Lesson 1- An Overview of Abortion
Abortion is defined as the expulsion of the products of conception from the uterus. An abortion can occur spontaneously due to complications during pregnancy or can be induced. The term “miscarriage” is often used to refer to spontaneous abortions while the term “abortion” is commonly used to reference an induced abortion.
1.1) Abortion – A Global Perspective
Abortion is a common reproductive outcome of pregnancies around the world. Research by the World Health Organization (WHO) and the Guttmacher Institute indicate that approximately one in four pregnancies worldwide ended in an abortion between 2010-2014. The Guttmacher Institute estimates that during 2010–2014, an estimated 56 million induced abortions occurred each year worldwide. This represents roughly 25% of all pregnancies for the period between 2010–2014. In developed countries, the proportion declined from 39% to 28% between 1990–1994 and 2010–2014, whereas it increased from 21% to 24% in developing countries.
Most women seek an abortion because they became pregnant when they did not intend to. While a large majority of these women have an unmet need for contraception, it is important to remember that all methods of contraception can fail at some point and that women may seek an abortion even while using contraception. It is also interesting to note that, according to research by the WHO and Guttmacher Institute, three out of four abortions were sought by married women.
When trained providers perform abortions with appropriate equipment or drugs, correct techniques & doses, and in sanitary standards in early pregnancy, it is one of the safest medical procedures and carries less risk that a full term pregnancyii.
However, abortions that do not maintain the above mentioned standards can lead to complications that may result in death. In developing countries, unsafe abortion is a significant contributor to high rates of maternal mortality. Recent studies on maternal mortality estimate that between 8–18% of maternal deaths worldwide are due to unsafe abortion, and the number of abortion-related deaths in 2014 ranged from 22,500 to 44,000iiiiv v.
1.2) Safety in Abortion
The increasing availability of medical abortion drugs has contributed to changes in how abortion safety is viewed by the medical community. Based on research undertaken by the WHO and Guttmacher Institute, the WHO has released a new conceptual model to understand safety in abortions1.
1 Ganatra B, Gerdts C, Rossier C, Johnson Jr B R, Tuncalp Ö, Assifi A, Sedgh G, Singh S, Bankole A, Popinchalk A, Bearak J, Kang Z, Alkema L. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet. 2017 September
According to research published in the medical journal, The Lancet , in September 2017, the WHO recognizes abortions as safe if they satisfy two primary conditions: 1) If they are performed using a gestation-appropriate method recommended by the WHO; and 2) If the person involved has the necessary training for the method.
Given that abortions can be done either using drugs (known as medical abortion) or surgical procedures (such as vacuum aspiration, dilatation and evacuation), this new definition of safety acknowledges that the people, skills, and medical standards for a safe induced abortion are different for medical and surgical abortions. This is important to note as the skills required to provide medical abortion can be gained quickly through structured training quickly. There is also a reduced need for infrastructure and infection control during a safe medical abortion compared with a surgical abortion.
Contrary to safe abortion, unsafe abortion is defined by WHO as a procedure for terminating an unintended pregnancy, carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. The health consequences of unsafe abortion depend on the facilities where abortion is performed; the skills of the abortion provider; the method of abortion used; the health of the woman; and the gestational age of her pregnancy. In comparison, unsafe abortion procedures may involve a) the insertion of an object or substance into the uterus, like roots, metallic objects, or traditional herbal concoction; b) dilatation and curettage performed incorrectly by an unskilled provider; c) ingestion of harmful substances; or d) an application of external force. All of these can lead to a number of medical complications or even be life-threatening.
Continuum of Safety in medical Abortion
In the past, the WHO definition of safety in an abortion has focused around the legality of the service, the knowledge and skills of the provider, and safety of the surroundings in which the abortion is performed. However, with both an increasing body of evidence and changes in medical abortion access, the standards for abortion safety have been re-conceptualisation.
Box 1 - Classification of abortion safety (WHO, 2017)
Safe abortion: Use of a recommended method and a trained person
Less safe abortion: Use of outdated method by trained provider OR unsupported self-use of medical abortion drugs
Least safe abortion: Ingestion of caustic substances or use of invasive methods by untrained persons
Moving from a previously published, dichotomous classification of abortions as safe and unsafe, the WHO has recently released a three-tiered classification of safety of abortions. The three categories of safety are: safe, less safe and least safe. Both “less safe” and “least safe” abortions are considered unsafe. This classification takes into account a wide range of factors such as the persons involved, their skills, methods used, access to information and care provided throughout the process. This allows the safety of an abortion to be viewed as a continuum. This classification also helps both women and health care providers understand the areas to improve the clinical safety of abortion care.
It is important to note that while both mifepristone and misoprostol both very safe drugs when used correctly, they are not without any risks. The use of incorrect doses of the medical abortion drugs can often lead to potentially dangerous situations, especially with misoprostol. The sensitivity of the pregnant uterus to misoprostol increases dramatically with gestational age. Thus, it is important to remember that earlier pregnancies (in the first trimester) require larger doses of misoprostol to achieve an abortion. As pregnancy advances the dose of misoprostol should be reduced in line with gestational age.
Administering a less than needed dose of misoprostol in early pregnancy may result in an incomplete abortion, which can lead to serious adverse events such as bleeding and infection. Administering a larger than needed dose of misoprostol, on the other hand, can over-stimulate the uterus and lead to a possible uterine rupture that can be life-threatening.
