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Medication Abortion

A training module for health professionals

Ibis Reproductive Health


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Ibis Reproductive Health

Ibis Reproductive Health aims to improve women’s reproductive health, choices, and autonomy worldwide. Our work includes clinical and social science research, policy analysis, and evidence-based advocacy.

Ibis Reproductive Health


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Objectives

  • Define medication abortion

  • Identify current medication abortion methods and present

    • Mechanisms of action

    • Regimens, efficacy, and safety

    • Eligibility requirements and contraindications

    • Side effects and complications

  • Provide general information on medication abortion methods

  • Outline references and resources

Ibis Reproductive Health


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What is medication abortion?

Medication abortion, also known as non-aspiration or non-surgical abortion, refers to a family of safe and effective methods for terminating an early unwanted pregnancy. Through the use of a drug or combination of drugs that are administered orally, vaginally, and/or intramuscularly, medication abortion first causes the pregnancy to terminate and then causes the uterus to expel the products of conception.

Ibis Reproductive Health


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Why “medication abortion”?

Non-aspiration or non-surgical abortion is commonly referred to as “medical abortion”. However, this phrase has led to confusion among both providers and the public, as the term “medical” is often associated with physician-based practices and/or medical necessity.

“Medication abortion” more accurately represents the family of safe and effective drug-based methods that can terminate an unwanted pregnancy and will be used throughout this presentation.

Ibis Reproductive Health


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Methods of medication abortion

  • Mifepristone and misoprostol

  • Methotrexate and misoprostol

  • Misoprostol alone

    Medication abortion methods can be used throughout early pregnancy (≤63 days’ gestation)

Ibis Reproductive Health


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Medication abortionMethods of action of the medications

  • Mifepristone

    • Anti-progestin that blocks the action of progesterone

    • Alters the uteral lining

  • Methotrexate

    • Anti-metabolite

    • Interferes with DNA synthesis and cell growth

  • Misoprostol

    • Prostaglandin E1 analog

    • Stimulates uterine contractions and induces cervical softening

Ibis Reproductive Health


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Medication abortion Additional uses of the medications

  • Mifepristone

    • Labor induction (under investigation)

    • Infertility treatment (under investigation)

  • Methotrexate

    • Treatment of neoplastic diseases

    • Treatment of rheumatoid arthritis

  • Misoprostol

    • Prevention of gastric ulcers

    • Obstetric and gynecologic indications

Ibis Reproductive Health


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Mifepristone/misoprostol regimen

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MifepristoneWorldwide approval

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Mifepristone/misoprostol regimenGeneral protocol

  • Day 1 (Clinic)

    • Clinician counsels the woman, takes a medical history and performs an exam and lab tests

    • Mifepristone is orally administered

  • Day 2-4 (Home or clinic)

    • Misoprostol is administered

  • Day 7-14 (Clinic)

    • Patient returns to the clinic for follow-up

    • Clinician assesses for the completion of the abortion

Ibis Reproductive Health


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Mifepristone/misoprostol regimensComparison of protocols

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Mifepristone/misoprostol regimenEfficacy and safety

  • Approximately 95% of women will have a successful abortion when using mifepristone/misoprostol within 49 days’ gestation

  • Completion rates appear to decline slightly with increasing durations of pregnancy after 56 days’ gestation

  • Approximately 67% of women will have a complete abortion within four hours of using misoprostol

  • Approximately 90% of women will have a complete abortion within 24 hours of using misoprostol.

Ibis Reproductive Health


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Mifepristone/misoprostol regimenEligibility for use

  • Non-ectopic pregnancy of ≤63 days’ gestation

  • Absence of contraindications

  • Willingness to undergo vacuum aspiration or dilation and curettage (D&C), if indicated

Ibis Reproductive Health


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Mifepristone/misoprostol regimenContraindications to use

  • Confirmed or suspected ectopic (extra-uterine) pregnancy

  • Allergy to either mifepristone or misoprostol

  • Presence of an intrauterine device (IUD)

  • Chronic systemic use of corticosteroids

  • Chronic adrenal failure

  • Coagulopathy or current therapy with anticoagulants

  • Inherited porphyria

Ibis Reproductive Health


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Effects of abortion process

Cramping

Often described as similar to menstrual cramps

Vaginal bleeding

Median bleeding time 9-13 days

Often described as similar to a heavy period or spontaneous miscarriage

Common side effects

Nausea

Vomiting

Diarrhea

Headache

Dizziness

Fever, chills, hot flashes, warmth

Mifepristone/misoprostol regimenSide effects

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Mifepristone/misoprostol regimenComplications

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Mifepristone/misoprostol regimenSummary

  • Millions of women worldwide have safely used mifepristone/misoprostol

  • Mifepristone/misoprostol is more than 95% effective in terminating early pregnancies

  • Mifepristone/misoprostol is widely acceptable to both patients and providers

Ibis Reproductive Health


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Methotrexate/misoprostol regimen

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MethotrexateWorldwide availability

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Methotrexate/misoprostol regimenEvidence-based protocol

  • Day 1 (Clinic)

    • Clinician counsels the woman, takes a medical history and performs an exam and lab tests.

