At this time, the only scheme of medical abortion that meets the criteria of effectiveness is the combination of mifepristone and Cytotec (Pfizer, New York. NY, USA). Recommendations presented herein refer to medical abortion implemented at the beginning of the first trimester of pregnancy (before the 63rd day of pregnancy, counting from the first day of the last menstrual period).
Although the consecutive administration of mifepristone and Cytotec allows for the termination of pregnancy of any length (e.g., in some countries, this combination is permitted for use until the 24th week of pregnancy), the induction of abortion at more than 63 days is less frequent; requires hospitalization; and may be complicated by medical, legal, and organizational issues.
Is it possible to conduct a medical abortion on your own at home without seeing a gynecologist?
Medical abortion alone at home is not recommended in order to avoid any complications. Moreover, it has been shown that the percentage of unsuccessful medical abortions is increased due to such “at-home” abortion attempts and thus the true expediency of using abortion in practice is distorted.
Scenarios in which medical abortion is more appropriate include:
- When the woman desires it
- Very early gestation (i.e., until the 49th day of pregnancy, medical abortion is considered more effective than surgical, especially if the existing clinical practice does not require a detailed study of the removed fetal egg)
- In the case of pronounced obesity (i.e., body mass index more than 30 kg/m2), in the absence of other risk factors for atherosclerosis, and/or when technical difficulties in performing surgical abortion are possible
- With the occurrence of developmental or uterine fibroids, surgical interventions on the cervix in the past
- When the woman is unwilling to undergo surgery
Scenarios in which surgical abortion is more appropriate include:
- When the woman prefers such
- When the woman has a desire to simultaneously undergo sterilization
- When there are contraindications to medical abortion
- When there are temporary or geographical factors that prevent observation after medical abortion when it is necessary to ensure that the fetal egg has been completely removed
What are the contraindications to medical abortion?
Contraindications to medical abortion are few. These include:
- Allergic reactions to one of the drugs used for medical abortion, in the anamnesis
- Hereditary porphyria
- Chronic adrenal insufficiency
- Possible or proven ectopic pregnancy
Additionally, precautions are required to be taken when performing a medical abortion in the following cases:
- Long-term treatment with glucocorticoids, including for severe bronchial asthma
- Blood-clotting disorders
- Severe anemia
- Cardiovascular diseases or risk factors for atherosclerosis (e.g., hypertension, smoking)
What characteristics of the woman should be considered before performing a medical abortion?
- Age: adolescent or older (i.e., over 35 years) age should be considered a contraindication to medical abortion.
- Anemia: this condition should be considered a contraindication to medical abortion; however, if anemia is detected during an induced abortion, treatment is indicated.
- Lactation: mifepristone can enter the breast milk. When studying the effects of mifepristone on the fetal endocrine system, there was found to an increase in the levels of adrenocorticotropic hormone and cortisol. The clinical significance of these changes is not known at this time.
- Diabetes mellitus type 1 and pathology of the thyroid gland: there is no information about the fact that medical abortion causes a worsening of patients with this pathology. However, mifepristone in vitro changes insulin sensitivity, which can affect plasma glucose and serum insulin levels.
- Multiple pregnancies: there is no information that multiple pregnancies influence the effectiveness of medical abortion or that such requires a change in the dose of drugs.
- Obesity: There is no evidence that the effectiveness of medical abortion is lower for obese individuals or if there is a need to change the dose of the drugs in such a case.
- Cesarean section in the anamnesis: according to one study, a cesarean section in history doesn’t affect the safety and effectiveness of medical abortion in the early stages of pregnancy.
- Smoking: there is no evidence that smoking directly affects the outcome of medical abortion. However, smoking increases the risk for atherosclerosis, which should be taken into account when assessing contraindications to medical abortion.
- Congenital and acquired organic changes in the uterus, surgical interventions on the cervix in the anamnesis: there is no information that this serves as a contraindication to medical abortion.
What kinds of tests are required before a medical abortion?
Along with other methods of abortion, contraindications and risk factors for complications are specified when collecting an anamnesis. It is important to determine whether a woman or her relatives suffer from a disease in which medical abortion is contraindicated, what medicines a woman takes, whether she has an allergic reaction, or whether there is a potential for excessive bleeding.
One should also elucidate obstetric and gynecological history, including the presence of ectopic pregnancies and sexually transmitted diseases, and assess the risk of sexually transmitted diseases. The doctor must take into account that an unwanted pregnancy could be a result of rape.
The basic examination includes the determination of pulse, blood pressure, and body temperature. Laboratory research before a medical abortion is optional. Given the identified risk factors and available resources, it is possible to determine the level of hemoglobin, blood group, and Rh-factor as well as to conduct research to detect hepatitis B and hepatitis C, human immunodeficiency virus infection, and sexually transmitted disease status.
What anesthesia is needed during a medical abortion?
The pain is caused both by the abortion itself and by the influence of Cytotec. Most often, pain occurs a few hours after the administration of the medication, when the fetal egg is expelled from the uterine cavity.
According to the existing research, medical abortion is accompanied by less intense pain in older women. However, none of these factors makes it possible to predict the individual course of a medical abortion. In any case, doctors should provide adequate anesthesia to all women who require it during a medical abortion.
Is surgery necessary for incomplete abortion?
Bleeding after medical abortion, gradually decreasing, continues on average for about two weeks. Occasionally, minor spotting persists for up to 45 days. Bleeding after a medical abortion usually lasts longer than that after vacuum aspiration.
With a good general condition of the woman, neither prolonged bloody discharge nor the presence of the remains of the fetal egg in the uterine cavity according to ultrasound data represents an indication to the surgical intervention. The remains of the fetal egg will be removed from the uterus cavity along with the blood.
How should one evaluate the effectiveness of medical abortion?
In each case of medical abortion, it is important to make sure that the pregnancy is interrupted. If a qualified medical professional confirms the allocation of the fetal egg a few hours after Cytotec administration, further monitoring is not required.
Conversely, in cases of uncertainty, a woman should be invited for examination at a convenient time about two weeks after the use of mifepristone. During this consultation, a bimanual or, if possible, an ultrasound study should be performed so as to confirm a complete abortion.