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
Medical abortions as a percentage of all abortions
France 64% (2016)
Sweden 92% (2016)
UK: Eng. & Wales 62% (2016)
UK: Scotland 83% (2016)
United States 30% (2014)
Infobox references

A medical abortion, also known as medication abortion, is a type of non-surgical abortion in which medication is used to bring about 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 WHO in 2006 a number of factors should be taken into account when counseling a woman.[5] Safety and effectiveness is similar between medical and surgical abortions.[5]

Medical abortions may be the first choice if:[5]

  • That is what a woman chooses
  • It is undertaken in the first 50 days of pregnancy
  • The woman's body mass index is greater than 30 (obese) and she is free from other cardiovascular risk factors
  • There are structural problems with the uterus

Surgical abortion may be the first choice if:[5]

  • That is what a woman chooses
  • The woman has asked for sterilization at the same time
  • Any of the contraindications listed below are present
  • The necessary follow-up to medical abortion is difficult

Side effects

When performed early the risk of complications is low and no different than that of a miscarriage. Per 100 women around 3 will need medical care.[6]

Possible complications of medical and surgical abortion include:[7]

  • Medical abortion
    • Hemorrhage
    • Incomplete abortion
    • Uterine or pelvic infection
    • Ongoing intrauterine pregnancy, requiring a surgical abortion for completion
    • Misdiagnosed/unrecognized ectopic pregnancy
  • Surgical abortion
    • Hemorrhage
    • Incomplete abortion
    • Uterine or pelvic infection
    • Ongoing intrauterine pregnancy, requiring a second procedure
    • Misdiagnosed/unrecognized ectopic pregnancy
    • Hematometra (blood clots accumulating in the uterus)
    • Uterine perforation
    • Cervical laceration

Although medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different.[8] 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.[8][9] 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.[8]

Cases of deaths from clostridial toxic shock syndrome have occurred following medical abortions.[10]

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.[11]

Contraindications

Contraindications to a medical abortion may include:[12]

  • previous allergic reaction to one of the drugs involved;
  • inherited porphyria;
  • chronic adrenal failure;
  • ectopic pregnancy

Caution is required in a range of circumstances including:

Management of prolonged bleeding

According to the 2006 WHO Frequently asked clinical questions about medical abortion,[12] 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.[13][14] A methotrexate-misoprostol regimen can also be used;[15] 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.[13][14] 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.[16]

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.[17]

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.[18]

Prevalence

Medical abortions as a percentage of all abortions
CountryPercentage
Italy17% in 2015[19]
Spain19% in 2015[20]
Belgium22% in 2011[21]
Netherlands22% in 2015[22]
Germany23% in 2016[23]
United States30% in 2014[24]
England and Wales62% in 2016[25]
France64% in 2016[26]
Iceland67% in 2015[27]
Denmark70% in 2015[27]
Portugal71% in 2015[28]
Switzerland72% in 2016[29]
Scotland83% in 2016[30]
Norway87% in 2016[31]
Sweden92% in 2016[32]
Finland96% in 2015[33]

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.[24][34]

At Planned Parenthood clinics in the United States, medical abortions accounted for 32% of first trimester abortions in 2008,[11] 35% of all abortions in 2010 and 43% of all abortions in 2014.[35]

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.[36] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.[37]

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.[38]

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.