Finally, this concept of safety is focused on the clinical safety of the medical care provided. It is important as a health care provider to also take into consideration that in many settings, the need and process of accessing abortion care can compromise the physical safety of the woman. Incidents of incarceration, honor killings and physical abuse of women seeking and receiving abortion care has been documented across the world. As health care providers aiming to facilitate the achievement of holistic health, it is important that medical students are aware of these issues in line with local context.
1.3) Safe abortion - Definition and Methods
Based on a systematic review of evidence, the WHO has recommended the following as safe methods for terminating a pregnancy. Please note that as with other areas of medical science, advancements in technology, clinical evidence and research will lead to improvements and updates on the clinical practice guidelines.
It is important to note that Dilatation and Curettage (commonly referred to as “D&C” or “curettage”) is NOT considered to be a safe procedure based on the review of evidence and thus the WHO does not recommend it as a safe procedure to terminate pregnancies.
Lesson 2: Providing Abortion Care
Abortion has been recognized as a human rights issue by numerous entities including governments, civil society organizations, and rights advocacy groups. Though it is recognized as a human rights issue and part of essential health care, it nevertheless is a complex issue with interplay of moral, ethical, religious and cultural values. This makes the issue particularly controversial and difficult to navigate publicly or within institutions.
A key challenge in the abortion debate is the use of polarizing labels – like “pro-choice” and “anti-choice”- that has given rise to a dichotomy around abortion. This limits opportunities for a nuanced thinking of a complex issue and engagement with others to build consensus. It is critical for health professionals to move away from such polarizing views that can influence their practice. Instead, it is critical that health care providers cultivate a mutually respectful relationship with their patients focused on their health well-being without any moral judgment.
There are two primary goals of this lesson. First, we will provide information around the rights of patients. Secondly, we will explore the ethical and professional standards applicable to physicians while women’s access to safe abortion.
2.1) Rights of Patients
The concept of fundamental human dignity was first incorporated into international law under The Universal Declaration of Human Rights 1948. The Declaration was monumental, as its recognition of individual rights provided new legal groundwork for improved standards of care. Based on this foundation, values such as individual autonomy, personhood, and the fundamental equality of all individuals were increasingly incorporated into medical practice, and the concept of patient rights was finally developed. Some of the key rights of patients include the right to privacy, to confidentiality, to consent to or to refuse treatment, and to be informed about the relevant risk of medical procedures.
In addition to a patient’s rights, it is important to acknowledge sexual and reproductive rights of all individuals. Sexual rights protect all people's right to fulfill and express their sexuality and enjoy sexual health, free of discrimination, and with due regard for the rights of others.
Based on this working definition, the key human rights that are critical to sexual health include:
It is important to take a moment to reflect on the application of these rights in the context of abortion care, especially the rights surrounding equality, privacy, highest attainable standard of health, information and education, the number and spacing of one’s children and the right to be free of inhumane or degrading treatment.
2.2) Medical Ethics Related To Abortion
In addition to supporting key rights of their patients, providers should be guided by professional values and principles of the medical practice. Professionals must avoid causing harm, maximize healthcare options, prioritize alternatives that are feasible for their patients, and protect patient dignity during their treatment. The study of both Bioethics and Medical Professionalism is key to understanding the entirety of this issue.
Bioethics in medicine is grounded in the promotion of three principles: the principles of
1) autonomy; 2) beneficence and non- malfeasance and; 3) justice.
The principle of autonomy is based on a practitioner’s duty to respect individuals’ right to choose which health care interventions are acceptable to them. Autonomy also guarantees patients the right to determine the involvement of others, such as family or community members, in their decision-making and treatment. Under the principle of autonomy, health care providers are responsible for providing all information necessary for informed decision-making, but do not themselves make decisions about the type of care to be received.
Beneficence and non-malfeasance require that providers assess with their patients both prospective advantages of a treatment option and possible side effects or consequences that could cause harm. It is critical that this information is communicated clearly to the patient to help them understand their various options and select the best option for their individual situation.
The principle of justice, within the context of health care, guarantees that all individuals have equal access to necessary health services. It also denotes the right of individuals to fair and equitable distribution of the benefits and the risks of available health care.
These principles are critically embedded within the understanding and practice of abortion care. Together, they ensure that professional standards of medicine are upheld at all times.
In addition to these principles of ethics, it is important to also consider medical professionalism as a key guide in defining and outlining the roles of physicians in abortion care. Medical professionalism is grounded in values of discipline, commitment and competence. In the context of abortion care, medical professionalism highlights the importance that health professionals understand, accept and adopt the role of protecting and promoting rights of the patients. Medical professionalism demands that at no point in the care of patients should physicians use coercion or impose their personal, moral or religious principles onto the patient.
Access to safe abortion services continues to be a low priority in many settings. Unsafe induced abortions are a public health problem that involves violations of justice, human rights and gender equality. Bioethical principles dictate that health professionals have an obligation to respond to health crises, and thus practitioners must approach abortion as a public health issue before it is a legal issue. Facing an unwanted pregnancy and seeking access to information and services for a safe abortion should be considered as part of essential health care and physicians should acknowledge that working to eliminate morbidity and mortality from unsafe abortion is not crime but an integral part of their roles as health professionals.
