Medical abortion
What is medical abortion?
Medical abortion is a way to end pregnancy without surgery. This can be used safely at any stage of pregnancy, but in later pregnancies (after 9 weeks from the beginning of the last period) women would need to stay in hospital until the procedure is completed and this may take more than one day.
In New Zealand at this time (September 2004) only two clinics offer early medical abortion (up to 63 days from the beginning of the last period); Level J Unit at Wellington Hospital and AMAC in Auckland.
Many other hospitals offer medical abortion for later terminations, especially terminations for fetal abnormalities. Under New Zealand law all medications used have to be given in a licensed hospital/clinic and women must stay in the hospital until it is considered medically safe for them to be discharged home. Both AMAC and the Level J Unit offer women the opportunity to remain at the hospital 4-6 hours after the misoprostol and most pass the pregnancy tissue in this time and can get stronger pain relief if they need it. In many other counties the women will either take the misoprostol pill at home if it legally allowed (USA) or go home immediately after taking the pill (some UK clinics).
Early medical abortion
(Up to 63 days after the beginning of the last menstrual period)
There are different drugs which can be used:
- Prostaglandin alone
- Methotrexate plus prostaglandin
- Mifepristone plus prostaglandin
Mifepristone plus prostaglandin is the combination that is used in New Zealand.
The treatment
The treatment will usually consist of one Mifegyne® tablet containing 200mg of mifepristone. This acts by blocking the effects of progesterone, a hormone which is needed for pregnancy to continue. The Mifegyne® data sheet can be viewed on the MedSafe website.
This will be followed 36-48 hrs later by the insertion into the vagina of four tablets each containing 200µg of Cytotec® (misoprostol). This is a different type of hormone (a prostaglandin) that helps to expel the pregnancy. In some cases the doses of both drugs may be changed by the doctor. A second dose may be given if the woman has not passed the sac within 4 hours time.
Who can use this treatment?
Most women can have the treatment. However it is not suitable:
- if there is an ectopic pregnancy (where the egg has implanted in the tube rather than in the womb).
- if the first day of the last normal menstrual period was more than 63 days ago. The doctor will check the age of your pregnancy with an ultrasound scan.
- if the woman has ever had a bad reaction or are allergic to mifepristone (Mifegyne®) or misoprostol (Cytotec®).
- if an intrauterine contraceptive device (IUCD) is in place. This must be removed before taking Mifegyne®.
In some other circumstances the treatment may also be unsuitable so the doctor must be advised:
- If the woman is a smoker aged more than 35 years.
- If she has a medical condition such as a heart complaint, high blood pressure or diabetes.
- If she suffers badly from asthma or is on long-term steroid treatment for any other reason.
- If she is anaemic or has a bleeding disorder or is receiving anticoagulants.
The doctor will discuss whether the treatment is suitable.
Some other precautions
- The treatment is not suitable if the woman does not have a telephone or is living more than one hour travelling time from emergency hospital medical services. This is in case of heavy bleeding needing emergency treatment.
- The treatment is not suitable if the woman is unsure about the decision to have an abortion because once the Mifegyne® is taken there is a risk that if the pregnancy continues the baby may be born with abnormalities. Difficulties in making a decision must be discussed with the doctor, nurse/midwife or counsellor.
- If the woman is breast feeding she should stop for at least 14 days after taking Mifegyne®.
- She should not drink alcohol or smoke once the Mifegyne® has been taken and for at least two days after taking the vaginal tablets. Recreational drugs or herbal preparations, such as St John's Wort, should not be taken.
- If the woman is taking other medicines the doctor must be advised. Some medicines may interfere with the treatment. Paracetamol, with or without codeine, is usually sufficient for pain relief.
Taking the treatment
- The woman will be given one tablet of Mifegyne® to swallow with some water which must be taken at the hospital/clinic. This is less than recommended in the data sheet but has been found to be effective in clinical studies. She will be able to go home about an hour after taking the tablet, once the nurse/midwife or doctor is sure she will not be sick.
- Women need a good supply of maxi-pads for use at home.
- If there is any cause for concern such as heavy bleeding, the clinic must be consulted for advice. There is a 24 hour telephone service for any emergencies. In a few cases (3-5%) the abortion may occur after Mifegyne® alone.
- The woman will be given an appointment to return to the clinic 36-48 hours later (except in those women who have already aborted) and the vaginal tablets will be inserted. If the abortion is not completed within 4 hours this may be followed by a further dose taken by mouth. The woman may stay at the clinic for up to 6 hours. Most women will pass the pregnancy tissue in this time.
- If the pregnancy tissue has not been passed after 6 hours the doctor may examine and check if the pregnancy sac is just sitting in the vagina.
- After this the woman may go home. If the sac has not been passed it may be passed at home any time over the next few days.
- Advice will be given about what to do if there is severe pain or heavy bleeding.
What are the effects of treatment?
- After taking the Mifegyne® tablet nothing much will happen for about 12 hours. The woman may feel unwell, perhaps a little faint or sick during the first few hours.
