RISK FACTORS: Chromosomal abnormalities, Luteal phase defect, Leiomyomas, Incompetent cervix, Infections, Antifetal antibodies, Autoimmune disease - phospholipid syndrome, Alloimmune disease (shared paternal antigens), Drugs, chemicals, X-irradiation
POSSIBLE COMPLICATIONS
β’ Complications of D&C include uterine perforation, infection and bleeding
β’ Possibly retained products of conception WITH BLEEDING
β’ Depression and feelings of guilt (patient may need education and reassurance that she did not cause the
miscarriage)
First- and second-trimester medical abortion :
First-trimester terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or mifepristone with or without misoprostol. Other prostaglandins are used in other countries.
Medical abortions are indicated for women who consent to a medical abortion but are also willing to undergo a surgical abortion if the medical abortion fails. Gestational age for the FDA-approved protocol is 49 days, but many protocols, including up to 63 days from the LMP, are in the literature and in widespread clinical practice. Also, literature documenting the safety of medical abortion protocols at 11-13 weeks is accumulating. Only scant reports exist of continuing pregnancies after misoprostol, but the current data do not suggest a teratogenic action of misoprostol exposure during pregnancy.
Contraindications to medical abortion vary depending on the regimen selected. Contraindications to mifepristone include serious medical problems, such as cerebrovascular or cardiovascular disease, severe liver, kidney or pulmonary disease, preoperative anemia (<10 mg/dL), undiagnosed ectopic pregnancy, allergies, contraindications to prostaglandin use, active uterine bleeding, or large uterine leiomyomata.
The mifepristone/misoprostol appointment schedule is as follows:
On day 1, mifepristone, typically 200 mg (600 mg PO is FDA regimen), is administered in the office.
On day 2 or day 3, the misoprostol (800 mcg vaginally or 400 mcg PO) is administered at home. The FDA regimen is administering the medication on day 3 with a 4 hour observation period after insertion; however, if the patient is bleeding, the misoprostol may be used immediately, as soon as 8 hours after the mifepristone.
The patient returns to the office for a follow-up 7 days after the medical abortion to determine if the abortion has been completed.
If the abortion is not complete, repeat misoprostol is administered or the patient may undergo a surgical abortion.
The methotrexate/misoprostol regimen is similar, as follows:
Methotrexate is injected on day 1.
On days 6-7, misoprostol is taken at home vaginally, and the patient returns to the office on day 8 to determine if the abortion has taken place. Misoprostol can be repeated and the patient monitored, or surgical abortion may be completed.
Prostaglandin-induced second-trimester abortion :
Prostaglandin can be administered vaginally, orally, or via extraovular or intra-amniotic infusion. The intra-amniotic route was associated with greater rates of uterine rupture, although rarely, and has been abandoned largely in favor of the safety and technical ease of oral or vaginal administration.
In a recent comparison study by Perry of intra-amniotic 15-methyl-prostaglandin F2-alpha and intravaginal misoprostol, the mean evacuation time was slightly less in the intra-amniotic group and the rate of success by 24 hours was higher in the intra-amniotic group. The total complete abortion rate and incidence of severe effects were similar in both groups.
Saline-induced abortion :
Twenty years ago, saline-induced abortion was the only viable means of aborting a mid second-trimester pregnancy, and most of the literature regarding this technique is from that era.
The process was long, laborious, had some potentially serious adverse effects, and has been abandoned for the greater maternal comfort offered by the dilatation and extraction procedures that subsequently have been developed. However, dilatation and extraction procedures are risky in the hands of inexperienced providers or providers who do not perform the procedures often enough to maintain competency.
In these circumstances, the saline-induced abortion can be safely used.
DRUG TREATMENT :
1. PROSTAGLANDINS : Abortifacient drugs of various types can be used for medical termination or treatment of ectopic pregnancy. Rarely, they are used to complete an incomplete surgical abortion. This class of drugs includes misoprostol, gemeprost, and PG05 (15MF2 alpha prostaglandin).
- MISOPROSTOL
2. ANTIPROGESTERONES : Antiprogesterone class of drugs used for medical termination. Other potential uses include postcoital contraception, leiomyomatas, endometriosis, endometrial cancer, breast cancer, ovarian cancer, glaucoma, myomas, and Cushing syndrome. Antiprogesterones do not effectively treat ectopic pregnancy and should not be used for this indication.
- MIFEPRISTONE
3. ANTIMETABOLITES : Methotrexate has been used for more than 15 years for the medical treatment of early, unruptured ectopic pregnancies. Success rate for this indication is greater than 90%. Adverse effects are minimal and regimens are cost effective. This offers effective destruction of rapidly dividing placental cells. Used for medical termination of pregnancy, although for complete expulsion, usually must be administered in conjunction with prostaglandin.
- METHOTREXATE
4. UTEROTONICS : The rapid and complete emptying of the uterus usually provides a natural uterine contraction process that successfully halts postabortion blood loss and eventually leads to normal uterine blood loss and normal uterine involution back to the prepregnant state. The uterotonic medications are typically used to enhance this process or to halt immediate postabortion bleeding. In some cases, these drugs can be inducers of uterine activity that are potent enough to lead to abortion without other drugs or regimens.
- OXYTOCIN
5. ERGOT ALKALOIDS : Also in the category of uterotonics and used almost exclusively for treatment of postabortal bleeding, atony, or hemorrhage
- METHYLERGONOVINE
6. PROSTAGLANDINS :
- CARBOPROST