12.2 Medication abortion


Medication abortion is a safe and effective method of ToP. The risk of severe complications is less than 0.1% and the success rate is 97-98%.

The combination mifepristone + misoprostol is more effective than misoprostol alone and reduces the number of misoprostol doses needed, thus reducing its adverse effects. Misoprostol, however, is an effective and safe option even when used alone.

12.2.1 Precautions

– Coagulation disorders: MVA is preferred, if medication abortion is performed it must be carried out under observation. 
– Chronic adrenal failure and severe uncontrolled asthma: use misoprostol alone.
– In case of 2 or more previous uterine scars, given the risk of uterine rupture:
• Preferably use the combined regimen mifepristone + misoprostol, as fewer numbers of misoprostol doses are required.
• From 13 to 22 weeks LMP: admit patient for observation; reduce the dose of misoprostol to 200 micrograms; respect a minimum interval of one day between mifepristone and misoprostol.

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

12.2.2 Protocol 

Before 13 weeks LMP

Between 13 and 22 weeks LMP

mifepristone PO: 200 mg single dose
Then 1 to 2 days later:
misoprostol sublingually or vaginally: 800 micrograms1

If expulsion has not occurred within 24 hours, give a second dose of 800 micrograms of misoprostol. 

If mifepristone is not available or contra-indicated:
misoprostol sublingually or vaginally: 800 micrograms every 3 hours (even if bleeding starts after the first or second dose); max. 3 doses.2

mifepristone PO: 200 mg single dose
Then 1 to 2 days later:
misoprostol sublingually or vaginally:
400 micrograms every 3 hours until foetal and placental expulsion2

If mifepristone is not available or contra-indicated: give misoprostol alone as above.




AND

An analgesic or a combination of analgesics:
ibuprofen PO: 800 mg every 8 hours (max. 2400 mg daily); start with misoprostol and continue as needed after expulsion, up to 3 days max.
If needed, add: codeine PO: 30 to 60 mg every 6 hours (max. 240 mg daily) or tramadol PO: 50 to 100 mg every 6 hours (max. 400 mg daily).
Use one of these 2 drugs alone if ibuprofen is contra-indicated.

Notes:
– All these doses may be used in adults and adolescents over 12 years.
– Depending on the patient's specific constraints, mifepristone and misoprostol can be taken simultaneously. 
– In the event of nausea/vomiting (not routinely): metoclopramide PO: 5 mg per dose for women < 60 kg; 10 mg per dose for women > 60 kg. The interval between each dose of metoclopramide should be at least 6 hours.

12.2.3 Patient care 

Before 13 weeks LMP

– Medication abortion is performed on an outpatient basis. A single visit is organized to provide information and counselling on ToP and the medication used for that purpose as well as on contraception and the specific method chosen by the patient.
– Mifepristone is usually given under direct observation but it is not mandatory. The woman can choose to take all medications at home.
– Misoprostol is taken at home 1 to 2 days later (4 tablets of 200 micrograms for the first dose). Bleeding and cramping are expected to start within 3 hours. In the vast majority of cases this treatment is successful. If expulsion has not occurred within 24 hours, a second dose (4 tablets of 200 micrograms) should be taken. Women can choose come back in consultation to take the misoprostol rather than taking it home.
– If misoprostol only regimen is used, provide the patient with the total number of doses (4 tablets of 200 micrograms every 3 hours; a total of 12 tablets). 
– Ibuprofen is given to the patient to be taken once cramping starts. Provide quantity to cover 3 days of treatment. 
– All contraceptive methods can be started that same day (implant is inserted or injection given during the consultation, oral contraceptive is given for a minimum of 3 months) except the IUD which can only be inserted after expulsion.

Between 13 and 22 weeks LMP

– Due to an increased risk of complications, admit patient for observation after 12 weeks LMP, however, between 13 and 16 weeks LMP the woman can choose to take the treatment at home, unless there is a risk of uterine rupture (Section 12.2.1).
– As gestational age increases, expulsion takes more time and is more painful (ensure pain management accordingly).
– The foetus is more developed and is usually stillborn. In exceptional cases, transient spontaneous breathing and/or movements may be observed. This may be emotionally difficult for both the woman and medical staff. 
– The disposal of the dead foetus must be handled discreetly and respectfully. 
– For women 13-16 weeks LMP who chose to take the treatment at home, provide necessary information and counselling as above, including considerations regarding the disposal of the foetus. 
– For misoprostol, give sufficient doses to ensure treatment for 24 hours (2 tablets of 200 micrograms every 3 hours; a total of 16 tablets). Advise the woman to stop misoprostol as soon as expulsion has taken place.

12.2.4 Patient information

Before administering medications, the patient should be informed that:
– Medical abortion is effective and safe. Only 2 out of 100 women will need vacuum aspiration to end the pregnancy. Complications are rare. 
– 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).

– During abortion, she will experience cramping, bleeding, expulsion of blood clots, and between 13 and 22 weeks LMP, expulsion of the foetus and placenta.
– Most often there will be no cramping and bleeding after taking mifepristone. Cramping and bleeding start 1 to 3 hours after taking misoprostol and usually slow down within 24 hours. They should not exceed 48 hours. Light bleeding may last up to 1 month.
– The abortion will be usually completed within 24 to 48 hours.
– Misoprostol, especially when several doses are taken, can cause nausea, diarrhoea, chills and fever that should not persist longer than 24 hours after taking the medication.
– Severe pain, heavy bleeding (soaking 2 pads per hour for 2 consecutive hours), foul smelling discharge and fever lasting more than 24 hours are signs requiring immediate medical attention.

– Menstrual periods will resume within 4 to 8 weeks but fertility returns rapidly; ovulation can occur as early as 10 days post-abortion. It is recommended to start contraception immediately.

12.2.5 Post-abortion consultation

– No routine post-abortion consultation is required.
– The woman is encouraged to come back at any time if she has concerns, complications or questions.
– The woman is invited to return for contraception if she did not start a method immediately at the time of the abortion.

In the event of incomplete abortion, see Chapter 2, Section 2.1.3.

In the event of ectopic pregnancy, see Chapter 2, Section 2.2.3.

In the event of ongoing pregnancy before 13 weeks LMP, perform a vacuum aspiration (Chapter 9, Section 9.5).