Medical abortion refers to the use of pills to terminate a pregnancy. Medical abortion may also be referred to as "non-surgical abortion" or "medication abortion". Abortifacient pills used to terminate a pregnancy are commonly referred to as "abortion pills."
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) in the 1980s. The combination of mifepristone and misoprostol, or misoprostol alone, are the safest and most effective drugs to medically induce an abortion.
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Medical uses
According to the World Health Organization (WHO) 2012 Safe abortion: Technical and Policy Guidance for Health Systems-2nd Edition, both surgical and medical options are recommended. Considering the geographical and political barriers that hinder some women's access to abortion services, medical abortion is designed to allow for a safe abortion to be completed privately and within a home setting. This process of medically inducing an abortion is similar to a miscarriage, and when done within the first 9 weeks of pregnancy poses minimal risks.
The safest and most effective method to induce a medical abortion is via a regimen that involves both mifepristone and misoprostol. If used as directed, mifepristone plus misoprostol is effective in ending a pregnancy before 10 weeks 95% of the time. This regimen can be found at websites such as the site of the organization Women Help Women. However, misoprostol alone may also be used to terminate a pregnancy. A different regimen of 12 tablets of misoprostol is used and is 80-85% effective in ending a pregnancy up to 12 weeks. Medical abortion is a less invasive procedure than an aspiration abortion (also called surgical abortion). Medical abortion is safe regardless of:
- Age
- Weight,
- Single or twin pregnancies
- Women who are breastfeeding at the time of their pregnancy
- Women who have previously undergone a caesarean procedure
HIV-positive women are also eligible for medical abortion, however they may be at a higher risk of infection and may need to use antibiotics following the administration of the abortion pills. In addition, women who are more than 9 weeks pregnant and RH-negative should receive RH-immunoglobin injection within the same day or up to 72 hours following the administration of the abortion pills if possible.
Side effects
According to the World Health Organization (WHO) 2012 policy guidance, the possible side effects of medical abortion are the same as those associated with miscarriages. These include uterine cramping and prolonged menstrual bleeding which typically takes place over the span of 9 days but in a rare number of cases can last for up to 45 days.
Nausea and vomiting are frequent pregnancy-related symptoms. Therefore, it is recommended that a woman use an anti-nausea medicine (an anti-emetic) before using the medicines if she has been experiencing nausea. If a woman vomits the mifepristone medication within the first 1.5 hours after having taken the pill, the medicine may not be effective. However, usually mifepristone is absorbed within 1.5 hours, so vomiting after this period usually will not impact the abortion process. Misoprostol must be absorbed either under the tongue (sublingual) or in the cheek (buccal) for 30 minutes. If vomiting takes place before the 30 minutes, the misoprostol may not be effective.
Nausea, chills, diarrhea, headache, and flu-like symptoms are other reported side effects of misoprostol and are often resolved within 6 hours of using the drug. If any of these symptoms last for more than 24 hours, seeking medical attention is advised.
Misoprostol's wide availability and low cost have contributed to a decrease in complications from unsafe abortion. The risk of a complication arising from a medical abortion is very low, with mortality rates comparable to a spontaneous abortion which occurs in 15-20% of all pregnancies.
Possible complications from medical abortion include
- Hemorrhage
- Incomplete abortion
- Uterine or pelvic infection
- Ongoing intrauterine pregnancy, requiring a surgical abortion for completion
- Misdiagnosed/unrecognized ectopic pregnancy
Despite the low rate of complications, it is important for women to seek medical attention if they are experiencing signs of ongoing pregnancy, severe bleeding, severe abdominal pain that isn't relieved with painkillers, fever over 38-39 degrees Celsius (101 degrees Fahrenheit) for more than 24 hours, and abnormal vaginal discharge. Bleeding is considered severe if more than 2 maxi sanitary pads are soaked per hour for more than 2 hours.
