Medical Abortion is a termination of pregnancy when it is unwanted or wanted but there is a certain abnormality in early part of pregnancy, called first trimester, until average of 9 weeks gestation.
This is an alternative way of surgical termination of pregnancy, which was a usual method of terminating pregnancy prior to discovery of the abortion pills.
The abortion pill’s name is Mifepristone and must be followed by other pills called Misoprostol. Neither of these two can act independently, i.e you can not use Misoprostol alone or you can not use Mifepristone alone. In a very rare case each of these two can terminate pregnancy, but it is exceptionally rare and it is also not recommended. There is also another medication called Methotrexate which is used for cancer treatment and sometimes it is given for an ectopic pregnancy to avoid surgical intervention of treating ectopic pregnancy, i.e terminating an ectopic pregnancy which is totally unwanted and can cause a severe emergency if it ruptures, and that can cause internal damage.
Some people use Methotrexate as a method for medical abortion and that to be followed by Misoprostol.
Clinician must be experienced in medical abortion. Clinician must also make sure that he or she is capable to carry out an ultrasound to access the size and the stage of the pregnancy and viability of the pregnancy and whether it is single or multiple foetuses. From the medico-legal part and from the licences and authority part he or she must differentiate between medical abortion for a viable pregnancy and medical abortion for a non-viable pregnancy.
Woman who is pregnant of unwanted pregnancy and continuity of the pregnancy can cause damages either to mother or to the baby this is the most common reason used for the legal documentation.
The woman must be counselled very well as some women are making a decision of terminating a viable pregnancy which has got no medical indication whatsoever and on a hasty decision, it probably might be a very simple decision on the basis of professional engagements, small argument with a husband/partner, worries that she may have had some exposure to medications or smoking, playing in her mind that baby could have been affected and became abnormal.
It is the clinician’s role and duty of care to ensure that these cases are properly counselled and addressing the fact that abortion is not a simple matter and it should be taken very seriously and decided upon very seriously to avoid future regret, psychological disturbance following a wrong non thoughtful decision of abortion.
Medical abortion is not usually an option after 9 weeks and surgical abortion, which is in the form of suction termination of pregnancy, is the safest and the best option. However, if an abnormal pregnancy is discovered after, 15, and up to 24 weeks there is a combination of medical and surgical intervention which can lead to a safe termination and a better option than straight surgical procedure.
Patients would be given the medications once clinician has made up his opinion jointly with the patients , the case is genuine and the woman is in full knowledge of the possible consequences of losing her baby; that is in case of a viable pregnancy. But in case of missed abortions the sooner the decision is made by the clinician the better to reduce any pain, agony or upset of the pregnant woman.
We use Mifepristone RU486 as medications which was developed and tested specially as an abortion inducing agents. It was discovered in France and China in 1988. Since then it has been used safely by millions of women worldwide. It was approved in the US 12 years later, in 2000.
Mifepristone is a medication which block the progesterone hormone which is essential to sustain a health progressive pregnancy, as a result of that block the Endometrium lining of the uterus and the deciduas breaks down and the cervix gently open and the bleed may begin; sometimes it does not begin before giving Misoprostol which is not recommended on BNF for abortion, but it has been found to be of great importance to create contractions and empty the uterus.
Methotrexate has been used in the US since early 1950s and it was approved by FTA as a drug for early abortions. Methotrexate is usually given to women in form of injection, although it can also be taken orally. The idea of Methotrexate is that it stops an ongoing implantation, process that occurs during the first weeks of conception. The earlier is the better.
The third medication we mentioned, Misoprostol, is given following Methotrexate or Mifepristone. It depends on the clinician’s choice to give it 6 hours later or 48 hours after the initial medications given. The dose must be calculated and given appropriately.
Woman usually bleeds following the medications and the bleeding can last up to 2 weeks and then patient should be assessed by scan following the initial dose of Misoprostol and one week later scan should confirm whether the uterus became totally empty or the pregnancy is still ongoing . There is a small chance of about 5% in case of Misoprostol and 15-20% in case of Methotrexate that the completion of pregnancy will take place in one week. After 2 weeks the majority of 2 methods will be terminated, the clinician must determine by then that the uterus is completely empty.
Clinician should be available at all times for patient in case the patient bleeds heavily to assess further or to intervene surgically if it is required.
Clinician should also be aware that patient may develop severe abdominal pain following Misoprostol medication which contracts the uterus. That severe pain should be alleviated by anti inflammatory suppressor, such as Voltarol, to help out ease the pain of the patient.
Clinician must also be careful that the future fertility of the patient is maintained and this is our philosophy at Queensway Clinic that the patient’s future fertility must be maintained at all times during any kind of treatment. Therefore we should spell it out for all the patients that the future of their fertility must be kept at best. Patient must be given antibiotic once she starts bleeding to ensure that there will be no possibility if pelvic infections which can cause damages to Endometrium as well as Fallopian Tubes and cause block of the tubes.
Blood test is mandatory prior any medical termination and if blood group RH –ve(negative), Anti-D must be given or else future pregnancy is at BIG Risk.
Medical termination should be available to all women who do not wish to continue their pregnancy on medical grounds.
Medical termination on social grounds is debatable and should be assessed very carefully for each case as an individual case by both the clinician and the counseller, if the clinician is not counselling himself.
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