- After 12 hours she may start to bleed. About half the women who have taken Mifegyne® will start to bleed before returning to have the vaginal tablets inserted. The bleeding may be quite heavy, like a heavy period. There may also be cramps like period pains.
- After being given the vaginal tablets, if bleeding has not already started, it will now start and most women will get stomch pain and cramps which may be quite strong. A medical abortion is like having a miscarriage. In some cases the bleeding can be very heavy and in a very small number of cases (about 1 in 300) it may be necessary to give a blood transfusion and/or perform a surgical abortion to stop the bleeding.
- If there is a lot of pain the doctor will prescribe painkillers, such as paracetamol, a NSAID like Nurofen, or codeine or something stronger if needed. Pain can be worse in women who have never been pregnant before or in women who normally suffer from painful periods.
- Some women have diarrhoea, sickness, headache, dizziness, hot flushes and chills after being given the vaginal tablets. Occasionally there may be a skin rash. Any side effects must be reported to the nurse/midwife or doctor.
- In over 90% of cases the pregnancy will be expelled in the 6 hours after taking the vaginal tablets. If the medical treatment fails a surgical abortion will be necessary.
- Many women ask if they will be able to see the embryo. The sac and the placenta surrounding the embryo can be seen clearly but the embryo at this stage is sometimes too small to be seen.
Follow-up
- If the pregnancy tissue has been passed in the clinic, the woman will be given an appointment with her referring doctor for a final check-up in 10-14 days to make sure that she is well and has suffered no complications.
- If the tissue has not been passed the woman may still experience pain and bleeding at home while the pregnancy tissue is being passed. Arrangements will be made to have blood tests and possibly another ultrasound examination before seeing the doctor for a final check in 10-14 days to ensure the abortion is complete.
- The follow-up visit is most important and the woman will be contacted if she fails to attend. Bleeding and cramping are not proof that the abortion is complete.
What about contraception?
- A plan for future birth control should be discussed with the doctor.
- It is possible for a woman to become pregnant again immediately after the abortion is complete, so that contraception, such as oral contraceptives, should be started, within five days of taking the Mifegyne®.
- An IUCD can be inserted with the next menstrual period.
- Women are advised not to have sex for 14 days after the abortion is complete.
If the woman is Rh negative
- The routine tests by the referring doctor will have checked the blood group. If the blood group is Rh negative the woman will be given an injection to stop antibodies forming which could be a problem if she ever becomes pregnant again.
What may be expected after going home
- The woman will be advised not to put anything into the vagina for 14 days i.e. no tampons, no sex, no bathing or swimming.
- Women need to wear a well-fitting bra day and night as the breasts may start to fill with milk.
- A small number of women may develop an infection. This may cause a temperature, or pain, discharge or unusual bleeding. A doctor should be consulted if this occurs so that antibiotics can be given, if needed.
- The woman may continue to bleed for several weeks. If the bleeding is heavy (more than two maxi-pads an hour for two hours) she should ring the clinic, their referring doctor or emergency hospital medical services.
- The woman should recover quickly from the abortion but will be advised to take things easy for a few days and avoid aerobic exercise for two weeks. She may feel emotional and extra counselling may be needed.
- Menstrual period may re-establish in 4-8 weeks.
Second trimester medical abortion
In the second trimester of pregnancy (after 12 weeks) a pregnancy is aborted medically by inducing labour. This process has been used for many years in NZ in preference to late surgical abortion.
Methods used in New Zealand are either prostaglandin alone or Mifegyne® followed by a prostaglandin. Prostaglandins used are misoprostol (Cytotec®), gemeprost (Cervagen®) (now rarely used and will shortly not be available) or prostaglandin f2a which may be used as a second-line prostaglandin.
The process is similar to that with early medical abortion except that it is likely to take longer be more painful.
The treatment
If Mifegyne® is used it is given 36-48 hours before the prostaglandin. A dose of 200-600mg is used (one to three tablets). This acts by blocking the effects of progesterone, a hormone which is needed for pregnancy to continue.
This will be followed 36-48 hrs later by a course of prostaglandin. The type of prostaglandin, the amount, frequency and method of delivery of the drugs varies from clinic to clinic. This prostaglandin acts on the uterus in a number of ways to induce contractions that expel the pregnancy.
Who can use this treatment?
Most women can have the treatment. However it is not suitable:
- If there is an ectopic pregnancy (where the egg has implanted in the tube rather than in the womb).
- If there is any doubt about how big the pregnancy is. The doctor will check the age of the pregnancy with an ultrasound scan.
- If the woman has ever had a bad reaction or are allergic to mifepristone (Mifegyne®) or the prostaglandin.
- If an IUCD is in place. This must be removed before taking Mifegyne®.
In some other circumstances the treatment may also be unsuitable so the doctor must be advised:
- If the woman is a smoker aged more than 35 years.
- If she has a medical condition such as a heart complaint, high blood pressure, kidney failure or diabetes.