2.3) Ensuring Respectful Abortion Care
The ways in which women seek and receive abortion care have begun to shift within the last few years. With wider availability and knowledge about medical abortion, there are now multiple sources from which women seek information and access to medical abortion care. , These new sources, many of which are outside the domain of traditional health care, can include:
Thus, within your practice, it is possible to engage with women at various points in their abortion care, including seeking access to information , or seeking clinical care before, during, or after an abortion.
It is imperative that physicians reflect on the rights of their patients, sexual and human rights, and their personal values within bioethics and medical professionalism when engaging with women during this process. No woman should be denied her rights when seeking care at any point during the abortion process, before, during or after.
Lesson 1- An Overview of Abortion
This lesson will provide a quick overview of the relevant anatomy, physiology and essential pharmacology for early medical abortions. Information in this lesson should be supplemented with additional information gained through the formal medical training.
3.1) Essential Reproductive Anatomy and Physiology
The female reproductive organs can be subdivided into the internal and external genitalia The external genitalia lie outside the true pelvis and include the following structures: the perineum, the mons pubis, the clitoris, the urethral meatus, the labia majora and minora, the vestibule and vestibular glands, and the Peri-urethral area. In contrast, the internal genitalia are the organs that are within the true pelvis. These include the vagina, the uterus, the cervix, the fallopian tubes, and the ovaries. Let’s walk through some of the internal genitalia organs one by one for a more in-depth understanding.
Essential Reproductive Physiology:
This section outlines the salient points about the menstrual cycle, the physiology of early pregnancy, and the key hormones that are essential for the continuation of the pregnancy.
The menstrual cycle refers to the natural change that occurs in the body, specifically within the uterus and ovaries, as a result of the changes in the quantity and balance of different female sex hormones. The menstrual cycle is controlled by hormones secreted by the hypothalamus, the pituitary gland, and the ovaries. The onset of this cycle usually begins during puberty with menarche and continues throughout a woman’s reproductive period until menopause. Each woman is born with a predetermined number of follicles, one of which will be released during a menstrual cycle and thus determines the duration between puberty and menopause. The length of the menstrual cycle can vary among women and even during different times of a woman’s reproductive life as a result of internal factors, such as changing hormone levels, or external factors such as stress.
The timing of the menstrual cycle starts with the first day of menses, referred to as day one of a woman’s period. Cycle length is determined by counting the days between the onset of bleeding in two subsequent cycles. Because the average length of a woman’s menstrual cycle is 28 days, this is the time period used to identify the timing of events in the cycle. However, the length of the menstrual cycle varies among women, and even in the same woman from one cycle to the next, typically from 21 to 32 days. The menses cycle can be divided into the following stages:
1) Menses Phase: The menses phase of the menstrual cycle is the phase during which the lining is shed; that is, the days that the woman menstruates. Although it averages approximately five days, the menses phase can last from 2 to 7 days, or longer. This phase occurs as a result of declining progesterone concentrations in the body caused by the degradation of the corpus luteum. This decline in progesterone triggers the shedding of the outer layers of the endometrium and marks the end of the luteal phase.
2) Proliferative phase (follicular phase): This phase is characterized by the growth and maturation of the follicles containing the oocytes. The anterior pituitary secretes both FSH and LH, which act directly on the follicular cells. FSH stimulates the follicular cells to grow and secrete estrogen. These hormones also lead to the proliferation of the endometrial tissue (which grow in preparation for implantation should the ovum be fertilized), changes in the cervical mucus, and the stimulation of LH receptors in the follicular cells. Under the influence of several hormones, all but one of these follicles will stop growing. The follicle that reaches maturity is called a Graffian follicle, and it contains the ovum that will be released during ovulation.
Around day 14 of the cycle, the levels of estrogen reach a threshold that stimulates the production of a large amount of LH, known as the LH surge. The release of LH matures the egg and causes the fully developed follicle to release its secondary oocyte. This is referred to as ovulation.
3) Secretory phase (Luteal phase): The anterior pituitary hormones FSH and LH then cause the remaining parts of the Graffian follicle to transform into the corpus luteum. The corpus luteum secretes progesterone, and to a lesser extent, estrogen, for a period of up to 12 days after ovulation. The effect of progesterone leads to a further thickening of the endometrial lining, secretory and proliferative changes, and a relaxation of the myometrium to prevent contractions that can disrupt implantation of the zygote.
The anterior pituitary hormones FSH and LH then cause the remaining parts of the Graffian follicle to transform into the corpus luteum. The corpus luteum secretes progesterone, and to a lesser extent, estrogen, for a period of up to 12 days after ovulation. The effect of progesterone leads to a further thickening of the endometrial lining, secretory and proliferative changes, and a relaxation of the myometrium to prevent contractions that can disrupt implantation of the zygote.
3.2) Essential Pharmacology of Medical Abortion Drugs
Medical abortion using pharmaceutical agents has been the most significant advancement since vacuum aspiration to revolutionize abortion service delivery. Although a number of drugs, such as gemeprost and methotrexate, have been used and studied for medical abortion, the two recommended drugs for a medical abortion are mifepristone and misoprostol
Mifepristone: Mifepristone, also known as RU- 486, is a steroidal anti-progestin and anti-glucocorticoid acting at the receptor level. When given orally, mifepristone competes with progesterone, the hormone necessary for a pregnancy to continue. Mifepristone binds to receptors and blocks the effects of progesterone. This leads to:
Depending on the process by which the drug is manufactured, its shelf-life can vary from 24 – 48 months. Mifepristone must be administered orally, with the effects noted in 12 -24 hours. The pharmacokinetics of mifepristone is characterized by rapid absorption, and a long half-life of 25 to 30 hours with adequate serum concentrations for biological action following ingestion of currently recommended doses.
