Medical abortion

Medical abortion
Background
Abortion type Medical
First use United States 1979 (carboprost),
West Germany 1981 (sulprostone),
Japan 1984 (gemeprost),
France 1988 (mifepristone),
United States 1988 (misoprostol)
Gestation 3–24+ weeks
Usage
France 58% (2013)
Sweden 88% (2014)
UK: Eng. & Wales 51% (2014)
UK: Scotland 80% (2014)
United States 23% (2011)
Infobox references

A medical abortion is a type of non-surgical abortion in which abortifacient pharmaceutical drugs are used to induce abortion. An oral preparation for medical abortion is commonly referred to as an abortion pill.

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)[1] in the 1980s.[2][3][4]

Medical uses

According to the 2006 WHO Frequently asked clinical questions about medical abortion, regarding factors that should be taken into account when counseling a woman about her choice between medical and surgical abortion:[5]

There is little, if any, difference between medical and surgical abortion in terms of safety and efficacy. Thus, both methods are similar from a medical point of view and there are only very few situations where a recommendation for one or the other method for medical reasons can be given.

Medical abortion may be preferred:
  • if it is the woman’s preference;
  • in very early gestation; up to 49 days of gestation, medical abortion is considered to be more effective than surgical abortion, especially when clinical practice does not include detailed inspection of aspirated tissue;
  • if the woman is severely obese (body mass index greater than 30) but does not have other cardiovascular risk factors, as surgical treatment may be technically more difficult;
  • if the woman has uterine malformations or a fibroid uterus, or has previously had cervical surgery (which may make surgical abortion technically more difficult);
  • if the woman wants to avoid a surgical intervention.

Surgical abortion may be preferred:

  • if it is the woman’s preference, or if she requests concurrent sterilization;
  • if she has contraindications to medical abortion;
  • if time or geographical constraints preclude the follow-up needed to confirm that abortion is complete.

Side effects

According to Women on Web, a telemedicine support service for women around the world who are seeking medical abortions:[6]

If performed in the first 9 weeks, a medical abortion carries a very small risk of complications. This risk is the same as when a woman has a miscarriage. A doctor can easily treat these problems. Out of every 100 women who do medical abortion, 2 or 3 women will have to go to a doctor, first aid center or hospital to receive further medical care.[7]

A table in the 2010 Handbook of Obstetric and Gynecologic Emergencies, 4th edition lists these possible complications of medical and surgical abortion:[8]

Although medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different.[9] 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.[9][10] 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.[9]

Since 2001, ten women—one in Canada,[11] eight in the United States,[12][13][14] one in Portugal[15]—have died from clostridial toxic shock syndrome (nine from Clostridium sordellii,[11][12][13][14] one from Clostridium perfringens[13]) following early medical abortions using 200 mg mifepristone orally followed by 800 mcg misoprostol—nine vaginally,[11][12][13][14][15] one buccally[13]—without prophylactic antibiotics.

A retrospective study published in The New England Journal of Medicine in July 2009 of 227,823 women who underwent medical abortion at Planned Parenthood affiliate centers from January 2005 through June 2008, found that the rate of serious infection after medical abortion declined by 93% after a change from vaginal to buccal administration of misoprostol combined with the routine prophylactic administration of doxycycline antibiotics.[16]

Contraindications

According to the 2006 WHO Frequently asked clinical questions about medical abortion:[5]

There are very few absolute contraindications to medical abortion. They include:
  • previous allergic reaction to one of the drugs involved;
  • inherited porphyria;
  • chronic adrenal failure;
  • known or suspected ectopic pregnancy.

Caution is required in a range of circumstances including:

  • if the woman is on long-term corticosteroid therapy (including those with severe, uncontrolled asthma);
  • if she has a hemorrhagic disorder;
  • if she has severe anemia;
  • if she has pre-existing heart disease or cardiovascular risk factors (e.g. hypertension and smoking).

Management of prolonged bleeding

According to the 2006 WHO Frequently asked clinical questions about medical abortion,[5] vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion, but in individual cases spotting can last up to 45 days. 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.

