Medical Abortion

Basics

Description

Medical abortion is induced termination of an early pregnancy (generally up to 63 days gestation) by use of medications.
The FDA has approved a combination of two medications; mifepristone (RU-486) an antiprogesterone and a prostaglandin, which are given in succession to interfere with development of the fetus and to expel the products of conception (POC), respectively.
Methotrexate was used in medical protocols before mifepristone and remains a useful medication when ectopic pregnancy is possible. Misoprostol (prostaglandin analogue) alone is used in some areas for termination as well as for management of incomplete/missed abortion.
Women may prefer medical abortion if they desire to avoid surgery, considering it to be a more natural and private process compared with surgical abortion.

Epidemiology

Incidence

There are 62 million women of reproductive age, and 6.4 million pregnancies per year in the United States. Of these, 48% are unintended.
40% of unintended pregnancies end in termination.
The overall rate of abortion is declining (falling 13%, from 23 per 100 pregnancies in 2008 to 21 per 100 pregnancies in 2011).
There are about 1.2 million abortions in the United States annually, of which about 16% are medical abortions. The proportion of abortions by medical means is increasing.
States have varying regulatory requirements regarding preprocedure ultrasound, mandatory waiting periods between patient counseling and the abortion, and the need for parental involvement when minors seek abortion.

Diagnosis

History

Careful, nonjudgmental assessment of a woman 's thoughts and feelings about her pregnancy is the starting point for all subsequent counseling regarding options for the pregnancy. A medical abortion can be an elective and therapeutic treatment for a woman with an unwanted or nonviable pregnancy.
It is important to establish a definite date of last menstrual period (LMP), if possible, to determine eligibility for the procedure. Additional history should be taken to assist in assessment of the possibility of an ectopic pregnancy. Mifepristone is ineffective for ectopic pregnancy.
Determine any exposures from LMP to current date (alcohol, substance abuse, NSAID or aspirin use, etc.).
A willingness to undergo a surgical abortion if necessary is required for consent to medical abortion.

Physical Exam

A thorough pelvic exam including bimanual should be done to assess the size and position of the uterus, as well as for adnexal tenderness and masses. STD testing should be performed.

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

Pregnancy testing by either urine or serum hCG is standard. Decision to obtain quantitative versus qualitative hCG may be influenced by plans for postprocedure confirmation of effectiveness (see "Follow-up Tests & Special Considerations " ).
STD testing
Dating of pregnancy is important to ensure that gestational age (GA) falls within defined medication protocols. GA must be confirmed by either certain LMP (the woman has regular cycles and is certain of the first day of her last normal period) and concordant bimanual examination or by 1st trimester dating ultrasound. Ultrasound is also useful in confirming an intrauterine pregnancy (IUP), as ectopic pregnancy cannot be managed with the standard medical abortion protocol.
Maternal Rh status should be checked. Rh-negative women usually receive anti-D immunoglobulin to avoid possible alloimmunization. Because fetal blood volume is so small at GAs eligible for medication abortion, some protocols choose not to test for Rh.
In a patient with suspected anemia, a baseline hemoglobin/hematocrit is indicated, as moderate to heavy vaginal bleeding can be expected with normal medical abortion.

Follow-up tests & special considerations

Pregnancy diagnosed by qualitative hCG will require follow-up ultrasound to confirm complete abortion.
Successful termination of a pregnancy diagnosed by quantitative hCG can be monitored by observation of appropriate downward trend in hCG levels following the abortion. hCG should fall by at least 50% in 48 " 72 hours following misoprostol use and by 80% at 6 " 14 days postmisoprostol.
Failure of hCG to decline by >50% in 48 " 72 hours should prompt consideration of failed termination (either IUP or ectopic pregnancy).