Following oral intake and absorption, mifepristone is extensively metabolized by demethylation and hydroxylation to generate three metabolites: the mono-demethylated, di-demethylated and hydroxylated metabolites of mifepristone. All three of these metabolites retain considerable affinity toward the human progesterone and glucocorticoid receptors and are responsible for the biological actions of mifepristone.
Misoprostol: Misoprostol is a synthetic prostaglandin (Type E1) that was initially registered for the prevention of gastric ulcers associated with non-steroidal anti-inflammatory drugs. However, since its initial discovery, a number of uses for Misoprostol have been identified in Obstetrics and Gynaecology. Misoprostol is currently used in many countries to start labor, prevent and treat post –partum bleeding, and treat incomplete or induced abortion. Given its wide range of uses, Misoprostol is included in the WHO List of Essential Medicines for Adults. It is also recognized in the UN Commission on Life saving commodities for women and children, specifically for its use in safe abortion.
Misoprostol is a relatively heat stable compound (particularly when compared to Oxytocin) but can rapidly deteriorate in the presence of high humidity and high temperature. Hence, it is important that misoprostol tablets should be in double aluminum blister packaging and stored in a cool and dry place.
Once it is absorbed into the blood, misoprostol is converted to misoprostol acid, which leads to the following two actions;
2Heikinheimo O, Clinical pharmacokinetics of mifepristone , Clinical Pharmacokinetics - 1997 Jul;33(1):7-17. DOI: 10.2165/00003088-199733010-00002
3O.S. Tang et al. misoprostol: Pharmacokinetic profiles, effects on the uterus and side-effects. International Journal of Gynaecology and Obstetrics, 2007 99, S160-167
Misoprostol can be administered through a wide range of modes such as oral, sub- lingual, buccal or vaginal. The following is a brief overview of the pharmacokinetics of absorption and action for each of these routes:
1) Oral route: After oral administration, misoprostol is rapidly and almost completely absorbed but undergoes extensive first-pass metabolism to form misoprostol acid. Following a single dose of 400mcg oral misoprostol, the plasma misoprostol level increases rapidly and peaks at about 30 minutes then declines rapidly by 120 minutes and remains low thereafter. As a result, administering misoprostol through the oral route is associated with a sustained contraction of the uterus and not usually with rhythmic contractions essential for inducing an abortion. Due to this pattern of uterine stimulation, the oral route of administration of misoprostol is recommended as an option for treatment of an early, uncomplicated incomplete abortion only.
2) Vaginal route: Following vaginal administration, the plasma concentration increases gradually, reaching its maximum level after 70 -80 minutes, and then slowly declining with detectable drug levels present after 6 hours. This longer bioavailability of the drug is the possible explanation for the effectiveness noted with this route of administration.
3) Sublingual route: Although misoprostol tablets were made for oral use they are very soluble and usually dissolve in 20 minutes when put under the tongue. This leads to rapid absorption from the mucosa and avoids the first pass metabolism in the liver, thus reaching a peak concentration in about 30 minutes. This sublingual misoprostol administration is noted to have the shortest time to peak concentration, the highest peak concentration, the greatest bioavailability, and therefore a quick onset of its action. However, this rapid rise in peak concentration can also be often associated with a higher incidence of side-effects such as chills, fever and diarrhea.
4) Buccal route: Another way of administering misoprostol is by placing the tablet between the bottom teeth and the cheek, allowing it to be absorbed through the buccal mucosa. While there are limited clinical studies on the effectiveness of outcomes on this route, it is an acceptable route for some women. Following this route of administration, the time to peak concentration and the levels of peak concentration are similar to vaginal routes of administration.
Thus depending on the route of administration, most women will usually experience cramping and bleeding within 1-2 hours of the first dose of misoprostol and will expel the pregnancy within 24 hours of taking the last pills of misoprostol.
Lesson 4: Pre-abortion Care
In this lesson, we will discuss the importance of screening patients for medical abortion. We will also identify the key objectives of screening, and how to satisfy these objectives in a simple and efficient manner. Upon completing this lesson, you will be able to explain the importance and goals of screening patients for a medical abortion within your practice.
4.1) Goal of Pre-abortion Care
Pre-abortion care refers to a focused interaction between the physician and the client to ensure that the client is eligible to receive a medical abortion with minimal or no medical support and supervision.
The main goal of pre-abortion care is to make sure that appropriate drugs and information can be provided to women to ensure that the medical abortion process is safe, reduces the risk of avoidable complications, and improves the possibility of a successful abortion.
4.2) Objectives of Pre-abortion Care
The critical objectives of pre-abortion care include:
Objective 1: The first objective of pre-abortion care for patients is to establish a pregnancy and confirm the site and gestational age.
Why is this important? In order to assess eligibility for medical abortion, it is essential to ascertain that a woman is pregnant, and confirm the site and duration of the pregnancy to ensure a safe and successful abortion. Medical abortion using misoprostol alone or in combination with mifepristone will be effective for uterine pregnancies. Additionally, the appropriate dose of misoprostol will reduce the chance of a failed procedure due to low dosing or uterine over-stimulation from over dosing relative to the duration of pregnancy.