Methods

There are three methods for medical abortion: the drug mifepristone followed by misoprostol, methotrexate followed by misoprostol, and misoprostol alone. The World Health Organization (WHO) recommends an evidence-based mifepristone-misoprostol combination regimen for medical abortion; where mifepristone is not available it recommends a misoprostol-only regimen.[17][18] A methotrexate-misoprostol regimen can also be used;[19] however, because methotrexate may be teratogenic to the fetus in cases of incomplete abortion, the WHO does not recommend a methotrexate-misoprostol combination regimen for medical abortion.[17][18] Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens.[3] Mifepristone–misoprostol and methotrexate–misoprostol combination regimens are more effective than misoprostol alone.[3]

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;[4] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.[20]

The early first-trimester medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of buccal misoprostol) currently used by Planned Parenthood clinics in the United States since April 2006 is 98.3% effective through 59 days gestation.[21]

A 2011 systematic review found that it was simpler and equally safe to administer mifepristone in clinic and have the pregnant woman later take misoprostol at home as it was to administer both drugs in the clinic.[22]

Cost

In the United States in 2009, the median price charged for a medical abortion up to 9 weeks gestation was $490, four percent higher than the $470 median price charged for a surgical abortion at 10 weeks gestation.[23] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.[24]

In April 2013, the Australian government commenced an evaluation process to decide whether to list the 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.[25]

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 terminations early in pregnancies consistent with the recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC). These listings on the PBS occurred on 1 August 2013.

Prevalence

Medical abortions as a percentage of all abortions
Country Percentage
Netherlands 12% in 2008[26]
Spain 17% in 2014[27]
Belgium 22% in 2011[28]
Germany 22% in 2015[29]
United States 23% in 2011[30]
England and Wales 51% in 2014[31]
Iceland 55% in 2013[32]
France 58% in 2013[33]
Denmark 63% in 2013[32]
Switzerland 70% in 2014[34]
Scotland 80% in 2014[35]
Norway 86% in 2015[36]
Sweden 88% in 2014[37]
Finland 95% in 2014[38]

A Guttmacher Institute survey of abortion providers estimated that early medical abortions accounted for 23% of all nonhospital abortions and 36% of abortions before 9 weeks gestation in the United States in 2011;[30][39] medical abortions accounted for 32% of first trimester abortions at Planned Parenthood clinics in the United States in 2008.[16]

