Information about Abortion

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•	neither she nor her partner has used a method of contraception at their most recent intercourse OR
•	they fear that the contraceptive used has failed (e.g. the condom broke or slipped off in the vagina)
•	sexual intercourse was within the past 120 hours.

•	mifepristone, an anti-progestogen drug, taken first, and
•	misoprostol, a prostaglandin drug , taken 24-48 hours later

Misoprostol alone

Methotrexate and misoprostol

•	Her health provider suspects or has confirmed that she has an ectopic pregnancy (see BOX 2).
•	She has an allergy to mifepristone .
•	She has an allergy to misoprostol .
•	She has a disease or condition affecting blood's ability to clot.
•	She is taking drugs for thinning the blood.
•	She is taking certain steroid drugs. If she is taking drugs orally or as injections for treating chronic arthritis, asthma and other allergic conditions, she should check to see if these are (or contain) corticosteroids. If in doubt, her health provider may be consulted.
•	She suffers from chronic failure of adrenal glands. Adrenal glands are small, triangular glands located on top of the kidneys and produce a variety of hormones including adrenaline, essential to help the body cope with stress.
•	She has inherited porphyries, which is an uncommon disorder of certain enzymes responsible for the formation of the iron-containing pigments in proteins.

•	belief that it was safer
•	more natural
•	no surgery and/or anaesthesia
•	one or both drugs may be taken at home
•	can be used in the early stages of pregnancy
•	easier and simpler

“I liked the tablets. See, I did not need to stay in the hospital. With curetting I would have spent two days there. I told my mother-in-law I was going to the market. I did not abort at the hospital although I waited for 3 hours. I was scared, would mother-in-law come to know? How many days I bled…I was going to the toilet every hour to check. See, we don’t have our own toilet. I felt embarrassed. But it happened when she was out. A little pain was there but that much is to be tolerated. Whatever you would have done, pain is always there. Everything has turned out well. I am very happy now. I will definitely use this method again. (Woman from India) [13]

“ ..Being outside of a doctor’s office makes you feel more in control, like you are not under somebody’s command. That this is my body, I’m in charge. I think actually the fact that you insert (misoprostol) yourself is a feeling like….this is my choice..my decision. There’s so much more power in it. (Woman from United States) [14].

In most countries, a home pregnancy test kit is available. This is a urine test. If a woman tests positive in a home pregnancy test, it is fairly certain she is pregnant. If her test is negative, it may still be too early to detect the pregnancy because theamount of hCG in the urine is still too low. The urine test can detect pregnancy about a week to ten days after a woman has missed her last period [15].

•	Calculating the number of days that have elapsed since the first day of the woman’s last menstrual period. Many women make a note of the first day of each menstrual period on a calendar so that they can check it if needed.
•	Having a pelvic examination carried out by a health provider. An experienced provider will be able to assess the duration of pregnancy through a pelvic examination starting from around six weeks LMP.

•	a woman is not sure of the date of her last menstrual period,
•	she has become pregnant without resuming her period after an abortion or a delivery, or
•	there are doubts about the duration of pregnancy even after the health provider has performed a pelvic examination.

Medical abortion for pregnancy ≤ 9 weeks	Surgical abortion using vacuum aspiration for pregnancy ≤ 9 weeks
Can be used from 4 weeks LMP.	May not be available before 7 weeks LMP.
Resembles a natural miscarriage.	Involves inserting a tube into the uterus to aspirate the contents.
Abortion usually happens at home. If misoprostol is given in the health facility , abortion happens there.	Abortion happens in a health facility.
Abortion process lasts more than one day.	Procedure is completed within 10–15 minutes.
Takes at least two clinic visits.	Takes one to two clinic visits.
May be painful for 2-3 hours or more after using misoprostol.	May be painful during aspiration and afterwards when the uterus contracts.
Severe complications are rare.	Severe complications are rare.
Longer period of bleeding up to several weeks, although amount of blood lost is the same as with surgical abortion.	Shorter period of bleeding, as most blood is aspirated during the procedure.
Anaesthesia is not needed. Pain medication should be available.	Pain medication, light sedation and local anaesthesia should be provided , .
Most effective for pregnancy of less than 7 weeks.	Most effective in pregnancies of more than 7 weeks.
Woman may see blood clots and the products of conception.	Woman does not see products of conception.