- If she suffers badly from asthma or are on long term steroid treatment for any other reason.
- If she is anaemic or has a bleeding disorder or is receiving anticoagulants.
The doctor will discuss whether the treatment is suitable.
Some other precautions
- The treatment is not suitable if the woman does not have a telephone or is living more than one hour travelling time from emergency hospital medical services. This is in case of heavy bleeding needing emergency treatment.
- The treatment is not suitable if the woman is unsure about the decision to have an abortion because once the Mifegyne® is taken there is a risk that if the pregnancy continues the baby may be born with abnormalities. Difficulties in making a decision must be discussed with your doctor, nurse/midwife or counsellor.
- If the woman is breast feeding she should stop for at least 14 days after taking Mifegyne®.
- She should not drink alcohol or smoke once the Mifegyne® has been taken and for at least two days after taking the vaginal tablets. Recreational drugs or herbal preparations, such as St John's Wort, should not be taken.
- If the woman is taking other medicines the doctor must be advised. Some medicines may interfere with the treatment. Paracetamol, with or without codeine, is usually sufficient for pain relief.
How is the treatment taken?
- The woman will be given one to three tablets of Mifegyne® to swallow with some water, which must be taken at the hospital/clinic. This is less than recommended in the data sheet but has been found to be effective in clinical studies. She will be able to go home about an hour after taking the tablet, once the nurse/midwife or doctor is sure she will not be sick.
- Women need a good supply of maxi-pads for use at home.
- If there is any cause for concern such as heavy bleeding, the clinic must be consulted for advice. There should be a 24 hour telephone service for any emergencies. In a few cases the abortion may occur after Mifegyne® alone.
- The woman will be given an appointment to return to the clinic 36-48 hours later and (except in those women who have already aborted) the course of prostaglandin will be begun. This may be oral or vaginal tablets. The dose will be repeated every few hours until the fetus is delivered.
- After a variable time contractions will start and the cervix (neck of the womb) will dilate similar to a labour. Most women find these contractions painful and are likely to need pain relief.
What are the effects of treatment?
- After taking the Mifegyne® tablet nothing much will happen for about 12 hours. The woman may feel unwell, perhaps a little faint or sick during the first few hours.
- After 12 hours she may start to bleed. About half the women who have taken Mifegyne® will start to bleed before returning to have the prostaglandin course. The bleeding may be quite heavy, like a heavy period. There may also be cramps like period pains.
- After being given the prostaglandin, if bleeding has not already started, it will now start and most women will get stomach pain and cramps which may be quite strong. A second trimester medical abortion is like having a labour. In some cases the bleeding can be very heavy and in a very small number of cases (about 1 in 300) it may be necessary to give a blood transfusion and other drugs which contract the uterus.
- If there is a lot of pain the doctor will prescribe painkillers, ranging from simple analgesics such as paracetamol, a NSAID like Nurofen, or codeine or a stronger narcotic such as Fentanyl, Pethidine or morphine given by injection.
- Some women have diarrhoea, sickness, headache, dizziness, hot flushes and chills after being given the prostaglandin tablets. Occasionally there may be a skin rash. Any side effects must be reported to the nurse/midwife or doctor.
- If Mifegyne® has been given before the prostaglandin the average time taken to expel the pregnancy is about 8 hours. If only prostaglandin is used the average time is about 15 hours. However, a number of women will need to have a second course of prostaglandin the next day and occasionally on the third day.
- A number of women do not pass the placenta after the fetus and require a surgical procedure to assist with this (retained placenta).
Follow-up
- The woman should be given an appointment for a follow-up check one to two weeks after the abortion either with the clinic or with her referring doctor/specialist.
- If the reason for the termination is a fetal anomaly arrangements will be made to review any post-mortem findings with the parents.
What about contraception?
- A plan for future birth control should be discussed with the doctor.
- It is possible for a woman to become pregnant again immediately after the abortion is complete, so that contraception, such as oral contraceptives, within five days of taking the Mifegyne®.
- An IUCD can be inserted with the next menstrual period
- Women are advised not to have sex for 14 days after the abortion is complete.
If the woman is Rh negative
- The routine tests by the referring doctor will have checked the blood group. If the blood group is Rh negative the woman will be given an injection to stop antibodies forming which could be a problem if she ever becomes pregnant again.
What may be expected after going home
- The woman will be advised not to put anything into the vagina for 14 days i.e. no tampons, no sex, no bathing or swimming.
- A small number of women may develop an infection. This may cause a temperature, or pain, discharge or unusual bleeding. A doctor should be consulted if this occurs so that antibiotics can be given, if needed.
- The woman may continue to bleed for several weeks. If the bleeding is heavy (more than two maxi-pads an hour for two hours) she should ring the clinic, their referring doctor or emergency hospital medical services.
- The woman should recover quickly from the abortion but will be advised to take things easy for a few days. She may feel emotional and extra counselling is available if needed. She should have a regular period in 4-8 weeks.
Last Updated: 2 May 2005