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P RACTICE BULLET IN
clinical management guidelines for obstetrician gynecologists
Background
Medications Currently Used for
Medical Abortion
Mifepristone
Mifepristone, a derivative of norethindrone, binds to
the progesterone receptor with an affinity greater than
progesterone itself but does not activate the receptor,
thereby acting as an antiprogestin (2). Its known actions
on a uterus in pregnant women include decidual necrosis,
cervical softening, and increased uterine contractility and
prostaglandin sensitivity (3, 4). Human studies have suggested that uterine contractility does not increase until
2436 hours after mifepristone administration (3). At this
point, the sensitivity of the myometrium to the stimulatory effects of exogenous prostaglandins increases fivefold (3). However, more recent studies have shown high
efficacy when vaginal misoprostol is administered less
than 15 minutes after mifepristone (5). The effectiveness
of such a regimen cannot be attributed to the actions of
the misoprostol because misoprostol alone has a much
lower efficacy than mifepristone. Accordingly, these
studies suggest that some or all of these actions occur
sooner than previously believed or that the effects of
mifepristone that are important and necessary for its
abortifacient activity remain incompletely understood.
As a progesterone receptor antagonist, mifepristone
also has several other potential medical applications,
including emergency contraception; cervical ripening and
Committee on Practice BulletinsGynecology and the Society of Family Planning. This Practice Bulletin was developed by the Committee on
Practice BulletinsGynecology and the Society of Family Planning with the assistance of Mitchell D. Creinin, MD and Daniel A. Grossman, MD. The
information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed
as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources,
and limitations unique to the institution or type of practice.
Misoprostol
Misoprostol is an inexpensive prostaglandin E1 analogue
in a tablet form that is stable at room temperature. It is
approved by the U.S. Food and Drug Administration
(FDA) for oral administration to prevent gastric ulcers
in individuals who take antiinflammatory drugs on a
long-term basis, and it is included in the FDA-approved
labeling of mifepristone for use in abortion. It is used
off-label in other regimens for abortion, labor induction,
treatment of early pregnancy loss, prevention and treatment of postpartum hemorrhage, and cervical priming
before uterine procedures, such as hysteroscopy (8).
Pharmacokinetic evaluations of misoprostol absorption
when administered by various routes have been performed (913). Routes that result in a longer duration
of action (ie, buccal and vaginal) also appear to result
in greater efficacy compared with oral administration.
Similarly, those routes with rapid and significant absorption (ie, sublingual) also have high efficacy, but the
greater maximum concentration results in more adverse
effects. Misoprostol-only medical abortion regimens are
significantly less effective than those that use a combination of mifepristone and misoprostol (14, 15).
Other Agents
Methotrexate in combination with misoprostol was
adopted in the United States and Canada as an alternative to mifepristone regimens before mifepristone was
available (16, 17). However, methotrexate rarely is used
anymore in the United States for medical abortion
because of the greater availability and efficacy of mifepristone regimens. Methotrexate blocks dihydrofolate
reductase, an enzyme involved in producing thymidine
during DNA synthesis. Methotrexate exerts its action
primarily on the cytotrophoblast rather than the developing embryo, which inhibits syncytialization of the cytotrophoblast (18). Thus, methotrexate stops the process of
implantation rather than weakening the implantation site
directly. In contrast, the antiprogestin mifepristone has
no direct effect on the trophoblast.
Tamoxifen has been used in some studies of early
abortion in combination with misoprostol. However,
randomized trials have demonstrated no benefit of using
tamoxifenmisoprostol over methotrexatemisoprostol
or misoprostol alone regimens (19, 20).
