Medical abortion

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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 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]

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.[9]

On 30 June 2013, the 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[10]
Spain 14% in 2011[11]
Belgium 17% in 2009[12]
United States 17% in 2008[7]
Germany 19% in 2012[13]
England and Wales 48% in 2012[14]
France 55% in 2011[15]
Iceland 55% in 2011[16]
Denmark 56% in 2011[16]
Switzerland 67% in 2012[17]
Sweden 75% in 2011[16][18]
Scotland 77% in 2012[19]
Norway 79% in 2011[16][20]
Finland 89% in 2011[16][21]

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][22] medical abortions accounted for 32% of first trimester abortions at Planned Parenthood clinics in the United States in 2008.[23]

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.[24]
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.[25]

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:[26]

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,[27] eight in the United States,[28][29][30] one in Portugal[31]—have died from clostridial toxic shock syndrome (nine from Clostridium sordellii,[27][28][29][30] one from Clostridium perfringens[29]) following early medical abortions using 200 mg mifepristone orally followed by 800 mcg misoprostol—nine vaginally,[27][28][29][30][31] one buccally[29]—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.[23]

A table in the 2010 Handbook of Obstetric and Gynecologic Emergencies, 4th edition lists these possible complications of medical and surgical abortion:[32]

  • 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:[26]
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

