s preference, or if she requests concurrent sterilization;
  • if she has contraindications to medical abortion;
  • if time or geographical constraints preclude the follow-up needed to confirm that abortion is complete.

Side effects

According to Women on Web, a telemedicine support service for women around the world who are seeking medical abortions:[6]
If performed in the first 9 weeks, a medical abortion carries a very small risk of complications. This risk is the same as when a woman has a miscarriage. A doctor can easily treat these problems. Out of every 100 women who do medical abortion, 2 or 3 women will have to go to a doctor, first aid center or hospital to receive further medical care.[7]

A table in the 2010 Handbook of Obstetric and Gynecologic Emergencies, 4th edition lists these possible complications of medical and surgical abortion:[8]

  • Medical abortion
    • Hemorrhage
    • Incomplete abortion
    • Uterine or pelvic infection
    • Ongoing intrauterine pregnancy, requiring a surgical abortion for completion
    • Misdiagnosed/unrecognized ectopic pregnancy
  • Surgical abortion
    • Hemorrhage
    • Incomplete abortion
    • Uterine or pelvic infection
    • Ongoing intrauterine pregnancy, requiring a second procedure
    • Misdiagnosed/unrecognized ectopic pregnancy
    • Hematometra (blood clots accumulating in the uterus)
    • Uterine perforation
    • Cervical laceration

Although medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different.[9] In a large-scale prospective trial published in 1992 of more than 16,000 women undergoing medical abortion using mifepristone with varying doses of gemeprost or sulprostone, only 0.1% had hemorrhage requiring a blood transfusion.[9][10] It is often advised to contact a health care provider if there is bleeding to such degree that more than two pads are soaked per hour for two consecutive hours.[9]

Since 2001, ten women—one in Canada,[11] eight in the United States,[12][13][14] one in Portugal[15]—have died from clostridial toxic shock syndrome (nine from Clostridium sordellii,[11][12][13][14] one from Clostridium perfringens[13]) following early medical abortions using 200 mg mifepristone orally followed by 800 mcg misoprostol—nine vaginally,[11][12][13][14][15] one buccally[13]—without prophylactic antibiotics.

A retrospective study published in The New England Journal of Medicine in July 2009 of 227,823 women who underwent medical abortion at Planned Parenthood affiliate centers from January 2005 through June 2008, found that the rate of serious infection after medical abortion declined by 93% after a change from vaginal to buccal administration of misoprostol combined with the routine prophylactic administration of doxycycline antibiotics.[16]

Contraindications

According to the 2006 WHO Frequently asked clinical questions about medical abortion:[5]
There are very few absolute contraindications to medical abortion. They include:
  • previous allergic reaction to one of the drugs involved;
  • inherited porphyria;
  • chronic adrenal failure;
  • known or suspected ectopic pregnancy.

Caution is required in a range of circumstances including:

  • if the woman is on long-term corticosteroid therapy (including those with severe, uncontrolled asthma);
  • if she has a hemorrhagic disorder;
  • if she has severe anemia;
  • if she has pre-existing heart disease or cardiovascular risk factors (e.g. hypertension and smoking).

Management of prolonged bleeding

According to the 2006 WHO Frequently asked clinical questions about medical abortion,[5] vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion, but in individual cases spotting can last up to 45 days. If the woman is well, neither prolonged bleeding nor the presence of tissue in the uterus (as detected by obstetric 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. Still, surgical intervention may be carried out on the woman's request, if the bleeding is heavy or prolonged, or causes anemia, or if there is evidence of endometritis.

Methods

A fetus of a gestational age of 10 weeks being expelled from the uterus during a medical abortion. The opening of the cervix is seen at lower left in the image.

The evidence-based mifepristone-misoprostol combination regimen for medical abortion; where mifepristone is not available it recommends a misoprostol-only regimen.[17][18] A methotrexate-misoprostol regimen can also be used;[19] however, because methotrexate may be teratogenic to the fetus in cases of incomplete abortion, the WHO does not recommend a methotrexate-misoprostol combination regimen for medical abortion.[17][18] Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens.[3] Mifepristone–misoprostol and methotrexate–misoprostol combination regimens are more effective than misoprostol alone.[3]

Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used to induce second-trimester abortions in Canada, most of Europe, China and India;[4] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.[20]

The early first-trimester medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of buccal misoprostol) currently used by Planned Parenthood clinics in the United States since April 2006 is 98.3% effective through 59 days gestation.[21]