How to confirm pregnancy: A pregnancy can be confirmed through one or a combination of the following methods:
How to confirm site of pregnancy:
A bimanual pelvic examination that confirms signs of pregnancy along with an increase in the size of the uterus is usually adequate to establish a uterine pregnancy. It is also important to ensure absence of signs suggesting an ectopic pregnancy. Signs of an ectopic pregnancy can include a significant discrepancy between the LMP and the uterine size, the presence of an adnexal mass or tenderness felt through the lateral walls of the vagina, and tenderness in the pouch of Douglas.
The most definitive way to confirm the site of a pregnancy is by an ultra sonogram. The ultra sonogram should be trans-vaginal if there is less than 6 weeks of amenorrhea, or trans-abdominal if there is greater than 6 weeks of amenorrhea.
Given the low incidence of ectopic pregnancies, there is no clinical indication for a routine use of ultra sonograms in early medical abortions. Ultra sonograms should only be used if there is a clinical suspicion of either an ectopic pregnancy, or if there are doubts about gestation age of the pregnancy.
Note: A combination of rising human chorionic gonadotropin (hCG) levels, an empty uterus observed on ultra sonogram, abdominal pain, and vaginal bleeding indicate an ectopic pregnancy. Medical abortion drugs are ineffective to end an ectopic pregnancy. Additionally, these are often the primary cause of first trimester maternal mortality and should be diagnosed early.
How to confirm duration of pregnancy:
The duration of a pregnancy can be confirmed through one or a combination of the following methods:
Ensure that the pregnancy is not likely to be beyond 11 weeks based on your calculation. If the pregnancy is expected to be 11 weeks or less based on your calculation, you can safely dispense medical abortion drugs as indicated in the regimens in lesson 5
If the pregnancy is likely to be beyond 11 weeks based on your calculation, then do not dispense medical abortion drugs as per the protocol in lesson 5. You will need to adjust the dose of the misoprostol based on the gestational age, and the woman may need additional support and or medical supervision.
Objective 2: Assess eligibility for medical abortion and screen for contra-indications to the use of medical abortion drugs.
Like all medications and drugs, mifepristone and misoprostol have certain contra-indications to use, such as a known allergy to mifepristone, misoprostol or other prostaglandins, or if the woman has certain medical conditions which exclude the use of these drugs.
Contra-indications for Mifepristone use include:
Contra indications for Misoprostol use include:
Where a woman has a contra-indication to the use of Mifepristone, a Misoprostol-only regimen can be used safely, provided there is no contra-indication to Misoprostol use.
While the presence of any inherited bleeding disorder is a contraindication for medical abortion, the concurrent use of low-dose aspirin or clopidrogel (an anti-platelet drug) is usually not an absolute contra-indication for use of medical abortion drugs. While no recent study has examined the risk of bleeding for either therapy in women undergoing abortion, in general, low-dose aspirin therapy does not increase the severity of bleeding complications or perioperative mortality. However, if a client is using both low-dose aspirin and clopidrogel, they should be medically evaluated before administration of medical abortion drugs4.
The prevalence of porphyrias is variable in different populations, and is a difficult condition to screen for in the absence of prior history. Even in health facilities, this condition may only be diagnosed retrospectively following administration of the medical drugs. Thus, be aware of this and inform the patient that an acute attack may be triggered by administration of medical abortion drugs.
In addition to the above conditions it is important to note that there are a number of other medical conditions that can necessitate the need for medical supervision or support during a medical abortion.
4Burger W, Chemnitius JM, Kneissl GD, Rucker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005;257(5):399–414
Stable, controlled chronic medical conditions such as hypertension, diabetes, or asthma are common, and an early medical abortion can be safely managed in outpatient settings. Occasionally, preexisting medical conditions necessitate referral to a hospital setting for abortion care. These conditions usually include uncontrolled chronic illnesses such as hypertension, diabetes mellitus, asthma or complex medical conditions involving the central nervous system, endocrine, pulmonary, and cardiac conditions.
It is also important to note that medications to treat epilepsy, TB and anti-retro-viral drugs can reduce the effectiveness of mifepristone if they are taken regularly. This should be taken into account when providing a medical abortion.
Objective 3: Assessing pain management needs of patients:
As outlined in lesson 3, key sources of pain during a medical abortion include cramping and pain from uterine contraction and when products of conception are expelled through the cervix. Pain levels experienced by women are variable depending on a number of factors, such as duration of pregnancy, tolerance to pain, anxiety levels, and level of comfort when undergoing the medical abortion process. Pain relief should be always offered to all women undergoing medical and surgical abortion without delay. Each woman should be individually assessed with regards to her pain management needs. The role of non-pharmacological methods to reduce pain and anxiety for abortion procedures are essential. These include preparation before taking medical abortion drugs, being in a safe and comfortable place, wearing comfortable clothing, access to emotional support, and the use of hot water bottles to place over the lower abdomen during the abortion process. Additional discussions on the management of pain during a medical abortion are discussed in lesson 6.
Lesson 5: Medical Abortion Drugs and Their Use
In this lesson, we will discuss important considerations while dispensing medical abortion drugs. Upon completing this module, you will be able to correctly indicate the drugs used for medical abortion, their doses, timing and route of administration for an abortion in the first 11 weeks of a pregnancy.
