A medical abortion is a type of non-surgical abortion in which medication is used to bring about 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) in the 1980s.
Medical uses
According to WHO in 2006 a number of factors should be taken into account when counseling a woman. Safety and effectiveness is similar between medical and surgical abortions.
Medical abortions may be the first choice if:
- That is what a woman chooses
- It is undertaken in the first 50 days of pregnancy
- The woman's body mass index is greater than 30 (severely obese) and she is free from other cardiovascular risk factors
- There are structural problems with the uterus
Surgical abortion may be the first choice if:
- That is what a woman chooses
- The woman has asked for sterilization at the same time
- Any of the contraindications listed below are present
- The necessary follow-up to medical abortion is difficult
Side effects
When performed early the risk of complications is low and no different than that of a miscarriage. Per 100 women around 3 will need medical care.
Possible complications of medical and surgical abortion include:
- 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. 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. 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.
Cases of deaths from clostridial toxic shock syndrome have occurred following medical abortions.
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.
Contraindications
Contraindications to a medical abortion may include:
- previous allergic reaction to one of the drugs involved;
- inherited porphyria;
- chronic adrenal failure;
- ectopic pregnancy
Caution is required in a range of circumstances including:
- long-term corticosteroid use;
- bleeding disorder;
- severe anemia;
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. Mifepristoneâ€"misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexateâ€"misoprostol combination regimens. Mifepristoneâ€"misoprostol and methotrexateâ€"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 early first-trimester medical abortion regimen (200 mg of oral mifepristone, followed 24â€"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.
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.
Prevalence
A Guttmacher Institute survey of abortion providers estimated that early medical abortions accounted for 31% of all nonhospital abortions and 45% of nonhospital abortions before 9 weeks gestation in the United States in 2014; medical abortions accounted for 32% of first trimester abortions at Planned Parenthood clinics in the United States in 2008.
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. In the United States in 2008, 57% of women who had abortions paid for them out of pocket.
In April 2013, the Australian government commenced an evaluation process to decide whether to list 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 priceâ€"the cost would be reduced from between AU$300 and AU$800, to AU$12 (subsidised rate for concession card holders) or AU$35.
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.
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 92-4-120871-6. WARNING: LINK GIVES ONLY THE FIRST PAGE OF THE REPORT; THE REST IS LISTED AS "OUT OF PRINT"
- Royal College of Obstetricians and Gynaecologists (November 23, 2011). The care of women requesting induced abortion. Evidence-based clinical guideline number 7 (PDF) (3rd rev. ed.). London: RCOG Press.Â
- ICMA (2013). "ICMA Information Package on Medical Abortion". ChiÈ™inău, Moldova: International Consortium for Medical Abortion (ICMA).Â
