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Medical abortion

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Medical abortion
Background
Abortion typeMedical
First useUnited States 1979 (carboprost),
West Germany 1981 (sulprostone),
Japan 1984 (gemeprost),
France 1988 (mifepristone),
United States 1988 (misoprostol)
Gestation3–24+ weeks
Usage
Medical abortions as a percentage of all abortions
France64% (2016)
Sweden92% (2016)
UK: Eng. & Wales62% (2016)
UK: Scotland83% (2016)
United States39% (2017)
Infobox references
Mifepristone/misoprostol
Combination of
MifepristoneProgesterone receptor modulator
MisoprostolProstaglandin
Clinical data
Trade namesMifegymiso,[1] Medabon Combipack
ATC code
Legal status
Legal status

A medical abortion, also known as medication abortion, occurs when medically-prescribed drugs (medication) are used to bring about an abortion. A typical regimen consists of a combination of medications, with mifepristone followed by misoprostol being the most common abortifacient regimen.[4] Mifepristone followed by misoprostol for abortion is considered both safe and effective throughout a range of gestational ages.[5] When mifepristone is not available, misoprostol alone may be used. In addition to mifepristone/misoprostol, other medications may be used depending on availability and patient-specific considerations.

Medical procedures to physically induce abortion that do not primarily use medication are generally referred to as surgical abortion.

Medical use

200 mg mifepristone and 800 mcg misoprostol, the typical regimen for early medical abortion.

Through 12 weeks' gestation

For medical abortion prior to 12 weeks' gestation, the World Health Organization (WHO) recommends mifepristone 200 mg by mouth followed 1–2 days later by misoprostol 800 mcg inside the cheek, vaginally, or under the tongue; misoprostol may be repeated to maximize success.[6] The success rate of mifepristone followed by one dose of misoprostol through 10 weeks' pregnancy is 96.6%.[7] Those who took misoprostol less than 24 hours after mifepristone had higher failures rates compared to women who waited 1–2 days.[8] The National Abortion Federation (NAF) also recommends a mifepristone and misoprostol combination regimen. For medication abortion up to 10 weeks of pregnancy, 200 mg mifepristone is taken followed in 24 to 48 hours by 800 mcg misoprostol. For pregnancies after 9 weeks, repeating the dose of misoprostol makes the treatment more effective.[9] From 10 to 11 weeks of pregnancy, NAF protocol includes a routine second dose of misoprostol 800 mcg four hours after the first dose.[10]

If mifepristone is not available, the WHO recommends misoprostol 800 mcg inside the cheek, under the tongue, or in the vagina.[6] The success rate of misoprostol alone for first trimester abortion is 78%.[11]

Though not a first line choice, a methotrexate/misoprostol combination regimen is appropriate. Methotrexate is given either orally or intramuscularly, followed by vaginal misoprostol 3–5 days later.[12] This is an appropriate option for gestations through 63 days. Per the WHO, a methotrexate-misoprostol regimen can also be used;[13] but is not recommended as methotrexate may be teratogenic to the fetus in cases of incomplete abortion. However, this combination is considered more effective than misoprostol alone.[14]

After 12 weeks' gestation

WHO recommends mifepristone 200 mg by mouth (orally) followed 1–2 days later by misoprostol 400 mcg under the tongue, inside the cheek, or in the vagina.[6] Misoprostol may be taken in repeated doses every 3 hours until successful abortion is achieved, the mean time to abortion after starting misoprostol is 6–8 hours, and approximately 94% will abort within 24 hours after starting misoprostol.[15] When mifepristone is not available, misoprostol may still be used though the mean time to abortion after starting misoprostol will be extended compared to regimens using mifepristone followed by misoprostol.[16]

Self-administered medical abortion

Self-administered medical abortion is available to women who prefer to take the abortion drug without direct medical supervision, in contrast to provider-administered medical abortion where the woman takes the abortion drug in the presence of a trained healthcare provider. Evidence from clinical trials indicates self-administered medical abortion may be as effective as provider-administered abortion but the safety aspects remain uncertain.[17]

Telehealth

Medical abortion was introduced as a service where a person visits a health center in-person due to FDA requirements that the first abortion pill, mifepristone, be dispensed directly by a health provider and not by prescription.[18] Other models exist to safely increase patient access to medication abortion. These models were expanded during the COVID-19 pandemic.[19][20] Women report high levels of satisfaction with telehealth abortion services.[21][22] Telehealth options for people in the United States seeking medication abortion include Aid Access, Hey Jane, and Plan C Pills.

Clinic-to-clinic

In this model, a provider communicates with a patient located at another site using clinic-to-clinic videoconferencing to provide medication abortion. This was introduced by Planned Parenthood of the Heartland in Iowa to allow a patient at one health facility to communicate via secure video with a health provider at another facility.[23] This model has expanded to other Planned Parenthoods in multiple states as well other clinics providing abortion care.[23]

Direct-to-patient

The direct-to-patient model allows for medication abortion to be provided without an in-person clinic visit. Instead of an in-person clinic visit, the patient receives counseling and instruction from the abortion provider via videoconference. The patient can be at any location, including their home. The medications necessary for the abortion are mailed directly to the patient. This is a model, called TelAbortion or no-test medication abortion (formerly no-touch medication abortion), being piloted and studied by Gynuity Health Projects, with special approval from the U.S. Food and Drug Administration (FDA).[24] This model has been shown to be safe, effective, efficient, and satisfactory.[19][25][26] Complete abortion can be confirmed via telephone-based assessment.[27]