  1. ↑ 1.0 1.1 Kulier, Regina; Kapp, Nathalie; Gülmezoglu, A. Metin; Hofmeyr, G. Justus; Cheng, Linan; Campana, Aldo (November 9, 2011). "Medical methods for first trimester abortion". Cochrane Database Syst Rev. (11): CD002855. doi:10.1002/14651858.CD002855.pub4. PMID 22071804. 
  2. ↑ 2.0 2.1 2.2 Creinin, Mitchell D.; Danielsson, Kristina Gemzell (2009). "Medical abortion in early pregnancy". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 111–134. ISBN 1-4051-7696-2. 
  3. ↑ 3.0 3.1 Kapp, Nathalie; von Hertzen, Helena (2009). "Medical methods to induce abortion in the second trimester". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 1-4051-7696-2. 
  4. ↑ Hammond, Cassing; Chasen, Stephen T. (2009). "Dilation and evacuation". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 1-4051-7696-2. 
  5. ↑ Fjerstad, Mary; Sivin, Irving; Lichtenberg, E. Steve; Trussell, James; Cleland, Kelly; Cullins, Vanessa (September 2009). "Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days". Contraception. 80 (3): 282–286. doi:10.1016/j.contraception.2009.03.010. PMID 19698822. 
    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.
  6. ↑ Ngo, T. D.; Park, M. H.; Shakur, H.; Free, C. (2011). "Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review". Bulletin of the World Health Organization 89 (5): 360–370. doi:10.2471/BLT.10.084046. PMC 3089386. PMID 21556304. 
  7. ↑ 7.0 7.1 7.2 Jones, Rachel K.; Kooistra, Kathryn (March 2011). "Abortion incidence and access to services in the United States, 2008". Perspect Sex Reprod Health. 43 (1): 41–50. doi:10.1363/4304111. PMID 21388504.  94% of nonhospital medical abortions used mifepristone and misoprostol—6% used methotrexate and misoprostol—in the United States in 2008.
    Stein, Rob (January 11, 2011). "Decline in U.S. abortion rate stalls". The Washington Post. p. A3. 
  8. ↑ Jones, Rachel K.; Finer, Lawrence B.; Singh, Shusheela (May 4, 2010). "Characteristics of U.S. abortion patients, 2008". New York: Guttmacher Institute. 
    Mathews, Anna Wilde (May 4, 2010). "Most women pay for their own abortions". The Wall Street Journal (online). 
  9. ↑ Kerry Peterson (30 April 2013). "Abortion drugs closer to being subsidised but some states still lag". The Conversation Australia. The Conversation Media Group. Retrieved 29 April 2013. 
  10. ↑ Kruijer, Hans; Lee, Laura; Wijsen, Ciel (December 2009). "Landelijke Abortus Registratie 2008 (National Abortion Registration 2008)". Utrecht: Rutgers Nisso Group, Netherlands. 
  11. ↑ . (December 21, 2012). "Interrupción voluntaria del embarazo; datos definitivos correspondientes al año 2011 (Voluntary interruption of pregnancy; final data for 2011". Madrid: Ministerio de Sanidad, Politica Social e Igualdad (Ministry of Health and Social Policy).  7.5% mifepristone + 6.1% prostaglandin
  12. ↑ . (March 2011). "Feiten & Cijfers: Abortus in België 2009 (Facts & Figures: Abortion in Belgium 2009)". Antwerp: Sensoa, Belgium. 
  13. ↑ . (March 6, 2013). "Schwangerschaftsabbrüche 2012 (Abortions 2012)". Wiesbaden: Statistisches Bundesamt (Federal Statistical Office), Germany.  16.15% mifepristone + 3.32% other medical = 19.48% medical abortions
  14. ↑ . (July 11, 2013). "Abortion statistics, England and Wales: 2012". London: Department of Health, United Kingdom. 
    Medical abortion was the most common method used in abortions before 7 weeks gestation—and accounted for 61% of abortions before 9 weeks gestation—in England and Wales in 2012.
  15. ↑ Vilain, Annick; Mouquet, Marie-Claude; Gonzalez, Lucie; de Riccardis, Nicolas (June 21, 2013). "Les interruptions volontaires de grossesse en 2011 (Voluntary terminations of pregnancies in 2011)". Paris: DREES (Direction de la Recherche, des Études, de l'Évaluation et des Statistiques), Ministère de la Santé (Ministry of Health), France. 
  16. ↑ 16.0 16.1 16.2 16.3 16.4 Heino, Anna; Gissler, Mika (March 20, 2013). "Pohjoismaiset raskaudenkeskeytykset 2011 (Induced abortions in the Nordic countries 2011)". Helsinki: Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland. 
  17. ↑ . (June 12, 2013). "Interruptions de grossesse en Suisse en 2012 (Abortions in Switzerland 2012)". Neuchâtel: Office of Federal Statistics, Switzerland. 
  18. ↑ . (May 10, 2012). "Aborter 2011 (Induced Abortions 2011)". Stockholm: Socialstyrelsen (National Board of Health and Welfare), Sweden. 
    Medical abortions accounted for 89% of abortions before 9 weeks gestation in Sweden in 2011.
  19. ↑ . (May 28, 2013). "Abortion statistics, year ending 31 December 2012". Edinburgh: Information Services Division (ISD), NHS National Services Scotland. 