Two small studies from China suggest that multiple
daily administrations of letrozole followed by misoprostol, 800 micrograms vaginally, may be another effective
Mifepristone Regimens
Regimen approved by the U.S. Food and
Drug Administration
The FDA-approved regimen, as detailed in the mifepristone package labeling, is based on the original regimen
registered in France 25 years ago. This regimen includes
mifepristone, 600 mg orally, followed approximately
48 hours later by a prostaglandin analogue, usually
misoprostol 400 micrograms orally. The FDA-approved
regimen includes this treatment with a follow-up visit
approximately 14 days after mifepristone administration
(23). If clinical history indicates that the woman had a
confirmed abortion, a pelvic examination is performed
to confirm uterine involution. If clinical history and
physical examination do not confirm expulsion, ultrasonography is performed. Suction aspiration at the followup evaluation is not specified as necessary unless the
pregnancy is ongoing (23).
The efficacy of the FDA-approved regimen is
approximately 92% in women with gestations up to 49
days (24, 25). Complete abortion rates are higher with
earlier gestations; approximately 9698% in gestations
of up to 42 days, 9195% in gestations from 43 days to
49 days, and less than 85% in gestations beyond 49 days
(24, 26, 27). When abortion does not occur within 34
hours after oral misoprostol administration, use of an
additional dose does not improve efficacy (26, 28).
Evidence-Based Regimens
Additional evidence-based regimens have been developed to improve medical abortion in terms of expense,
safety, speed, and adverse effects. Regimens that use low
doses of mifepristone (200 mg) have similar efficacy and
lower costs compared with those that use mifepristone
at 600 mg (29). Based on efficacy and the adverse effect
profile, evidence-based protocols for medical abortion
are superior to the FDA-approved regimen. Vaginal,
buccal, and sublingual routes of misoprostol administration increase efficacy, decrease continuing pregnancy
rates, and increase the gestational age range for use as
compared with the FDA-approved regimen (30). By
changing the route of misoprostol administration, the
timing between mifepristone and misoprostol dosing
can be varied to allow women more flexibility to accommodate personal situations, such as work and childcare.
Regimens that use vaginal misoprostol can be provided
simultaneously with mifepristone to terminate gestations of up to 63 days (5). A 68-hour interval between
mifepristone administration and vaginal misoprostol
Counseling Patients
Medical Abortion Versus Surgical Abortion
Counseling must first emphasize early pregnancy options
to ensure that a woman is certain about her decision to
have an abortion. If she is uncertain, then the decision
about abortion technique must be delayed until she has
reached a firm decision, even if the delay means that she
will be unable to choose a medical option.
Only when a woman has considered her options and
decided to have an abortion does the discussion about
the different methods become an issue. Most women
who seek early abortion will be eligible for medical and
surgical methods. The general advantages and disadvantages of each approach should be explained early in the
counseling process (Box 1) (3638). Even for women
who think they are unsure about the method, most will
have some preference after counseling (37). Studies
that have compared abortion method preferences have
included groups of patients who choose their method and
those who are randomized to their method. The applicability of these studies to current U.S. medical abortion
practice is limited given that no studies included the
mifepristonemisoprostol regimen, and in two studies,
surgical abortion was performed only under general
anesthesia. Generally, women are satisfied with the
method they choose but, when randomized, prefer surgical abortion to medical abortion (3638).
Most women choose medical abortion because
of a desire to avoid surgery, a perception that medical
abortion is safer than surgical abortion, and a belief that
medical abortion is more natural and private than a surgical procedure (39). Compared with surgical abortion,
medical abortion takes longer to complete, requires more
active patient participation, and is associated with higher
reported rates of bleeding and cramping. With medical
abortion, expulsion of the products of conception most
likely will occur at home, but a few women will still
require surgical evacuation to complete the abortion. An
early surgical abortion takes place most commonly in
one visit and involves less waiting and less doubt about
when the abortion occurs compared with medical abortion. In addition, women who undergo surgical abortion
will not see any products of conception or blood clots
during the procedure.
Adverse Effects
Bleeding and cramping will be experienced by most
women undergoing medical abortion and are necessary
for the process to occur. Adverse effects commonly
associated with mifepristone use include nausea, vomiting, diarrhea, headache, dizziness, and thermoregulatory
effects (5, 31, 32, 4042; Table 1). The incidence of each
adverse effect is based on the regimen used (especially
the prostaglandin analogue), the dose and route of administration of the prostaglandin analogue, and the gestational age. Gastrointestinal adverse effects are less common
when misoprostol is administered vaginally as compared
with regimens that use oral, buccal, or sublingual misoprostol (29, 43). Buccal and sublingual administration
cause similar adverse effects, with the sublingual route
associated with a higher rate of chills (44).
