**2. Medical abortion to 63 days gestation**

Medical abortion has several advantages over surgical abortion in that the overall cost is usually lower, medical staff with surgical skills are not required, and in terminations below 9 weeks gestation no hospital admission is required. Medical abortion virtually eliminates the risks of surgery and anaesthesia, and allows more flexible timing, with out-patient treatment, and the convenience of completion in the home environment; also women feel more in control and many feel that an induced miscarriage is a more natural process. Disadvantages of medical compared with surgical abortion are a higher failure rate, more prolonged bleeding, and a higher risk of retained products of conception complicating recovery.

#### **2.1 Mifepristone and misoprostol**

The gold standard of medical abortion is the combination of mifepristone followed by misoprostol. Mifepristone is a potent antiprogestogen with antiglucocorticoid activity; it acts

et al., 1977). Menstrual regulation continued to be used in government funded clinics in some developing countries where abortion has never been legalised because it occurs technically without verification of the presence of a pregnancy (Dixon-Mueller, 1988). A report on the menstrual regulation policy in Bangladesh states that the provision of menstrual regulation averts unsafe abortion and associated maternal morbidity and mortality, and on a per capita basis, saves scarce health system resources (Johnson et al.,

Son preference and sex-selective abortion is another major problem found in some Asian countries. Zhou et al., (2011) report that in China the sex ratio at birth is 120 male births to 100 females. Jha et al., (2011) estimate that in China selective abortion of girls totalled about

Women worldwide want to control the timing and number of their children, not just for personal and family reasons, but in the interest of being able to provide adequately for a child at the point in time in question. Whilst first trimester abortion is accessible to some degree in most western countries, access to second trimester abortion tends to be very restricted. This is despite there being a constant proportion over the years of approximately 12% of legal abortions occurring after 12 weeks gestation (Gamble et al., 2008), most of these being for psycho-social reasons, and a small but increasing proportion being for suspected or confirmed foetal anomaly. Teenagers in all countries seek abortions later; approximately 30% of abortions in girls under 15 years of age take place in the second trimester (Jones et al., 2002}. This delay is due to teenagers having little or no experience at recognising pregnancy symptoms, a lack of general knowledge, and the problems associated with emotional immaturity. At any age delay in seeking an abortion may be due to periods normally being irregular, bleeding during pregnancy being mistaken for periods, a past history of infertility, menopausal symptoms, having been conscientiously using contraception, ambivalence due to conflicting beliefs, sudden financial stress, breakdown of a relationship, domestic violence, disorganised or chaotic life associated with substance abuse, delaying by medical attendants with mis-diagnosis of the pregnancy, or obstruction

Medical abortion has several advantages over surgical abortion in that the overall cost is usually lower, medical staff with surgical skills are not required, and in terminations below 9 weeks gestation no hospital admission is required. Medical abortion virtually eliminates the risks of surgery and anaesthesia, and allows more flexible timing, with out-patient treatment, and the convenience of completion in the home environment; also women feel more in control and many feel that an induced miscarriage is a more natural process. Disadvantages of medical compared with surgical abortion are a higher failure rate, more prolonged bleeding, and a higher risk of retained products of conception complicating

The gold standard of medical abortion is the combination of mifepristone followed by misoprostol. Mifepristone is a potent antiprogestogen with antiglucocorticoid activity; it acts

2010).

recovery.

4.2 -12.1 million per year from 1980-2010.

by health advisers with anti-abortion views.

**2.1 Mifepristone and misoprostol** 

**2. Medical abortion to 63 days gestation** 

at the level of the progesterone receptor being a competitive progesterone antagonist, and in combination with a prostaglandin is effective for medical abortion at all gestations (Ashok et al., 2002). The effects of mifepristone on the pregnant uterus are induced contractility, decidual necrosis with bleeding (Garfield et al., 1988), and cervical softening. Oral mifepristone achieves peak serum concentrations in pregnant women in 2 hours, with a half life of 24-29 hours (Heikinheimo, 1989). Contraindications to the use of mifepristone are adrenal failure and hereditary porphyria. Misoprostol is a synthetic prostaglandin E1 analog which regulates various immunologic cascades (Davies et al., 2001). It is a potent uterotonic drug, but its use in obstetrics and gynaecology is in all countries apart from France an offlabel use as it is only marketed for the prevention and treatment of peptic ulcer disease. It has been used widely in obstetrics and gynaecology practice because of its effectiveness, low cost, stability in light and hot climate conditions, and ease of administration compared with its licensed counterparts dinoprostone and gemeprost (Song, 2000). Misoprostol is marketed as a 200 mcg tablet that is rapidly absorbed by the vaginal, rectal, oral, sublingual and buccal routes. The sublingual route results in the highest serum peak concentration levels and the highest bioavailability; the vaginal route has the lowest peak concentrations, but the longest duration of peak levels (Tang et al., 2002; 2009). Nevertheless measures of uterine contractility have shown similar effects for both routes (Tang et al., 2007).

