**3. Medical abortion beyond 63 days gestation**

Late first trimester and second trimester medical termination of pregnancy is more challenging than early first trimester medical abortion and should only take place in an inpatient setting, either in a hospital, or in a day clinic that can stay open for extended hours. Although second trimester termination by D&E can take place in a day-surgery clinic in a shorter time, and has been shown to have a lower complication rate than medical abortion (Bryant et al., 2011}, there are many institutions that do not have the facilities, specialised equipment, or staff with the required expertise to offer a D&E service. Medical termination can be performed with a lower level of staff training. The mifepristone and misoprostol combination is the method of choice, but where mifepristone is not available induction with misoprostol alone can be used. Messenger in

#### **3.1 Induction with mifepristone and misoprostol**

The priming dose of mifepristone is one 200 mg tablet administered orally 48 hours before admission for misoprostol induction. If the woman is nauseous an anti-emetic should be administered first. Hou et al., (2010) have compared one and two day intervals and have determined that a 2-day mifepristone–misoprostol interval resulted in fewer incomplete abortions than a 1-day interval for second trimester termination of pregnancy. Misoprostol historically has been administered vaginally in the second trimester, but a meta-analysis of published randomised controlled trials that compared sublingual and vaginal routes concluded that the sublingual route shortened the induction-foetal expulsion interval and was the route preferred among women and staff (Cabrera et al., 2011). No statistically significant differences between treatment groups were observed for placental retention or for side effect except for fever, which was more common in the vaginal group; the preferred route is therefore sublingual. Brouns et al., (2010) have compared misoprostol 200 mcg or 400 mcg given at 4 hour intervals, with a maximum of 10 administrations in 48 hours, until the foetus was delivered. They found that both regimens were equally effective, but the time to delivery of the foetus was significantly longer in the 200 mcg group; they concluded that the misoprostol 400 mcg four-hourly regimen is the one of choice.

#### **3.2 Induction with misoprostol alone**

Where mifepristone is not available misoprostol alone can be used. Cheng et al., (2010) have reported a 100% success rate in gestation up to 25 weeks with a regimen of oral misoprostol given in a dose of 200 mcg hourly for the first 12 hours and 400 mcg hourly after 12 hours

Medical and Surgical Induced Abortion 109

operation the same day as the initial consultation. Therefore only women whose residence is a long distance from the clinic are scheduled for same day surgery. All other women are seen at a clinic consultation on a day prior to their surgery and given a misoprostol tablet to take home and use 3 hours before their operation appointment. Satisfactory cervical priming is achieved in first trimester gestations up to 9 weeks gestation with one misoprostol 200 mcg tablet taken orally. The oral route is preferred to minimise side effects occurring before the woman arrives for surgery, distressing cramping being more likely to occur with the

Chambers et al., (2009) surveyed the number of women making either a phone or an attendance contact with pain and bleeding after surgical termination of a first trimester pregnancy following four different regimens. The first regimen included no misoprostol priming, in the second regimen oral misoprostol 200 mcg was administered 30 minutes preoperatively, in the third regimen sublingual misoprostol 200 mcg was administered 30 minutes preoperatively, and in the fourth regimen oral misoprostol 200 mcg was administered 3 hours preoperatively. All women receiving preoperative misoprostol also were administered misoprostol 200 mcg vaginally at the end of the operation. Figure 1 shows the results of the survey: each new regimen led to an approximate halving of the number of women making contact with symptoms of retained products of conception.

The results of a survey (Chambers et al., 2009) of side effects occurring in 1,000 women taking one oral tablet of misoprostol 200 mcg at home 3 hours before surgery are shown in

Fig. 2. Side effects in 1,000 women taking one misoprostol 200µg tablet orally 3 hours before

The only significant side effect was mild cramping in 52.2% of women. Mild nausea was reported in 28.3% of women, but this was difficult to separate from pregnancy morning sickness. If the operator wishes to avoid mechanical dilatation completely then a higher dose of misoprostol should be used; 2 or 3 misoprostol 200 mcg tablets sublingually can be

sublingual, buccal or vaginal route (Aronsson et al., 2004).

Figure 2.

surgery (Chambers et al., 2009).

until delivery. The median induction to delivery interval was 12.0 hours, with a range of 6.3 to 30.9 hours. Delivery occurred within 24 hours in 81.3% of women. The median dosage of misoprostol was 2,600 mcg (13 misoprostol 200 mcg tablets). The most common side effect was diarrhoea which was easily relieved by medication.

#### **3.3 Complications of medical abortion**

The three main complications of second trimester medical abortion are placental retention, infection and haemorrhage. A large retrospective study of misoprostol induced terminations by Green et al., (2007) reported that the retained placenta rate needing surgical intervention was 6%; in 59% of women the placenta was expelled naturally within one hour of the delivery of the foetus, and expectant management did not increase the haemorrhage rate. In another large retrospective study by Ashok et al., (2004) the infection rate was 2.6% and the haemorrhage requiring transfusion rate was less than 1%. Lavoué et al., (2011) have performed a retrospective study of a medical abortion series at 12 to 14 weeks gestations and reported that the secondary manual revision or vacuum aspiration rate was 41%. Bryant et al., (2011) have compared the complication rates of medical and surgical termination of second trimester pregnancies for foetal anomalies or foetal death. In this retrospective cohort study they found that labour-induction abortions had higher complication rates and lower effectiveness than did D&E. They reported that 24% of women undergoing labour induction experienced one or more complications, in contrast to 3% undergoing D&E. They concluded that D&E is significantly safer and more effective than labour induction for second-trimester abortion for foetal indications and women should be offered a choice of method.
