Medical abortions

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Woman at the first month of pregnancy.

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Mifepristone

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A diagram of a vacuum aspiration abortion proc...

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 Using Mifepristone & Misoprostol

Medical abortions in early pregnancy upto 6-7 weeks using mifepristone & Misoprostol is a very good method for the termination of pregnancy , provided the drug is taken after consulting a Dr and emergency facilities for 24 hours are available nearby.
Failure rate is very low.Surgical intervention is also avoided.
In this knol I am discussing advantages , side efects , dosage schedule and regular follow ups after taking these drugs.
Unfortunately they have gone in the hands of quacks , chemists & paramedical staff .They give these drugs without much knowledge and usually give when duration of pregnancy is more than 7 weeks.Patients usually come with incomplete abortions and excessive bleeding blaming the drug which is not true.

Contents

Use of mifepristone and misoprostol for terminating preganacy is recommended upto 6-7 weeks.

Mifepristone or RU-486


The drug was invented in France in 1980. RU means, Roussel-Ulclaf , a Pharmaceutical Company.
Misoprostol is synthetic PGE1 analogue,well absorbed from the gastrointestinal tract and vaginal mucosa.It is having lesser side effects on bronchi and blood vessels.
Mifepristone
Mechanism of action

  • It is a derivative of norethindrone with antiprogestin action.It binds to progesterone receptors at endometrium and decidua resulting in necrosis of placenta.
  • It also softens cervix and causes mild uterine contractions.
  • It sensitizes uterus to prostaglandins , which is given within 1 to 2 days.

Misoprostol


It binds to the myometrial cells causing strong myometrial contractions.It also softens the cervix and dilates it thereby causing expulsion of the conceptus.
Success rate is 95-98% upto 6-7 weeks.
1-2% go under surgical evacuation due to excessive bleeding.Others go because usually the drug is misused
by chemists and quacks.Sometimes they give only misoprostol.or they give after 2 months of pregnancy.
Anms in villages give only vaginal misoprost leading to incomplete abortions or exceesive bleeding.

Advantages

  • Less invasive
  • More privacy
  • No anaesthesia
  • No instrumentation
  • No effect on future fertility.
  • Number of late abortions have decreased due to this drug.

Disadvantages


Bleeding duration is 8 to 15 days.
If fails then chances of congenital malformations are there.
It should be used under MTP act , 1971.Only registered practitioner can prescribe the drug.

Contraindications


  • Anaemia
  • Women on steroids for medical reasons
  • BP >160/100
  • Angina, Valvular disease, Arrythmias
  • Severe renal failure
  • Liver disorders
  • Seizures
  • Respiratory diseases
  • Porphyrias
  • Allergy to prostaglandins
  • Medical abortions should not be performed if there is no 24 hours facility for an emergency.

Cautious use of drugs


  • If there is an IUCD inside the uterus.Remove it before giving the drug therapy.
  • Women having large fibroids , can have excessive bleeding.
  • Uterine scar and previous history of caesarean , hysterotomy and myomectomy then it should be given cautiously.
  • Bronchial asthma
  • Misoprostol is a weak bronchodilator, can be used in asthma cautiously under medical supervision.

Pre abortion Counseling


  • She should come for the regular follow up or three visits.
  • Tell her about the excessive bleeding in some cases and she may require surgical intervention.
  • Side effects should be told to her.
  • Risk of congenital malformations in case the drug fails
  • Easy approach to the hospital and transport facility should be there in case more bleeding is there.

Dosage schedule


First day
200mgm of mifepristone orally in the presence of a health functionary.
2nd visit
2 tablets of misoprostol each containing 200micrograms after 48 hours.
Third visit
To ensure the abortion is complete.
  • Consent form is signed by the patient.
  • Vaginal bleeding usually occurs upto 10 to 15 days.
  • She keeps on doing the card test herself and getting disturbed so she should be told about it.
  • Next menses is usually delayed by 1 to 2 weeks.Till next period it is better to avoid intercourse or use barrier methods.
  • In case of failure suction aspiration is required , she can not continue due to the risk of congenital malformations.
When a patient comes to take a drug

  • History is taken.
  • General examination is done.
  • Haemoglobin is done. Blood pressure is recorded.
  • Cardiovascular & respiratory systems should be examined
  • Rule out ectopic pregnancy
  • Bimanual examination is done to confirm the size of pregnanacy.
  • Pregnancy test is must
  • ABO & Rh grouping is done.If she is Rh-ve , anti -D is given after abortion.
  • Usg in women who are not sure of the dates or conceived during lactational amenorrhoea or recently used OCPs
  • History of bleeding to exclude ectopic.
200 mg of mifepristone orally and 400micrograms of misoprostol orally or vaginally after 48 hours.
If bleeding starts after mifepristione alone then also she has to take the complete course of misoprostol, otherwise it will be an incomplete abortion.
For vaginal use misoprostol must be moistened with a few drops of clean water.
If she stays for 4 hours in the hospital it is better as dr can assure her not to become anxious.If bleeding is more it can be dealt within the hospital.
Drugs for pain relief are given like tramazac or paracetamol
fourth visit 

After 15 days
  • History is taken.
  • Pelvic examination is done.
  • Usg may be required if no history of expulsion is there.
  • Pregnancy test and curettage may be required if incomplete.
Role of  antibiotics

Only in women having vaginal infections and in nulliparous.
Antiemetics and Antidiarrhoeals

Can be given as 12 -40% of women complain of vomiting and diarrhoea.They are self limiting but if required can be given.

Side effects

  • Pain
  • Vomiting
  • Bleeding
  • Nausea
  • Headache
  • Dizziness
  • Fatigue
Proper counseling is required
Contact on telephone number.
24 hors emergency facility must be there.

Failure


Less than 1 %.If fails then surgical intervention is required.
Ectopic pregnancy should always be kept in mind if woman does not expel out the foetus.

What is Heavy bleeding ?

Soaking of 2 pads per hour for 2 hours is okay at the peak time when expulsion occurs.More than this is excessive bleeding which continues upto a week or so at the same rate.
If patient is dizzy she should consult the doctor.

Pain

Abdominal cramps are expected at the time of expulsion.There is fear factor also.Paracetamol can be given
Codeine or oxycodeine can be added according to US protocols.

Fever

Due to prostaglandin analog,.it is short lived and resolves soon without any treatment.

Incomplete abortion

Woman having gestational sac without cardiac activity after 2 weeks of the drug administration are diagnosed as cases of incomplete abortion.They usually expel the conceptus 36 days after the mifepristone dose.
Uterus may contain blood , decidua which appear as hyperechoic tissue on usg.
If there is no excessive bleeding follow the patient conservatively.

Teratogenesis

If she does not abort she should undergo surgical intervention.

Delay in next menses

3 to 6 weeks is the normal duration after abortion.

Contraception

  • Within 15 days of abortion it should be initiated.
  • IUCD after first normal period should be adviced.
  • Barrier methods
  • OCPs
  • Tubal ligation is adviced if she has completed the family.
  • Counseling about prevention of HIV should be done.
  • They shoud be informed about the emergency contraception.

Record keeping

Every hospital or doctor should send the record of the medical abortions to the CMO of the state as per MTP act.
Confidentiality should be maintained.

Reference


Professor sunita mittal

HOD
Director incharge , WHO-CCR in human reproduction
Chief co ordinator , consortium on national consensus for medical abortion in india.
AIIMS
New Delhi

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