Following the screening step, you should be have assessed the duration of the pregnancy and established that the client is eligible to take medical abortion drugs. Based on the local situation and the availability of drugs, there are two options for a medical abortion:
Option 1: A combination regimen that uses mifepristone followed by
Option 2: Using repeated doses of misoprostol only
Where both options are available, information on their effectiveness should be presented to the client along with the cost options for them to decide their preferred option. Salient features of both the methods are compared in the following table.
|Mifepristone and Misoprostol||Misoprostol only medical abortion|
|Highly effective when used on the first 10 weeks of a pregnancy (95% – 99%), with success comparable to vacuum aspiration||Effective with success rates in the range of 75% – 90%|
|The risk of an continuing pregnancy as an adverse event of this method is very low (<1 %)||The risk of the pregnancy continuing even after taking the prescribed regimen is fairly significant about 5 -10%|
|More expensive as there are two types of drugs used||Likely to be less expensive|
5.1) How To Use Abortion Pills: Mifepristone And Misoprostol
When prescribing both mifepristone and misoprostol, ensure that the full regimen is available to the client. It is important to have the full set of medicines before the first dose is taken to ensure that the process is successful.
The patient should have access to one 200mg tablet of mifepristone and four 200mcg tablets of misoprostol with the following instructions on how to take them:
Step 1: Swallow one pill of Mifepristone (200 mg) with water. Some women (up to 40%) can experience nausea after taking Mifepristone. If the client vomits within one hour of swallowing the Mifepristone pill, it is unlikely to work and she should repeat the dose. If the client vomits after an hour of swallowing the Mifepristone pill, enough drug would have been absorbed for the abortion and she does not have to repeat the dose.
Step 2: Wait 24-48 hours. You should tell the client to wait 24 hours before using Misoprostol, but wait no longer than 48 hours. While the client waits, they can do the things that they normally do in their everyday life, like taking care of family or going to work or school. Less than 10% of women experience bleeding or cramping following the administration of Mifepristone.
Step 3: After 24 hours and before 48 hours, drink some water to make your mouth moist. Put the 4 Misoprostol pills (200 mcg each) between your cheek and bottom gums (2 pills on each side), or directly under your tongue.
Step 4: Hold the Misoprostol pills in your cheeks or under your tongue for 30 minutes. It may make the mouth dry or taste chalky as they dissolve. Do not eat or drink anything for these 30 minutes. Swallow any secretions in your mouth normally and do not spit out anything during these 30 minutes.
Step 5: After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.
5.2) How To Use Abortion Pills: Misoprostol Only
When prescribing misoprostol only, ensure that the full regimen is dispensed to the client. Since it is difficult to identify which women will need additional doses and how many, providing less than the full dose may lead to a lower success rate in terminating pregnancies and other adverse events.
Ensure that twelve (12) 200mcg tablets of misoprostol are available with the patient and provide the following instructions on how to take them. When instructing patients on how to take the tablets, ensure that they take the tablets out of their blister packaging only prior to using them. All other doses should be retained intact in their blister package until they are to be taken by the patient.
The instructions for a misoprostol-only medical abortion are as follows:
Step 1: Drink some water to make your mouth moist. Put the 4 pills directly under the tongue, and let it dissolve. Hold them in place under your tongue for 30 minutes. They may make your mouth dry or taste chalky as they dissolve. Do not eat or drink anything for 30 minutes. Swallow any secretions in your mouth normally and do not spit out anything during these 30 minutes.
After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.
Wait 3-4 hours before proceeding.
Step 2: After 3 -4 hours, even if you are cramping and have started bleeding, repeat Step 1 with 4 more pills.
Wait 3-4 hours after completing Step 2.
Step 3: After an additional 3 - 4 hours (i.e. 6- 8 hours from taking the first dose of Misoprostol) repeat Step 1 with the last set of 4 pills. Make sure you complete Step 3 even if you are cramping actively and bleeding and can see the products of conception coming out.
Lesson 6: Clinical Course - Medical Abortion
In this lesson, we will discuss the additional care that you can provide to women undergoing a medical abortion. Information in this module will help you to support patients in managing both the expected and undesirable side effects of medical abortion, and increase satisfaction of patients with a medical abortion experience.
In addition to providing the medical abortion drugs, there are other efforts that you can provide as a physician that will ensure a positive and comfortable experience to patients undergoing a medical abortion. These efforts are integral to ensuring that the service you offer is high quality and leads to client satisfaction.
6.1) Expected Effects and Their Management
The common symptoms experienced during a medical abortion include cramping and bleeding. Both of these symptoms are essential and expected of the medical abortion process. It is important that all women are informed of these symptoms and provided with appropriate support and care beforehand to help manage these symptoms better.
In addition to these symptoms, as with any medication, some women may experience side effects that are not desirable and can affect the overall experience of a medical abortion for the client. It is important that women are aware of both the expected symptoms necessary for the abortion to be completed, and the side-effects that can be experienced as a result of taking the medications.
While prolonged or serious side effects are rare, minor side effects can be common during medical abortion. For most women, these side effects typically go away within 4 to 6 hours of taking the misoprostol. There are no long-term side effects of medical abortion.
Supportive care is aimed at effectively managing the symptoms and side effects of the medical abortion drugs to help patients have a safe and comfortable abortion.
Managing expected symptoms
Before starting the abortion process, make sure that women know:
It is important to inform the woman that most of the side effects are likely associated with misoprostol, and thus she should arrange to be in a safe, comfortable and private place before she uses the misoprostol.
