Transcript Medical Abortion

Medication Abortion
Dr. Sasan Zaeri
(PharmD, PhD)
Department of Pharmacology
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What is medication abortion?
Medication abortion, also known as non-aspiration or
non-surgical abortion, refers to a family of safe and
effective methods for terminating an early unwanted
pregnancy.
Through the use of a drug or combination of drugs that
are administered orally, vaginally, and/or
intramuscularly, medication abortion first causes the
pregnancy to terminate and then causes the uterus to
expel the products of conception
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Why “medication abortion”?
Non-aspiration or non-surgical abortion is commonly
referred to as “medical abortion”. However, this phrase
has led to confusion among both providers and the
public, as the term “medical” is often associated with
physician-based practices and/or medical necessity.
“Medication abortion” more accurately represents the
family of safe and effective drug-based methods that
can terminate an unwanted pregnancy and will be used
throughout this presentation.
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Methods of medication abortion
Mifepristone
and misoprostol
Methotrexate (MTX) and misoprostol
Misoprostol alone
Medication abortion methods can be used
throughout early pregnancy (≤63 days’
gestation)
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Medication abortion
Mechanisms of action of the medications
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Mifepristone
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Methotrexate
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Anti-progestin that blocks the action of progesterone
Alters the uteral lining
Anti-metabolite
Interferes with DNA synthesis and cell growth
Misoprostol
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Prostaglandin E1 analog
Stimulates uterine contractions and induces cervical
softening
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Medication abortion
Additional uses of the medications
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Mifepristone
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Methotrexate
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Labor induction (under investigation)
Infertility treatment (under investigation)
Treatment of neoplastic diseases
Treatment of rheumatoid arthritis
Misoprostol
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Prevention of NSAID-induced gastric ulcers
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Medication abortion
Dosage forms of the medications
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Mifepristone
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Methotrexate
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Tablet 200 mg (Mifeprex) and 300 mg (Korlym)
Tablet 2.5, 5, 7.5, 10, 15 mg
Injection solution 5 mg/mL
Powder for injection 1 g/vial
Misoprostol

Tablet 100 and 200 µg (Cytotec)
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Mifepristone/misoprostol regimen
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Mifepristone/misoprostol regimen
General protocol
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Day 1 (Clinic)
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Day 1-4 (Home or clinic)
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Mifepristone (100-600 mg) is orally administered
Misoprostol is administered
200-600 µg (oral) or 400-800 µg (vaginal, buccal or
sublingual)
Day 7-14 (Clinic)
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Patient returns to the clinic for follow-up
Clinician assesses for the completion of the abortion
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Mifepristone/misoprostol regimen
Efficacy and safety
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Approximately 95% of women will have a
successful abortion when using
mifepristone/misoprostol within 49 days’ gestation

Completion rates appear to decline slightly with
increasing durations of pregnancy after 56 days’
gestation
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Mifepristone/misoprostol regimen
Efficacy and safety
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Approximately 67% of women will have a complete
abortion within four hours of using misoprostol.

Approximately 90% of women will have a complete
abortion within 24 hours of using misoprostol.
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Mifepristone/misoprostol regimen
Eligibility for use

Non-ectopic pregnancy of ≤63 days’ gestation

Absence of contraindications
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Willingness to undergo vacuum aspiration or
dilation and curettage (D&C), if indicated
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Mifepristone/misoprostol regimen
Contraindications to use
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Confirmed or suspected ectopic (extra-uterine)
pregnancy
Allergy to either mifepristone or misoprostol
Presence of an intrauterine device (IUD)
Chronic systemic use of corticosteroids
Chronic adrenal failure
Coagulopathy or current therapy with anticoagulants
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Mifepristone/misoprostol regimen
Side effects
Effects of abortion process
 Cramping
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Often described as similar to
menstrual cramps
Vaginal bleeding
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Median bleeding time 9-13
days
Often described as similar to
a heavy period or
spontaneous miscarriage
Common side effects
 Nausea
 Vomiting
 Diarrhea
 Headache
 Dizziness
 Fever, chills, hot flashes,
warmth
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Mifepristone/misoprostol regimen
Complications
Type of complication
Continued pregnancy
Incomplete abortion requiring
aspiration
Percentage of women
1%-5%
1%
Hemorrhage requiring
aspiration
1%-2%
Hemorrhage requiring
transfusion
0.1%
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Mifepristone/misoprostol regimen
Summary
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Millions of women worldwide have safely
used mifepristone/misoprostol
Mifepristone/misoprostol is more than 95%
effective in terminating early pregnancies
Mifepristone/misoprostol is widely acceptable
to both patients and providers
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Methotrexate/misoprostol regimen
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Methotrexate/misoprostol regimen
Evidence-based protocol
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Day 1 (Clinic)
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Methotrexate is administered either orally (50 mg) or intramuscularly
(50 mg/m2)
Day 3-7 (Home)
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Misoprostol is self-administered vaginally (800 µg) at home.
Day 8 (Clinic)
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Clinician performs a vaginal ultrasound to determine if the abortion is
complete.
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If abortion is complete (75% of women) no further visits are required.
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If the abortion is incomplete additional misoprostol is given and
patient returns
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On Day 15 if cardiac activity is detected
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On Day 28-45 if no cardiac activity is detected on ultrasound 18
Methotrexate/misoprostol regimen
Evidence-based protocol continued
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Day 15 (Clinic, if necessary)
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Patient is assessed for continued pregnancy.
If cardiac activity is detected, a aspiration termination is
performed.
If no cardiac activity is detected, patient returns in three
weeks.
Day 28-45 (Clinic, if necessary)
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The patient is assessed for continued pregnancy.
If the abortion is incomplete (5% of cases), a aspiration
termination is performed.
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Methotrexate/misoprostol regimen
Efficacy and safety
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Approximately 95% of women will have a complete
abortion when using methotrexate/misoprostol up to
49 days’ gestation.