    Medical abortions accounted for 86% of abortions before 9 weeks gestation in Scotland in 2012.
  20. ↑ Gåsemyr, Kristin; Totlandsdal, Joan Kristina; Mjaatvedt, Aase Gunn; Seliussen, Ingvei (June 15, 2012). "Rapport om svangerskapsavbrudd for 2011 (Report on abortions for 2011)". Oslo: Divisjon for epidemiologi (Division of Epidemiology), Nasjonalt Folkehelseinstitutt (Norwegian Institute of Public Health), Norway. 
  21. ↑ Heino, Anna; Gissler, Mika; Soimula, Anne (October 1, 2012). "Raskaudenkeskeytykset 2011 (Induced abortions 2011)". Helsinki: Suomen virallinen tilasto (Official Statistics of Finland), Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland. 
  22. ↑ Pazol, Karen; Creanga, Andreea A.; Zane, Suzanne B.; Burley, Kim D.; Jamieson, Denise J.; Division of Reproductive Health (November 23, 2012). "Abortion surveillance – United States, 2009". MMWR Surveill Summ. 61 (8): 1–44. PMID 21346710.  Medical abortions accounted for 17.1% of abortions—and 25.2% of abortions before 9 weeks gestation—in the United States in 2009 that were voluntarily reported to the CDC by 34 reporting areas (excluding Alabama, California, Connecticut, Delaware, Florida, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Nebraska, Nevada, New Hampshire, Pennsylvania, Tennessee, Vermont, Wisconsin, and Wyoming).
  23. ↑ 23.0 23.1 Fjerstad, Mary; Trussell, James; Sivin, Irving; Lichtenberg, E. Steve; Cullins, Vanessa (July 9, 2009). "Rates of serious infection after changes in regimens for medical abortion". N Engl J Med. 361 (2): 145–151. doi:10.1056/NEJMoa0809146. PMID 19587339. 
    Allday, Erin (July 9, 2009). "Change cuts infections linked to abortion pill". San Francisco Chronicle. p. A1. 
  24. ↑ Grossman, Daniel (September 3, 2004). "Medical methods for first trimester abortion: RHL commentary". The WHO Reproductive Health Library. Geneva: World Health Organization. 
  25. ↑ Chien, Patrick; Thomson, Maggie (December 15, 2006). "Medical versus surgical methods for first trimester termination of pregnancy: RHL commentary". The WHO Reproductive Health Library. Geneva: World Health Organization. 
  26. ↑ 26.0 26.1 International Consensus Conference on Non-surgical (Medical) Abortion in Early First Trimester on Issues Related to Regimens and Service Delivery (2006). Frequently asked clinical questions about medical abortion. Geneva: World Health Organization. ISBN 92-4-159484-5. 
  27. ↑ 27.0 27.1 27.2 Sinave, Christian; Le Templier, Geneviève; Blouin, Daniel; Léveillé, François; Deland, Éric (December 1, 2002). "Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease". Clin Infect Dis. 35 (11): 1441–1443. doi:10.1086/344464. PMID 12439811. 
  28. ↑ 28.0 28.1 28.2 Fischer, Marc; Bhatnagar, Julu; Guarner, Jeannette; Reagan, Sarah; Hacker, Jill K.; Van Meter, Sharon H.; Poukens, Vadims; Whiteman, David B.; Iton, Anthony; Cheung, Michele; Dassey, David E.; Shieh, Wun-Ju; Zaki, Sherif R. (December 1, 2005). "Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion". N Engl J Med. 353 (1): 2352–2360. doi:10.1056/NEJMoa051620. PMID 16319384. 
  29. ↑ 29.0 29.1 29.2 29.3 29.4 Cohen, Adam L.; Bhatnagar, Julu; Reagan, Sarah; Zane, Suzanne B.; D'Angeli, Marisa A.; Fischer, Marc; Killgore, George; Kwan-Gett, Tao Sheng; Blossom, David B.; Shieh, Wun-Ju; Guarner, Jeannette; Jernigan, John; Duchin, Jeffrey S.; Zaki, Sherif R.; McDonald, L. Clifford (November 2007). "Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion". Obstet Gynecol. 110 (5): 1027–1033. doi:10.1097/01.AOG.0000287291.19230.ba. PMID 17978116. 
  30. ↑ 30.0 30.1 30.2 Meites, Elissa; Zane, Suzanne; Gould, Carolyn; C. sordellii investigators (September 30, 2010). "Fatal Clostridium sordellii infections after medical abortions". N Engl J Med. 363 (14): 1382–1383. doi:10.1056/NEJMc1001014. PMID 20879895. 
  31. ↑ 31.0 31.1 Reis, T.; Chaves, C.; Soares, A.; Moreira, M.; Boaventura, L.; Ribeiro, G. (May 2011). "A Clostridium sordellii fatal toxic shock syndrome post-medical-abortion in Portugal". Clin Microbiol Infect. 17 (Suppl s4): S761. 
  32. ↑ Botha, Rosanne L.; Bednarek, Paula H.; Kaunitz, Andrew M.; Edelman, Alison B. (2010). "Chapter 18. Complications of medical and surgical abortion". In Benrubi, Guy I. (ed.). Handbook of obstetric and gynecologic emergencies (4th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 258. ISBN 1-60547-666-8.  Table 18.1 Possible complications of surgical and medical abortion.

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