[16]

Oral mifepristone and oral misoprostol

Between 4 and 7 weeks of pregnancy [4]

Oral mifepristone and vaginal misoprostol

Between 4 and 9 weeks of pregnancy [5]

Misoprostol alone: vaginal or sublingual

Between 4 and 9 weeks of pregnancy [17]

Mifepristone: One 200 milligram pill , taken orally, followed by

Misoprostol: 400 micrograms (2 pills of 200 micrograms each), taken orally 24-48 hours after mifepristone .

Mifepristone : One 200 milligram pill taken orally, followed by

Misoprostol: 800 micrograms (4 pills of 200 micrograms each), to be inserted deep into the vagina 24-48 hours after mifepristone

Between 7-9 weeks, if bleeding does not occur within 4 hours after administration of misoprostol, a second dose of misoprostol 400 micrograms (2 pills of 200 micrograms each) may be inserted vaginally or taken orally.

Misoprostol 800 micrograms (4 pills of 200 micrograms each), to be inserted deep into the vagina,

Followed 3-6 hours later by a second dose of misoprostol 800 micrograms (4 pills of 200 micrograms each), inserted vaginally.

If abortion does not take place within 3-6 hours after the second dose, a third dose of 800 micrograms of misoprostol (4 pills of 200 micrograms each), can be inserted vaginally.

If the tablets are given sublingually, the three doses of 800 μg each are administered at 3 hour intervals
[32].

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Oral mifepristone and vaginal misoprostol

+ further doses of oral or vaginal misoprostol

Between 9 and 13 weeks of pregnancy

Oral mifepristone and vaginal misoprostol

+ further doses of oral misoprostol

Between 13 and 24 weeks of pregnancy

Mifepristone : one 200 milligram pill, taken orally, followed by

Misoprostol: 800 micrograms (4 pills of 200 micrograms each) to be inserted deep into the vagina 24-48 hours after mifepristone.

Further doses of 400 micrograms (2 pills of 200 micrograms each) of misoprostol, taken every 3 hours orally or vaginally (depending on the amount of bleeding) , to a maximum of 4 doses.

The woman is kept under observation in the clinic until several hours after she aborts.

Mifepristone: one 200 milligram pill, taken orally, followed by

Misoprostol: 800 micrograms (4 pills of 200 micrograms each), to be inserted deep into the vagina 24-48 hours after mifepristone.

Further doses of 400 micrograms of misoprostol (2 pills of 200 micrograms each), taken orally every 3 hours, to a maximum of 4 doses.

The woman is kept under observation in the clinic until several hours after she aborts.

•	counsels the woman
•	takes medical history to ensure that she does not suffer from any of the medical conditions that would make medical abortion inappropriate for her
•	asks the woman when the first day of her last period was and performs a pelvic exam to determine or confirm duration of pregnancy and absence of genital infection (if infection is present, it is treated)
•	may perform an ultrasound if duration of pregnancy cannot be accurately assessed through medical history and pelvic exam
•	gives her mifepristone to be taken orally
•	gives her the choice of either taking misoprostol at home, or coming back to the clinic for taking misoprostol under medical supervision.

•	gives her the 800 microgram dose of misoprostol (4 pills of 200 micrograms each) to be inserted vaginally, or 400 microgram dose of misoprostol (2 pills of 200 micrograms each) to be taken orally at home, 24-48 hours after mifepristone.
•	gives a pain-killer to help cope with the cramps and pain that the woman will experience once she has taken misoprostol.

•	carries out a physical examination to confirm that the pregnancy has been terminated
•	if in doubt after the physical exam, performs a pregnancy test or an ultrasound exam to confirm termination of pregnancy
•	if abortion is not complete, either asks the woman to come back after a few more days, as the abortion may be complete by then, or administers further misoprostol, or performs a surgical procedure to complete the abortion.

•	A small number of women develop bleeding after mifepristone alone. It is a good idea to go prepared with sanitary pads (bought from the shops or home-made).
•	In settings that require women to return to the health facility to take misoprostol, again, the woman should go prepared with sanitary pads in case she develops bleeding before returning home.
•	It is possible that some women cannot afford to buy sanitary pads from the pharmacy to last for the entire duration of bleeding. It is important for a woman to wash and sun-dry home-made sanitary pads and make sure that she changes pads as soon as they get soaked and she begins to feel discomfort because of the wetness.

Pain

•	Cramps and pain experienced by women are variable. Between a third and two-thirds of women experience only mild pain and do not even need an analgesic. Others may experience cramps that are comparable to severe menstrual cramps.
•	It may be good for the woman to be accompanied to the health facility by someone who can help if the woman has to travel back home on foot or by public transport, in case she develops severe pain and cramps.
•	When at home, the woman may lie down or sit comfortably to relieve pain. She may try to relax by listening to music, watching television, talking to friends/family members, taking a warm shower, or using a hot water bottle or heating pad on her abdomen for pain relief [11].
•	The woman may have been given pills for pain relief by the health provider on her first or second visit to the clinic. These may be taken as instructed. If no painkillers have been prescribed, she can take one available without prescription, such as Paracetamol.

