Choosing the method of abortion

The determining factors in an individual woman's choice for medical or surgical abortion are complex. Some women see the advantages of the surgical methods to be that they are simple and quick and associated with a relatively low risk of complication or failure. Medical methods are often favoured because they appear more physiological, like a miscarriage and avoid the need for uterine instrumentation and also share the advantages of low rates of complication and failure. Some women feel that they lack control where a surgical procedure is undertaken, whereas others specifically wish to remain unaware and have the procedure undertaken by their clinician. In 1991, the anti-progestogen mifepristone was licensed for termination up to 9 weeks' gestation and since then an extensive literature has built up to support the safety, efficacy and acceptability of the medical regimen for early first trimester abortion [12-15]. 1995 saw an extension of licence to include pregnancies over 13 weeks' gestation. At present, the medical regimen is not licensed for use in women over 9 and up to 13 weeks' gestation and the majority of abortions at these gestations remain surgical. There is randomized trial evidence comparing medical and surgical termination at 10-13 weeks' gestation confirming that the medical regimen is an effective alternative to surgery with high acceptability [16] and increasing numbers of units now offer medical termination as an alternative choice at these gestations. While ideally abortion services should be able to offer a choice of recommended methods across all the gestation bands, the minimum recommended by the RCOG guideline is that a service should be able to offer abortion by one of the recommended methods in a particular gestation band (Fig. 33.1).

Clinical practice in three larger Scottish units indicates that more than half of eligible women opt for medical methods when given a choice at early gestations up to 9 weeks and Scottish abortion statistics reveal that over 50% of all terminations in Scotland are now performed medically [2]. Medical abortion has been more patchy in its introduction in England and Wales and there continues to be significant variation in its provision across Health Authorities. Interestingly, the introduction of medical termination has not affected the overall abortion rate. That women value choice of method appropriate to the gestation of their pregnancy has been confirmed from patient surveys [17,18].

The RCOG guidelines recommend that conventional suction termination should be avoided at very early gestations under 7 weeks because the procedure is three times more likely to fail to remove the gestation sac than where the termination is performed between 7 and 12 weeks [19]. Although medical termination has been advocated at these very early gestations under 7 weeks, there is renewed interest in manual vacuum aspiration (MVA) under local anaesthetic using strict protocols to identify tissue and track subsequent serum beta hCG levels. The selection of medical or surgical method for later abortions beyond 15 weeks depends on the availability of health-care personnel who are trained and willing to participate in late dilatation and evacuation (D + E). There are fewer abortions at these gestations and they tend to be undertaken within the specialist independent sector. It is the case that as gestational age increases the safety of second trimester surgical abortion depends highly on the operator's skill and experience. Clinics and clinicians usually set the limits for operative care based on these considerations. It should be noted that there has been no formal comparison in randomized trials between second trimester D + E and the modern methods of medical midtrimester termination. Hysterotomy with its high associated morbidity and mortality has disappeared from practice.

Day-case care is recognized as a cost-effective model of service provision and a typical abortion service will be able to manage 90% of its patients on a day-care basis. Pre-existing medical problems, social factors, geographical distance and the possibility of a planned day case subsequently requiring overnight stay because of surgical






















Manual vacuum aspiration (MVA)

Manual vacuum aspiration (MVA)

Suction termination under local or general anaesthetic

Specialist practitioner surgical abortion by dilatation and evacuation (D+E)

Medical termination mifepristone + single dose prostaglandin

Fig. 33.1 Methods of abortion suitable at different gestations.

Medical termination mifepristone and repeated doses of prostaglandin or medical problems will, of course, influence the day-care rate. Those women undergoing a midtrimester procedure in particular should be advised of the possible need for an overnight stay.

Medical termination in the first trimester

The anti-progestogen mifepristone is used in combination with prostaglandin doses to achieve medical abortion. There are few contraindications to medical termination and they include: suspected ectopic pregnancy, chronic adrenal failure, long-term steroid use, haemorrhagic disorders, treatment with anticoagulants, known allergy to mifepristone or misoprostol, smokers over 35 with ECG abnormalities and breastfeeding women. Medical abortions require to be performed in hospitals or premises registered for abortion. The patient attends briefly to take the mifepristone dose and attends subsequently for day-patient admission, usually 36 to 48 h later. It is customary for legal reasons to supervise the swallowing of the mifepristone tablets, but side effects are trivial and the women can leave after 10 min. Women may bleed slightly in the 48 h following the mifepristone dose and, particularly at early gestations, a very small number may miscarry. The route of prostaglandin administration and regimens vary, but it is customary for the women to remain under supervision for 4-6 h after prostaglandin administration, during which time the majority will have expelled the pregnancy (Table 33.2). The nursing staff supervising the procedure confirm passage of the products. The amount of bleeding can be variable, but is often similar to a heavy period and increases with the gestation. It is usual for women to have some lower abdominal cramp

