Background

Medical methods of abortion have great potential to improve women’s health and advance their reproductive rights especially in developing countries where unsafe abortion practices result in serious morbidity and mortality. WHO estimates that, globally, one in eight maternal deaths is due to abortion-related complications, which refers to surgical abortions. In contrast, there have been no serious complications so far reported in women using ifepristone and misoprostol combination for pregnancy termination. To maintain this safety record, however, the introduction of medical abortion into more widespread clinical practice requires continued emphasis on follow-up due to higher failure rates as compared to surgical abortion and to monitor potential side-effects of drugs. Most side-effects are self-limiting but rarely emergency treatment may be necessary to prevent adverse outcome.

QUESTIONS TO BE ANSWERED

VIEWS OF THE GROUP

A. Follow-up Schedule

First Visit (Day1)

Sensitive counseling assumes a larger role in the case of medical abortion because the patient is a more active participant in this abortion process. Counselingand administration of mifepristone is often combined on the first visit. Mifepristone must be administered under the supervision of a physician able to assess the gestational age of a pregnancy and diagnose ectopic pregnancy.

Mifepristone is taken as a single oral dose of 200mg (1 tablet). Rh-negative women may received Anti-D immune globulin on the same day as mifepristone administration because some women (2 to 5%) abort with mifepristone alone.

Nausea and vomiting on day1 may not require any prophylactic antiemetics but metoclopramide or domperidone tablets can be used. Bleeding, spotting, cramping may occur in women who start the process of abortion i.e. expulsion of products of conception.

Second Visit (Day3)

Patients who have been administered mifepristone should be assessed after 36 to 48 hours for the possibility of pregnancy expulsion clinically. Women who have aborted will, probably, have bleeding and cramping. Irrespective of abortion status, 400µg misoprostol (2 tablets, 200µg each) is administered in a single oral/vaginal dose by or under the supervision of the prescribing physician. After misoprostol administration, patients are monitored in the daycare clinic or medical office for about 4 hours or until they are in a stable condition. A few women abort within 1- 2 hours, 57% within 4 hours and 87% within 24 hours of misoprostol administration.

Routine pelvic examination is not required. If vaginal misoprostol is administered, the patient has to lie down for half an hour, otherwise she may remain ambulatory in day care. Oral intake is not restricted. Monitoring of temperature, pulse and blood pressure has to be done along with observation for pain, bleeding, and passage of clots or products during the four hours-waiting period. The patient may also have allergic reaction, chills and rigor, nausea, vomiting, diarrhoea, dizziness and headache. Paracetamol or nonsteroidal anti inflammatory drugs (NSAIDS) can be given for pain relief.

If pain is not relieved by analgesics and not followed by expulsion of products of conception, ectopic gestation should be excluded.

Third Visit (Day 14 – 20)

A follow-up visit any time between 14 and 20 days seems adequate to confirm clinically or by ultrasonography that complete expulsion of the gestational sac has occurred.

If the clinician suspects an ongoing pregnancy, an ultrasonographic examination is necessary to assess gestational cardiac activity. Surgical abortion is recommended if cardiac activity is present.

After expulsion, women bleed for a median of 9 to 13 days. Expectant management of persistent bleeding should always be preferred over surgical intervention. Heavy bleeding, especially if accompanied by bimanual examination finding of an enlarged or tender uterus, should always be evaluated by vaginal ultrasonography.

B. Management of side-effects and complications

1. Pain

Bleeding and cramping pain are the most frequent side-effects, which occur in almost all women. Proper counseling about the abortion process helps the patient to be more tolerant as pain perception is modified by fear, anxiety and emotions. Acetaminophen, ibuprofen, paracetamol alone, or in combination with codeine or oxycodeine, can be used for pain relief.

Failure of a woman’s pain to respond to basic palliative measures and medication for a period of several hours warrants evaluation for ectopic pregnancy, infection or incomplete abortion.

2. Bleeding

Pre-abortion counseling should emphasize that bleeding would be heavier than normal menses and also give information about the passage of fleshy products or clots. A recommended guideline for the woman is to contact the provider if bleeding soaks more than 2 pads per hour for 2 consecutive hours. Less than 1% of women require blood transfusion and emergency curettage each. Duration of bleeding is variable,averaging 9 to13 days and patient should be counseled. Even with relatively long period of bleeding, clinicallysignificant changes in haemoglobin values are rare with medical abortion.