Misoprostol has uterotonic and cervical priming actions; its advantage over other prostaglandins is that it is cheap, can be administered through any mucosal surface, can be used by asthmatics, and can be stored at room temperature for years. Misoprostol is a very safe and well tolerated drug. Pre-clinical toxicological studies indicate a safety margin of at least 500-1000 fold between lethal doses in animals and therapeutic doses in humans (Kotsonis et al., 1985). The misoprostol 200 mcg tablet is tolerated even in relatively high dosage; attempted suicide with high single dosage has failed with 30 tablets but succeeded with 60 tablets (Henriques et al., 2007). No clinically significant haematological, endocrine, biochemical, immunological, respiratory, ophthalmic, platelet, or cardiovascular effects have been found with misoprostol; diarrhoea is the major adverse reaction that has been reported consistently with misoprostol, but it is usually mild and self-limiting; nausea and vomiting may also occur and will resolve in 2-6 hours; fever and chills are common with high doses (Tang et al., 2007). Chambers et al., (2009) reported that in 1,000 women taking one misoprostol 200 mcg tablet orally three hours before suction termination of pregnancy the side effects were cramps: mild 52.2%, moderate 4%, severe 0.7%; nausea: mild 28.3%, moderate 4.9%, severe 1.4%; bleeding mild 8.6%, moderate 1.7%, severe 0.1%; diarrhoea: mild 3.8%, moderate 0.2%, severe 0% (Fig. 2).

#### **2.2 Preparation for abortion**

A consultation requirement is the completion of a health check questionnaire by the woman of her present and past medical and surgical history including allergies. A health worker should then interview the woman alone, without the presence of her partner or friends, to determine that her decision to terminate her pregnancy is her own and that she is not being unduly influenced by others. If the health worker feels a woman has not made a clear decision she should be offered an appointment with a counsellor for supportive decision making counselling to assist her to clarify her ambivalence. Specialised genetic counselling should be offered to all women seeking termination of pregnancy (TOP) for foetal anomaly.

Medical and Surgical Induced Abortion 105

globulin in a dose of 50 mcg (250 IU) under 13 weeks and 300 mcg (1500 IU) over 13 weeks (Lubusky et al., 2010). The risk of an ectopic pregnancy should be explained if relevant; pelvic ultrasound examination and repeat quantitative beta-hCG should be ordered if an ectopic pregnancy has not been excluded. Kaneshiro et al., (2011) state that medical abortion can be provided in a safe and effective manner up to 63 days gestation without the routine use of ultrasound. It is important to discuss contraceptive methods that can be offered: a prescription for the oral contraceptive pill; long acting slow release progesterone intrauterine device (IUD) or implant – the latter should be inserted with the misoprostol dose not the mifepristone dose as this reduces the efficacy of the mifepristone (Church et al., 2010). Immediate IUD insertion after abortion has been shown to result in higher rates of IUD use at 6 months than delayed insertion, without an increased risk of complications (Bednarek et al., 2011). It is important to ensure that informed consent is given in writing for

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

all procedures before any treatment is commenced.

**2.3 Induction with mifepristone and misoprostol** 

The different methods of abortion that the clinic can offer are then explained, with the advantages and disadvantages of each method being detailed. It is important to determine the number of weeks' gestation of the woman as medical abortion past 9 weeks (63 days) gestation needs closer medical supervision and it is generally considered that it is not good practice to terminate these pregnancies on an out-patient basis. Bracken et al., (2011) have shown that reliance on a woman's report of her last menstrual period together with a bimanual pelvic examination is almost as accurate as ultrasound examination and therefore safe in determining eligibility for medical abortion at home.