Counseling should emphasize that the woman is
likely to have bleeding that is much heavier than menses (and potentially with severe cramping) and is best
described to patients as comparable with a miscarriage.
The woman should understand how much bleeding is
considered too much. An easy reference for the patient
Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol
45 39 13 15
5 16
Mifepristone, 600 mg, followed by misoprostol, 800 micrograms vaginally, 3648 hours later. (Schaff EA, Stadalius LS, Eisinger SH, Franks P. Vaginal misoprostol administered at home after mifepristone (RU486) for abortion. J Fam Pract 1997;44:35360.)
Mifepristone, 200 mg, followed by misoprostol, 800 micrograms vaginally, 48 hours later. (Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low-dose mifepristone 200 mg and vaginal misoprostol for
abortion. Contraception 1999;59:16.)
Mifepristone, 600 mg, followed by misoprostol, 400 micrograms orally, 3648 hours later. (Wiebe E, Dunn S, Guilbert E, Jacot F, Lugtig L. Comparison of abortions induced by methotrexate or mifepristone followed by
misoprostol. Obstet Gynecol 2002;99:8139.)
||
Mifepristone, 200 mg, followed by misoprostol, 800 micrograms vaginally, 68 hours later (first row) or 24 hours later (second row). (Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA. A randomized comparison
of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. Obstet Gynecol 2004;103:8519.)
Mifepristone, 200 mg, followed by misoprostol, 800 micrograms vaginally, 015 minutes later (first row) or 24 hours later (second row). (Creinin MD, Schreiber CA, Bednarek P, Lintu H, Wagner MS, Meyn L. Mifepristone
and misoprostol administered simultaneously compared with 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol 2007;109:88594.)
#
Mifepristone, 200 mg, followed by misoprostol, 800 micrograms orally (first row) or buccally (second row), 2436 hours later. (Winikoff B, Dzuba IG, Creinin MD, Crowden WA, Goldberg A, Gonzales J, et al. Two distinct
oral routes of misoprostol in mifepristone medical abortion. A randomized controlled trial. Obstet Gynecol 2008;112:130310.)
Creinin 20 44 5 23 1 27 10
37 12 35 9
56
(2004)|| 39 52 14 30 7 25 20 37 20 37 19 53
Wiebe
(2002)
Schaff 45 43 13 26 11 23 14 13 15 28 14 32
(1999)
Schaff 36 36 14 14 8 22 18 19 22 37 20 37
(1997)
Trial
Thermoregulatory
Nausea Vomiting Diarrhea Headache Dizziness Effects*
Table 1. Adverse Effects in Selected North American Trials of Medical Abortion Regimens ^
to use is the soaking of two maxi pads per hour for 2 consecutive hours (45). Patients should be advised to call
their health care providers if they experience this level
of bleeding. The need for emergency care is based on
how the patient is feeling, her baseline hemoglobin (Hb)
or hematocrit level, whether the bleeding seems to be
slowing, and her distance from an emergency facility.
Overall, large series demonstrate that less than 1% of
women will need emergency curettage because of excessive bleeding (26, 4648). Moreover, the risk of clinically significant bleeding and transfusion may be lower
in women who undergo medical abortion of gestations
up to 49 days compared with those who undergo medical abortion of gestations of more than 49 days (24); this
risk will vary based on the regimen used.
Pain management is an important consideration.
The woman should be sent home with appropriate
instructions for analgesia with over-the-counter medications and can be provided with prescriptions for oral
narcotics to use when needed. Nonsteroidal antiinflammatory drugs, such as ibuprofen, are not contraindicated in women who undergo a medical abortion and
are appropriate first-line agents for pain management.
One randomized trial found that ibuprofen taken when
needed was more effective than acetaminophen to
reduce pain associated with medical abortion (49).
