Termination of Pregnancy in First Trimester - Medical Option


MCQ:

Method of termination of pregnancy in first trimester except

a) Misprostol + Mifepristone
b) Methotrexate + Mifepristone
c) Suction and evactuation
d) Ethyl dacrycyanate

Method of termination of pregnancy in first trimester

Introduction

Termination of pregnancy has been practiced since the time immemorial. Most widely used methods for terminating pregnancy in first trimester are surgical, primarily suction evacuation. An estimated 26 million pregnancies are terminated legally throughout the world, and 20 million are terminated illegally, with more than 78,000 deaths .

In India alone 10-12 million abortions take place annually, resulting in 15-20 thousand maternal deaths, mainly due to illegal abortions . Non availability of trained medical help and the unwarranted secrecy surrounding the unwanted pregnancy often force women to go for illegal abortion which may be fatal at times. The availability of safe drugs for termination of pregnancy would be of great value to the patients and medical profession and may save many lives. A number of drugs, considered safe for termination of pregnancy, have been tried recently. Some like mifepristone are expensive and not so easily available. In this article we focused on trial of easily available and cheaper alternatives like misoprostol and methotrexate for termination of pregnancy.

Methotrexate has long been used for the treatment of ectopic pregnancy with excellent results. Its use for termination of intra-uterine pregnancy is the natural outcome. The Food and Drug Administration, USA has approved misoprostol for prevention of gastric ulcer disease with the warning that it may lead to abortion in regnant patients. This particular side effect of the drug is now being used for therapeutic effect. This study has been undertaken to assess the efficacy and safety of misoprostol and methotrexate as abortifacient.


What Is Medical Abortion?



Definition

A medical abortion is one that is brought about by taking medications that will end a pregnancy. The alternative is surgical abortion, which ends a pregnancy by emptying the uterus (or womb) with special instruments. Either of two medications, mifepristone or methotrexate, can be used for medical abortion. Each of these medications is taken together with another medication, misoprostol, to induce an abortion.

When Is Medical Abortion Used?

Before any abortion can be done, a medical professional must confirm that a woman is indeed pregnant and determine how long she has been pregnant. The length of a pregnancy is usually measured by the number of days that have passed since the first day of the woman's last menstrual period (abbreviated as LMP). Medical abortions can be provided as early as a pregnancy can be confirmed. In fact, the shorter the time that a woman has been pregnant, the better the medications will work. Because they do not work as well later in the first trimester of pregnancy, medical abortion is not usually an option after nine weeks (or 63 days) LMP. After that, surgical abortion is the safest and best option.

How the Medications Work

Mifepristone. Mifepristone (the abortion pill or RU-486) is a medication that was developed and tested specifically as an abortion-inducing agent. It was first licensed in France and China in 1988. Since then it has been used safely by millions of women worldwide. It was approved for use in the U.S. in September, 2000.

Mifepristone is taken in the form of a pill. It works by blocking the hormone progesterone, which is necessary to sustain pregnancy. Without this hormone, the lining of the uterus breaks down, the cervix (opening of the uterus or womb) softens, and bleeding begins.

Methotrexate. Methotrexate has been used in the U.S. since 1953, when it was approved by the FDA to treat certain types of cancer. Since that time, medical researchers have discovered other important uses for the drug. One of these uses is to end unintended pregnancies. Although the FDA did not consider methotrexate for this specific purpose, clinicians may prescribe methotrexate for early abortion.

Methotrexate is usually given to a pregnant woman in the form of an injection, or shot, although it also can be taken orally. It stops the ongoing implantation process that occurs during the first several weeks after conception.

Misoprostol. Within a few days after taking either mifepristone or methotrexate, a second drug, misoprostol, is taken. Misoprostol tablets (which may be placed either into the vagina, between cheek and gum, or swallowed) cause the uterus to contract and empty. This ends the pregnancy.