Contraindications

Contraindications to mifepristone are inherited porphyria, chronic adrenal failure, and ectopic pregnancy.[28][29] Some consider an intrauterine device in place to be a contraindication as well.[29] A previous allergic reaction to mifepristone or misoprostol is also a contraindication.[28]

Many studies excluded women with severe medical problems such as heart and liver disease or severe anemia.[29] Caution is required in a range of circumstances including:[28]

In some cases, it may be appropriate to refer people with preexisting medical conditions to a hospital-based abortion provider.[30]

Adverse effects

Symptoms that require immediate medical attention:[31]

  • Heavy bleeding (enough blood to soak through four sanitary pads in 2 hours)
  • Abdominal pain, nausea, vomiting, diarrhea, fever for more than 24 hours after taking mifepristone
  • Fever of 38 °C (100.4 °F) or higher for more than 4 hours

Most women will have cramping and bleeding heavier than a menstrual period.[29] Nausea, vomiting, diarrhea, headache, dizziness, and fever/chills are also common. Misoprostol taken vaginally tends to have fewer gastrointestinal side effects. Nonsteroidal antiinflammatory medications such as ibuprofen reduce pain with medication abortion.

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.

Management of bleeding

Vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion, but in individual cases spotting can last up to 45 days.[28] 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.

Complications

Complications following medical abortion with mifepristone and misprostol under 10 weeks' pregnancy are rare; according to two large reviews, bleeding requiring a blood transfusion occurred in 0.03–0.6% of women and serious infection in 0.01–0.5%.[7][8] Because infection is rare after medication abortion, the American College of Obstetricians and Gynecologists (ACOG), The Society of Family Planning (SFP), and NAF do not recommend use of routine antibiotics.[32][12] A few rare cases of deaths from clostridial toxic shock syndrome have occurred following medical abortions.[33]

Pharmacology

Mifepristone blocks the hormone progesterone,[34][35] causing the lining of the uterus to thin and preventing the embryo from staying implanted and growing. Methotrexate, which is sometimes used instead of mifepristone, stops the cytotrophoblastic tissue from growing and becoming a functional placenta.[36] Misoprostol, a synthetic prostaglandin, causes the uterus to contract and expel the embryo through the vagina.[37]

Frequency

Medical abortions as a percentage of all abortions
Country Percentage
Italy 17% in 2015[38]
Spain 19% in 2015[39]
Belgium 22% in 2011[40]
Netherlands 22% in 2015[41]
Germany 23% in 2016[42]
United States 39% in 2017[43]
England and Wales 62% in 2016[44]
France 64% in 2016[45]
Iceland 67% in 2015[46]
Denmark 70% in 2015[46]
Portugal 71% in 2015[47]
Switzerland 72% in 2016[48]
Scotland 83% in 2016[49]
Norway 87% in 2016[50]
Sweden 92% in 2016[51]
Finland 96% in 2015[52]

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.[53][54] A subsequent survey also by the Guttmacher Institute estimated that medication abortions accounted for 39% of all abortions in the US that year, a 25% increase from 2014.[43]

At Planned Parenthood clinics in the United States, medical abortions accounted for 32% of first trimester abortions in 2008,[55] 35% of all abortions in 2010 and 43% of all abortions in 2014.[56]

History

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)[57] in the 1980s.[14][58][59] Mifepristone was initially approved in China and France (1988); in 2000, the United States Food and Drug Association approved mifepristone followed by misoprostol for abortion through 49 days.[60] In 2016, the United States FDA updated mifepristone's label to support usage through 70 days' gestation.[61]

Society and culture

The legal and political setting should support people's access to evidence-based medically approved care, including medical abortion.[62][63]

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;[59] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.[64]

"Reversal" controversy

Some anti-abortion groups claim that the abortifacient effect of mifepristone can be reversed by administering progesterone before the person takes misoprostol.[65][66] At this time there is no scientifically rigorous evidence that the effects of mifepristone can be reversed this way.[67][68] Even so, several states in the US require providers of non-surgical abortion who use mifepristone to tell patients that reversal is an option.[69] In 2019, researchers initiated a small trial of the so-called "reversal" regimen using mifepristone followed by progesterone or placebo.[70][71] The study was halted after 12 women enrolled and three experienced severe vaginal bleeding. The results raise serious safety concerns about using mifepristone without follow-up misoprostol.[68]

Cost

In the United States in 2009, the typical price charged for a medical abortion up to 9 weeks' gestation was $490, four percent higher than the $470 typical price charged for a surgical abortion at 10 weeks' gestation.[72] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.[73]

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 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.[74]

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 termination in early pregnancy consistent with the recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC).[75] These listings on the PBS commenced on 1 August 2013.[76]

References

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    Medical abortions accounted for 89% of abortions before 9 weeks' gestation in Scotland in 2016.
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    96% of all abortions performed in nonhospital facilities × 31% early medical abortions of all nonhospital abortions = 30% early medical abortions of all abortions; 97% of nonhospital medical abortions used mifepristone and misoprostol—3% used methotrexate and misoprostol, or misoprostol alone—in the United States in 2014.
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