Treatment

General Measures

The FDA has approved mifepristone and misoprostol given in combination to induce abortion.
Mifepristone is an antiprogestin causing decidual necrosis, cervical softening, and increased uterine contractility.
Misoprostol is a prostaglandin E1 analog causing uterine contractions and opening of cervix.
The original FDA-approved regimen and newer, alternatively developed "evidence-based regimens " differ in dose, route, timing, and range of GA.
Evidence-based protocols have been found to be as efficacious as FDA protocol, with the benefit of decreased side effect profiles and cost.
Contraindications include confirmed or suspected ectopic pregnancy, IUD in place, current long-term systemic corticosteroid use, chronic adrenal failure, known coagulopathy, current anticoagulant therapy, and allergy to mifepristone or misoprostol. Severe anemia is a relative contraindication.

Medication

First Line

Evidence-based regimen: mifepristone 200 mg PO followed by misoprostol 800 ธg vaginally, buccal, or sublingually 6 " 72 hours later (1)[A],(2)[A]
Completion rates of 95 " 99%
Misoprostol may be given vaginally as early as 6 hours after mifepristone with no decrease in efficacy and has lower side effect profile when given earlier (3)[A].
Due to a cluster of cases involving toxic shock syndrome due to the organism Clostridium sordellii that was hypothesized to be related to vaginally administered misoprostol, many clinic protocols now recommend buccal administration over vaginal (see "Complications " ) (4).
Patients can safely administer misoprostol at home at a convenient time within the given time frames mentioned earlier.
Some protocols coadminister methotrexate 50 mg/m2 IM with mifepristone in very early gestations when ectopic pregnancy remains a consideration.
NSAIDs for pain control and antiemetics can be safely used with medical abortion.

Second Line

FDA-approved regimen: mifepristone 600 mg PO followed by misoprostol 400 ธg PO 48 hours later
Completion rates of ~92% up to 49 days GA, rates higher with earlier GA (5)
Misoprostol may be used alone to induce abortion if mifepristone unavailable; however, much less effective this way (~85% success rate).
Methotrexate IM or vaginally followed by misoprostol as alternative, although rarely used in United States and with lower rates of expulsion than earlier methods

Issues for Referral

Excessive bleeding (saturation of ≥2 pads/hour for ≥2 hours) is uncommon but requires prompt evaluation for possible aspiration/surgical abortion procedure.
Women may need emergency surgical care or may require a surgical termination in the event of a continued pregnancy due to potential teratogenicity of misoprostol. A willingness to undergo a surgical abortion if necessary is required for consent to medical abortion.
Clinicians providing medical abortion should be trained in or able to refer to a clinician who can provide aspiration abortion.

Additional Therapies

Pain management is important. NSAIDs are appropriate first-line treatment and do not interfere with the action of exogenous prostaglandins. Some patients may require additional pain control from a small quantity of oral opioid.
There is no strong evidence to support use of prophylactic antibiotics.

Ongoing Care

Follow-up Recommendations

Patient should be evaluated within 2 weeks of medication administration to assess for symptoms of successful termination, or earlier (within days), if there is any initial consideration of an ectopic pregnancy.
A history of several hours of severe cramping accompanied by heavy bleeding that decreased after passage of what appeared to be tissue is highly suggestive of a complete abortion. A firm, involuted uterus on pelvic exam also supports complete abortion. Symptoms of pregnancy (nausea, breast tenderness) disappear rapidly following successful termination.
Ultrasound is often performed to confirm that POC have passed, although it may not be necessary if patient and clinician are confident in the history. In cases where ultrasonography is unavailable, often, serial quantitative hCG monitoring is done to ensure appropriate fall (see "Follow-Up Tests & Special Considerations " ).
If gestational sac and persistent cardiac activity on ultrasound, reasonable alternatives include expectant management, additional dose of misoprostol, or surgical aspiration. If cardiac activity persists after second dose of misoprostol, surgical evacuation should be performed.
Although most women report relief following successful abortion, abortion can sometimes be both a physically and psychologically difficult experience. Websites and hotlines exist to provide support for the immediate and remote postabortion time period.

