Chinese draft guidelines of medical abortion stipulate that mifepristone may be used to t e r m i n a t e pregnancies of 49days gestation or less and is available to women aged 18-40 years, regardless of their marital status. They also recommend medical abortion to women who may be ill-suited for, or uncomfortable with, surgical abortion.

Table 2.6.1

Four different mifepristone regimens are available in single dose or sequential doses. Pharmacokinetic studies have shown that 150 mg mifepristone given in multiple doses is more effective. Patients can also choose single dose 200 mg mifepristone. Single dose administration is much easier and most of the clinics use single dose.

The most widely-used regimen entails four sequential doses of mifepristone over 2 days. (50 mg mifepristone early on Day 1 followed 8-12 hrs later by an additional 25 mg mifepristone, same dosage schedule on Day 2).

There are certain problems with draft guidelines for early medical abortion:

1. While screening women for medical abortion by certified providers, general and gynaecological examination is done to ensure a normal pregnancy. Ultrasound scan to rule out ectopic pregnancy is not available at all clinics. Some private clinics only perform urine pregnancy test.

2. The draft guidelines indicate that misoprostol should be administered in the clinic. Following ingestion of the PG, medical professionals who have undergone some training in medical abortion observe the woman for 6 hours or until 1 hour after expulsion of the products of conception. One study showed that 95.5% of clinics in Beijing, compared to 55.6% in Hunan required women to stay on site for the specified six hours of observation (Wu et al
1999). The problem of a long observation period leads to staff and space constraints. Outcome of medical abortion is expressed as complete, incomplete or failed abortion.

3. Evaluation criteria for complete abortion include expulsion of an intact fetal sac or a partial fetal sac accompanied by an ultrasound documenting an empty uterus, cessation of bleeding without recourse to vacuum aspiration, negative urine HCG test, and uterine size consistent with non-pregnant state. Criteria for incomplete abortion include expulsion of a fetal sac accompanied by prolonged bleeding requiring vacuum aspiration. An abortion is considered failed if no fetal sac is expelled during the 8 days following mifepristone, or USG examination confirms a fetal heartbeat or a growing fetus. Premature surgical interventions because of fear of incomplete abortion and bleeding lead to higher surgical intervention rates (15-20%).

4. Recommended follow-up visit after medical abortion is scheduled at 1 and 6 weeks but the follow-up rate is very low.

5. Referral system has not been well-established. Subjects often have problems seeking a doctor because of heavy or prolonged bleeding.

6. Medical abortion services are out of control in some areas.

a. It is easy to get mifepristone at pharmacy
b. Some clinics provide services without certification (>80%, Hunan).
c. Advertisements provide inaccurate information (70-80%).

7. There is inadequate monitoring of adverse events and formal reporting of serious adverse events is rare. Providers should remain alert for allergic shock, heavy bleeding requiring blood transfusion, laceration of cervix, infection and death from undiagnosed ectopic pregnancy (3 cases reported till now).