    • Methotrexate is administered either orally (50 mg) or intramuscularly (50 mg/m2)

  • Day 3-7 (Home)

    • Misoprostol is self-administered vaginally at home.

  • Day 8 (Clinic)

    • Clinician performs a vaginal ultrasound to determine if the abortion is complete.

    • If abortion is complete (75% of women) no further visits are required.

    • If the abortion is incomplete additional misoprostol is given and patient returns

      • On Day 15 if cardiac activity is detected

      • On Day 28-45 if no cardiac activity is detected on ultrasound

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Methotrexate/misoprostol regimenEvidence-based protocol continued

  • Day 15 (Clinic, if necessary)

    • Patient is assessed for continued pregnancy.

    • If cardiac activity is detected, a aspiration termination is performed.

    • If no cardiac activity is detected, patient returns in three weeks.

  • Day 28-45 (Clinic, if necessary)

    • The patient is assessed for continued pregnancy.

    • If the abortion is incomplete (5% of cases), a aspiration termination is performed.

Ibis Reproductive Health


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Methotrexate/misoprostol regimenEfficacy and safety

  • Approximately 95% of women will have a complete abortion when using methotrexate/misoprostol up to 49 days’ gestation.

  • Medication abortion completion rates decline with increasing gestational age

  • Approximately 20% of patients using methotrexate/misoprostol will experience a complete abortion three to four weeks after misoprostol administration.

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Methotrexate/misoprostol regimenEligibility for use

  • Pregnancy of ≤49 days’ gestation

    • Methotrexate/misoprostol is preferable for women with ectopic pregnancies

  • Absence of contraindications

  • Willingness to undergo vacuum aspiration or dilation and curettage (D&C), if indicated

Ibis Reproductive Health


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Methotrexate/misoprostol regimenContraindications to use

  • Allergy to either methotrexate or misoprostol

  • Presence of an intrauterine device (IUD)

  • Coagulopathy or current severe anemia

  • Acute or chronic renal or hepatic disease

  • Acute inflammatory bowel disease

  • Uncontrolled seizure disorders.

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Effects of abortion process

Cramping

Often described as similar to menstrual cramps

Vaginal bleeding

Median bleeding time 2-3 weeks

Often described as similar to a heavy period or spontaneous miscarriage

Common side effects

Nausea

Vomiting

Diarrhea

Headache

Dizziness

Fever, chills, hot flashes, warmth

Oral ulcers

Fetal malformations

Methotrexate/misoprostol regimenSide Effects

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Methotrexate/misoprostol regimenComplications (≤49 days’ gestation)

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Methotrexate/misoprostol regimenSummary

  • Methotrexate/misoprostol is approximately 95% effective in terminating pregnancies ≤49 days’ gestation

  • Methotrexate/misoprostol is the preferred medication abortion method for confirmed or suspected ectopic pregnancies

  • Methotrexate/misoprostol is widely acceptable to both patients and providers

Ibis Reproductive Health


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Misoprostol-only regimen

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MisoprostolWorldwide availability

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Misoprostol-only regimenEvidence-based protocols

  • No consensus exists on optimal protocol

  • Various regimens, dosing schedules and routes of administration are currently under investigation

  • Most commonly used protocol

    • Vaginal administration of 800 µg of misoprostol

    • If abortion fails, misoprostol dose is repeated every 24 hours, up to three doses

Ibis Reproductive Health


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Misoprostol-only regimenEfficacy and Safety

  • Efficacy varies widely (65%-93%)

  • Efficacy varies by route of administration, dose, dosing schedule, and gestational age

  • Misoprostol-only regimens are not as effective as either mifepristone/misoprostol or methotrexate/misoprostol regimens

Ibis Reproductive Health


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Misoprostol-only regimenEligibility for use

  • Non-ectopic pregnancy of ≤63 days’ gestation

  • Absence of contraindications

  • Willingness to undergo vacuum aspiration or dilation and curettage (D&C), if indicated

  • Lack of access to either mifepristone or methotrexate

Ibis Reproductive Health


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Misoprostol-only regimenContraindications for use

  • Confirmed or suspected ectopic pregnancy

  • Allergy to misoprostol

  • Presence of an intrauterine device (IUD)