References

  1. ↑ Rowan, Andrea (2015). "Prosecuting Women for Self-Inducing Abortion: Counterproductive and Lacking Compassion". Guttmacher Policy Review 18 (3): 70–76. Retrieved 12 October 2015.
  2. ↑ Kulier, Regina; Kapp, Nathalie; Gülmezoglu, A. Metin; Hofmeyr, G. Justus; Cheng, Linan; Campana, Aldo (November 9, 2011). "Medical methods for first trimester abortion". Cochrane Database of Systematic Reviews (11): CD002855. doi:10.1002/14651858.CD002855.pub4. PMID 22071804.
  3. 1 2 3 Creinin, Mitchell D.; Danielsson, Kristina Gemzell (2009). "Medical abortion in early pregnancy". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 111–134. ISBN 1-4051-7696-2.
  4. 1 2 Kapp, Nathalie; von Hertzen, Helena (2009). "Medical methods to induce abortion in the second trimester". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 1-4051-7696-2.
  5. 1 2 3 International Consensus Conference on Non-surgical (Medical) Abortion in Early First Trimester on Issues Related to Regimens and Service Delivery (2006). Frequently asked clinical questions about medical abortion (PDF). Geneva: World Health Organization. ISBN 92-4-159484-5.
  6. ↑ Bazelon, Emily (August 28, 2014). "The dawn of the post-clinic abortion". The New York Times Magazine.
  7. ↑ Women on Web (2014). "How do you know if you have complications and what should you do?". Amsterdam: Women on Web.
  8. ↑ Botha, Rosanne L.; Bednarek, Paula H.; Kaunitz, Andrew M.; Edelman, Alison B. (2010). "Chapter 18. Complications of medical and surgical abortion". In Benrubi, Guy I. (ed.). Handbook of obstetric and gynecologic emergencies (4th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 258. ISBN 1-60547-666-8. Table 18.1 Possible complications of surgical and medical abortion.
  9. 1 2 3 Kerns, Jennifer; Steinauer, Jody (March 2013). "Management of postabortion hemorrhage: release date November 2012 SFP (Society of Family Planning) Guideline #20131". Contraception 87 (3): 331–342. doi:10.1016/j.contraception.2012.10.024. PMID 23218863.
  10. ↑ Ulmann, André; Silvestre, Louise; Chemama, Laurence; Rezvani, Yvonne; Renault, Marguerite; Aguillaume, Claude J.; Baulieu, Étienne-Émile (May 1992). "Medical termination of early pregnancy with mifepristone (RU 486) followed by a prostaglandin analogue. Study in 16,369 women". Acta Obstetricia et Gynecologica Scandinavica 71 (4): 278–283. doi:10.3109/00016349209021052. PMID 1322621.
  11. 1 2 3 Sinave, Christian; Le Templier, Geneviève; Blouin, Daniel; Léveillé, François; Deland, Éric (December 1, 2002). "Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease" (PDF). Clinical Infectious Diseases 35 (11): 1441–1443. doi:10.1086/344464. PMID 12439811.
  12. 1 2 3 Fischer, Marc; Bhatnagar, Julu; Guarner, Jeannette; Reagan, Sarah; Hacker, Jill K.; Van Meter, Sharon H.; Poukens, Vadims; Whiteman, David B.; Iton, Anthony; Cheung, Michele; Dassey, David E.; Shieh, Wun-Ju; Zaki, Sherif R. (December 1, 2005). "Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion". New England Journal of Medicine 353 (1): 2352–2360. doi:10.1056/NEJMoa051620. PMID 16319384.
  13. 1 2 3 4 5 Cohen, Adam L.; Bhatnagar, Julu; Reagan, Sarah; Zane, Suzanne B.; D'Angeli, Marisa A.; Fischer, Marc; Killgore, George; Kwan-Gett, Tao Sheng; Blossom, David B.; Shieh, Wun-Ju; Guarner, Jeannette; Jernigan, John; Duchin, Jeffrey S.; Zaki, Sherif R.; McDonald, L. Clifford (November 2007). "Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion". Obstetrics & Gynecology 110 (5): 1027–1033. doi:10.1097/01.AOG.0000287291.19230.ba. PMID 17978116.
  14. 1 2 3 Meites, Elissa; Zane, Suzanne; Gould, Carolyn; C. sordellii investigators (September 30, 2010). "Fatal Clostridium sordellii infections after medical abortions". New England Journal of Medicine 363 (14): 1382–1383. doi:10.1056/NEJMc1001014. PMID 20879895.
