Medical abortion

For medical abortion prior to 12 weeks gestation, the World Heath Organization recommends mifepristone 200 mg by mouth followed 1–2 days later by misoprostol 800 mcg inside the cheek, vaginally, or under the tongue; misoprostol may be repeated to maximize success.[6] The success rate of mifepristone followed by one dose of misoprostol through 10 weeks pregnancy is 96.6%.[7] Those who took misoprostol less than 24 hours after mifepristone had higher failures rates compared to women who waited 1–2 days.[8] The National Abortion Federation (NAF) also recommends a mifepristone and misoprostol combination regimen. For medication abortion up to 10 weeks of pregnancy, 200 mg mifepristone is taken followed in 24 to 48 hours by 800 mcg misoprostol. For pregnancies after 9 weeks, repeating the dose of misoprostol makes the treatment more effective.[9] From 10 to 11 weeks of pregnancy, NAF protocol includes a routine second dose of misoprostol 800 mcg four hours after the first dose.[10]

If mifepristone is not available, the WHO recommends misoprostol 800 mcg inside the cheek, under the tongue, or in the vagina.[6] The success rate of misoprostol alone for first trimester abortion is 78%.[11]

Though not a first line choice, a methotrexate/misoprostol combination regimen is appropriate. Methotrexate is given either orally or intramuscularly, followed by vaginal misoprostol 3–5 days later.[12] This is an appropriate option for gestations through 63 days. Per the WHO, a methotrexate-misoprostol regimen can also be used;[13] but is not recommended as methotrexate may be teratogenic to the fetus in cases of incomplete abortion. However, this combination is considered more effective than misoprostol alone.[14]

WHO recommends mifepristone 200 mg by mouth (orally) followed 1–2 days later by misoprostol 400 mcg under the tongue, inside the cheek, or in the vagina.[6] Misoprostol may be taken in repeated doses every 3 hours until successful abortion is achieved, the mean time to abortion after starting misoprostol is 6–8 hours, and approximately 94% will abort within 24 hours after starting misoprostol.[15] When mifepristone is not available, misoprostol may still be used though the mean time to abortion after starting misoprostol will be extended compared to regimens using mifepristone followed by misoprostol.[16]

Self-administered medical abortion is available to women who prefer to take the abortion drug without direct medical supervision, in contrast to provider-administered medical abortion where the woman takes the abortion drug in the presence of a trained healthcare provider. Evidence from clinical trials indicates self-administered medical abortion may be as effective as provider-administered abortion but the safety aspects remain uncertain.[17]

Medical abortion was introduced as a service where a person visits a health center in-person due to FDA requirements that the first abortion pill, mifepristone, be dispensed directly by a health provider and not by prescription.[18] Other models exist to safely increase patient access to medication abortion. These models were expanded during the COVID-19 pandemic.[19][20] Women report high levels of satisfaction with telehealth abortion services.[21][22]

In this model, a provider communicates with a patient located at another site using clinic-to-clinic videoconferencing to provide medication abortion. This was introduced by Planned Parenthood of the Heartland in Iowa to allow a patient at one health facility to communicate via secure video with a health provider at another facility.[23] This model has expanded to other Planned Parenthoods in multiple states as well other clinics providing abortion care.[23]

The direct-to-patient model allows for medication abortion to be provided without an in-person clinic visit. Instead of an in-person clinic visit, the patient receives counseling and instruction from the abortion provider via videoconference. The patient can be at any location, including their home. The medications necessary for the abortion are mailed directly to the patient. This is a model, called TelAbortion or no-test medication abortion (formerly no-touch medication abortion), being piloted and studied by Gynuity Health Projects, with special approval from the U.S. Food and Drug Administration (FDA).[24] This model has been shown to be safe, effective, efficient, and satisfactory.[25][26][19] Complete abortion can be confirmed via telephone-based assessment.[27]

Vaginal bleeding generally diminishes gradually over about two weeks after a medical abortion, but in individual cases spotting can last up to 45 days.[28] If the woman is well, neither prolonged bleeding nor the presence of tissue in the uterus (as detected by obstetric ultrasonography) is an indication for surgical intervention (that is, vacuum aspiration or dilation and curettage). Remaining products of conception will be expelled during subsequent vaginal bleeding. Still, surgical intervention may be carried out on the woman's request, if the bleeding is heavy or prolonged, or causes anemia, or if there is evidence of endometritis.

Complications following medical abortion with mifepristone and misprostol under 10 weeks pregnancy are rare; according to two large reviews, bleeding requiring a blood transfusion occurred in 0.03-0.6% of women and serious infection in 0.01-0.5%.[7][8] Because infection is rare after medication abortion, the American College of Obstetricians and Gynecologists (ACOG), The Society of Family Planning (SFP), and NAF do not recommend use of routine antibiotics.[32][12] A few rare cases of deaths from clostridial toxic shock syndrome have occurred following medical abortions.[33]

Some anti-abortion groups claim that the abortifacient effect of mifepristone can be reversed by administering progesterone before the person takes misoprostol.[65][66] At this time there is no scientifically rigorous evidence that the effects of mifepristone can be reversed this way.[67][68] Even so, several states in the US require providers of non-surgical abortion who use mifepristone to tell patients that reversal is an option.[69] In 2019, researchers initiated a small trial of the so-called "reversal" regimen using mifepristone followed by progesterone or placebo.[70][71] The study was halted after 12 women enrolled and three experienced severe vaginal bleeding. The results raise serious safety concerns about using mifepristone without follow-up misoprostol.[68]

In the United States in 2009, the typical price charged for a medical abortion up to 9 weeks' gestation was $490, four percent higher than the $470 typical price charged for a surgical abortion at 10 weeks' gestation.[72] In the United States in 2008, 57% of women who had abortions paid for them out of pocket.[73]

In April 2013, the Australian government commenced an evaluation process to decide whether to list mifepristone (RU486) and misoprostol on the country's Pharmaceutical Benefits Scheme (PBS). If the listing is approved by the Health Minister Tanya Plibersek and the federal government, the drugs will become more accessible due to a dramatic reduction in retail price—the cost would be reduced from between AU$300 and AU$800, to AU$12 (subsidised rate for concession card holders) or AU$35.[74]

On 30 June 2013, the Australian Minister for Health, the Hon Tanya Plibersek MP, announced that the Australian Government had approved the listing of mifepristone and misoprostol on the PBS for medical termination in early pregnancy consistent with the recommendation of the Pharmaceutical Benefits Advisory Committee (PBAC).[75] These listings on the PBS commenced on 1 August 2013.[76]