Mifepristone and methotrexate work in different ways, and so they will have slightly different effects on a woman's body. A clinician can help a woman decide whether medically induced abortion is the right option for her, and which of the two drugs she should use.

How Long Do Medical Abortions Take?

It can take anywhere from about a day to 3-4 weeks from the time a woman takes the first medication until the medical abortion is completed. The length of time depends in part on which medications are taken and when the misoprostol is used. Complete abortion generally occurs sooner with mifepristone compared to methotrexate. The majority of women who take mifepristone will abort within four hours of using misoprostol. About 95% will have a complete abortion within a week. With methotrexate, 80-85% of women will abort within 2 weeks of taking the first medication. Some will take longer and may use additional doses of misoprostol.

During and After a Medical Abortion

Some women will have vaginal bleeding after the first drug. This bleeding may be light, or it may be like a heavy period. After taking the misoprostol, cramping and bleeding usually begin within a few hours, although it may take longer. The cramping and bleeding may be more than with a normal menstrual period. Written and verbal guidelines are given to all women to help them know what to expect, and when to call the clinic for further evaluation.

Most women in the United States use the misoprostol and expel the embryo at home. A woman considering medical abortion will need to be prepared for this. The clinic staff will provide guidance and answer questions about what to expect and how to manage the side effects at home.

The most common side effects of medical abortion are caused by misoprostol. In addition to cramps and bleeding, early side effects may include: headache, nausea, vomiting, diarrhea, fever, chills, or fatigue. If a woman experiences flu-like symptoms or abdominal pain more than 24 hours after using misoprostol, she is advised to call the clinic.

Most women have cramps for several hours, and many pass blood clots as they are aborting. Some women may see the grayish gestational sac. However, the embryo will probably not be seen among the blood clots. At 49 days LMP, the size of the embryo will be about one-fifth of an inch. In an earlier pregnancy, it might be much smaller than that. Cramps and bleeding usually begin to ease after the embryonic tissue has been passed, but bleeding may last for one to two weeks after medical abortion.

Some women report that their first regular menstrual period after a medical abortion is heavier, or longer, or in some other way different from normal for them. By the second period after the abortion, their cycles should be back to normal.

Possible Complications

About 95-98% of women will have a successful medical abortion. Complications are rare. However, a small percentage of women (approximately 0.5-2%) will need a suction aspiration (similar to a surgical abortion) because of heavy or prolonged bleeding. In about half of these cases, this heavy bleeding occurs 3-5 weeks after taking the medications. Rarely, in approximately 0.1-0.2% of cases, a blood transfusion might be required to treat very heavy bleeding. Some women also choose to have a suction aspiration because they would prefer not to wait for the medical abortion to be completed on its own.

In about 1% of cases or fewer, the medications do not work and the embryo continues to grow. In these cases, a suction procedure (surgical abortion) must be done to empty the uterus and complete the abortion. Deciding to continue the pregnancy to term is not an option after taking the first medication because the medications can cause birth defects in the pregnancy.

Seven deaths in North America have been reported in women following the use of mifepristone/misoprostol, out of more than one million cases. One death was the result of an ectopic pregnancy (a pre-existing condition not related to mifepristone/misoprostol use), and six deaths have been attributed to sepsis. No causal relationship has been established between the medications and these rare fatalities.

There do not appear to be any long-term complications associated with use of these drugs.
Follow-Up Care

Medical abortion requires a follow-up visit to the clinic or medical office. This return visit is very important to be sure that the abortion has been completed. In addition, a woman should contact her health care provider about any problems or concerns she has during the medical abortion.

Anti-Abortion Propaganda About Medical Abortion

Anti-abortion activists claim that medical abortion is unsafe for women, even though there is no evidence to support this claim. The real goal of those activists is to stop all types of legal abortion - a situation which would put the lives and health of women in danger. When abortion was illegal in the United States (from the late 1800s until 1973), more pregnant women died from complications from self-induced abortions or abortions performed by untrained practitioners than from any other cause. Today, abortion is one of the most common and safest medical procedures. Because earlier abortions are the safest, medical abortion is an important medical advance for women, and an option that many choose.


