Medical abortion offers an important alternative to surgical abortion for women with early pre Medical abortion regimens are safe, effective and offer a new range of choices for patients and providers . Currently, septic abortions account for 98 out of 1000 maternal deaths. The reasons for septic abortion include sticks in 77% and surgical methods like D&C in 23%. They are performed by dais in 13%, ANMs 4%, relatives 38% and doctors in 45% (Figure 5.4.1).

Figure 5.4.1

Surgical abortion complications occur in 9 per 1000procedures, with a mortality rate lower than 1 per 100,000 cases. Complications reported in 15,700 women undergoing surgical abortion were uterine perforation (0.52%), aemorrhage (0.18%), incomplete abortion (0.37%), failure of MTP (0.03%) and infection (0.02%). Analysis of post-abortion or case load over 30 days in an Egyptian Hospital of 568 public sector hospitals revealed a total of 22,656 admissions. Of these, 19% admissions were for abortions. 14% of these had heavy blood loss, 1% trauma and 5% infection.

Essential pre-requisites for medical abortion are counseling, communication and transport facility, availability of pregnancy test, trans-vaginal sonography and second-level care.

Indian trials on medical abortion have been done using 600 mg mifepristone followed by 400 µg misoprostol with good success rate. When used for women up to 56 days of amenorrhoea, the success rate has been 97% but this declines to some extent when the period of amenorrhoea extends, the success being 94% when used up to 63 days of gestation. Krishna et al used lower dose of mifepristone (200 mg) followed by 400 µg misoprostol up to 56 days of amenorrhoea and showed a success rate of nearly 100%.

A large number of clinical trials in France at 450 centres showed an average blood loss of 70 to 80 ml, bleeding for 10 days, pain requiring opiod analgesia in10%, blood transfusion in 0.1%, incomplete abortion in 3 to 4% and myocardial infarction in one patient. Medical supervision was required in all women and ovulatory cycles were restored in 1 to 2 months.

The ICMR Taskforce Multicentric study with RU 486(200 mg/600 mg) followed by 9-methylene –PGE2vaginal gel (3 mg/5mg) showed a success rate of nearly92%.

The BGH – Medical Termination – Extended Study up to 63 days using mifepristone 600 mg followed 48 hours later by misoprostol 400 µg had a complete abortion rate of 91.7% and incomplete abortion 4.4%. Onset of bleeding within 4 hours after misoprostol was noticed in 78%, nausea in 29%, vomiting in 22% and abdominal pain in 22%. Bleeding continued for 12 days with no requirement of blood transfusion.

No significant difference in general, reproductive and psychological health was found in women who had medical or surgical abortion when followed up for 2 years. Menstrual cycle regularization took 2 months, 18% of patients requested for repeat medical termination. When interviewed, 95% said that they would prefer medical abortion again. The use of mifepristone (200 – 600 mg) prior to 2nd trimester termination has reduced the induction abortion interval to almost 6 hours vs misoprostol only regimen (400 µg3-6 hourly) of 17 hours.

Anticipated problems with medical abortion are misuse in perimenopausal patients and those with advanced pregnancy, poor compliance and follow-up, failure and side-effects and poor acceptance of family planning. Only 23% of patients return for contraception.

Side-effects encountered in patients with mifepristone-misoprostol abortion were nausea, vomiting, abdominal cramps in 25%, occasional diarrhoea, post-abortal bleeding for 10 days, bleeding requiring curettage in 5%, need for blood transfusion in 0.15%. Rare complications were few serious adverse events, ventricular arrythmia and death due to myocardial infarction in one patient.

Misoprostol is known to cross the placenta. Surgical evacuation is recommended in failed cases. Data on infants born after exposure are inadequate. Few data have shown teratogenic effects in the form of Mobius syndrome (congenital facial paralysis). Lim et al, 1990, Pom et al, 1991 followed infants exposed to RU 486, and did not report any congenital malformation till 2001. Probable mechanism of teratogenecity by misoprostol is by decreasing uterine blood flow.

Compliance is an important factor for success of medical abortion. Women have to be compliant to take the drugs appropriately, as well to report for follow-up visits even for a trivial problem. Similarly providing appropriate post-abortion care is another important component.