Mifepristone and Misoprostol for Early Pregnancy Loss and Medication Abortion
Am Fam Physician. 2021 Apr 15;103(8):473-480.
Author disclosure: No relevant financial affiliations.
Medication regimens using mifepristone and misoprostol are safe and effective for outpatient treatment of early pregnancy loss for up to 84 days' gestation and for medication abortion up to 77 days' gestation. Gestational age is determined using ultrasonography or menstrual history. Ultrasonography is needed when gestational dating cannot be confirmed using clinical data alone or when there are risk factors for ectopic pregnancy. The most effective regimens for medication management of early pregnancy loss and medication abortion include 200 mg of oral mifepristone (a progesterone receptor antagonist) followed by 800 mcg of misoprostol (a prostaglandin E1analogue) administered buccally or vaginally. Cramping and bleeding are expected effects of the medications, with bleeding lasting an average of nine to 16 days. The adverse effects of misoprostol (e.g., low-grade fever, gastrointestinal symptoms) can be managed with nonsteroidal anti-inflammatory drugs or antiemetics. Ongoing pregnancy, infection, hemorrhage, undiagnosed ectopic pregnancy, and the need for unplanned uterine aspiration are rare complications. Clinical history, combined with serial quantitative beta human chorionic gonadotropin levels, urine pregnancy testing, or ultrasonography, is used to establish complete passage of the pregnancy tissue.
Medication management of early pregnancy loss and medication abortion has become increasingly common since the U.S. Food and Drug Administration (FDA) approval of mifepristone (Mifeprex) in 2000. Medication abortion now accounts for 60% of all abortions completed before 10 weeks' gestation.1 The most effective medication regimens combine mifepristone, a progesterone receptor antagonist that causes decidual necrosis and uterine contractions, and misoprostol (Cytotec), a prostaglandin E1 analogue that causes cervical ripening and uterine contractions. These regimens are safe and acceptable to patients and can be prescribed by primary care clinicians in the outpatient setting.2–4 Primary care clinicians are uniquely positioned to counsel patients and provide access to medications, with their wide geographic distribution, skills in shared decision-making, and longitudinal relationships with patients; however, only 1% of abortions currently occur in clinicians' offices.1
WHAT'S NEW ON THIS TOPIC
Early Pregnancy Loss and Medication Abortion
Based on a 2018 review, the National Academies of Sciences, Engineering, and Medicine concluded that medication abortion does not increase the risk of breast cancer, mental health problems, infertility, pregnancy loss, or preterm birth.
Medication abortion accounts for 60% of all abortions before 10 weeks' gestation.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A = consistent, good-quality patient-oriented evidence; B = inconsistent
Referencesshow all references
1. Jones RK, Witwer E, Jerman J; Guttmacher Institute. Abortion incidence and service availability in the United States, 2017. September 2019. Accessed September 23, 2020. https://www.guttmacher.org/report/abortion-incidence-service-availability-us-2017...
2. Schreiber CA, Creinin MD, Atrio J, et al. Mifepristone pretreatment for the medical management of early pregnancy loss. N Engl J Med. 2018;378(23):2161–2170.
3. Sinha P, Suneja A, Guleria K, et al. Comparison of mifepristone followed by misoprostol with misoprostol alone for treatment of early pregnancy failure: a randomized double-blind placebo-controlled trial. J Obstet Gynaecol India. 2018;68(1):39–44.
4. National Academies of Sciences, Engineering, and Medicine. The Safety and Quality of Abortion Care in the United States. National Academies Press; 2018.
5. Winikoff B, Dzuba IG, Chong E, et al. Extending outpatient medical abortion services through 70 days of gestational age. Obstet Gynecol. 2012;120(5):1070–1076.
6. Hsia JK, Lohr PA, Taylor J, et al. Medical abortion with mifepristone and vaginal misoprostol between 64 and 70 days' gestation. Contraception. 2019;100(3):178–181.
7. Dzuba IG, Chong E, Hannum C, et al. A non-inferiority study of outpatient mifepristone-misoprostol medical abortion at 64–70 days and 71–77 days of gestation. Contraception. 2020;101(5):302–308.
8. Dzuba IG, Castillo PW, Bousiéguez M, et al. A repeat dose of misoprostol 800 mcg following mifepristone for outpatient medical abortion at 64–70 and 71–77 days of gestation: a retrospective chart review. Contraception. 2020;102(2):104–108.
9. Bracken H, Clark W, Lichtenberg ES, et al. Alternatives to routine ultrasound for eligibility assessment prior to early termination of pregnancy with mifepristone-misoprostol. BJOG. 2011;118(1):17–23.
10. Raymond EG, Tan YL, Comendant R, et al. Simplified medical abortion screening: a demonstration project. Contraception. 2018;97(4):292–296.
11. Clark W, Panton T, Hann L, et al. Medication abortion employing routine sequential measurements of serum hCG and sonography only when indicated. Contraception. 2007;75(2):131–135.
12. Guiahi M, Davis A; Society of Family Planning. First-trimester abortion in women with medical conditions: release date October 2012 SFP guideline #20122. Contraception. 2012;86(6):622–630.
