CASE REFLECTION

Medical Abortion

William Ray Cassidy

08/268114/KU/12814

Instructor:
Prof. dr. Djaswadi Dasuki, MPH, Ph.D, SpOG(K)

Department of Obstetric and Gynecology

Faculty of Medicine Gadjah Mada University
RSUP Dr Sardjito
2013
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Case
A 36 years old woman (G2P1A0) came to ER in RSUP Dr Sardjito with
complaints of early amniotic membrane rupture. She was referred from a women and
child hospital with EGA 20 weeks. The patient has felt some contractions since evening.
Examination results revealed imminent abortion. The patient agreed to terminate the
pregnancy and received misoprostol 400 micrograms / 6 hours orally. The fetus and
placenta were expulsed few hours afterwards, but USG showed signs of incomplete
abortion. A D&C was then planned for the patient.
What method of abortion is preferred for this patient?

Clinical Problem
Early pregnancy failures occur in 15 percent of clinically recognized pregnancies.
The most common types of early pregnancy failure include spontaneous abortion,
anembryonic gestation, and embryonic or fetal death. Approximately one in four women
will have an early pregnancy failure during her lifetime.
Induced abortion is one of the most common medical interventions. In the
United States, approximately 1.2 million abortions were performed in 2008. About
one of three women will have had an induced abortion by the time she reaches
menopause.
Approximately 90% of abortions are performed in the first trimester because
the pregnancy is unintended or unwanted. A small but important proportion (1 to
2%) of abortions are performed later because of a fetal abnormality (e.g.,
anencephaly, trisomy, or myelomeningocele) or serious illness (e.g., cancer or
pulmonary hyper- tension) in the woman.
Until recently, the main method of abortion was surgical, but since 1992 in
the United Kingdom and since 2000 in the United States, medical abortion has
become increasingly available. Medical abortion involves the combined use of the
proges- terone antagonist RU-486 (now known as mifepristone), which initiates the
abortion, and a prostaglandin, which causes uterine contractions and empties the
uterus.
Strategies and Evidence
Medical management with misoprostol for early pregnancy failure appears to
offer more prompt evacuation of the uterus and has become an increasingly popular
alternative.
For most of the 20th century, dilatation and curettage was the commonly
accepted approach to early pregnancy failure. This practice can be traced back to the
late 19th and early 20th centuries, when illegally induced abortions commonly resulted
in hemorrhage and sepsis.

Diagnosis
For this case, a gynecological examination was performed to determine the
cervical condition, showing no dilatation, ruptured amniotic membrane with amniotic
fluid still present. USG should be performed in every patient suspected with imminent
abortion or other intrauterine abnormalities, before the decision of abortion is made.
Management
For pregnancies up to 12 completed weeks since last menstrual period, the
preferred methods are manual or electric vacuum aspiration, or medical methods using a
combination of mifepristone followed by a prostaglandin. Mifepristone followed by a
prostaglandin has been shown safe and effective up to 9 completed weeks of pregnancy,
and the safety and effectiveness of the regimen between 9 and 12 completed weeks is
under investigation.
The preferred medical method for abortions after 12 completed weeks since last
menstrual period is mifepristone followed by repeated doses of a prostaglandin such as
misoprostol or gemeprost. The preferred surgical method is dilatation and evacuation
(D&E), using vacuum aspiration and forceps.
In this patient, misoprostol was used to induce abortion, thus making it a
medically induced abortion, although a D&C was planned afterwards due to incomplete
abortion. It is chosen because the risks of hemorrhage and pelvic infection are similar to
those with vacuum aspiration, and the side effects are tolerable. Misoprostol treatment is
an acceptable alternative to surgical management for most women.
Natural prostaglandins, the first agents of this class used for medical abortion,
are unstable, lack specificity, and are poorly tolerated. Use of the parenteral
prostaglandin analogue sulprostone has been discontinued because it was associated
with cardiovascular complications, such as acute myocardial infarction and severe
hypotension. The synthetic prostaglandin E compounds currently used are misoprostol
and gemeprost (Fig. 2). Misoprostol is inexpensive, can be stored at room temperature,
and is available in many countries for the treatment and prevention of peptic ulcer
caused by nonsteroidal antiinflammatory drugs.
Oral doses of misoprostol ranging from 400 to 3200 g induce abortion in only 4
to 11 percent of women with pregnancies of 56 days duration or less. The
bioavailability is greater when the drug is administered vaginally, and higher success
rates have been reported with vaginal administration. Nonetheless, the results with
doses ranging from 800 to 2400 g vary considerably.