Table 33.2 Medical methods

Up to 9 weeks (63 days) gestation

* Mifepristone 200 mg orally followed 1-3 days later by misoprostol 800 ng vaginally either by the woman or clinician

7-9 weeks (49-63 days) gestation

If abortion has not occurred 4 h after misoprostol administration, a second dose of 400 ng misoprostol may be administered vaginally or orally (depends upon bleeding or preference)

Other licensed regimen

Mifepristone 600 mg orally followed 36-48 h later by gemeprost 1 mg vaginally

9-13 weeks gestation

* Mifepristone 200 mg orally followed 36-48 h later by misoprostol 800 ng vaginally - a maximum of four further doses of misoprostol 400 ng may be administered at 3 h intervals, vaginally or orally depending on amount of bleeding

Midtrimester (abortion (13-24 weeks gestation)

* Mifepristone 200 mg orally, followed 36-48 h later by misoprostol 800 mg vaginally then misoprostol 400 ng orally, 3 h intervals, to a maximum of four oral doses

Other licensed regimen

Mifepristone 600 mg orally, followed 36-48 h later by gemeprost. 1 mg vaginally every 3 h, to a maximum of five pessaries

* These regimens are unlicensed.

which will require administration of oral analgesia and a minority (less than 5%) might require opiate analgesia. The length of gestation influences the efficacy and complete abortion rate for the procedure, as well as complications, but this is more of an issue at 9-13 weeks' gestation. The risk of a continuing pregnancy, particularly in the 9-13 week gestation band remains a problem, and those units undertaking medical termination at these gestations are careful in counselling women regarding this. Where women pass only minimal or no products of conception, ultrasound should be carried out. An unrecognized ongoing pregnancy would be of particular concern because of the risk of fetal abnormality associated with misoprostol use.

Early medical abortion at gestations up to 9 weeks

Single agents have been abandoned in favour of combined regimens with mifepristone plus prostaglandin. The conventional prostaglandin analogue used for medical abortion is gemeprost, but a disadvantage is its cost and the fact that it is unstable at room temperature. The manufacturer's summary of product characteristics for mifepristone recommends a dose of 600 mg prior to prostaglandin administration for early medical abortion. A Cochrane review concluded that the dose could be lowered to 200 mg without significantly decreasing efficacy and a multicentre trial conducted by the World Health Organization (WHO) has further assessed the effect of reducing the dose of Mifepristone [20,21]. Although geme-prost is the conventional prostaglandin analogue used for abortion the alternative Ei analogue misoprostol is also effective. Misoprostol is more effective if administered vaginally rather than orally [22-24]. A large review of 2000 women undergoing medical abortion up to 63 days' gestation using mifepristone 200 mg followed by a single dose of misoprostol 800 p,g given vaginally achieved a complete abortion rate of 97.5% [25]. It was noticed, however, that efficacy significantly decreased at gestations greater than or equal to 49 days. A subsequent large-case series has shown that mifepristone in combination with two doses, rather than a single dose of misoprostol abolishes this gestation effect [26].

Medical abortion in the late first trimester (9-13 weeks)

Data are accumulating for the high uptake, acceptability and efficacy of medical termination at 9-13 weeks and, although still unlicensed at these gestations, it is likely to be offered as a choice for women undergoing abortion in many units. Arandomized trial [27] comparing vacuum aspiration under general anaesthetic with medical abortion using a regimen of mifepristone 200 mg followed 36-48 h later by up to five doses of misopros-tol showed that complete abortion rates for women not requiring a second procedure were 94.6% in the medical group and 97.9% in the surgical group, which was not a statistically significant difference. The same group has subsequently reported a consecutive series of 1076 women at 64-91 days of gestation managed using the same regimens. The complete abortion rate for the series was 95.8% with an ongoing pregnancy rate of 1.5% and a clear gestation effect was apparent [28].

Midtrimester medical abortion

Midtrimester medical abortion with mifepristone followed by prostaglandin has been shown to be safe and effective with shorter induction to abortion intervals than previous methods with prostaglandin alone or supplemented by oxytocin infusion. Again randomized trial evidence supports use of a 200 mg mifepristone dose [29]. The induction abortion interval tends to be longer with increasing gestation [30] and reported cumulative experience suggests that 97% of women abort successfully on the day of treatment within five doses of misoprostol. A second or third day of treatment may be required to complete the termination medically and patients should be forewarned of this possibility. Surgical evacuation of the uterus is not required routinely following midtrimester medical abortion and should only be undertaken where there is clinical evidence that the abortion is incomplete and this is likely to be required in only about 8% of cases [30].

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