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. 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. Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 1-4051-7696-2.
  5. 1 2 3 4 Organization, World Health (2006). Frequently Asked Clinical Questions about Medical Abortion. World Health Organization. p. 3. ISBN 9789241594844.
  6. ↑ Women on Web (2014). "How do you know if you have complications and what should you do?". Amsterdam: Women on Web.
  7. ↑ 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. 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.
  8. 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.
  9. ↑ 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.
  10. ↑ Beal, MW (2007). "Update on medication abortion". Journal of Midwifery & Women's Health. 52 (1): 23–30. doi:10.1016/j.jmwh.2006.10.006. PMID 17207747.
  11. 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.
  12. 1 2 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.
  13. 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.
  14. 1 2 Dunn, Shelia; Cook, Rebecca (January 7, 2014). "Medical abortion in Canada: behind the times". Canadian Medical Association Journal. 186 (1): 13–14. doi:10.1503/cmaj.131320. PMC 3883814. PMID 24277708.
  15. ↑ http://www.webmd.com/women/methotrexate-and-misoprostol-for-abortion
  16. ↑ 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. Management of unintended and abnormal pregnancy : comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 1-4051-7696-2.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ . (December 15, 2016). "Relazione Ministro Salute attuazione Legge 194/78 tutela sociale maternità e interruzione volontaria di gravidanza - dati definitivi 2014 e 2015 [Ministry of Health report implementation Act 194/78 social protection maternity and voluntary interruption of pregnancy - definitive data 2014 and 2015]". Rome: Ministero della Salute [Ministry of Health]. Table 25 - IVG and type of intervention, 2015: mifepristone + mifepristone+prostaglandin + prostaglandin = 17%.
  20. ↑ . (December 30, 2016). "Interrupción Voluntaria del Embarazo; Datos definitivos correspondientes al año 2015 (Voluntary interruption of pregnancy; final data for 2015" (PDF). Madrid: Ministerio de Sanidad, Politica Social e Igualdad (Ministry of Health and Social Policy). Table G.15: 17,916 (sum of the greater of mifepristone or prostaglandin abortions by gestation period) / 94,188 (total abortions) = 19.0%.
  21. ↑ 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
  22. ↑ . (February 9, 2017). "Jaarrapportage 2015 van de Wet afbreking zwangerschap [Annual Report 2015 of the Discontinuation of Pregnancy Act]". Utrecht, Netherlands: Inspectie voor de Gezondheidszorg (IGZ) [Health Care Inspectorate], Ministerie van Volksgezondheid, Welzijn en Sport (VWS) [Ministry of Health, Welfare and Sport].
  23. ↑ . (March 9, 2017). "Schwangerschaftsabbrüche 2016 (Abortions 2016)" (PDF). Wiesbaden: Statistisches Bundesamt (Federal Statistical Office), Germany. 20.237% Mifegyne + 3.021% Medikamentöser Abbruch = 23.257% medical abortions
  24. 1 2 Jones, Rachel K.; Jerman, Jenna (January 17, 2017). "Abortion incidence and service availability in the United States, 2014". Perspectives on Sexual and Reproductive Health. 49 (1): 17–27. doi:10.1363/psrh.12015. PMC 5487028. PMID 28094905.
    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.
  25. ↑ . (May 30, 2017). "Abortion statistics, England and Wales: 2016" (PDF). London: Department of Health, United Kingdom.
    Medical abortion accounted for 72% of abortions under 10 weeks' gestation—in England and Wales in 2016.
  26. ↑ Vilain, Annick (June 26, 2017). "211 900 interruptions volontaires de grossesse en 2016 (211,900 voluntary terminations of pregnancies in 2016)" (PDF). Paris: DREES (Direction de la Recherche, des Études, de l'Évaluation et des Statistiques), Ministère de la Santé (Ministry of Health), France.
