Medication Abortion
In Early Pregnancy
Induced termination
of early intrauterine pregnancy
using medications
6.4 Million Pregnancies/Year
in the U.S.
24% Unintended
Used Contraception
51%
Intended
25 % Unintended
Used No
Contraception
Finer, 2006 (2002 data)
Unintended pregnancy rate: by
race/ethnicity/income
180
160
140
Unintended
pregnancies
per 1,000
women
120
all
white
latina
black
100
80
60
40
20
0
Below poverty Above poverty
level
level
Finer, 2006
Outcomes of Unintended Pregnancies
(Approximately 3.1 Million Annually)
% of unintended pregnancies
100%
80%
60%
42%
44%
40%
14%
20%
0%
Abortions
Births
Miscarriages
Finer, 2006 (2002 data)
89% of abortions occur in the
first 12 weeks of pregnancy
3.3%
6.5%
9.4%
<9 weeks
9 to 10
11-12
weeks
9-10 weeks
17.3%
1.0%
11 to 12
Under
9 weeks
13 to 15
62.5%
16 to 20
21 or more
Guttmacher Institute, 2004 data
Abortion Access
• 87% of counties have
no abortion provider
• 35% of women live in
these counties
• 25% of women travel >
50 miles to find provider
Source: Jones et al., 2008; Kaiser Family Foundation
% of Women in Counties
with No Abortion Provider
Primary care
shortage areas:
with
and
without family
physicians
Graham Center, 2000
Abortion in Family Medicine:
Training Issues
450
400
350
300
abortion training
250
200
no abortion
training
150
100
50
0
1997
2007
Could training family
physicians in medication
abortion make a
difference?
Abortion in Family
Medicine:
Implementation Issues
Wanted versus unwanted pregnancy:
consequences
Medication & Aspiration Abortion:
both safe and effective
Safety of Abortion
First trimester abortions DO NOT increase risk of:
•
•
•
•
•
Infertility
Ectopic pregnancy
Miscarriage
Birth defect
Preterm or low-birth-weight delivery
Sources: Boonstra, 2006
Virk, J et al, NEJM, 2007
Medication Abortion Regimens:
Three Choices
Mifepristone + Misoprostol
Methotrexate + Misoprostol
Misoprostol alone
Most common med abortion regimen in US:
Mifepristone/Misoprostol
Medication Abortion: Advantages
• 95-99% effective
• Avoids surgical and
anesthetic risk
• Greater patient
autonomy & privacy
• Less invasive
• More “natural”
Aspiration Abortion: Advantages
Slightly more effective (about 99%)
Shorter time to completion
Shorter bleeding duration
Can be performed later in gestation
Mifepristone-Misoprostol Regimens
FDA Protocol
Alternate Protocol
Gestational age limit
49 days
63 days
Mifepristone dose
600 mg. oral
200 mg. oral
Misoprostol dose,
route, and timing
400 mcg. oral
Office administration
48 hours later
800 mcg. vaginal or buccal
Home self-administration
6 - 72 hours later
(vaginal)
24 - 36 hours later
(buccal)
Office follow-up visit
10-15 days after
mifepristone
4-10 days after mifepristone
Minimum office
visits
3
2
Cost of medications
$270 for mifepristone
$2.00 for misoprostol
$90 for mifepristone
$4.00 for misoprostol
MIFEPRISTONE
Causes
progesterone blockade
Decidual
Necrosis
Cervical
Ripening
Detachment
MISOPROSTOL
Causes uterine cramping & expulsion
Misoprostol
Yolanda
22 years old
Requests a pregnancy test
Counseling issues
Review all options
Assure that decision is hers
Establish gestational age
Rule out contraindications
•
•
•
•
Allergy to meds
Adrenal insufficiency
Current steroid use
Coagulopathy or
anticoagulant use
• IUD in place
• No access to follow-up
Indications for sonography
Yolanda
Gestational age:
6 weeks
Patient agreement
Yolanda takes mifepristone
in your office
At home:
Yolanda takes pain medication, then misoprostol
Follow-up visit
•4 - 14 days later
•Assure completion
•Process experience
•Review contraceptive
choice
Phone calls after medication abortion
Clostridium sordellii
• 6 deaths in North America due to toxic shock
with Clostridium following medication abortion
• Similar deaths, however, also seen following
miscarriage, childbirth, trauma, & surgery
• CDC: no causal link between medications and
these incidents
Source: CDC 2006, FDA 2006
Methotrexate + Misoprostol
medication abortion
Misoprostol-only medication abortion
800 mcg vaginally
> 1 dose may be needed
Conclusion
From pregnancy diagnosis through week nine,
medication abortion is safe and effective. As its
success depends on accessibility and
counseling, medication abortion is well suited
to the family medicine home.