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Induced abortions are performed using drugs or surgery. The safest and most appropriate method is determined by the age of the fetus, which is calculated from the beginning of the pregnant woman’s last menstrual period. Most pregnancies last an average of 39 to 40 weeks. This period is divided into three stages known as trimesters. The first trimester consists of the first 13 weeks, the second trimester spans weeks 14 to 28, and the third trimester lasts from the 29th week to birth. Abortions in the first trimester of pregnancy are easier and safer to perform while abortions in the second and third trimesters require more complicated procedures and pose greater risks to a woman’s health. In the United States, a pregnant woman’s risk of death from a first-term abortion is less than 1 in 100,000. The risk increases by about 30 percent with each week of pregnancy after 12 weeks.
Medical abortion may be an alternative to surgical abortion for some women seeking to terminate their pregnancies during the first trimester. Currently, there are two combinations of drugs that are most commonly used. The first is mifepristone, an antiprogestin that is distributed in Europe under the name RU-486, coupled with the prostaglandin misoprostol, an ulcer medicine marketed in the United States as Cytotec. The second method utilizes methotrexate, a drug also used to treat some cancers, arthritis, and psoriasis, as well as ectopic pregnancies. It, too, is combined with misoprostol for medical abortion.
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More than 300,000 women in Europe, and possibly more than three million in China, are estimated to have used mifepristone with misoprostol or another prostaglandin to safely end pregnancies of up to nine weeks from their last menstrual period. In the United States, the Population Council, a non-profit research organization, has completed a year-long clinical trial to determine the safety, efficacy, acceptability, and feasibility of the mifepristone/misoprostol method. More than 2,100 women participated in the research effort, carried out in 17 sites, including six Planned Parenthood clinics. Once the trials were concluded in September 1995, the Population Council asked the Food and Drug Administration to approve the drug combination for use as a method of medical abortion. One year later, the FDA issued a letter finding mifepristone safe and effective for terminating pregnancies. Additional information concerning labeling and manufacturing must still be provided before the agency will issue final approval.
To date, the only method of medical abortion available to women in the United States is the regimen using methotrexate and misoprostol. Although methotrexate has been available in the United States for more than 40 years, researchers have only recently discovered its efficacy in safely ending early pregnancies. Planned Parenthood Federation of America is now conducting a research project at 28 of its affiliates to study the use of the methotrexate/misoprostol combination for medical abortion. Thousands of women have already safely obtained abortions using this method in clinical trials, clinics, and doctors' offices. Both methotrexate and misoprostol are approved by the FDA, but not specifically for use in abortion. Doctors frequently prescribe approved medications for unapproved uses and this is perfectly legal.
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Mifepristone: In the clinical trials already conducted in the United States, 600 mg. (3 pills) of mifepristone were prescribed orally followed two days later by an oral dose of two pills of misoprostol. Other protocols are also being tested here. Mifepristone works by blocking receptors of progesterone, a key hormone that prepares the uterine lining to receive a fertilized egg and later maintains the pregnancy.
Methotrexate: is given through an intramuscular injection. Five to seven days later, four pills of misoprostol are inserted into the vagina. If an abortion has not occurred within 48 hours, a second set of four pills may be inserted. Methotrexate works by stopping development of the placenta or the embryo because it prevents cells from dividing and multiplying.
Misoprostol: whether administered orally or vaginally, causes the uterus or womb to contract and, when taken after mifepristone or methotrexate, results in a medical abortion. Outside of the United States, prostaglandins other than misoprostol are also used to induce contractions. In addition, misoprostol is being used by itself in other countries for medical abortion, but it is not nearly as effective as the combined regimens.
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Roughly half of women who obtain a medical abortion using mifepristone experience termination of the pregnancy within four hours of receiving misoprostol. Approximately 75 percent abort within 24 hours of taking misoprostol. For a few women, the process may take up to two weeks after the dose of misoprostol. After that point, women who have not ended their pregnancies do so surgically.
Usually, the minimum amount of time from the methotrexate injection to completion of the abortion is six to eight days. Uterine cramping and bleeding may begin within several hours after insertion of the misoprostol pills. For many women, the entire process will take two weeks or longer, and some women will not have completed their abortions in one month. Those women will still need a surgical abortion.
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Mifepristone/misoprostol: This regimen has been found to be approximately 95 percent effective in inducing a complete abortion when given through the end of the seventh week of pregnancy (49 days from the last menstrual period).
Methotrexate/misoprostol: Published studies by other medical researchers have found that the combination of methotrexate and misoprostol is approximately 85-90 percent effective in terminating pregnancies through the end of the seventh week (49 days from the last menstrual period).
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For mifepristone plus prostaglandin, the side effects are similar to those experienced by a woman who has a spontaneous miscarriage: uterine cramps, bleeding, nausea, and fatigue. Side effects of a single low dose of methotrexate might include nausea, diarrhea, abdominal cramping, hot flashes, or sores in the mouth. These are usually mild and do not last long. Other women experience vomiting, headache, dizziness, sleeplessness, or vaginal bleeding. In extremely rare cases, a woman may experience a severe, temporary drop in the number of white blood cells. Misoprostol produces the uterine cramping and bleeding needed to end the pregnancy. Other possible side effects might include nausea, vomiting, diarrhea, abdominal pain, dizziness, and/or fever and chills.
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The most common complication of a medical abortion, like the most common complication of miscarriage, is heavy bleeding. A small number of women may need curettage to stop the bleeding. Very rarely, a woman may need a blood transfusion.
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When medical abortion becomes widely available, it is likely to result in several changes in abortion practice, including:
More providers may be willing to offer abortion services because this drug regimen can be prescribed in their offices, potentially increasing the availability of early abortions.
Medical abortion gives women an alternative to even early surgical abortion, allowing them to choose to terminate their pregnancies much sooner, in some cases before they have missed a period.
Medical abortion may offer women more privacy in the abortion decision because they will not necessarily have to seek services at women’s health clinics that are often targeted for violence and harassment by abortion opponents.
Medical abortion gives women who want it greater personal control over the process of ending their pregnancy. Mifepristone has many potential uses beyond pregnancy termination. Researchers have found that it is more than 99 percent effective in preventing pregnancy when used as a post-coital contraceptive within 72 hours after unprotected intercourse or when other birth control methods may have failed. It is also useful as a hormonal contraceptive method. Mifepristone is also being tested for possible treatment of breast and prostate cancer, meningioma, Cushing's syndrome, glaucoma, endometriosis, and induction of labor.
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