Medical abortion


A medical abortion, also known as medication abortion or non-surgical abortion, occurs when 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 around the world.
Medical abortions are most commonly performed by administering a two-drug combination: mifepristone followed by misoprostol. This two-drug combination is more effective than other drug combinations. When mifepristone is not available, misoprostol alone may be used in some situations.
Medical abortion is both safe and effective throughout a range of gestational ages, including the second and third trimester. It gets progressively riskier and less effective as the pregnancy advances, especially in the third trimester. In the United States, the mortality rate for medical abortion is 14 times lower than the mortality rate for childbirth, and the rate of serious complications requiring hospitalization or blood transfusion is less than 0.4%. Medical abortion can be administered safely by the patient at home, without assistance, in the first trimester. However, access to at home use varies by country and jurisdiction depending on legal, regulatory, and medical guidelines. In the second trimester and beyond, it is recommended to take the second drug in a clinic, provider's office, or other supervised medical facility.

Drug regimens

Less than 12 weeks' gestation

For medical abortion up to 12 weeks' gestation, the recommended drug dosages are 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. The success rate of this drug combination is 96.6% through 10 weeks' pregnancy.
Medical abortion performed very early, before the pregnancy can be detected by ultrasound, is just as safe and effective as medical abortion after the pregnancy is detectable by ultrasound. Misoprostol should be administered 24 to 48 hours after the mifepristone; taking the misoprostol before 24 hours have elapsed reduces the probability of success. However, one study showed that the two drugs may be taken simultaneously with nearly the same efficacy.
For pregnancies after 9 weeks, two doses of misoprostol makes the treatment more effective. From 10 to 11 weeks of pregnancy, the National Abortion Federation suggests second dose of misoprostol four hours after the first dose. If the pregnancy involves twins, a higher dosage of mifepristone may be recommended.
After the patient takes mifepristone, they must also administer the misoprostol. While there is a chance for the pregnancy to successfully abort, failure to take the misoprostol may result in any of these outcomes: 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 continue with a healthy fetus. For those reasons, misoprostol should always be taken after the mifepristone.

Self-administered medical abortion

In the first trimester, self-administered medical abortion is available for patients who prefer to take the abortion drugs at home without direct medical supervision. Self-administered medical abortion during the first trimester is as safe and effective as provider-administered abortion.
The procedure used to administer the two drugs depends on specific drugs prescribed. A typical procedure, for 200 mg mifepristone tablets, is:
  1. Take the 200 mg mifepristone tablet by mouth
  2. Take the 800 μg misoprostol between 24 hours and 48 hours after the mifepristone
  3. The pregnancy will be expelled through the vagina within 2 to 24 hours after taking misoprostol, so the patient should remain near toilet facilities at that time. Cramps, nausea and bleeding may be experienced while the pregnancy is being expelled, and afterwards
  4. To avoid infection, the patient should not use tampons, be submerged in water, or engage in intercourse for 2 to 3 weeks
  5. The patient should contact their provider 7 to 14 days after the administration of mifepristone to confirm that complete termination of pregnancy has occurred and to evaluate the degree of bleeding

    After 12 weeks' gestation

Medical abortion is safe and effective in the second and third trimesters. The World Health Organization recommends that medical abortions performed after 12 weeks' gestation be supervised by a generalist medical practitioner or specialist medical practitioner.
For medical abortion 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. When mifepristone is not available, misoprostol may still be used though the mean time to abortion after starting misoprostol will be extended compared to regimens using mifepristone followed by misoprostol.

Alternative drug combinations

The mifepristone-misoprostol combination is, by far, the most recommended drug regimen for medical abortions, but other drug combinations are available.
Misoprostol alone, without mifepristone, may be used in some circumstances for medical abortion, and has even been demonstrated to be successful in the second trimester. Misoprostol is more commonly available than mifepristone, and is easier to store and administer, so misoprostol without mifepristone may be suggested by the provider if mifepristone is not available. 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 terminating pregnancy is nearly the same as the mifepristone-misoprostol combination. However, 15% of the women using misoprostol alone required a surgical follow-up procedure, which is significantly more than the mifepristone-misoprostol combination.
Tests have shown that letrozole or methotrexate may be included in the mifepristone-misoprostol regimen to improve the outcome in the first trimester.
A rarely used drug combination for uterine pregnancies is methotrexate-misoprostol, which is typically reserved for ectopic pregnancies. Methotrexate is given either orally or intramuscularly, followed by vaginal misoprostol 3–5 days later. The methotrexate combination is available through 63 days. 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. The methotrexate-misoprostol combination is considered more effective than misoprostol alone.