Safety of Abortion


Surgical abortion is one of the safest types of medical procedures. Complications from having a first-trimester aspiration abortion are considerably less frequent and less serious than those associated with giving birth. Early medical abortion (using medications to end a pregnancy) has a similar safety profile.



Illegal Abortion is Unsafe Abortion

Abortion has not always been so safe. Between the 1880s and 1973, abortion was illegal in all or most U.S. states, and many women died or had serious medical problems as a result. Women often made desperate and dangerous attempts to induce their own abortions or resorted to untrained practitioners who performed abortions with primitive instruments or in unsanitary conditions. Women streamed into emergency rooms with serious complications - perforations of the uterus, retained placentas, severe bleeding, cervical wounds, rampant infections, poisoning, shock, and gangrene.

Around the world, in countries where abortion is illegal, it remains a leading cause of maternal death. An estimated 68,000 women worldwide die each year from unsafe abortions.

Many of the doctors who provide abortions in the United States today are committed to providing this service under medically safe conditions because they witnessed and still remember the tragic cases of women who appeared in hospitals after botched, illegal abortions.



Evaluating the Risk of Complications

Since the Supreme Court reestablished legal abortion in the U.S. in the 1973 Roe v. Wade decision, women have benefited from significant advances in medical technology and greater access to high-quality services.3 Generally, the earlier the abortion, the less complicated and safer it is.

Serious complications arising from aspiration abortions provided before 13 weeks are quite unusual. About 88% of the women who obtain abortions are less than 13 weeks pregnant.4 Of these women, 97% report no complications; 2.5% have minor complications that can be handled at the medical office or abortion facility; and less than 0.5% have more serious complications that require some additional surgical procedure and/or hospitalization.

Early medical abortions are limited to the first 9 weeks of pregnancy. Medical abortions have an excellent safety profile, with serious complications occurring in less than 0.5% of cases.6 Over the last five years, six women in North America have died as a result of toxic shock secondary to a rare bacterial infection of the uterus following medical abortion with mifepristone and misoprostol. This type of fatal infection has also been observed to occur following miscarriage, childbirth and surgical abortion, as well as other contexts unrelated to pregnancy. The Centers for Disease Control and Prevention's (CDC) continuing investigations have found no causal link between the medications and these incidents of infection. Although the Food and Drug Administration (FDA) has issued an updated advisory for warning signs of infection following medical abortion, it has recommended that there be no changes in the current standards for provision of medical abortion.7,8

Complication rates are somewhat higher for surgical abortions provided between 13 and 24 weeks than for the first-trimester procedures. General anesthesia, which is sometimes used in surgical abortion procedures of any gestation, carries its own risks.

In addition to the length of the pregnancy, significant factors that can affect the possibility of complications include:

•the kind of anesthesia used;
•the woman's overall health;
•the abortion method used; and
•the skill and training of the provider.


Types of Complications from Surgical Abortion

Although rare, possible complications from a surgical abortion procedure include:

•blood clots accumulating in the uterus, requiring another suctioning procedure, (less than 0.2% of cases);
•infections, most of which are easily identified and treated if the woman carefully observes follow-up instructions, (0.1%-2.0% of North American cases);
•a tear in the cervix, which may be repaired with stitches (0.6%-1.2% of cases);
•perforation (a puncture or tear) of the wall of the uterus and/or other organs (less than 0.4% of cases).5,9 This may heal itself or may require surgical repair or, rarely, hysterectomy;
•missed abortion, which does not end the pregnancy and requires the abortion to be repeated (less than 0.3% of cases);
•incomplete abortion, in which tissue from the pregnancy remains in the uterus, and requires a repeat suction procedure, (0.3%-2.0% of cases);
•excessive bleeding requiring a blood transfusion (0.02%-0.3% of cases).