Medication abortion completion rates decline with
increasing gestational age
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Methotrexate/misoprostol regimen
Eligibility for use

Pregnancy of ≤49 days’ gestation
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Methotrexate/misoprostol is preferable for
women with ectopic pregnancies

Absence of contraindications

Willingness to undergo vacuum aspiration or
dilation and curettage (D&C), if indicated
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Methotrexate/misoprostol regimen
Contraindications to use
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Allergy to either methotrexate or misoprostol
Presence of an intrauterine device (IUD)
Coagulopathy or current severe anemia
Acute or chronic renal or hepatic disease
Acute inflammatory bowel disease
Uncontrolled seizure disorders.
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Methotrexate/misoprostol regimen
Side Effects
Effects of abortion process
 Cramping
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Often described as similar to
menstrual cramps
Vaginal bleeding

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Median bleeding time 2-3
weeks
Often described as similar to
a heavy period or
spontaneous miscarriage
Common side effects
 Nausea
 Vomiting
 Diarrhea
 Headache
 Dizziness
 Fever, chills, hot flashes,
warmth
 Oral ulcers
 Fetal malformations
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Methotrexate/misoprostol regimen
Complications (≤49 days’ gestation)
Type of complication
Percentage of women
Continued pregnancy
3-5%
Incomplete abortion requiring
aspiration
3-5%
Hemorrhage requiring
aspiration
1%-2%
Hemorrhage requiring
transfusion
0.1%-0.5%
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Methotrexate/misoprostol regimen
Summary

Methotrexate/misoprostol is approximately
95% effective in terminating pregnancies ≤49
days’ gestation

Methotrexate/misoprostol is the preferred
medication abortion method for confirmed or
suspected ectopic pregnancies
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Misoprostol-only regimen
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Misoprostol-only regimen
Evidence-based protocols
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No consensus exists on optimal protocol
Various regimens, dosing schedules and
routes of administration are currently under
investigation
Most commonly used protocol
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Vaginal administration of 800 µg of misoprostol
If abortion fails, misoprostol dose is repeated
every 24 hours, up to three doses
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Misoprostol-only regimen
Efficacy and Safety
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Efficacy varies widely (65%-93%)
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Efficacy varies by route of administration,
dose, dosing schedule, and gestational age
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Misoprostol-only regimens are not as
effective as either mifepristone/misoprostol or
methotrexate/misoprostol regimens
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Misoprostol-only regimen
Eligibility for use

Non-ectopic pregnancy of ≤63 days’ gestation

Absence of contraindications
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Willingness to undergo vacuum aspiration or dilation
and curettage (D&C), if indicated
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Lack of access to either mifepristone or methotrexate
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Misoprostol-only regimen
Contraindications for use
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Confirmed or suspected ectopic pregnancy
Allergy to misoprostol
Presence of an intrauterine device (IUD)
Uncontrolled seizure disorder
Inflammatory bowel disease
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Misoprostol-only regimen
Side effects
Effects of abortion process
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Cramping
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Often described as similar to
menstrual cramps
Often described as more severe
than the cramping of either
mifepristone/misoprostol or
methotrexate/misoprostol
regimens
Vaginal bleeding

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Median bleeding time 2 weeks
Often described as similar to a
heavy period or spontaneous
miscarriage
Common side effects
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Nausea

Vomiting
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Diarrhea
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Headache

Dizziness
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Fever and chills
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Rashes
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Pelvic pain
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Misoprostol-only regimen
Complications
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Approximately 10%-35% of women will
require an aspiration intervention
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Misoprostol-only regimen is less effective in
terminating early pregnancy than when used
in combination with either mifepristone or
methotrexate
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Misoprostol-only regimen
Summary
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Misoprostol used in conjunction with either mifepristone or
methotrexate is more effective at terminating early pregnancy than
misoprostol alone
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Efficacy varies widely
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Optimal regimen has yet to be determined
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Misoprostol-only regimen is an important alternative for women
who do not have access to other medical or aspiration abortion
methods
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Medication abortion
Comparing the three regimens
Regimen
Advantages
Disadvantages
Mifepristone/
misoprostol
High efficacy (≈95%)
Can be used through 63 days’ gestation
Abortion typically occurs within hours
of misoprostol administration
Mifepristone is often expensive
Mifepristone is not available in many
countries
Can not be used to treat ectopic pregnancies
Methotrexate/
misoprostol
High efficacy (90%-95%)
Can be used through 56 days’ gestation
Often less expensive than mifepristone
Treats ectopic pregnancies
Abortion can occur over a four week period
May cause fetal abnormalities in continued
pregnancies
Efficacy decreases after 49 days’ gestation
Misoprostol-only
Can be used through 63 days’ gestation
Widely available worldwide
Often very inexpensive
Stable at room temperature
Efficacy is variable (65%-90%)
Regimen is currently under investigation
May cause fetal anomalies in continued
pregnancies
Can not be used to treat ectopic pregnancies
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Medication Abortion in the 2th trimester
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Medication abortion vs. aspiration abortion:
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similar advantages and disadvantages as in early
gestational age
Main medication regimen: High-dose IV oxytocin
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50-300 unit oxytocin in 500 mL NS in 3h followed by 1 h
diuresis without oxytocin
Success rate: 80-90%
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Medication Abortion in the 2th trimesterOther medications used
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Dinoprostone (Prostin E2 ) (PG E2)
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One vaginal suppository (20 mg) (high in vagina)
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More adverse effects than oxytocin
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Nausea, vomiting, fever, diarrhea
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