  15. 1 2 Reis, T.; Chaves, C.; Soares, A.; Moreira, M.; Boaventura, L.; Ribeiro, G. (May 2011). "A Clostridium sordellii fatal toxic shock syndrome post-medical-abortion in Portugal (Abstract number R2542)". Clinical Microbiology and Infection 17 (Suppl s4): S761. doi:10.1111/j.1469-0691.2011.03559.x.
  16. 1 2 Fjerstad, Mary; Trussell, James; Sivin, Irving; Lichtenberg, E. Steve; Cullins, Vanessa (July 9, 2009). "Rates of serious infection after changes in regimens for medical abortion" (PDF). New England Journal of Medicine 361 (2): 145–151. doi:10.1056/NEJMoa0809146. PMC 3568698. PMID 19587339.
    Allday, Erin (July 9, 2009). "Change cuts infections linked to abortion pill". San Francisco Chronicle. p. A1.
  17. 1 2 WHO Department of Reproductive Health and Research (2012). Safe abortion: technical and policy guidance for health systems (PDF) (2nd ed.). Geneva: World Health Organization. pp. 1–9, 46. ISBN 978-92-4-154843-4.
  18. 1 2 Dunn, Shelia; Cook, Rebecca (January 7, 2014). "Medical abortion in Canada: behind the times". CMAJ: Canadian Medical Association Journal 186 (1): 13–14. doi:10.1503/cmaj.131320. PMID 24277708.
  19. ↑ http://www.webmd.com/women/methotrexate-and-misoprostol-for-abortion
  20. ↑ Hammond, Cassing; Chasen, Stephen T. (2009). "Dilation and evacuation". In Paul, Maureen; Lichtenberg, E. Steve; Borgatta, Lynn; Grimes, David A.; Stubblefield, Phillip G.; Creinin, Mitchell D. (eds.). Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 1-4051-7696-2.
  21. ↑ Fjerstad, Mary; Sivin, Irving; Lichtenberg, E. Steve; Trussell, James; Cleland, Kelly; Cullins, Vanessa (September 2009). "Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days". Contraception. 80 (3): 282–286. doi:10.1016/j.contraception.2009.03.010. PMC 3766037. PMID 19698822.
    The medical abortion regimen (200 mg of oral mifepristone, followed 24–48 hours later by 800 mcg of vaginal misoprostol) previously used by Planned Parenthood clinics in the United States from 2001 to March 2006 was 98.5% effective through 63 days gestation—with an ongoing pregnancy rate of about 0.5%, and an additional 1% of patients having uterine evacuation for various reasons, including problematic bleeding, persistent gestational sac, clinician judgment or patient request.
  22. ↑ Ngo, Thoai D.; Park, Min Hae; Shakur, Haleema; Free, Caroline (2011). "Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review". Bulletin of the World Health Organization 89 (5): 360–370. doi:10.2471/BLT.10.084046. PMC 3089386. PMID 21556304.
  23. ↑ Jones, Rachel K.; Kooistra, Kathryn (March 2011). "Abortion incidence and access to services in the United States, 2008" (PDF). Perspectives on Sexual and Reproductive Health 43 (1): 41–50. doi:10.1363/4304111. PMID 21388504.
    Stein, Rob (January 11, 2011). "Decline in U.S. abortion rate stalls". The Washington Post. p. A3.
  24. ↑ Jones, Rachel K.; Finer, Lawrence B.; Singh, Shusheela (May 4, 2010). "Characteristics of U.S. abortion patients, 2008" (PDF). New York: Guttmacher Institute.
    Mathews, Anna Wilde (May 4, 2010). "Most women pay for their own abortions". The Wall Street Journal (online).
  25. ↑ Peterson, Kerry (30 April 2013). "Abortion drugs closer to being subsidised but some states still lag". The Conversation Australia. The Conversation Media Group. Retrieved April 29, 2013.
  26. ↑ Kruijer, Hans; Lee, Laura; Wijsen, Ciel (December 2009). "Landelijke Abortus Registratie 2008 (National Abortion Registration 2008)" (PDF). Utrecht: Rutgers Nisso Group, Netherlands.
  27. ↑ . (December 22, 2015). "Interrupción Voluntaria del Embarazo; Datos definitivos correspondientes al año 2014 (Voluntary interruption of pregnancy; final data for 2014" (PDF). Madrid: Ministerio de Sanidad, Politica Social e Igualdad (Ministry of Health and Social Policy). Table G.15: 16,375 (sum of the greater of mifepristone or prostaglandin abortions by gestation period) / 94,796 (total abortions) = 17.3%.
