|  Women
with fibroid uterus a n d previous caesarean were previously
thought to be contraindications to medical abortion but, lately,
medicalabortion regimens have been used for ermination of
early pregnancy in high surgical risk women (w i t h fibroid,
previous caesarean scar, myomectomy, hysterotomy etc.). Fibroid
uterus is a relatively common entity. It has been computed
that about 30% of all women after the age of 35 years have
myomas. Caesarean section rates are also increasing worldwide.
So, more number of these high surgical risk women would be
approaching for medical abortion.
Medical abortion is a preferred option when:
i) medical condition of woman makes surgical abortion potentially
dangerous; and
ii) surgical abortion is technically difficult as in markedly
enlarged leiomyomatous uterus.
Pregnancy in the scarred uterus is a thorny situation in
daily clinical work, especially in hospitals where caesarean
section rates are increasing. Serious complications such as
placenta praevia and rupture uterus are prone to take place
following conception, and, consequently, vacuum aspiration
procedure with increased death by uterine perforation, serious
haemorrhage and shock.
One such study by Xu et al, 2001 analyzed the safety and
possibility of terminating early pregnancy with mifepristone
and misoprostol upto 49 days of gestation in women with previous
caesarean scar. A total of 192 women with early pregnancy
were recruited, of which 35 cases were with uterine scar and
157 cases with no uterine scar. All of them took 25 mg mifepristone,
b.i.d. for 3 days and 600 µg of misoprostol on the 4th
day. Thirty-three out of 35 cases
with uterine scar achieved complete abortion. Thecomplete
abortion rate was 94.29% in the scar group and 89.81% in the
control group. There were no obvious complications e.g. uterine
rupture, serious haemorrhage and shock in the scar group.
Also, the chances of uterine perforation, cervical laceration
and complications of anaesthesia were reduced by resorting
to non-surgical abortion. There are isolated reports of successful
use of medical abortion even in women with two previous caesarean
scars.
Research needs to be done to study whether uterine scar can
withstand intra-uterine pressure of 49.7 mmHg within 30 minutes
to 2 hours after misoprostol. Larger studies are required
to confirm the acceptability of medical abortion as a routine
method in such situations.
In women with symptomatic larger fibroids encroaching on
the endometrial cavity, there can be heavy bleeding as fibroids
are thought to decrease myometrial contractility.
Successful results of medical abortion in women with fibroids
have been documented in various studies.
(1) Buckshee et al, 1992 reported early pregnancy termination
up to 9 weeks with 25 mg methotrexate in a woman with myoma
of 32 to 34 weeks gestation size.
(2) Creinin et al, 1995 has shown successful medical abortion
of 49 days fundal pregnancy in a woman with multiple myomas,
irregular cavity and history of previous multiple myomectomies
with 104 mg intramuscular methotrexate followed by 800µg
intravaginal misoprostol. Cramping pain appeared in 3 hours,
bleeding lasted for 4 days and spotting 10 days.
(3) Fenwick et al, 1995 has shown complete abortion of 6 weeks
fundal pregnancy in a 24 weeks size uterus with 14x10x10cm
intramural fibroid. Drug used was 600 mg RU 486 orally, followed
36 hours later by 1 mg gemeprost vaginal pessary.
Thus, medical abortion can be advocated in high surgical
risk women with special precautions and proper monitoring,
as has been proved from several studies. |
 Medical
abortion has come up as a new approach for termination of
pregnancy up to 63 days of amenorrhoea. Its efficacy ranges
between 92 and 98% in early gestation.
The combination of mifepristone followed by misoprostol
(prostaglandin analogue) has become very popular in some European
and Asian countries. Women are offered a choice between medical
and surgical abortion. But medical abortion is still being
carried out only for research purposes. Researchers have also
strictly followed the exclusion criteria to recruit patients
for the safety of medical abortion. All women who desire medical
abortion cannot be offered medical abortion.
High surgical risk women include those with previous scar
on the uterus (caesarean, myomectomy or hysterotomy) or with
large fibroids.
Medical abortion may be associated with risk of failure (15
to 20%), prolonged bleeding (8 to 15 days), cramping pain
(92%), nausea and vomiting (80%),diarrhoea (20%), fever (32%),
infection and vasospastic angina pectoris. Acceptability studies
comparing medical and surgical abortion have shown the acceptance
of medical abortion of up to 91.8% (Lindhardt et al, 2000)
More women (71.3%) choose medical abortion for expected privacy
of aborting at home, 65% for emotional support and 44.7% for
fear of anaesthesia and surgery (Wiebe et al 1996). But the
high-risk patients cannot be left alone at home to abort.
Time required for patients to abort is longer in medical abortion
and the provider is also less able to directly control the
timing and outcome of abortion. Approximately 1 in 100 woman
bleed profusely and require blood transfusion (Studies done
in France, Britain and USA) and 2 in 100 women require surgery
after medical abortion (FDA).
A rare case of vasopastic angina pectoris with loss of consciousness,
bradycardia and seizures were induced by medical abortion
following administration of mifepristone and gemeprost.
Therefore, medical personnel should take a long and careful
look for this protocol and, certainly, it should not be provided
a blanket approval in the high surgical risk group. |
