12.2 Medical abortion


The combined mifepristone + misoprostol regimen is more effective than misoprostol used alone1 and reduces the number of misoprostol doses needed, thus reducing its adverse effects.

The unit where medical abortion is performed should be set up for vacuum aspiration (or for easy referral for vacuum aspiration), should the medical method fail (ongoing pregnancy) or a complication occur (significant bleeding or incomplete expulsion).

12.2.1 Contra-indications

– Coagulation disorders: in this case, vacuum aspiration is preferred.
– Chronic adrenal failure and severe uncontrolled asthma (for mifepristone only).

Note: mifepristone and misoprostol are not to be used for the termination of an ectopic or molar pregnancy.

12.2.2 Protocol

The treatment includes:

– A combination of abortion medications:
mifepristone PO: 200 mg as a single dose
then, 36 to 48 hours later:
misoprostol sublingually or vaginally: 800 micrograms
Bleeding and cramping can be expected to start within 1 to 3 hours. If there is no bleeding within 3 hours, administer additional doses of misoprostol: 400 micrograms every 3 hours if necessary, until expulsion starts; maximum 4 additional doses.
If mifepristone is not available or contra-indicated, misoprostol alone is administered as above.

AND

– An analgesic or a combination of analgesics1 :
ibuprofen PO: 800 mg every 8 hours (max. 2400 mg/day); start with misoprostol and continue as needed after expulsion, up to 3 days maximum.
If needed, add:
codeine PO: 30 to 60 mg every 6 hours (max. 240 mg/day)
or
tramadol PO: 50 to 100 mg every 6 hours (max. 400 mg/day)
In case of nausea/vomiting (not routinely):
metoclopramide PO: 5 mg/dose for women < 60 kg; 10 mg/dose for women > 60 kg. The interval between each dose should be at least 6 hours.

In practice:
Mifepristone is given under direct observation then, the woman goes home. Analgesics are not required at this stage.

Then, according to the context:
– misoprostol is given to the woman to take at home 48 hours later (four 200 microgram tablets for the first dose and one or more additional doses (two 200 microgram tablets, maximum additional 8 tablets). In this case, the protocol should be clearly explained;
or
– the woman comes back and takes misoprostol at the health facility. Between 12 to 14 weeks, she should remain at the facility until complete expulsion.

In addition to misoprostol, analgesics are provided.

12.2.3 Patient information

Before administering medications, the patient should be informed that:
– Medical abortion has approximately a 95% success rate. In case of failure, vacuum aspiration will be performed.
– Mifepristone and misoprostol may have teratogenic effect (this information should be known, in case she changes her mind after taking the drugs or if the regimen fails).
– Abortion starts within hours after taking the first dose of misoprostol and is usually completed within 24 to 48 hours. Occasionally, it can take up to two weeks to complete the abortion.
– She will experience cramping and bleeding. This normally lasts for a few days until abortion is completed. The heaviest bleeding occurs 2 to 5 hours after using misoprostol and usually slows down within 24 hours and should not exceed 48 hours. Light bleeding will last for 1 to 2 weeks.
– Misoprostol, especially when several doses are given, can cause: nausea, diarrhoea, and a fever that should not persist longer than 24 hours after taking the medication.
– Severe pain, heavy bleeding, foul smelling discharge and fever are danger signs requiring immediate medical attention.
– Menstrual periods will resume within 4 to 8 weeks but fertility returns rapidly; ovulation can occur as early as 2 weeks post-abortion.

With regard to contraception, depending on the method chosen, the patient should be informed that:
– Hormonal contraception will be started the day the misoprostol is taken.
– An intrauterine device will be inserted after complete expulsion at the post-abortion visit, provided there is no pelvic infection.

12.2.4 Post-abortion visit

A clinical consultation is routinely recommended 10 to 14 days after the administration of misoprostol to:
– Make sure the abortion is complete;
– Diagnose and treat potential complications;
– Provide contraception, if not done during the procedure. An intrauterine device can be inserted once complete abortion is confirmed.

Confirmation that the abortion is complete is based on clinical evidence: there is a sufficient amount of bleeding, the signs of pregnancy disappear, and the uterus returns to its normal size.
If in doubt:
– Confirm complete evacuation by ultrasound, if available.
– Do not perform pregnancy test, as it remains positive up to one month after abortion.

In the absence of bleeding or in case of minimal bleeding, suspect a failure of abortion but also an ectopic pregnancy.

In case of incomplete abortion, see Chapter 2, Section 2.1.3.

In case of ectopic pregnancy, see Chapter 2, Section 2.2.3.

In case of ongoing pregnancy, perform a vacuum aspiration (Chapter 9, Section 9.5).



Footnotes
Ref Notes
1 These doses may be used in adults and adolescents over 12 years.