  28. ↑ Commission Nationale d'Evaluation des Interruptions de Grossesse (August 27, 2012). "Rapport Bisannuel 2010-2011". Brussels: Commission Nationale d'Evaluation des Interruptions de Grossesse. prostaglandin 0.40% + mifepristone 21.23% = 21.63% medical abortions
  29. ↑ . (March 9, 2016). "Schwangerschaftsabbrüche 2015 (Abortions 2015)" (PDF). Wiesbaden: Statistisches Bundesamt (Federal Statistical Office), Germany. 18.644% mifepristone + 3.024% other medical = 21.668% medical abortions
  30. 1 2 Jones, Rachel K.; Jerman, Jenna (March 2014). "Abortion incidence and service availability in the United States, 2011" (PDF). Perspectives on Sexual and Reproductive Health 46 (1): 3–14. doi:10.1363/46e0414. PMID 24494995.
    98% of nonhospital medical abortions used mifepristone and misoprostol—2% used methotrexate and misoprostol, or misoprostol alone—in the United States in 2011.
  31. ↑ . (June 9, 2015). "Abortion statistics, England and Wales: 2014" (PDF). London: Department of Health, United Kingdom.
    Medical abortion was the most common method used in abortions before 7 weeks gestation—and accounted for 62% of abortions before 9 weeks gestation—in England and Wales in 2014.
  32. 1 2 Heino, Anna; Gissler, Mika (March 26, 2015). "Pohjoismaiset raskaudenkeskeytykset 2013 (Induced abortions in the Nordic countries 2013)" (PDF). Helsinki: Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland. Appendix table 6. Drug-induced abortions in Nordic countries 1993–2013, %
  33. ↑ Vilain, Annick; Mouquet, Marie-Claude (July 9, 2015). "Les interruptions volontaires de grossesse en 2013 (Voluntary terminations of pregnancies in 2013)" (PDF). Paris: DREES (Direction de la Recherche, des Études, de l'Évaluation et des Statistiques), Ministère de la Santé (Ministry of Health), France.
  34. ↑ . (June 16, 2015). "Interruptions de grossesse en Suisse en 2014 (Abortions in Switzerland 2014)". Neuchâtel: Office of Federal Statistics, Switzerland.
  35. ↑ . (May 16, 2015). "Abortion statistics, year ending 31 December 2014" (PDF). Edinburgh: Information Services Division (ISD), NHS National Services Scotland.
    Medical abortions accounted for 88% of abortions before 9 weeks gestation in Scotland in 2014.
  36. ↑ Løkeland, Mette; Akerkar, Rupali; Askeland, Olaug Margrete; Bøyum, Bjug; Ebbing, Marta; Mjaatvedt, Aase Gunn; Pedersen, Yngve; Seliussen, Ingvei (March 16, 2016). "Rapport om svangerskapsavbrot for 2015 (Report on pregnancy terminations for 2015)" (PDF). Oslo: Divisjon for epidemiologi (Division of Epidemiology), Nasjonalt Folkehelseinstitutt (Norwegian Institute of Public Health), Norway.
    Medical abortions accounted for 89% of abortions before 9 weeks gestation in Norway in 2015.
  37. ↑ Öman, Maria; Lundqvist, Ellen; Gottvall, Karin (September 4, 2015). "Abortstatistik 2014 – Statistics on induced abortions 2014" (PDF). Stockholm: Socialstyrelsen (National Board of Health and Welfare), Sweden.
    Medical abortions accounted for 92% of abortions before 9 weeks gestation in Sweden in 2014.
  38. ↑ Heino, Anna; Gissler, Mika (October 30, 2015). "Raskaudenkeskeytykset 2014 (Induced abortions 2014)" (PDF). Helsinki: Suomen virallinen tilasto (Official Statistics of Finland), Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland.
  39. ↑ Pazol, Karen; Creanga, Andreea A.; Burley, Kim D.; Jamieson, Denise J. (November 28, 2014). "Abortion Surveillance — United States, 2011" (PDF). MMWR Surveillance Summaries 63 (11): 1–41. PMID 25426741.
    Medical abortions accounted for 20.0% of abortions—and 28.5% of abortions before 9 weeks gestation—in the United States in 2011 that were voluntarily reported to the CDC by 40 reporting areas (excluding Alabama, Arizona, California, Florida, Hawaii, Illinois, Louisiana, Maryland, New Hampshire, Tennessee, Vermont, Wisconsin, and Wyoming).

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