Nonsteroidal antiinflammatory drugs inhibit the synthesis of new prostaglandins, but they do not block the
action of prostaglandin receptors and should not inhibit
the action of a prostaglandin used for medical abortion.
In a retrospective analysis of nonsteroidal antiinflammatory drugs and complete abortion, in 416 women who
received misoprostol after methotrexate for medical
abortion of gestations up to 56 days, the use of ibuprofen
did not interfere with the action of misoprostol to induce
uterine contractions and expulsion of the products of
conception (50). One randomized trial found that multiple doses of ibuprofen given prophylactically at the
time of misoprostol administration did not significantly
reduce pain associated with medical abortion compared
with ibuprofen taken when needed (51).
Clinical Considerations
and Recommendations
Who are candidates for medical abortion
with mifepristone and misoprostol?
Women are candidates for medical abortion with mifepristone and misoprostol if they meet the gestational age
criteria for the regimen and have no contraindications to
the medical abortion process. Women with twin gestations can be treated with the same regimens as those with
singleton gestations (57). Medical contraindications are
infrequent.
Most studies exclude women with anemia who have
Hb levels of less than 9.5 g/dL or less than 10 g/dL;
accordingly, the safety of medical abortion in women
with anemia is unknown. Although the transfusion rates
associated with medical abortion are low (0.05%), they
exceed those reported for surgical abortion in early pregnancy (0.01%) (55, 58).
Other medical contraindications to abortion with
mifepristone regimens include confirmed or suspected
ectopic pregnancy, intrauterine device (IUD) in place,
current long-term systemic corticosteroid therapy,
chronic adrenal failure, known coagulopathy or anticoagulant therapy, and intolerance or allergy to mifepristone. Most clinical trials also have excluded women with
severe liver, renal, or respiratory disease or uncontrolled
hypertension or cardiovascular disease (angina, valvular
disease, arrhythmia, or cardiac failure).
Misoprostol should not be used in women who have
an allergy or intolerance to misoprostol or other prostaglandins. Asthma is not a contraindication because
misoprostol is a weak bronchodilator.
Women are not good candidates for medical abortion if they are unable or unwilling to adhere to care
instructions, desire quick completion of the abortion
process, are not available for follow-up contact or evaluation or cannot understand the instructions because of
language or comprehension barriers.
Gestational Age
Up to 49 days
Up to 63 days
Up to 49 days
Up to 63 days
Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med 1998;338:12417.
Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low-dose mifepristone 200 mg and vaginal misoprostol for abortion. Contraception 1999;59:16.
3
Schaff EA, Fielding SL, Westhoff C. Randomized trial of oral versus vaginal misoprostol at one day after mifepristone for early medical abortion. Contraception
2001;64:815.
4
el-Refaey H, Rajasekar D, Abdalla M, Calder L, Templeton A. Induction of abortion with mifepristone (RU 486) and oral or vaginal misoprostol. N Engl J Med 1995;
332:9837.
5
von Hertzen H, Honkanen H, Piaggio G, Bartfai G, Erdenetungalag R, Gemzell-Danielsson K, et al. WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: Efficacy. WHO Research Group on Post-Ovulatory Methods for Fertility Regulation. BJOG 2003;110:80818.
6
Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA. A randomized comparison of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. MOD
Study Trial Group. Obstet Gynecol 2004;103:8519.
7
von Hertzen H, Huong NT, Piaggio G, Bayalag M, Cabezas E, Fang AH, et al. Misoprostol dose and route after mifepristone for early medical abortion: a randomised
controlled noninferiority trial. WHO Research Group on Postovulatory Methods of Fertility Regulation. BJOG 2010;117:118696.
2
Creinin MD, Vittinghoff E, Schaff E, Klaisle C, Darney PD, Dean C. Medical abortion with oral methotrexate and vaginal misoprostol. Obstet Gynecol 1997;90:6116.
Creinin MD, Carbonell JL, Schwartz JL, Varela L, Tanda R. A randomized trial of the effect of moistening misoprostol before vaginal administration when used with
methotrexate for abortion. Contraception 1999;59:116.