  27. 1 2 Heino, Anna; Gissler, Mika (March 7, 2017). "Pohjoismaiset raskaudenkeskeytykset 2015 (Induced abortions in the Nordic countries 2015)" (PDF). Helsinki: Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland. ISSN 1798-0887. Appendix table 6. Drug-induced abortions in Nordic countries 1993–2015, %
  28. ↑ . (September 20, 2016). "Relatório dos Registos das Interrupções da Gravidez - Dados de 2015 [Report of the Interruptions of Pregnancy - Data of 2015]". Lisbon: Divisão de Saúde Sexual, Reprodutiva, Infantil e Juvenil [Division of Sexual, Reproductive, Child and Juvenile Health], Direção de Serviços de Prevenção da Doença e Promoção da Saúde [Directorate of Disease Prevention and Health Promotion Services], Direção-Geral da Saúde (DGS) [Directorate-General for Health].
  29. ↑ . (June 13, 2017). "Interruptions de grossesse en Suisse en 2016 (Abortions in Switzerland 2016)". Neuchâtel: Office of Federal Statistics, Switzerland.
  30. ↑ . (May 30, 2017). "Termination of pregnancy statistics, year ending December 2016" (PDF). Edinburgh: Information Services Division (ISD), NHS National Services Scotland.
    Medical abortions accounted for 89% of abortions before 9 weeks' gestation in Scotland in 2016.
  31. ↑ Løkeland, Mette; Mjaatvedt, Aase Gunn; Akerkar, Rupali; Pedersen, Yngve; Bøyum, Bjug; Hornæs, Mona Tornensis; Seliussen, Ingvei; Ebbing, Marta (March 8, 2017). "Rapport om svangerskapsavbrot for 2016 (Report on pregnancy terminations for 2016)" (PDF). Oslo: Divisjon for epidemiologi (Division of Epidemiology), Nasjonalt Folkehelseinstitutt (Norwegian Institute of Public Health), Norway. ISSN 1891-6392.
    Medical abortions accounted for 90% of abortions before 9 weeks' gestation in Norway in 2016.
  32. ↑ Öman, Maria; Gottvall, Karin (May 10, 2017). "Statistik om aborter 2016 (Statistics on abortions in 2016)" (PDF). Stockholm: Socialstyrelsen (National Board of Health and Welfare), Sweden.
    Medical abortions accounted for 94% of abortions before 9 weeks' gestation in Sweden in 2016.
  33. ↑ Heino, Anna; Gissler, Mika (October 20, 2016). "Raskaudenkeskeytykset 2015 (Induced abortions 2015)" (PDF). Helsinki: Suomen virallinen tilasto (Official Statistics of Finland), Terveyden ja hyvinvoinnin laitos (National Institute for Health and Welfare), Finland.
  34. ↑ Jatlaoui, Tara C.; Ewing, Alexander; Mandel1, Michele G.; Simmons, Katharine B.; Suchdev, Danielle B.; Jamieson, Denise J.; Pazol, Karen (November 25, 2016). "Abortion Surveillance — United States, 2013" (PDF). MMWR Surveillance Summaries. 65 (12): 1–44. doi:10.15585/mmwr.ss6512a1. PMID 27880751.
    Medical abortions accounted for 22.2% of abortions—and 32.8% of abortions at ≤8 weeks' gestation—in the United States in 2013 that were voluntarily reported to the CDC by 43 reporting areas (excluding California, Florida, Hawaii, Illinois, Louisiana, Maryland, New Hampshire, Tennessee, and Wyoming).
  35. ↑ Mindock, Clark (31 October 2016). "Abortion Pill Statistics: Medication Pregnancy Termination Rivals Surgery Rates In The United States". International Business Times. Retrieved 19 April 2018.
  36. ↑ 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.
  37. ↑ 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.
  38. ↑ 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.
  • WHO Scientific Group on Medical Methods for Termination of Pregnancy (December 1997). Medical methods for termination of pregnancy. Technical Report Series, No. 871. Geneva: World Health Organization. ISBN 92-4-120871-6. WARNING: LINK GIVES ONLY THE FIRST PAGE OF THE REPORT; THE REST IS LISTED AS "OUT OF PRINT"
  • Royal College of Obstetricians and Gynaecologists (November 23, 2011). The care of women requesting induced abortion. Evidence-based clinical guideline number 7 (PDF) (3rd rev. ed.). London: RCOG Press. Archived from the original (PDF) on May 29, 2012.
  • ICMA (2013). "ICMA Information Package on Medical Abortion". Chișinău, Moldova: International Consortium for Medical Abortion (ICMA). Archived from the original on July 10, 2010.
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