First Trimester Termination: procedure selection
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Determine the methods of early abortion for which a woman is eligible based on medical and other factors. Then after the options, with pros and cons, have been objectively and thoroughly explained, help the patient select a method.
If the woman has had sufficient counselling to make an informed choice, either surgical or medical abortion can be offered.
A. MEDICAL ABORTION (≤ 8Weeks)
Research from Canada, United Kingdom, and France indicates that more than one half of eligible women opt for medical methods if given the choice. There is no medication indicated for pregnancy termination in Canada, so this method is managed with the off-label use of methotrexate followed by misoprostol or with misoprostol alone. The reported success of methotrexate in the treatment of ectopic pregnancies led Creinin and Darney, in 1993, to use methotrexate (50 mg/m2) and misoprostol (800 ìg) to induce abortion in early intrauterine gestation.
Numerous trials have demonstrated the safety and efficacy of this method, although it is less efficacious than surgical means. Unconditional follow-up is required to ensure success, and an alternative method must be available in the event of failure. The complete abortion rate is approximately 90% or more in gestations up to 49 days. For gestations of greater duration, the success rate appears to decline. (II-1A) Within 24 hours of the first or second dose of misoprostol, 78 percent of patients pass the products of conception (POC). (IA) The remainder of patients who ultimately have a successful medical termination have a delayed termination that may extend over several days.
When medical termination fails, it is mainly due to the incomplete expulsion of POC. Approximately 1% of patients will have an ongoing viable gestation that will require surgical evacuation because of the potentially teratogenic effects of misoprostol. (II-2A) There is no clear evidence that non-chemotherapeutic doses of methotrexate cause congenital anomalies.
Misoprostol alone can induce abortion in the early first trimester, although repeated doses may be required. In one study, misoprostol 800 ìg placed vaginally every 48 hours up to three doses, had a complete abortion rate of 93%.
Patient Selection
Candidates for the medical termination of pregnancy need a comprehensive screening to ensure a commitment to follow-up. The patient must be able to participate in the process, tolerate a potential delay in the termination, comprehend the instructions, and be emotionally stable. In addition, the patient must be willing to have a surgical procedure if the medical termination fails. Evidence suggests that the efficacy of medical abortion decreases with increasing gestational age; however, this method may be offered up to 56 days of gestation.
Contraindications
1. Sensitivity to the medications
2. Known coagulopathy
3. Active liver or renal disease
4. Severe anemia
5. Acute inflammatory bowel disease
Protocol
Investigation as described earlier with the addition of a quantitative βhCG.
(i) Methotrexate and Misoprostol
1. Administer methotrexate 50mg/m2 IM (deltoid administration ensures muscular placement) or 50 mg oral (20, 2.5 mg tablets),14 (IA) and Rh immune globulin if the patient is Rh negative. Prescribe analgesics (not NSAIDS), an antiemetic, and eight misoprostol tablets 200 ìg. Ask patient to abstain from intercourse and avoid foods containing folic acid, e.g., green vegetables, legumes, and oranges.
2. On the fifth, sixth, or seventh day after methotrexate, the woman places four misoprostol high in the vagina. If there is no bleeding or passage of tissue after 24 hours, four more tablets should be inserted.
3. On the third day after the first application of misoprostol, a quantitative βhCG serum level should be taken.
4. After seven days, another quantitative βhCG serum level should be taken, followed by an office visit. If the βhCG level has fallen by more than 80% over the seven days, the procedure was a success. If the βhCG level has decreased by less than this amount, a weekly quantitative βhCG serum level should be taken until the level approaches zero or the interval decrease is greater than 80%. If the βhCG level plateaus or increases, this indicates an incomplete abortion or ongoing viable gestation, and a vacuum aspiration should be arranged immediately.
5. Once termination is complete, confirm a non-pregnant, non-tender uterus by bimanual examination and initiate contraception.
(ii) Misoprostol Alone
1. Following a quantitative βhCG, misoprostol 800 g is placed high in vagina by the woman every 24 or 48 hours (days 1 - 5) until abortion occurs, or a total of three applications is reached (2400 g).19,20,21 (IA)
2. Rh immune globulin is given days one to seven inclusive if the patient is Rh negative.
3. On day six or seven, a quantitative βhCG serum level should be taken, to be followed by an office visit. If the βhCG has fallen by more than 80% over the seven days, the procedure was a success; however, taking an additional quantitative βhCG serum leve after a further seven days is recommended to ensure continued decline. If the βhCG has decreased by less than this amount, a weekly quantitative βhCG serum level should be taken until the level approaches zero or the interval decrease is greater than 80%. If the βhCG plateaus or increases, this indicates an incomplete abortion or ongoing viable gestation, and a vacuum aspiration should be arranged immediately.
4. Once termination is complete, confirm a non-pregnant, non-tender uterus by bimanual examination, and initiate contraception.
Ultrasound may be used instead of a quantitative βhCG serum assay in sites with rapid on-site access to determine whether the uterus is evacuated and the termination complete. In the many areas in Canada that have a long waiting list for ultrasound, it is preferable to use a quantitative βhCG serum assay to determine the outcome of medical termination of pregnancy.
Advantages Compared With Surgical Termination
1. Non-invasive
2. Patient autonomy: the patient feels more in control, and the process is less frightening
3. Private
4. Inexpensive
5. Technically simple
6. Office procedure
7. Immediate application possible
8. Alternative for failed surgical abortion, particularly if the problem involved difficulty accessing the uterus because of uterine leiomyoma or a congenital anomaly (II-3A)
Disadvantages Compared With Surgical Termination
1. Commitment to follow-up by patient and physician
2. Longer interval from start to finish
3. Gastrointestinal (GI) upset associated with the medications
4. Up to 10% may have a delayed evacuation of POC for several days to weeks
5. Heavy bleeding and cramps can occur when POC are passed, and the woman should be aware that she would experience this at home
6. Failed termination, defined as the need for a surgical evacuation, can occur in up to 5% of patients Success of medical termination of pregnancy can be increased if the patient is well informed and given realistic expectations of the process. The well-informed woman will have a higher threshold for surgical intervention in the event of a delayed reaction.
Victoria Jane Davis, MD
These guidelines were reviewed by the Clinical
Practice - Gynaecology Committee and the Social and Sexual
Issues Committee and approved by the Executive and Council of
the Society of Obstetricians and Gynaecologists of Canada.
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