•	Eating a light diet and consuming plenty of fluids will help if nausea, vomiting or diarrhoea develops. If these symptoms become severe, and a woman is unable to keep any food in, she should contact her health provider for medication to control vomiting and diarrhoea [11].
•	If the woman vomits within half an hour of taking an oral dose of misoprostol, she has to take a repeat dose of the drug.

Consumption of alcohol and drugs

•	Alcohol and narcotic drugs should not be taken when mifepristone/misoprostol have been taken, at least till the completion of abortion [24].

•	two thick sanitary pads get soaked with blood within 1 hour, and
•	this happens 2 hours in a row, i.e. she has to use four pads in two hours

•	a woman develops a fever above 100.4^o F (38.0^o C) that lasts for more than 4 hours, or
•	if fever starts 6 to 8 hours after she has taken misoprostol.

Fatal infections from Clostridium sordellii have been known to occur in women following childbirth and miscarriage as well. These infections, as well as those occurring after medical abortion, are extremely rare. It has been standard practice in the United States, Sweden, the UK and in many other countries to administer misoprostol vaginally. In other countries, misoprostol has typically been administered orally. Again, there is no evidence to suggest that the route of administration of misoprostol is related to infection from Clostridium sordellii.

•	there is no or only slight bleeding after taking the drugs for medical abortion
•	she continues to experience symptoms of pregnancy.

•	cost of mifepristone
•	cost of misoprostol
•	dosages (number of pills) of mifepristone and misoprostol used
•	cost of clinic consultations
•	cost of pregnancy testing
•	cost of ultrasound (if used).

•	USA	:	US$ 250 (600 mg)
•	Germany, Switzerland	:	US$130-140 (600 mg)
•	UK	:	US $ 75 (600 mg)
•	China, India, Vietnam	:	US $ 6-8 (200 mg)

