Medical methods for first trimester abortion

RHL practical aspects by Grossman D

FIRST CONTACT (PRIMARY CARE) LEVEL

1. All reproductive age women and men should be informed about and given access to effective methods of contraception, including emergency contraception when necessary.

2. Where medical abortion is available, women should be informed about the availability of this option so that in case of need they can come early enough in their pregnancy to the health care centre in order to qualify for this method.

3. Medical abortion services need to be backed up by surgical abortion services in case of incomplete abortion with drugs. If such a facility is not available at a health care centre planning to offer medical abortion, appropriate nearby centres should be identified for backup uterine aspiration, as well as an emergency referral care for complex problems or complications.

4. As with surgical abortion, women choosing medical abortion must be carefully counselled about the procedure and given clear information about warning signs and where to obtain 24-hour emergency care.

5. If ultrasound is not available, clinicians providing medical abortion must be well trained in clinical assessment of gestational age (COHORT) (1, 2).

6. Women must be evaluated clinically for potential contraindications to medical abortion, including ectopic pregnancy, severe anaemia, cervicitis or upper genital tract infection, presence of an intrauterine device, or any contraindication to use of the specific medication(s) (3, 4).

7. If mifepristone is available, women with undesired pregnancies ≤63 days’ gestation may be offered the option of the following regimen:

Mifepristone 200 mg orally, followed by:

  • Misoprostol 800 µg vaginally administered once at any point 1–3 days later. Administering misoprostol 6–8 hours after mifepristone appears to be equally effective (3).
  • For women with a pregnancy of ≤49 days who prefer the oral route of administration, misoprostol may be administered as a 400-µg oral dose 2 days after mifepristone(5).
  • Misoprostol 800 µg sublingually 2 days after mifepristone is another option for women who prefer to avoid vaginal administration, but they should be counselled about increased side-effects (6).

Women are commonly advised to return for one or more follow-up visits, after 10-14 days during which:

  • cases of ongoing pregnancy should be referred for aspiration abortion (either at the center or at the next level of care);
  • cases of incomplete abortion may be managed either expectantly, with an additional dose of misoprostol, or with surgical abortion (7).
  • women whose abortion process is complete should be started on contraception.

8. If mifepristone is not available and methotrexate is available (or if methotrexate is preferred because of its lower cost or because of its efficacy when administered intramuscularly to treat ectopic pregnancy in cases of uncertain pregnancy location), women with a pregnancy ≤49 days of gestation may be offered the following regimen:

a. Methotrexate 50 mg/m2 (of body surface area) by either the oral or intramuscular route, followed by a single vaginal dose of 800 µg misoprostol at any time between 3 and 7 days later.

b. If the fetus is not expelled within 24 hours of misoprostol administration, a second virginal dose of 800 µg of misoprostol may be administered.

c. Women should be advised to return for one or more follow-up visits, after 10–14 days at which:

  • cases of ongoing pregnancy should be referred for surgical abortion (either at the centre or at the next level of care);
  • cases of incomplete abortion may be managed either expectantly or with an aspiration procedure (8).
  • women whose abortion process is complete should be started on contraception.

9. If neither mifepristone nor methotrexate is available (or if their cost is prohibitive), women with undesired pregnancies ≤63 days’ gestation may be offered the option of the following regimen:

a. Misoprostol 800 mcg vaginally repeated every 24 hours up to three doses. This regimen should only be used when neither mifepristone nor methotrexate is available, as it is less effective (RCT, EXPERT COMMITTEE). (9, 10).

b. Women are commonly advised to return for one or more follow-up visits, after 10-14 days during which:

  • cases of ongoing pregnancy should be referred for aspiration abortion (either at the center or at the next level of care).
  • cases of incomplete abortion may be managed either expectantly, with an additional dose of misoprostol, or with an aspiration procedure (EXPERT OPINION)(11).
  • women whose abortion process is complete should be started on contraception.

10. Women may be given the option of home administration of misoprostol after the initial clinic visit (COHORT)(2, 12, 13, 14).

