Pregnancy Termination/Abortion Pill
1. Introduction
Until the second half of the 20th century, dilatation and curettage (D&C) was the most common and virtually only method used for safe termination of early pregnancy. Abortion by vacuum aspiration gained greater acceptance in the 1960s and has become the standard of care. First trimester pregnancy can also be terminated safely pharmacologically (medical abortion).
Vaginal administration of 800 mcg (4 tablets of 200 mcg) of misoprostol (Cytotec) medication repeated up to three times at 12h intervals has 85% to 90% effectiveness, defined as complete abortion.
The oral route is less effective than vaginal. Vaginal administration should therefore be chosen unless there are reasons to avoid it.
2. Contradictations
- Known allergy to misoprostol;
- Suspected ectopic pregnancy or non-diagnosed adnexal mass;
- Unstable hemodynamics.
3. Precautions
- If molar pregnancy is diagnosed, intrauterine aspiration and curettage is preferred.
- If there is an intrauterine device (IUD) in place, this should be removed before administering misoprostol.
- Coagulation disorders
- Woman should be advised that the treatment can fail and she should be prepared to pregnancy termination by surgical method, because there have been reports of congenital malformations in newborn infants of mothers given misoprostol during the first trimester of pregnancy.
- Breastfeeding: It is recommended that breast milk is not given to the infant for 4h after oral administration or 6h after vaginal misoprostol administration.
- Previous cesarean section: The safety and efficacy of early abortion (up to seven weeks) is unaffected by previous cesarean section.
4. Dosage
The first choice is 800 mcg (4 tablets of 200 mcg) of misoprostol administered by the vaginal route every 12 hours for a maximum of three doses. Three doses of 800 mcg at 3h intervals can also be used sublingually. Doses higher than 800 mcg are not recommended due to increased side effects.
5. Effectiveness and Time to achieve effects
The success rate, defined as a complete abortion is around 90% during the first trimester of pregnancy.
Depending on the regimen used, pregnancy continues in 4% to 8% of women with gestational age of up to 63 days when vaginal misoprostol is used.
In the majority of cases, expulsion of the products of conception occurs hours after the administration: close to 70% within the first 12h, around 80% during the first 24h, 95% within 48h and further increases until least 72h after the initial dose. However there may be a large variability depending on route, dose and time interval between misoprostol doses.
6. Effects and side effects
Prolonged or serious side effects are rare.
6.1 Bleeding
Vagina bleeding during abortion induced with misoprostol is generally more intense than regular menstrual bleeding and is usually no different from that which occurs with a spontaneous abortion. Althrough there may be great variations, there is typically menstrual-like or heavier bleeding for the first week.
6.2 Cramping
Cramping usually starts within the first few hours and may begin as early as 30 min after misoprostol administration. The pain may be stronger than that experienced during a regular period and can be present in 80%-90% of women. Non-steroidal anti-inflammatory drugs (Ibuprofen (Motrin) is recommended) can be used for pain relief without affecting the success of the method.
6.3 Fever and chills
Chills are a common side effect of misoprostol but are transient. Fever does not necessarily indicate infection. An antipyretic can be used for relief of fever. Ibuprofen (Motrin) is effective in this case, too.
6.4 Nausea and vomiting
About 20% of women report pregnancy-related nausea and vomiting before treatment. These symptoms may increase after misoprostol administration. An anti-emetic (Metoclopramide (Reglan) is recommended) can be used if needed, but symptoms will usually resolve within 2 to 6 hours.
6.5 Diarrhea
Diarrhea may also occur following administration of misoprostol but should resolve within a day.
6.6 Fetal abnormalities
The risk of fetal abnormalities after misoprostol used early in pregnancy is probably very low, but women who do not abort after misoprostol, should have access to surgical abortion, if that is the woman's informed choice. Vacuum aspiration is the recommended option.
7. Follow-up
For those women who have not aborted within 72h after the last dose there is the option of a second course of misoprostol treatment or surgical abortion. It should be mentioned that the chances of success of the second course is around one in three.
Ultrasound is highly recommended to check the result of medical abortion.
Discussed topics:
abortion options; medical abortion; early abortion; abortion procedure; abortion alternatives.