Evaluation of bleeding in emergency
a. Clarify the stage of abortion process including medication details
b. Amount of bleeding i.e. details of pad number/size/soakage/clots
c. Bleeding episodic or continuous
d. Determine the level of activity patient can maintain
e. Whether used any other medication or drugs
f. Symptoms of dizziness, weakness and fatigue. The decision to intervene surgically is usually based on clinical impression

Indications for surgical evacuation
a. Persistent or recurrent heavy bleeding unresponsive to medical measures
b. Signs and symptoms of orthostatic instability
c. A low haemoglobin level (<7gm%), particularly if patient continues to bleed
d. Patient preference for surgical evacuation
e. Difficult for the patient to ‘avail’ emergency services again.

3. Failed/Incomplete abortion

True method failure is defined as the presence of gestational cardiac activity on trans-vaginal ultrasound (TVS) 2 weeks after either mifepristone or methotrexate administration. Surgical evacuation is required in 0.1- 0.5% of patients for incomplete abortion, missed abortion and continuing pregnancy.

Importantly, practitioners need to understand the difference between incomplete abortion and normal course of medical abortion. Heterogeneous intracavitary echoes are seen on ultrasound normally due to presence of blood, blood clots and decidua after expulsion of products. Such patients should be reassured and followed conservatively till they get a normal menstrual period 4-6 weeks later.

4. Gastro-intestinal side-effects

The medications used for medical abortion may cause minor gastro-intestinal symptoms. Nausea is the most frequent symptom, followed less commonly by vomiting or diarrhoea. They are usually self-limiting and resolve without therapy. The side-effects occur due to prostaglandin analogue and increase with the dose and are more with oral than intravaginal administration.

5. Headache, dizziness and thermo regulatory changes

Headache and dizziness are usually mild and selflimiting. Unless dizziness results from excessive bleeding, this symptom is best managed with rest, hydration, slow positional change and assistance with ambulation, if necessary.

Hot flushes and sensations of warmth or fever are also fairly common side-effects of medical abortion. They are usually short-lived and resolve spontaneously. Infection should be suspected if there is continuous fever.

6. Endometritis

Endometritis is a rare complication of medical abortion, which typically involves no instrumentation of cervix or uterine cavity. Any evidence of lower genital tract infection identified at the time of pre-abortion examination should be treated.

Any patient who reports persistent pelvic pain, with or without irregular bleeding or fever, foul smelling discharge and adnexal tenderness in the days after pregnancy expulsion should be evaluated for possible endometritis or incomplete abortion. Either condition might cause the uterus to feel slightly enlarged, softened and tender. USG is a useful adjunct. Infection should be treated with doxycycline and metrogyl. No data exist to support the use of prophylactic antibiotics for medical abortion.

7. Teratogenecity

It is important to counsel about need for surgical abortion if pregnancy continues following medical abortion. No evidence supports the teratogenecity of mifepristone. Methotrexate is an antimetabolite that can cause fetal anomalies when administered in high doses used for chemotherapy, whereas reports with low dose are scanty. Use of misoprostol in first trimester may result in congenital anomalies. The most likely mechanism is mild uterine contractions that result in decreased blood flow during organogenesis.

Goralez et al reported 7 cases of limb anomalies, 4 with the additional diagnosis of Mobius syndrome (mask like facies with ilateral 6th and 8th nerve cranial palsy and frequently coincident micrognathia).

Healthcare providers must counsel women fully regarding the potential teratogenic effects of the drugs and the need for a surgical evacuation in the event of a continuing pregnancy.

C. Contraceptive Counselling

Cafeteria approach can be offered to the patient as soon as it is determined that the pregnancy is terminated.
• Abstinence is preferred or else condoms prior to day 15.
• On follow-up visit at Day 15, patient can be offered barrier contraception, oral pills and injectable DMPA.
• After first menses, IUD insertion or laproscopic tubal ligation can be done. Tubectomy can also be done on day 15 follow-up visit, if one is sure of completeness of abortion.
• Option of Non Scalpel Vasectomy (NSV) is given to all.
• Information about emergency contraception is provided to all abortion seekers to prevent future unwanted pregnancy.

It is very essential to provide post-abortion contraceptive counseling and an effective contraception. After abortion, 75% women ovulate within 20 days and 6% of women conceive within 4-6 weeks unless they use contraception. Counseling regarding the choice of appropriate contraception must be a part of pre and post abortion counseling. Proper counseling prior to MTP persuades 94% of couples to accept contraception following MTP.

The information regarding the mode and duration of action, failure rates, side-effects, return of fertility and cost of therapy as well as the contraception method has to be provided to the couple.

Essential elements of post-abortion care include community and service-provider partnerships, counseling, treatment of unsafe and incomplete abortion, contraceptive and family planning services and other reproductive health services.

D. Unresolved Issues

50 µg Anti-D is not available in India, hence 100 µ infection can be given to Rh-Negative women.