  • Uncontrolled seizure disorder

  • Inflammatory bowel disease

Ibis Reproductive Health


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Effects of abortion process

Cramping

Often described as similar to menstrual cramps

Often described as more severe than the cramping of either mifepristone/misoprostol or methotrexate/misoprostol regimens

Vaginal bleeding

Median bleeding time 2 weeks

Often described as similar to a heavy period or spontaneous miscarriage

Common side effects

Nausea

Vomiting

Diarrhea

Headache

Dizziness

Fever and chills

Rashes

Pelvic pain

Fetal malformations

Misoprostol-only regimenSide effects

Ibis Reproductive Health


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Misoprostol-only regimenComplications

  • Approximately 10%-35% of women will require an aspiration intervention

  • Misoprostol-only regimen is less effective in terminating early pregnancy than when used in combination with either mifepristone or methotrexate

Ibis Reproductive Health


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Misoprostol-only regimenSummary

  • Misoprostol used in conjunction with either mifepristone or methotrexate is more effective at terminating early pregnancy than misoprostol alone

  • Efficacy varies widely

  • Optimal regimen has yet to be determined

  • Misoprostol-only regimen is an important alternative for women who do not have access to other medical or aspiration abortion methods

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Medication abortion: General issues

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Medication abortionComparing the three regimens

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Medication abortionSpecial considerations for early pregnancy termination

  • Determine eligibility for medication abortion

    • Diagnose and accurately date of early pregnancy

  • Discuss medical and aspiration options

    • Inform patients of potential side effects, complications, and follow-up requirements

  • Provide adequate follow-up and post abortion care

    • Aspiration intervention, if necessary

    • Family planning services

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Methods for determining gestational age

  • For all medication abortion methods, accurate pregnancy dating is important

  • Methods for determining gestation age include

    • Last menstrual period

    • Bimanual examination

    • Serum β-hCG testing

    • Ultrasound

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Alternatives to medication abortionAspiration abortion

  • Types of aspiration abortion

    • Manual vacuum aspiration

    • Dilation and curettage (D&C)

  • Aspiration procedure

    • Cannula is inserted into the uterus

    • Uterine contents are emptied through suction

  • Can be used throughout the first trimester

  • Highly effective (>99%) in terminating pregnancy

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Medication abortion vs. aspiration abortionAdvantages and disadvantages

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Medication abortionConditions requiring clinical assessment and/or intervention

  • Fever

  • Excessive or prolonged bleeding

  • Incomplete abortion

    • Retained fetal tissue

    • Persistent gestational sac on ultrasound

  • Continued pregnancy

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Medication abortion regimensAcceptability

  • Generally well-accepted by patients who report

    • High satisfaction

    • Desire to use the method again

    • Intention to recommend method to a friend or relative

  • Both mifepristone/misoprostol and methotrexate/misoprostol regimens are well-accepted by providers

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Medication abortion regimensBest and worst reported features

  • Women report the best features as

    • Ability to avoid surgery and anesthesia

    • Perception that the process is more “natural”

    • Privacy

    • Convenience

  • Women report the worst features as

    • Length and degree of bleeding

    • Number of clinic visits

    • Uncertainty as to whether or not the procedure had resulted in a complete abortion.

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Medication abortionFuture directions for research and clinical practice

  • Expand worldwide access to medication abortion medications

  • Establish optimal misoprostol-only regimens

  • Expand programs to educate women, health professionals, and policy makers about medication abortion

  • Train health professionals in medication abortion provision

Ibis Reproductive Health


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Medication AbortionConclusions

  • Medication abortion regimens have been used by millions of women worldwide to safely and effective terminate early pregnancy

  • Medication abortion regimens expand pregnancy termination options for women and health professionals

  • Medication abortion regimens are highly acceptable to both women and providers

  • Future research is needed to improve regimens and expand services

Ibis Reproductive Health


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Medication AbortionReferences and resources

The Alan Guttmacher Institute: www.agi-usa.org

  • This site provides numerous studies on abortion in the US and worldwide.

    American College of Obstetricians and Gynecologists: www.acog.org

  • This website provides information on the medical management of abortion and resources on practice guidelines.

    Ibis Reproductive Health: www.ibisreproductivehealth.org

  • The home page of Ibis Reproductive Health, this site provides information on the organization and contains a database of articles published by staff. Ibis also provides educational materials on medication abortion in English, Arabic, French, and Spanish.

    IPAS: www.ipas.org

  • IPAS manufactures and distributes manual vacuum aspiration equipment and trains providers in early abortion techniques worldwide.

    National Abortion Federation: www.earlyoptions.org

  • This site provides medication abortion educational materials for both providers and patients.

    Population Council: www.popcouncil.org

  • The Population Council provides information on reproductive health issues worldwide, including publications on medication abortion methods and acceptability.

Ibis Reproductive Health


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