**2.3 Induction with mifepristone and misoprostol**

The initial medication is one oral tablet of mifepristone 200 mg. It has been shown that increasing the dosage of mifepristone beyond this level markedly increases the cost with no additional benefit in outcomes (Shannon et al., 2005). The optimal time interval before the administration of misoprostol 800 µg is 48 hours. My personal experience of over 2000 women with the use of a 48 hour interval is a success rate of 99.9%. Ashok et al (1998) reported a success rate of 99.4% in 2000 women. Alternatives to the 48 hour interval are immediate with no interval, or a 24-36 hour interval; although the success rates for these are lower they are still in the high nineties (Goel et al., 2011). The highest success rates for stimulating expulsive uterine contractions are with the woman, after washing her hands and wetting the tablets with a quick dip in water, inserting the four misoprostol 200 mcg tablets vaginally. An alternative route of administration is bucally with a success rate almost as high. The misoprostol may be administered by the woman in the clinic or at home, providing there is no legal restriction of this. Prospective cohort studies have shown no difference in effectiveness of acceptability between home-based and clinic based medical abortion across countries (Ngo et al., 2011). It has been demonstrated that early firsttrimester abortion provided by certified nurses and auxiliary nurse midwives is as safe and effective as that provided by doctors (Warriner et al., 2011). Women should be provided with strong analgesic tablets to use, commencing with the first dose one hour before the administration of misoprostol. I have found that adding a home dosage of one sublingual misoprostol 200 mcg tablet three times a day on the two days following the initial misoprostol dose reduces the incidence of surgical intervention for complications.

Follow up two weeks later is essential to exclude the rare event of a continuing pregnancy. Grossman and Grindlay (2011) have reviewed the various alternatives to ultrasound and concluded that the most promising modalities include serum hCG measurement (a fall of at least 50%), standardised assessment of women's symptoms, low-sensitivity urine pregnancy testing and telephone consultation. Although ultrasound reliably detects the removal of a previously detected gestation sac, it has been shown to be unreliable in determining completion or otherwise of the abortion process, the serum hCG level being a more reliable indicator of the amount of any retained tissue. The commonest complication of medical abortion is retained products of conception causing prolonged bleeding. Published D&C

Medical and Surgical Induced Abortion 107

given at doses of 200 mcg/hr for the first 12 hours and 400 mcg/hr after 12hours until delivery; the most common side effect was diarrhoea, which was easily relieved by medication. This paper illustrates the safety of higher doses of misoprostol than previously used, with a much higher success rate that should be replicable in the first trimester. Whenever misoprostol is used it is essential that women are warned of the possible adverse consequences for the foetus of deciding to continue the pregnancy after already commencing misoprostol. Barbero et al., (2011) have reported that they have found a significant association between prenatal exposure to misoprostol and the occurrence of

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

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

fewer

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

major congenital anomalies.

misoprostol alone can be used.

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

**3.1 Induction with mifepristone and misoprostol** 

the misoprostol 400 mcg four-hourly regimen is the one of choice.

**3.2 Induction with misoprostol alone** 

rates for retained products vary from 0.9% (Clark et al., 2010) to 18.9% (Odeh et al., 2010) and 25.3% (Liao et al., 2010). These wide variations reflect the varying sensitivity thresholds of clinicians for diagnosing the need for surgical intervention. The highest figure is from China where the authors state that post-abortion curettage would be performed if the client continues to have vaginal bleeding 2 weeks after administration of mifepristone; this figure corresponds with my experience that approximately 25% of women are still bleeding at 2 weeks. The lower figure corresponds with my experience that most women with retained products will settle if given more time, surgery being reserved for persistent heavy bleeding. Although bleeding ceases in the majority of women in less than two weeks, some women will bleed for up to four weeks. Further treatment with misoprostol is a reasonable option for persistent or heavy bleeding, its efficacy having been shown in treating retained products following spontaneous miscarriage (Bui, 2011) and in retained products following surgical termination of pregnancy (Chambers & Mulligan, 2009). Using my experience of treating retained products of conception following surgical abortion with misoprostol the effective dosage has been determined as being four misoprostol 200 mcg tablets vaginally or buccally followed by two tablets sublingually or buccally four times a day for the next two days. Lower doses are ineffective, the non-pregnant uterus being much less responsive to misoprostol than the pregnant uterus, and the woman can be reassured that even this much higher dosage will not result in strong cramping pains.