The dosage regimens of the drugs to be used should be explained along with the clinic attendances that will be required. Bleeding with the passage of clots, and cramping of variable intensity, will occur as the expulsion of the pregnancy from the uterus occurs, usually 2-4 hours after the initial dose of misoprostol. Strong analgesic drugs including codeine, tramadol and ibuprofen should be prescribed to ease the severity of the cramping pains; antiemetic metoclopramide tablets should also be prescribed. Bleeding may continue for up to 2 weeks, and occasionally up to 4 weeks. Possible side effects of nausea, vomiting, diarrhoea, chills or mild fever are discussed. The risk of birth defects if the woman decides to continue the pregnancy after taking the abortion drugs should be emphasised. The possible complications of retained products of conception, heavy bleeding, infection and continuing pregnancy should be discussed. An emergency 24 hour contact number should be given for the woman to seek help if bleeding is heavier than soaking a pad an hour for 2 hours or if there is a persistent temperature over 380C. Blood testing for blood group, haemoglobin and quantitative beta-human chorionic gonadotrophin (hCG} should be performed. Medical abortion is contraindicated if the haemoglobin level is less than 9.5 g/dl. Previous caesarean section operations are not a contraindication; the incidence of caesarean scar rupture from misoprostol uterine contraction stimulation is extremely low. Explain that Rh(D) negative women with no anti-D antibodies will need anti-D immune Bleeding

The different methods of abortion that the clinic can offer are then explained, with the advantages and disadvantages of each method being detailed. It is important to determine the number of weeks' gestation of the woman as medical abortion past 9 weeks (63 days) gestation needs closer medical supervision and it is generally considered that it is not good practice to terminate these pregnancies on an out-patient basis. Bracken et al., (2011) have shown that reliance on a woman's report of her last menstrual period together with a bimanual pelvic examination is almost as accurate as ultrasound examination and therefore

Fig. 1. The percentage of all women making contact by phone or attendance with pain and

The dosage regimens of the drugs to be used should be explained along with the clinic attendances that will be required. Bleeding with the passage of clots, and cramping of variable intensity, will occur as the expulsion of the pregnancy from the uterus occurs, usually 2-4 hours after the initial dose of misoprostol. Strong analgesic drugs including codeine, tramadol and ibuprofen should be prescribed to ease the severity of the cramping pains; antiemetic metoclopramide tablets should also be prescribed. Bleeding may continue for up to 2 weeks, and occasionally up to 4 weeks. Possible side effects of nausea, vomiting, diarrhoea, chills or mild fever are discussed. The risk of birth defects if the woman decides to continue the pregnancy after taking the abortion drugs should be emphasised. The possible complications of retained products of conception, heavy bleeding, infection and continuing pregnancy should be discussed. An emergency 24 hour contact number should be given for the woman to seek help if bleeding is heavier than soaking a pad an hour for 2 hours or if there is a persistent temperature over 380C. Blood testing for blood group, haemoglobin and quantitative beta-human chorionic gonadotrophin (hCG} should be performed. Medical abortion is contraindicated if the haemoglobin level is less than 9.5 g/dl. Previous caesarean section operations are not a contraindication; the incidence of caesarean scar rupture from misoprostol uterine contraction stimulation is extremely low. Explain that Rh(D) negative women with no anti-D antibodies will need anti-D immune

bleeding following first trimester surgical termination of pregnancy with varying

misoprostol single 200mcg tablet regimens (Chambers et al., 2009).

safe in determining eligibility for medical abortion at home.

globulin in a dose of 50 mcg (250 IU) under 13 weeks and 300 mcg (1500 IU) over 13 weeks

(Lubusky et al., 2010). The risk of an ectopic pregnancy should be explained if relevant; pelvic ultrasound examination and repeat quantitative beta-hCG should be ordered if an ectopic pregnancy has not been excluded. Kaneshiro et al., (2011) state that medical abortion can be provided in a safe and effective manner up to 63 days gestation without the routine use of ultrasound. It is important to discuss contraceptive methods that can be offered: a prescription for the oral contraceptive pill; long acting slow release progesterone intrauterine device (IUD) or implant – the latter should be inserted with the misoprostol dose not the mifepristone dose as this reduces the efficacy of the mifepristone (Church et al., 2010). Immediate IUD insertion after abortion has been shown to result in higher rates of IUD use at 6 months than delayed insertion, without an increased risk of complications (Bednarek et al., 2011). It is important to ensure that informed consent is given in writing for all procedures before any treatment is commenced.