Contraindications

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. A previous allergic reaction to mifepristone or misoprostol is also a contraindication.
Many studies excluded women with severe medical problems such as heart and liver disease or severe anemia. Caution is required in a range of circumstances including:
In some cases, it may be appropriate to refer people with preexisting medical conditions to a hospital-based abortion provider.
Conversely, some medical conditions may make medication abortion more favorable than surgical abortion, such as large uterine fibroids, congenital uterine anomalies, or genital scarring related to infibulation.

Adverse effects

Most women will have cramping and bleeding heavier than a menstrual period. Other adverse effects may include nausea, vomiting, fever, chills, diarrhea, headache, dizziness, warmth or hot flashes. When used inside the vagina, misoprostol tends to have fewer gastrointestinal side effects. Nonsteroidal anti-inflammatory medications such as ibuprofen reduce pain with medication abortion.

Symptoms that require immediate medical attention

  • Heavy bleeding
  • Abdominal pain, nausea, vomiting, diarrhea, fever for more than 24 hours after taking mifepristone
  • Fever of or higher for more than 4 hours
Complications under 10 weeks' pregnancy are rare; according to two large reviews, bleeding requiring a blood transfusion occurred in 0.03–0.6% of women and serious infection in 0.01–0.5%. Because infection is rare after medication abortion, preventative antibiotics are not recommended. A few rare cases of deaths from clostridial toxic shock syndrome have occurred following medical abortions.
A 2013 systematic review which included 45,000 women who used the 200 mg mifepristone followed by misoprostol combination found that less than 0.4% had serious complications requiring hospitalization and/or blood transfusion.

Management of bleeding

Vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion, but in individual cases spotting can last up to 45 days. Emergency surgical or medical interventions for prolonged bleeding may be considered based on how the patient feels and if the bleeding seems to be getting better. Overall, less than 1% of individuals who undergo a medical abortion must obtain emergency services for excessive bleeding, and about 0.1% require a blood transfusion. 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.

Safety

Medical abortion is as safe as, or safer than, childbirth, surgical abortion, or unsafe abortion.
Medical abortion is about 14 times safer than childbirth, and also safer than the mortality rate for Penicillin and Viagra.
Medical abortion is as safe as, or safer than, surgical abortion. In the United States, an FDA report states that of the 3.7 million women who have had a medication abortion between 2000 and 2018, 24 died afterward, with 11 of those deaths likely unrelated to the abortion, including drug overdoses, homicides, and a suicide. When not taking the 11 likely unrelated deaths into account, the mortality rate for medication abortion is half the mortality rate of abortion overall. Including all deaths in the study, the data shows that the mortality rate for medication abortion is about equal to abortion overall.
Legal medical abortions reduce the risks associated with unsafe abortions. Globally, individuals who can get pregnant face substantial dangers to their health due to the significant challenges in obtaining safe abortion services. These negative outcomes arise from stringent abortion regulations, ineffective healthcare systems, a shortage of adequately trained healthcare professionals, societally imposed stigma, and limited services in remote regions. Additionally, within low and middle-income countries where abortion is legally allowed, a considerable number of unsafe abortions occur. Approximately 7 million women are hospitalized annually in these areas as a result of complications arising from unsafe abortion. Unsafe abortion is attributed to 4.7% to 13.2% of maternal deaths each year, with the estimated expense for managing its complications reaching $553 million. Many factors contribute to these health risks including lack of education about available choices, the varying stances of healthcare providers on abortion, a shortage of qualified personnel for safe abortion services, insufficient privacy and confidentiality, and services that fall short of meeting the demand.