A 2011 systematic review found that it was simpler and equally safe to administer mifepristone in clinic and have the pregnant woman later take misoprostol at home as it was to administer both drugs in the clinic.[22]

Cost

In the United States in 2009, the median price charged for a medical abortion up to 9 weeks gestation was $490, four percent higher than the $470 median price charged for a surgical abortion at 10 weeks gestation.[23] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.[24]

In April 2013, the Australian government commenced an evaluation process to decide whether to list the mifepristone (RU486) and misoprostol on the country's Pharmaceutical Benefits Scheme (PBS). If the listing is approved by the Health Minister Tanya Plibersek and the federal government, the drugs will become more accessible due to a dramatic reduction in retail price—the cost would be reduced from between AU$300 and AU$800, to AU$12 (subsidised rate for concession card holders) or AU$35.[25]

On 30 June 2013, the Australian Minister for Health, the Hon Tanya Plibersek MP, announced that the Australian Government had approved the listing of mifepristone and misoprostol on the PBS for medical terminations early in pregnancies consistent with the recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC). These listings on the PBS occurred on 1 August 2013.

Prevalence

Medical abortions as a percentage of all abortions
Country Percentage
Netherlands 12% in 2008[26]
Germany 21% in 2014[27]
Belgium 22% in 2011[28]
United States 23% in 2011[29]
Spain 27% in 2013[30]
England and Wales 51% in 2014[31]
Iceland 55% in 2013[32]
France 58% in 2013[33]
Denmark 63% in 2013[32]
Switzerland 70% in 2014[34]
Scotland 80% in 2014[35]
Sweden 83% in 2012[36]
Norway 84% in 2014[37]
Finland 94% in 2013[32][38]

A Guttmacher Institute survey of abortion providers estimated that early medical abortions accounted for 23% of all nonhospital abortions and 36% of abortions before 9 weeks gestation in the United States in 2011;[29][39] medical abortions accounted for 32% of first trimester abortions at Planned Parenthood clinics in the United States in 2008.[16]

References

  1. ^
  2. ^
  3. ^ a b c
  4. ^ a b
  5. ^ a b c
  6. ^
  7. ^
  8. ^ Table 18.1 Possible complications of surgical and medical abortion.
  9. ^ a b c
  10. ^
  11. ^ a b c
  12. ^ a b c
  13. ^ a b c d e
  14. ^ a b c
  15. ^ a b
  16. ^ a b
  17. ^ a b
  18. ^ a b
  19. ^ http://www.webmd.com/women/methotrexate-and-misoprostol-for-abortion
  20. ^
  21. ^
    The medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of vaginal misoprostol) previously used by Planned Parenthood clinics in the United States from 2001 to March 2006 was 98.5% effective through 63 days gestation—with an ongoing pregnancy rate of about 0.5%, and an additional 1% of patients having uterine evacuation for various reasons, including problematic bleeding, persistent gestational sac, clinician judgment or patient request.
  22. ^
  23. ^
  24. ^
  25. ^
  26. ^
  27. ^ 17.56% mifepristone + 3.30% other medical = 20.86% medical abortions
  28. ^ prostaglandin 0.40% + mifepristone 21.23% = 21.63% medical abortions
  29. ^ a b
    98% of nonhospital medical abortions used mifepristone and misoprostol—2% used methotrexate and misoprostol, or misoprostol alone—in the United States in 2011.
  30. ^ 14.2% mifepristone + 12.8% prostaglandin
  31. ^
    Medical abortion was the most common method used in abortions before 7 weeks gestation—and accounted for 62% of abortions before 9 weeks gestation—in England and Wales in 2014.
  32. ^ a b c Appendix table 6. Drug-induced abortions in Nordic countries 1993–2013, %
  33. ^
  34. ^
  35. ^
    Medical abortions accounted for 88% of abortions before 9 weeks gestation in Scotland in 2014.
  36. ^
    Medical abortions accounted for 90% of abortions before 9 weeks gestation in Sweden in 2012.
  37. ^
    Medical abortions accounted for 87% of abortions before 9 weeks gestation in Norway in 2014.
  38. ^
  39. ^
    Medical abortions accounted for 20.0% of abortions—and 28.5% of abortions before 9 weeks gestation—in the United States in 2011 that were voluntarily reported to the CDC by 40 reporting areas (excluding Alabama, Arizona, California, Florida, Hawaii, Illinois, Louisiana, Maryland, New Hampshire, Tennessee, Vermont, Wisconsin, and Wyoming).

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