13. DailyMed. Drug label information: mifepristone tablet. Updated June 18, 2020. Accessed September 23, 2020. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b63fad9b-7f12-4400-9019-b0586054e534
14. Silver RM; Committee on Practice Bulletins–Obstetrics. Practice bulletin no. 181: Prevention of Rh D alloimmunization. Obstet Gynecol. 2017;130(2):e57–e70.
15. Horvath S, Prak ETL, Schreiber CA. A highly sensitive flow cytometry protocol shows fetal red blood cell counts in first-trimester maternal circulation well below the threshold for Rh sensitization. Contraception. 2018;98(4):332.
16. Mark A, Foster AM, Grossman D, et al. Foregoing Rh testing and anti-D immunoglobulin for women presenting for early abortion: a recommendation from the National Abortion Federation's Clinical Policies Committee. Contraception. 2019;99(5):265–266.
17. Wieringa-De Waard M, Hartman EE, Ankum WM, et al. Expectant management versus surgical evacuation in first trimester miscarriage: health-related quality of life in randomized and non-randomized patients. Hum Reprod. 2002;17(6):1638–1642.
18. Biggs MA, Upadhyay UD, McCulloch CE, et al. Women's mental health and well-being 5 years after receiving or being denied an abortion: a prospective, longitudinal cohort study [published correction appears in JAMA Psychiatry. 2017;74(3):303]. JAMA Psychiatry. 2017;74(2):169–178.
19. American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 554: reproductive and sexual coercion. Obstet Gynecol. 2013;121(2 pt 1):411–415.
20. GenBioPro. Patient agreement form. Mifepristone tablets, 200mg. May 2016. Accessed November 7, 2019. https://genbiopro.com/wp-content/uploads/2019/05/GenBioPro-Patient-Agreement.pdf
21. Danco. Patient agreement form. Mifepristone tablets, 200 mg. May 2016. Accessed November 7, 2019. https://www.earlyoptionpill.com/wp-content/uploads/2019/10/DAN_PatientAgreement_10.2019.pdf
22. Zhang J, Gilles JM, Barnhart K, et al.; National Institute of Child Health and Human Development (NICHD) Management of Early Pregnancy Failure Trial. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Engl J Med. 2005;353(8):761–769.
23. Chen MJ, Creinin MD. Mifepristone with buccal misoprostol for medical abortion: a systematic review. Obstet Gynecol. 2015;126(1):12–21.
24. Creinin MD, Schreiber CA, Bednarek P, et al.; Medical Abortion at the Same Time (MAST) Study Trial Group. Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol. 2007;109(4):885–894.
25. Schaff EA, Fielding SL, Westhoff C, et al. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion: a randomized trial [published correction appears in JAMA. 2000;284(20):2597]. JAMA. 2000;284(15):1948–1953.
26. Heikinheimo O, Leminen R, Suhonen S. Termination of early pregnancy using flexible, low-dose mifepristone-misoprostol regimens. Contraception. 2007;76(6):456–460.
27. Schaff EA, Fielding SL, Eisinger SH, et al. Low-dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception. 2000;61(1):41–46.
28. Hamoda H, Ashok PW, Flett GM, et al. A randomised controlled trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion up to 13 weeks of gestation. BJOG. 2005;112(8):1102–1108.
29. National Abortion Federation. 2020 clinical policy guidelines for abortion care. Accessed October 3, 2020. https://5aa1b2xfmfh2e2mk03kk8rsx-wpengine.netdna-ssl.com/wp-content/uploads/2020_CPGs.pdf
30. Raymond E, Chong E, Winikoff B, et al. TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States. Contraception. 2019;100(3):173–177.
31. Upadhyay UD, Desai S, Zlidar V, et al. Incidence of emergency department visits and complications after abortion. Obstet Gynecol. 2015;125(1):175–183.
32. Shannon C, Brothers LP, Philip NM, et al. Ectopic pregnancy and medical abortion. Obstet Gynecol. 2004;104(1):161–167.
33. Achilles SL, Reeves MF; Society of Family Planning. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception. 2011;83(4):295–309.
34. Tam WH, Tsui MHY, Lok IH, et al. Long-term reproductive outcome subsequent to medical versus surgical treatment for miscarriage. Hum Reprod. 2005;20(12):3355–3359.
35. Grossman D, Grindlay K. Alternatives to ultrasound for follow-up after medication abortion: a systematic review. Contraception. 2011;83(6):504–510.
36. Raymond EG, Weaver MA, Tan YL, et al. Effect of immediate compared with delayed insertion of etonogestrel implants on medical abortion efficacy and repeat pregnancy: a randomized controlled trial. Obstet Gynecol. 2016;127(2):306–312.
37. Raymond EG, Weaver MA, Louie KS, et al. Effects of depot medroxyprogesterone acetate injection timing on medical abortion efficacy and repeat pregnancy: a randomized controlled trial. Obstet Gynecol. 2016;128(4):739–745.
38. Goldstein RRP, Croughan MS, Robertson PA. Neonatal outcomes in immediate versus delayed conceptions after spontaneous abortion: a retrospective case series. Am J Obstet Gynecol. 2002;186(6):1230–1234.
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