Guideline for methods of abortion (WHO)

Discussion
Misoprostol is particularly safe in many women, and the risk of side effects such
as hemorrhage is no greater than with curettage. In this case, oral administration was
chosen over vaginal administration. Although that method is also available, it is quite
intriguing since studies showed that vaginal administration will increase the efficacy
and successful rates of abortion. However, one study in United Kingdom showed that
the rate of serious infection after medical abortion declined by 93% after a change from
vaginal to buccal administration of misoprostol combined with routine administration of
antibiotics.
The usual regimen for induction of labor in the second trimester is 200 g of
misoprostol given vaginally every 12 hours. With this regimen, the rate of successful
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abortion (delivery of the fetus within 48 hours) ranges from 71 percent to 100 percent.
Increasing the frequency of misoprostol administration might be expected to increase
efficacy, but in one randomized study of 100 women, 200 g of misoprostol given
vaginally every 6 hours was no more effective than the same dose given every 12 hours
Toxic doses of misoprostol have not been determined; however, cumulative
doses of up to 2200 g administered over a period of 12 hours have been tolerated by
pregnant women, with no serious adverse effects. A dose of 6000 g of misoprostol,
taken orally to induce an abortion (in conjunction with trifluoperazine), resulted in
abortion, hyperthermia, rhabdomyolysis, hypoxemia, and a complex acidbase disorder.
The effects of misoprostol on the reproductive tract are increased, and gastrointestinal
adverse effects are decreased, if the oral preparation of misoprostol is administered
vaginally. When misoprostol tablets are placed in the posterior fornix of the vagina,
plasma concentrations of misoprostol acid peak in one to two hours and then decline
slowly (Fig. 1). Vaginal application of misoprostol results in slower increases and lower
peak plasma concentrations of misoprostol acid than does oral administration, but
overall exposure to the drug is increased.

Comparison between oral and vaginal administration of misoprostol.

Among women who were 9 to 11 weeks pregnant and given misoprostol before
a surgical abortion, intrauterine pressure began to increase an average of 8 minutes after
oral administration and 21 minutes after vaginal administration and was maximal 25
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minutes after oral administration and 46 minutes after vaginal administration. Uterine
contractility initially increased and then plateaued one hour after oral administration,
whereas uterine contractility increased continuously for four hours after vaginal
administration. Maximal uterine contractility was significantly higher after vaginal
administration
Prostaglandins are associated with a high incidence of side effects, including
pain, dizziness, nausea, vomiting, diarrhea, chills, and rashes. With misoprostol, the
mean duration of bleeding was 11 days. In cases in which misoprostol failed to
terminate pregnancy, congenital abnormalities in the infants, including scalp or skull
defects, cranial-nerve palsies, and limb defects such as talipes equinovarus, have been
reported. The increase in uterine pressure related to uterine contractions or vascular
spasm may be the cause of these teratogenic effects. Although prostaglandins can be
used alone to terminate pregnancy, because of the high incidence of side effects they are
usually used at reduced doses in combination with mifepristone or methotrexate.
Women with adrenal failure or severe asthma and those receiving long-term
glucocorticoid therapy should not be given mifepristone and prostaglandins. These
drugs should be used cautiously in women with complicated diabetes mellitus, severe
anemia, or hemorrhagic disorders and in those receiving treatment with anticoagulants.
Mbius syndrome (congenital facial paralysis) and limb defects have occurred
in the infants of women who have taken misoprostol during the first trimester in an
unsuccessful attempt to induce abortion.
Currently there are no evidence showing that a previous medical abortion, as
compared with a previous surgical abortion, increases the risk of spontaneous abortion,
ectopic pregnancy, preterm birth, or low birth weight, thereby making next safe
pregnancy is still possible.
Areas of Uncertainty
In studies available, vaginal administration of misoprostol is better than orally.
Even though there is one study showing increased rate of infection in vaginal
administration, the evidence is not strong enough. More evidence is needed to compare
incidence of complications between vaginal and oral administration of misoprostol.
Conclusion
In legal medicine practice, generally abortion methods is divided into medical and
surgical methods. In this case, medically induced abortion is more preferred. However,
it is not limited to only one method used in every patients, considering the risk of
incomplete abortion. Examinations and infection control should be done after every
abortion attempts.

Reference
Zhang, et al. A Comparison of Medical Management with Misoprostol and Surgical
Management for Early Pregnancy Failure. n engl j med 353;8
Templeton, A and Grimes, D A. A Request for Abortion. n engl j med 365;23
Wood, A J J (ed). Medical Termination Of Pregnancy. n engl j med 342;13
Fjerstad, et al. Rates of Serious Infection after Changes in Regimens for Medical
Abortion. N Engl J Med 2009;361:145-51
Safe Abortion : Technical and Policy Guideline for Health Systems. WHO 2003
Virk, et al. Medical Abortion and the Risk of Subsequent Adverse Pregnancy
Outcomes. N Engl J Med 2007;357:648-53