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 early 1970s and the antiprogestogen mifepristone in the 1980s.^[1][2][3]

Regimens

The most common early first-trimester medical abortion regimens use mifepristone in combination with a prostaglandin analog (misoprostol or gemeprost) up to 63 days of gestational age, methotrexate in combination with a prostaglandin analog up to 49 days gestation, or a prostaglandin analog alone.^[1] Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens.^[2] Mifepristone–misoprostol and methotrexate–misoprostol combination regimens are more effective than misoprostol alone.^[2]

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;^[3] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.^[4]

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.^[5]

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.^[6]

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.^[7] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.^[8]

Prevalence

A Guttmacher Institute survey of abortion providers estimated that early medical abortions accounted for 17% of all nonhospital abortions and slightly over one-quarter of abortions before 9 weeks gestation in the United States in 2008;^[7][21] medical abortions accounted for 32% of first trimester abortions at Planned Parenthood clinics in the United States in 2008.^[22]

Health risks

Reviews in 2004 and 2006 for the WHO Reproductive Health Library found that:

Medical methods for first trimester abortion have been demonstrated to be both safe and effective. Regimens that combine mifepristone or methotrexate with a prostaglandin such as misoprostol are more efficacious than a prostaglandin alone.^[23]

Prostaglandins alone seem to be less effective and more painful than surgical abortion. Evidence is inadequate on the acceptability and side-effects of the two methods. The medical approach avoids the use of anesthetics; this and the possibility of using it as an outpatient procedure may offer an advantage in under-resourced settings.^[24]

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:^[25]

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.

Since 2001, ten women—one in Canada,^[26] eight in the United States,^[27][28][29] one in Portugal^[30]—have died from clostridial toxic shock syndrome (nine from Clostridium sordellii,^{[26][27][28][29]} one from Clostridium perfringens^[28]) following early medical abortions using 200 mg mifepristone orally followed by 800 mcg misoprostol—nine vaginally,^{[26][27][28][29][30]} one buccally^[28]—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.^[22]

A table in the 2010 Handbook of Obstetric and Gynecologic Emergencies, 4th edition lists these possible complications of medical and surgical abortion:^[31]

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

Contraindications

According to the 2006 WHO Frequently asked clinical questions about medical abortion:^[25]

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).

References

External links

• WHO Scientific Group on Medical Methods for Termination of Pregnancy (December 1997). Medical methods for termination of pregnancy. Technical Report Series, No. 871. Geneva: World Health Organization. ISBN 9241208716. http://apps.who.int/bookorders/anglais/detart1.jsp?sesslan=1/&codlan=1&codcol=10&codcch=871. 
• Royal College of Obstetricians and Gynaecologists (November 23, 2011). The care of women requesting induced abortion. Evidence-based clinical guideline number 7 (3rd rev. ed.). London: RCOG Press. http://www.rcog.org.uk/files/rcog-corp/Abortion%20guideline_web_1.pdf. 
• The ICMA Information Package on Medical Abortion The International Consortium for Medical Abortion (ICMA)