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 antibiotics. A follow-up study published in 2017 examined women's experience undergoing medical abortion through an online telemedicine service. This study demonstrated that medical abortion using online telemedicine can be highly effective. Amongst the 1000 women enrolled in this study, 94.7% reported the successful termination of pregnancy without medical intervention. This study concluded that online telemedicine for abortion care compares favorably with clinical interventions, that women are able to self-identify the symptoms of potentially serious complications, and report seeking medical attention when advised.
Contraindications
According to the World Health Organization (WHO) 2012 Safe abortion: Technical and Policy Guidance for Health Systems-2nd Edition, most women can use abortion pills safely.. There are very few absolute contraindications to medical abortion. They include:
- Previous allergic reaction to one of the drugs involved
- Inherited poryphyria
- 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 (hypertension and smoking)
In addition, it is important to note that mifepristone is not an effective treatment for ectopic pregnancies (where the pregnancy is outside of the uterus, for example in the fallopian tubes).
Management of prolonged bleeding
According to the 2006 WHO Frequently asked clinical questions about medical abortion, 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
There are three methods for medical abortion: the drug mifepristone followed by misoprostol, methotrexate followed by misoprostol, and misoprostol alone. The World Health Organization (WHO) recommends an evidence-based mifepristone-misoprostol combination regimen for medical abortion; where mifepristone is not available it recommends a misoprostol-only regimen. A methotrexate-misoprostol regimen can also be used; 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. Mifepristone-misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate-misoprostol combination regimens. Mifepristone-misoprostol and methotrexate-misoprostol combination regimens are more effective than misoprostol alone.
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; in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.
The recommended method of the World Health Organization for medical abortion for pregnancies of gestational age up to 9 weeks is 200mg mifepristone followed 1 to 2 days later by misoprostol. For pregnancies up to 9 weeks, misoprostol can be administered vaginally, buccally (absorbed in the cheek), or sublingually (absorbed under the tongue) . Oral administration of misoprostol is not recommended due to its low efficacy. Medical abortion using mifepristone and misoprostol for pregnancy up to 9 weeks gestations results in a complete abortion in 95-98% of cases. The most common side effects from this abortion regimen are nausea, vomiting, pain, diarrhea, and shivering. More information about the mifepristone/misoprostol regimen is available on many websites, including the website Women Help Women.
Medical abortion may also be performed using misoprostol alone for pregnancies up to 12 weeks. Misoprostol is a medication that is used to treat an array of medical conditions including ulcers and arthritis. It has many gynecological uses, including post-partum hemorrhage prevention, cervical dilation, and labor induction and is registered in most countries, including those where abortion is legally restricted.
The recommended protocol for misoprostol alone requires 2400 mcgs, usually 12 tablets of 200 mcg each. Four tablets are placed under the tongue for 30 minutes; then the remains are swallowed. After 3 hours, four additional tablets are placed under the tongue for 30 minutes. This is repeated with the last four tablets after 3 more hours. The misoprostol only regimen results in a complete abortion in approximately 84% of cases and the side effects are generally slightly stronger than those associated with the mifepristone plus misoprostol regimen. More information about the use of misoprostol alone is available on many websites, including the website of Women Help Women.
Medical abortion regimens using mifepristone in combination with a prostaglandin such as misoprostol, are the most common methods used to induce second-trimester abortions in Canada, most of Europe, China and India; in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and extraction.
Prevalence and Cost
In the United States, abortion is legal in every state, and every state has at least one clinic that provides abortion care. However, certain state laws require abortion pills to be provided by licensed health care clinician. While often purchasing abortion pills is an out of pocket expense for most women in the USA, there are organizations that provide funds and grants to assist women's access to medical abortion. For women in the USA who use abortion pills outside of the medical system, information is available at the website of the World Health Organization as well as other organizations.
In Canada, Health Canada's approval of mifepristone for medical abortion in 2017 requires licensed medical practitioners to provide the prescription. There are currently several Canadian provinces which have decided to publicly fund the cost of medical abortion via the administration of mifepristone, including: Ontario, Alberta, Quebec, New Brunswick, and Nova Scotia.
In Europe, the cost varies based on the country's health system.
Misoprostol is available over the counter at low cost in most Latin American, Asian, and African countries as well as in some European countries.
Source of the article : Wikipedia
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