The convenience of medical abortion has to be balanced against a higher complication rate than surgical abortion. Ninimäki et al., (2009) reported on the comparative complication rates in two cohorts of over 20,000 women each in Finland and found that the overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort, 20.0% compared with 5.6%.; haemorrhage 15.6% compared with 2.1%, incomplete abortion 6.7% compared with 1.6%, surgical (re)evacuation 5.9% compared with 1.8%.There was no difference in infection rates, both being 1.7%. Operative complications occurred in 0.03% of medical and 0.6% of surgical cohorts. In a smaller South Australian study of women requiring hospital treatment for complications Mulligan & Messenger (2011) concluded that complication rates of early medical abortion compared favourably to early surgical abortion: haemorrhage 0.5% medical compared with 0.03% surgical, and admission for sepsis 0.2% medical compared with 0.06% surgical. It is noteworthy that no prophylactic antibiotics were used in either the medical or surgical cohorts in this study. Whilst doxycycline antibiotic infection prophylaxis is commonly used, Achilles & Reeves (2011) note that the universal requirement for such treatment has not been established, and Fjerstad et al., (2011) conclude there is no evidence that it offers any benefit, a finding that I concur with (Chambers et al.,2009).

#### **2.4 Induction with misoprostol alone**

When the cost of mifepristone which is up to 100 times that of misoprostol, precludes its use, misoprostol alone in the single dosage of 800 mcg vaginally has been widely used. Prasad et al., (2008) reported a complete abortion rate of 94.2% with this method. However Salakos et al., (2008) reported a success rate of only 85.2% with the same single dose method. Fekih et al., (2010) used a regimen of sublingual misoprostol 800mcg four hourly to a maximum of three doses with a success rate of 92.1%. Cheng et al., (2010) have reported a 100% success rate in terminating second trimester pregnancies with oral misoprostol alone

rates for retained products vary from 0.9% (Clark et al., 2010) to 18.9% (Odeh et al., 2010) and 25.3% (Liao et al., 2010). These wide variations reflect the varying sensitivity thresholds of clinicians for diagnosing the need for surgical intervention. The highest figure is from China where the authors state that post-abortion curettage would be performed if the client continues to have vaginal bleeding 2 weeks after administration of mifepristone; this figure corresponds with my experience that approximately 25% of women are still bleeding at 2 weeks. The lower figure corresponds with my experience that most women with retained products will settle if given more time, surgery being reserved for persistent heavy bleeding. Although bleeding ceases in the majority of women in less than two weeks, some women will bleed for up to four weeks. Further treatment with misoprostol is a reasonable option for persistent or heavy bleeding, its efficacy having been shown in treating retained products following spontaneous miscarriage (Bui, 2011) and in retained products following surgical termination of pregnancy (Chambers & Mulligan, 2009). Using my experience of treating retained products of conception following surgical abortion with misoprostol the effective dosage has been determined as being four misoprostol 200 mcg tablets vaginally or buccally followed by two tablets sublingually or buccally four times a day for the next two days. Lower doses are ineffective, the non-pregnant uterus being much less responsive to misoprostol than the pregnant uterus, and the woman can be reassured that even this much

The convenience of medical abortion has to be balanced against a higher complication rate than surgical abortion. Ninimäki et al., (2009) reported on the comparative complication rates in two cohorts of over 20,000 women each in Finland and found that the overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort, 20.0% compared with 5.6%.; haemorrhage 15.6% compared with 2.1%, incomplete abortion 6.7% compared with 1.6%, surgical (re)evacuation 5.9% compared with 1.8%.There was no difference in infection rates, both being 1.7%. Operative complications occurred in 0.03% of medical and 0.6% of surgical cohorts. In a smaller South Australian study of women requiring hospital treatment for complications Mulligan & Messenger (2011) concluded that complication rates of early medical abortion compared favourably to early surgical abortion: haemorrhage 0.5% medical compared with 0.03% surgical, and admission for sepsis 0.2% medical compared with 0.06% surgical. It is noteworthy that no prophylactic antibiotics were used in either the medical or surgical cohorts in this study. Whilst doxycycline antibiotic infection prophylaxis is commonly used, Achilles & Reeves (2011) note that the universal requirement for such treatment has not been established, and Fjerstad et al., (2011) conclude there is no evidence that it offers any benefit, a finding that I

When the cost of mifepristone which is up to 100 times that of misoprostol, precludes its use, misoprostol alone in the single dosage of 800 mcg vaginally has been widely used. Prasad et al., (2008) reported a complete abortion rate of 94.2% with this method. However Salakos et al., (2008) reported a success rate of only 85.2% with the same single dose method. Fekih et al., (2010) used a regimen of sublingual misoprostol 800mcg four hourly to a maximum of three doses with a success rate of 92.1%. Cheng et al., (2010) have reported a 100% success rate in terminating second trimester pregnancies with oral misoprostol alone

higher dosage will not result in strong cramping pains.

concur with (Chambers et al.,2009).

**2.4 Induction with misoprostol alone** 

given at doses of 200 mcg/hr for the first 12 hours and 400 mcg/hr after 12hours until delivery; the most common side effect was diarrhoea, which was easily relieved by medication. This paper illustrates the safety of higher doses of misoprostol than previously used, with a much higher success rate that should be replicable in the first trimester. Whenever misoprostol is used it is essential that women are warned of the possible adverse consequences for the foetus of deciding to continue the pregnancy after already commencing misoprostol. Barbero et al., (2011) have reported that they have found a significant association between prenatal exposure to misoprostol and the occurrence of major congenital anomalies.