REFERRAL HOSPITAL (SECONDARY CARE) LEVEL

All actions described above for the primary care level apply to the secondary care level. Medical abortion services do not need to be any more specialized at this level of care than at the primary level, and should be offered on an outpatient basis. In addition, hospitals providing these services should be prepared to manage all abortion-related complications and referrals from the areas they serve (EXPERT COMMITTEE)(15).

AT HOME OR IN THE COMMUNITY

1. All women and men of reproductive age should be informed about effective methods of contraception, including emergency contraception. Community-based distribution of appropriate methods (including emergency contraception) should be available (15).

2. Where medical abortion is available, women should be informed about the availability of this option so that in case of need they can come early enough in their pregnancy to the health care centre in order to qualify for this method.

3. Community health workers should be trained to recognize and treat minor complications of medical abortion and to arrange referral when necessary.

References

  • Coyaji K, Elul B, Krishna U, Otiv S, Ambardekar S, Bopardikar A, Raote V, Ellertson C, Winikoff B. Mifepristone-misoprostol abortion: a trial in rural and urban Maharashtra, India. Contraception 2002;66 (1):33-40.
  • Elul B, Hajri S, Ngoc NN, Ellertson C, Slama CB, Pearlman E, Winikoff B. Can women in less-developed countries use a simplified medical abortion regimen. The Lancet 2001;357(9266):1402-1405.
  • Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA. MOD Study Trial Group. A randomized comparison of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. Obstetrics and gynecology 2004;103 (5 Pt 1):851-859.
  • von Hertzen H, Honkanen H, Piaggio G, Bartfai G, Erdenetungalag R, Gemzell-Danielsson K, Gopalan S, Horga M, Jerve F, Mittal S, Ngoc NT, Peregoudov A, Prasad RN, Pretnar-Darovec A, Shah RS, Song S, Tang OS, Wu SC. WHO Research Group on Post-Ovulatory Methods for Fertility Regulation. WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: Efficacy. British journal of obstetrics and gynaecology 2003;110 (9):808-818.
  • Tang OS, Chan CC, Ng EH, Lee SW, Ho PC. A prospective, randomized, placebo-controlled trial on the use of mifepristone with sublingual or vaginal misoprostol for medical abortions of less than 9 weeks gestation. Human Reproduction 2003;18 (11):2315-2318.
  • Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low-dose mifepristone 200 mg and vaginal misoprostol for abortion. Contraception 1999;59(1):1-6.
  • Wiebe E, Dunn S, Guilbert E, Jacot F, Lugtig L. Comparison of abortions induced by methotrexate or mifepristone followed by misoprostol. Obstetrics and gynecology 2002;99 (5 Pt 1):813-819.
  • Jain JK, Dutton C, Harwood B, Meckstroth KR, Mishell DR Jr. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy. Human reproduction 2002;17 (6):1477-1482.
  • Consensus Statement: Instructions for Use – Abortion Induction with Misoprostol in Pregnancies up to 9 Weeks LMP. Expert Meeting on Misoprostol sponsored by Reproductive Health Technologies Project and Gynuity Health Projects July 28, 2003. Washington, DC. Available at:. http://www.rhtp.org/early/pdfs/instructions_for_use_final.pdf;Accessed 13 August 2004.
  • Stubblefield PG, Carr-Ellis S, Borgatta L. Methods for induced abortion. Obstetrics and gynecology 2004;104(1):174-185.
  • Blum J, Hajri S, Chelli H, Mansour FB, Gueddana N, Winikoff B. The medical abortion experiences of married and unmarried women in Tunis, Tunisia. Contraception 2004;69 (1):63-69.
  • Ngoc NT, Nhan VQ, Blum J, Mai TT, Durocher JM, Winikoff B. Is home-based administration of prostaglandin safe and feasible for medical abortion? Results from a multisite study in Vietnam. British journal of obstetrics and gynaecology 2004;111 (8):814-819.
  • Schaff EA, Stadalius LS, Eisinger SH, Franks P. Vaginal misoprostol administered at home after mifepristone (RU486) for abortion. Journal of family practice 1997;44 (4):353-360.
  • World Health Organization. Safe abortion: Technical and policy guidance for health systems. Geneva, The World Health Organization;2003.

This document should be cited as: Grossman D. Medical methods for first trimester abortion: RHL practical aspects (last revised: 3 September 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.

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