10
Wiebe E, Dunn S, Guilbert E, Jacot F, Lugtig L. Comparison of abortions induced by methotrexate or mifepristone followed by misoprostol. Obstet Gynecol 2002;
99:8139.
11
von Hertzen H, Piaggio G, Huong NT, Arustamyan K, Cabezas E, Gomez M, et al. Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomised controlled equivalence trial. WHO Research Group on Postovulatory Methods of Fertility Regulation. Lancet 2007;369:193846.
9
10
Summary of
Recommendations and
Conclusions
The following recommendations are based primarily on good and consistent scientific evidence
(Level A):
Based on efficacy and adverse effect profile, evidence-based protocols for medical abortion are
superior to the FDA-approved regimen. Vaginal,
buccal, and sublingual routes of misoprostol administration increase efficacy, decrease continuing
pregnancy rates, and increase the gestational age
range for use as compared with the FDA-approved
regimen.
11
Follow-up after receiving mifepristone and misoprostol for medical abortion is important, although
an in-clinic evaluation is not always necessary.
Proposed Performance
Measure
Percentage of patients presenting for abortion before 63
days of gestation who are offered medical management
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16
17
Table 1. Adverse Effects in Selected North American Trials of Medical Abortion Regimens ^
Thermoregulatory
Nausea Vomiting Diarrhea Headache Dizziness Effects*
Trial
Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol Mifepristone Misoprostol
Schaff 36 36 14 14 8 22 18 19 22 37 20 37
(1997)
Schaff 45 43 13 26 11 23 14 13 15 28 14 32
(1999)
Wiebe
(2002)
45 39 13 15
5 16
Creinin 20 44 5 23 1 27 10
37 12 35 9
56
(2004)|| 39 52 14 30 7 25 20 37 20 37 19 53
Creinin N/R 58 N/R 31 N/R 35 N/R 40 N/R 39 N/R 69
(2007) 29 51 9 31 5 26 18 36 9 37 15
56
Winikoff N/R 64 N/R 40 N/R 35 N/R 31 N/R 30 N/R 33
(2008) # N/R 66 N/R 40 N/R 34 N/R 34 N/R 32 N/R 41
Abbreviation: N/R, not reported.
*Fever, warmth, hot flushes, or chills.
Mifepristone, 600 mg, followed by misoprostol, 800 micrograms vaginally, 3648 hours later. (Schaff EA, Stadalius LS, Eisinger SH, Franks P. Vaginal misoprostol administered at home after mifepristone (RU486) for abortion. J Fam Pract 1997;44:35360.)
Mifepristone, 200 mg, followed by misoprostol, 800 micrograms vaginally, 48 hours later. (Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low-dose mifepristone 200 mg and vaginal misoprostol for
abortion. Contraception 1999;59:16.)
Mifepristone, 600 mg, followed by misoprostol, 400 micrograms orally, 3648 hours later. (Wiebe E, Dunn S, Guilbert E, Jacot F, Lugtig L. Comparison of abortions induced by methotrexate or mifepristone followed by
misoprostol. Obstet Gynecol 2002;99:8139.)
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Mifepristone, 200 mg, followed by misoprostol, 800 micrograms vaginally, 68 hours later (first row) or 24 hours later (second row). (Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA. A randomized comparison
of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. Obstet Gynecol 2004;103:8519.)
Mifepristone, 200 mg, followed by misoprostol, 800 micrograms vaginally, 015 minutes later (first row) or 24 hours later (second row). (Creinin MD, Schreiber CA, Bednarek P, Lintu H, Wagner MS, Meyn L. Mifepristone
and misoprostol administered simultaneously compared with 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol 2007;109:88594.)
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Mifepristone, 200 mg, followed by misoprostol, 800 micrograms orally (first row) or buccally (second row), 2436 hours later. (Winikoff B, Dzuba IG, Creinin MD, Crowden WA, Goldberg A, Gonzales J, et al. Two distinct
oral routes of misoprostol in mifepristone medical abortion. A randomized controlled trial. Obstet Gynecol 2008;112:130310.)