Most women experience abdominal pain and cramping within the 30 minutes after using misoprostol. Cramping is the sign that the uterus has started to contract and is in the process of expelling the products of termination. This is a sign that the medication is working. The level of pain experienced through cramping varies greatly. It is related to the duration of the pregnancy, strength of uterine contractions, anxiety levels and the pain tolerance limits of the individual.
Most women will experience bleeding closely associated with cramping. While less than 10% of women will experience bleeding after taking mifepristone, most women will begin bleeding after the first dose of misoprostol. Once started, bleeding may last several hours and is heaviest during the expulsion of the products of conception. Women may see large clots of blood or tissue during the process and should not be alarmed just by noticing these during the process of expulsion.
The amount and pattern of bleeding varies from women to women and is related to the duration of the pregnancy. For most women, bleeding will become less heavy 1-2 hours after expulsion of the pregnancy, and will continue for one to two weeks with diminishing intensity. Some women experience bleeding or spotting for up to four weeks after taking the medical abortion pills.
Both of these symptoms are useful because they show the medicines are working. However, to ease the experience and provide relief from the cramping, women should always be offered pain medication.
To help manage pain during a medical abortion:
6.2) Side Effects and Their Management
In addition to the previously mentioned expected effects, misoprostol can also have some unpleasant side effects. The incidence and severity of the side effects are related to the route of administration of the misoprostol. Sub- lingual administration is commonly associated with a reported higher incidence of side effects. Therefore, it is important to support women in managing these undesirable side effects for a comfortable experience.
Nausea and Vomiting
Nausea, dizziness and vomiting may occur for some women and will resolve 2 to 6 hours after using misoprostol. Sometimes nausea due to pregnancy can be worse or confused with that caused by the administration of misoprostol. This can be very bothersome for women and can lead to vomiting and dehydration. This usually resolves once the pregnancy is terminated and the effect of misoprostol has decreased.
Provide supportive advice, such as eating light dry food items, to help manage nausea. Additional anti-emetic medications, such as Domperidone, Onadansetron and Metaclopromide, can also be provided to the client to manage these side effects, provided there are no contraindications for their use.
Up to 20% of women using misoprostol can also experience dizziness that is poorly explained. Ensuring that the women are not hungry and lying down usually helps this side effect. As with other side effects, this also usually self-limiting and no supplementary medications are indicated.
Stomach cramps and Diarrhea:
Up to 40% of women also experience mild to moderate diarrhea. In some cases, using misoprostol with food can help limit this symptom. While this is usually self-limiting and resolves within a day after the last dose of misoprostol, additional medications such as Loperamide can be dispensed to help women manage this if needed.
Fever and Chills
The incidence of fever is related to misoprostol dosage and route of use. The highest incidence is found in the high-dose sublingual routes. However, there appears to be genetic variations between ethnic groups. Most women using a sub-lingual route of administration experience a transient increase in body temperature associated with chills. Fever is usually highest 1-2 hours after using misoprostol and usually ends within 8 hours of the last dose. Ibuprofen taken for pain management usually helps with this side effect as well. If that is not adequate and the fever is bothersome, paracetamol can also be used in addition to Ibuprofen. However caution has to be taken to limit the overall use of NSAIDs in a 24 hour period.
6.3) Warning Signs and Their Management
Medical abortion in the first trimester is a very safe procedure and thus major complications are rare. However it is important that women are provided with clear information on the warning signs of a serious complication so that they can take timely action to avoid adverse outcomes. Possible signs of complications a woman may experience are:
A woman experiencing any of these warning signs is likely to be experiencing an adverse event and should seek immediate care in a health facility. In many cases, limited intervention by a trained health provider is adequate to address the above mentioned conditions. In very rare cases, women may require hospitalization, additional surgical intervention, blood transfusion or advanced care.
At the end of the consultation it is always important to check if:
Lesson 7: Post Abortion Care
In this final lesson, we will discuss key information to assist women who seek post-abortion care, either following an induced abortion elsewhere or following care provided by you to terminate an unwanted pregnancy. By completing this lesson successfully, you will be able to provide effective post-abortion care to women, such as managing an incomplete abortion, discussing the return of fertility and its management as needed, and making needs-based or requested linkages to other sexual and reproductive health services.
7.1) Follow Up of Early Medical Abortion
Duration for Abortion
The pregnancy is usually expelled within 24 hours of taking the last misoprostol pills. However, the entire abortion process may continue over the following days. A majority of women complete the abortion process by 7 days, while some women may continue the process for a short period beyond 7 days. Since the duration of bleeding and cramping is different for every woman, it is very hard to predict what the experience will be like. As long as the woman is expelling the products of conception, not experiencing any warning signs, and experiences a decrease or absence of the symptoms of pregnancy, there is nothing more to be done.
Generally heaviest bleeding occurs during the actual abortion. Most often, this entails more bleeding than a heavy menstruation period with cramps. Bleeding and cramping decrease after the products of conception have been expelled. Some bleeding similar to the amount experienced during a menstruation period will continue for up to two weeks after the abortion. However, the intensity of the bleeding must gradually decrease over time.
Follow- up after a medical abortion:
Women who use mifepristone and misoprostol for an early medical abortion do not have a clinical indication for a follow-up visit with a healthcare provider, so long as after the abortion the patient no longer feels pregnancy symptoms, has no warning signs, is in good health, and her bleeding is decreasing.