[1]	Winikoff B. Global overview of medical abortion. Presentation at Medical Abortion: An International Forum on Policies, Programmes and Services, 17-20 October 2004, Johannesburg.
[2]	Shannon CS, Winikoff B. (editors). Misoprostol: An emerging technology for women’s health. Report of a seminar. New York, Population Council, 2004.
[3]	www.medicalabortion.org/questions/work.html, referred on 25 May 2005
[4]	World Health Organization. Safe abortion: Technical and policy guidelines for health systems. Geneva, WHO, 2003.
[5]	Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion. National Evidence-Based Clinical Guidelines. London: RCOG, September 2004. Summary at: <www.rcog.org.uk/resources/ Public/pdf/abortion_summary.pdf>. Accessed 27 October 2005.
[6]	Mifiprex (mifepristone) medication guide. www.fda.gov/cder/drug/ infopage/mifepristone/medguide.htm. Referred on 15 June, 2005.
[7]	Information on ectopic pregnancy from http://www.medicinenet.com/ectopic_pregnancy/article.htm. Referred on 10 June, 2005.
[8]	Hill NC, Selinger M, Ferguson J et al. The placental transfer of mifepristone during the second trimester and its influence upon maternal and fetal steroid concentrations. British Journal of Obstetrics and Gynaecology, 1990, 97:406-411.
[9]	Vogel D, Burkhardt T, Rentsch K et al. Misoprostol versus methylergometrine: pharmacokinetics in human milk. American Journal of Obstetrics and Gynecology, 2004, 191:2168-2173.
[10]	De Bruyn M. Safe abortion for HIV-positive women with unwanted pregnancy: A reproductive right. Reproductive Health Matters, 2003; Vol.11 No. 22: 52-61.
[11]	Gynuity. Providing medical abortion in developing countries: An introductory guidebook. New York, Gynuity Health Projects, 2004.
[12]	Berer M. Medical abortion: Issues of choice and acceptability. Reproductive Health Matters 2005;13(26):25-34):
[13]	Ganatra B. Contrasts and Common Ground: The Context of Abortion in Asia. Presentation at Medical Abortion: An International Forum on Policies, Programmes and Services, 17-20 October 2004, Johannesburg, South Africa
[14]	Elul B, Peralman E, Sorhaindo A, et al. In-depth interviews with medical abortion clients: Thoughts on the method and home administration of Misoprostol. Journal of the American Medical Women’s Association Volume 55, no. 3 supplement 2000 pp 169-172.
[15]	Information on pregnancy tests from www.4woman.gov/faq/pregtest.htm, referred on 10 June, 2005.
[16]	www.medicationabortion.org/questions/index.html referred on 15 May, 2005 with inputs from ICMA Steering Committee members and reviewers.
[17]	von Hertzen H, Nguyen H, Piaggio G, et al. Comparison of two routes and two intervals of administration of misoprostol for the termination of early pregnancy: a randomised multicentre trial. Interim results (unpublished)
[18]	Clinical Guidelines: medical abortion 13–20 weeks. London: bpas, 2005.
[19]	Schaff EA, Fielding SL, Westhoff C. Randomized trial of oral versus vaginal misoprostol 2 days after mifepristone 200mg for abortion up to 63 days of pregnancy. Contraception 2002;66:247-50
[20]	Hamoda H, Ashok PW, Flett G, et al. Medical abortion at 9–13 weeks' gestation: a review of 1,076 consecutive cases. Contraception 2005;71:327–32.
[21]	Consensus Statement: Instructions for use – Abortion induction with misoprostol in pregnancies up to 9 weeks LMP. Expert Meeting on misoprostol sponsored by Reproductive Health Technologies Project and Gynuity Health Projects. July 28, 2003, Washington D.C.
[22]	Fiala C, Swahn ML, Stephansson O, et al. The effect of non-steroidal anti-inflammatory drugs on medical abortion with mifepristone and misoprostol at 13-22 weeks gestation. Human Reproduction 2005;Aug 11 (Abstract only, e-publication).
[23]	Jain JK, Dutton C, Harwood B et al. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy. Human Reproduction 2005;17(6):1477-1482.
[24]	www.ppnyc.org/services/factsheets/mifep.htm referred on 2 June, 2005.
[25]	US Food and Drug Administration. FDA Alert for Healthcare Professionals: Mifepristone (marketed as Mifeprex), 22 July 2005. At: <http://www.fda.gov/cder/drug/InfoSheets/HCP/MifepristoneHCP.pdf> and <http://www.fda.gov/cder/drug/infopage/mifepristone/mifepristone-qa20050719.htm>. Accessed 29 August 2005.
[26]	Shannon C, Brothers LP, Philip NM, et al. Infection after medical abortion: a review of the literature. Contraception 2004;70:183–90.
[27]	Fischer M, Bhatnagar J, Guarner J et al. Fatal toxic shock syndrome associated with clostridium sordellii after medical abortion. New England Journal of Medicine 2005;353: 23522360.
[28]	Greene MF. Fatal infections associated with mifepristone-induced abortion. New England Journal of Medicine 2005;353: 23172318.
[29]	Grimes DA. Risk of mifepristone in context [Commentary]. Contraception 2005;71:161.
[30]	Chen A, Yuan W, Meirik O et al. Mifepristone-induced early abortion and outcome of subsequent wanted pregnancy. American Journal of Epidemiology 2004;160(2):110-117.
[31]	www.gynuity.org/pub_b.html#q6, referred on 7 February 2006.
[32]	Von Hertzen H, Piaggio G, Nguyen Thi My Huong, et al. Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomized controlled equivalence trial. Lancet 2007;369:1938-46.
[33]	US Food and Drug Administration. FDA Public Health Advisory Sepsis and Medical Abortion Update 17 March 2006. At: http://www.fda.gov/cder/drug/advisory/mifeprex200603.htm
[34]	US Food and Drug Administration. FDA Alert for Healthcare Professionals: Mifepristone (marketed as Mifeprex), 22 July 2005. At: www.fda.gov/cder/drug/InfoSheets/HCP/MifepristoneHCP.pdf and www.fda.gov/cder/drug/infopage/mifepristone/mifepristone-qa20050719.htm
[35]	Fischer M et al. Fatal toxic shock syndrome associated with clostridium sordellii after medical abortion. New England Journal of Medicine 2005;353:23522360.
[36]	Greene MF. Fatal infections associated with mifepristone-induced abortion. New England Journal of Medicine 2005;353:23172318.
[37]	Grimes DA. Risk of mifepristone in context [Commentary]. Contraception 2005;71:161
[38]	Jasveer Virk, M.S., M.P.H., Jun Zhang, Ph.D., M.D., and Jørn Olsen, M.D., Ph.D.Medical Abortion and the Risk of Subsequent Adverse Pregnancy Outcomes. New England Journal of Medicine, Volume 357:648-653, August 16,2007, Number 7