Patient Education

Nausea, vomiting, diarrhea, headache, and chills are commonly experienced and should be expected. Fewer GI side effects occur when misoprostol is administered vaginally.
Heavy bleeding and cramping much heavier than with normal menses are to be expected.
Patients should be counseled to call provider if they experience soaking of two maxipads per hour for 2 consecutive hours.
Mean duration of bleeding is 8 " 17 days but may persist for more than a month. Bleeding should decrease over time; otherwise, consider retained POC as cause for bleeding.
After induced abortion, ovulation resumes within weeks and another pregnancy could result prior to resumption of normal menses. A contraception plan should be discussed with the patient at initial or follow-up visit.

Prognosis

<1% of women undergoing medical abortion prior to 63 days ' GA will have an ongoing pregnancy.
<5% of women undergoing evidence-based medical abortion regimen will require a surgical evacuation at any point.

Complications

Incomplete abortion (2 " 8%)
Heavy bleeding requiring emergent curettage or blood transfusion is extremely rare but more common with later GA.
Infection is extremely rare. Monitor for fever, prolonged bleeding, and persistent abdominal pain. However, low-grade fever is common with misoprostol in absence of infection.
C. sordellii is an extremely rare (<1/100 000 cases of medical abortion) but potentially fatal cause of sepsis associated with childbirth, abortion, and gynecologic procedures (4). No specific correlation to abortion has been found. Patients present with flulike symptoms, leukocytosis, hemoconcentration, tachycardia, and generally lack fever or findings on pelvic exam.

References

1.Kulier R, Kapp N, G ผlmezoglu AM, et al. Medical methods for first trimester abortion. Cochrane Database Syst Rev. 2011;(11):CD002855. doi:10.1002/14651858.
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2.von Hertzen H, Huong NT, Piaggio G, et al. Misoprostol dose and route after mifepristone for early medical abortion: a randomized controlled noninferiority trial. WHO Research Group on Postovulatory Methods of Fertility Regulation. BJOG. 2010;117(10):1186 " 1196.
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3.Creinin MD, Fox MC, Teal S, et al. A randomized comparison of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. MOD Study Trial Group. Obstet Gynecol. 2004;103(5 Pt 1):851 " 859.
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4.Meites E, Zane S, Gould C, et al. Fatal Clostridium sordellii infections after medical abortions. N Engl J Med. 2010;363(14):1382 " 1383.
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5.Spitz IM, Bardin CW, Benton L, et al. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med. 1998;338(18):1241 " 1247.
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Additional Reading

American College of Obstetricians and Gynecologists. Practice Bulletin no. 143: medical management of first-trimester abortion. Obstet Gynecol. 2014;123(3):676 " 692.
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Cleland K, Creinin MD, Nucatola D, et al. Significant adverse events and outcomes after medical abortion. Obstet Gynecol. 2013;121(1):166 " 171.
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Luise C, Jermy K, Collons WP, et al. Expectant management of incomplete, spontaneous first-trimester miscarriage: outcome according to initial ultrasound criteria and value of follow-up visits. Ultrasound Obstet Gynecol. 2002;19(6):580 " 582.
Raymond EG, Shannon C, Weaver MA, et al. First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review. Contraception. 2013;87(1):26 " 37.
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Codes

ICD09

635.90 Legally induced abortion, without mention of complication, unspecified
635.91 Legally induced abortion, without mention of complication, incomplete
635.92 Legally induced abortion, without mention of complication, complete
632 Missed abortion

ICD10

Z33.2 Encounter for elective termination of pregnancy
O04.80 (Induced) termination of pregnancy with unsp complications
O03.4 Incomplete spontaneous abortion without complication
O02.1 Missed abortion

SNOMED

285409006 Medical termination of pregnancy (procedure)
267193004 Incomplete legal abortion (disorder)
16607004 Missed abortion (disorder)

Clinical Pearls

Medical abortion is a highly effective and safe method to terminate pregnancy that is preferred by some women over a surgical procedure.
Various medication regimens exist, with the "evidence-based " regimens of mifepristone and misoprostol having equal success rates and lower side effect rates in comparison to the FDA protocol, up to 63 days ' GA.
Women should expect bleeding and cramping, heavier than normal menses, which lasts an average of 8 " 17 days.
Women must be willing to undergo, and the clinician must be able to refer for, a surgical evacuation if the abortion fails. This is rarely needed.

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