However, when using misoprostol only for medical abortion, up to 10% of women may experience a continued or ongoing pregnancy. This indicates that the misoprostol has not been able to successfully terminate the pregnancy. Therefore, providers should take extra effort to counsel women about signs of continuing pregnancy, and provide appropriate care to terminate the pregnancy in a timely manner. Typically women who have light or no bleeding following the use of misoprostol and experience the continued symptoms of pregnancy should be alerted of a possible failed abortion. In such cases women must be provided with clear instructions on how to seek follow up care with a healthcare provider seven days after the last dose of misoprostol in order to confirm the successful termination of pregnancy.
In addition to this, it should be noted that misoprostol can affect the growing embryo or foetus. Therefore, if the abortion fails and the pregnancy continues, the embryo or foetus may be at risk of developing congenital skeletal, cranial, or nerve anomalies, as well as other birth defects. Patients should be fully informed of these serious risks should they be considering continuing a pregnancy following a failed misoprostol only medical abortion.
7.2) Management of an Incomplete Abortion
The definition of an incomplete abortion can sometimes vary from one clinical setting to another. However, in most settings, the following operational definition is accepted; an incomplete abortion is a condition in which parts of the products of conception are retained in the uterine cavity along with an open cervical os.
It is important to note that an incomplete abortion, in addition to being distressful to the patient, can also lead to continued loss of blood and increase the risk of infections. Thus, they must be managed to ensure a successful outcome. Since medical abortion is a process, it is important for physicians to be aware of the normal process and not intervene during an ongoing medical abortion to diagnose the condition as an incomplete abortion. In most cases, for women using good quality drugs in the regimens outlined in lesson 5, the abortion should be completed by 7 days.
Incomplete abortion can be treated with expectant management, which allows for spontaneous evacuation of the uterus, or active management, using surgical or medical methods. Expectant management is not preferred by many patients and physicians due to its relatively low efficacy and because the time interval to spontaneous expulsion is unpredictable. Surgical management using vacuum aspiration may also not be easily available or possible. The use of misoprostol for an early uncomplicated incomplete abortion is a safe, effective and feasible option in many settings.
In some settings, women with an incomplete abortion may experience complications often linked to the method of induction used for the abortion. Women may have internal or external injuries, infection, sepsis, significant blood loss, and/or hemodynamic shock. In cases where women have signs of a systemic infection, pelvic infection, sepsis or hemodynamic instability, they need advanced care. This includes an immediate evacuation of the uterus using a surgical method along with supportive care such as antibiotics and IV fluids.
Once you have identified that a woman experiencing an incomplete abortion meets the following criteria, she is eligible for a medical management using misoprostol.
The eligibility criteria for medical management of an early, uncomplicated incomplete abortion is as follows:
There are two options while properly dosing for medical management of an early uncomplicated incomplete abortion.
Providers can administer a single dose of either 600 mcg of misoprostol given orally, or a single dose of 400mcg of misoprostol given sub-lingually.
7.3) Fertility management After an Abortion
An uncomplicated abortion has no negative consequences on a woman’s future fertility. Return of fertility after an abortion in the first trimester does not differ by the method of abortion. In fact, ovulation can occur as early as 8 days after an abortion. Approximately 83% of women ovulate during the first cycle following an abortion.
As mentioned earlier, it is important to acknowledge that a wide range of factors unique to each woman may influence her decision to seek an abortion. In order to fully respect patient rights, all women should be given full, unbiased information around the return of fertility and its implications.
Where women request contraceptive services, they should be provided ideally at the same site and during the same visit. The WHO’s medical eligibility criteria for contraceptive recommends that all methods of modern contraception except the Intra uterine device and bilateral tubal ligation can be provided during the same visit when the medical abortion drugs are given. The intra uterine device and bilateral tubal ligation can be provided as soon as the medical abortion is deemed to be complete.
7.4) Linkages to Other Health Services
Another key consideration for physicians to acknowledge is that in some instances, seeking care for an unwanted pregnancy may be a critical opportunity for a woman to interact with the health system. Where clinically required and requested by the patient, this can be an opportunity to assess and facilitate access to other health care needs for the woman.
The interactions between the physician and the patient can be an important opportunity that contributes to increase recognition, access and use of the reproductive and other health services women need. One approach is to ensure that where available, acceptable and feasible, the physician facilitates providing appropriate reproductive and other health services at the time women receive treatment for abortion complications, preferably at the same facility.
When it is not possible for a facility to provide needed additional services, or if the women requests time to consider this, functional referral and follow-up mechanisms should be made available to ensure that women's needs are being met in a respectful and non-coercive manner. Appropriate caution based on the local situation and values of providers towards abortion must be considered when referral for other services are identified or suggested to women.
Other reproductive and other health services that might be considered for linkages include:
iSedgh G et al., Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends, The Lancet, 2016.
iiRaymond, Elizabeth G.; Grimes, David A. The Comparative Safety of Legal Induced Abortion and Childbirth in the United States. Obstetrics & Gynecology. 119(2, Part 1):215-219, February 2012.
iiiSingh S, Darroch JE and Ashford LS, Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014, New York: Guttmacher Institute, 2014.
ivKassebaum NJ et al., Global, regional and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013, The Lancet, 2014, 384(9947):980–1004.
vSay L et al., Global causes of maternal death: a WHO systematic analysis, The Lancet Global Health, 2014, 2(6):e323–e333.
viSafe Abortion: Technical and Policy Guidance for Health Systems, Second edition page 18 (World Health Organization 2012):