Death occurs in 0.0006% of all legal surgical abortions (one in 160,000 cases). These rare deaths are usually the result of such things as adverse reactions to anesthesia, embolism, infection, or uncontrollable bleeding.9 In comparison, a woman's risk of death during pregnancy and childbirth is ten times greater.



Possible complications of a medical abortion include:

•failure of the medications to terminate the pregnancy (less than 2% of cases), requiring a suction procedure to complete the abortion;
•incomplete expulsion of the products of conception, requiring a suction procedure to complete the abortion (occurs in less than 6% of cases);
•excessive bleeding, requiring a suction procedure, and rarely, transfusion (less than 1% of cases);
•uterine infection, requiring the use of antibiotics (0.09%-0.6% of cases) ;
•death secondary to toxic shock following infection with Clostridium sordellii (has occurred in less than 0.001% of cases in the US and Canada).


Signs of a Post-Abortion Complication

If a woman has any of the following symptoms after having either a surgical or medical abortion, she should immediately contact the facility that provided the abortion for follow-up care13:

•severe or persistent pain;
•chills or fever with an oral temperature of 100.4° or more;
•bleeding that is twice the flow of her normal menstrual period or that soaks through more than one sanitary pad per hour for two hours in a row;
•malodorous discharge or drainage from her vagina; or
•continuing symptoms of pregnancy.

In addition, if a woman who is having a medical abortion notices the onset of severe abdominal pain, malaise or "feeling sick," even in the absence of fever, more than 24 hours after the administration of the second medication, she must immediately contact the facility that provided the abortion.7

Health care providers and clinics that offer abortion services should provide a 24-hour number to call in the event of complications or reactions that the patient is concerned about.



Preventing Complications

There are some things women can do to lower their risks of complications. One way to reduce risk of complications is to have the abortion procedure early. Generally, the earlier the abortion, the safer it is.

Asking questions is also important. Just as with any medical procedure, the more relaxed a person is and the more she understands what to expect, the better and safer her experience usually will be.

In addition, any woman choosing abortion should:

•find a good clinic or a qualified, licensed practitioner. For referrals, call NAF's toll-free Hotline at 1-800-772-9100 or find a provider online;
•inform the practitioner of any health problems, current medications or street drugs being used, allergies to medications or anesthetics, and other health information;
•follow post-operative instructions; and
•return for a follow-up examination.


Anti-Abortion Propaganda

Anti-abortion activists claim that having an abortion increases the risk of developing breast cancer and endangers future childbearing. They claim that women who have abortions without complications are more likely to have difficulty conceiving or carrying a pregnancy, develop ectopic pregnancies, which are pregnancies outside of the uterus (commonly in one of the fallopian tubes), deliver stillborn

babies, or become sterile. However, these claims have been refuted by a significant body of medical research. In February 2003, a panel of experts convened by the National Cancer Institute to evaluate the scientific data concluded that studies have clearly established that "induced abortion is not associated with an increase in breast cancer risk."15 Furthermore, comprehensive reviews of the data have concluded that a vacuum aspiration procedure in the first trimester poses virtually no risk to future reproductive health.16 (See Abortion Myths: Abortion and Breast Cancer.)



Women's Feelings after Abortion

Women have abortions for a variety of reasons, but in general they choose abortion because a pregnancy at that time is in some way wrong for them. Such situations can cause a great deal of distress, and although abortion may be the best available option, the circumstances that led to the problem pregnancy may continue to be upsetting.

Some women may find it helpful to talk about their feelings with a family member, friend, or counselor. Feelings of loss or of disappointment, resulting, for example, from a lack of support from the spouse or partner, should not be confused with regret about the abortion. Women who experience guilt or sadness after an abortion usually report that their feelings are manageable.

The American Psychological Association has concluded that there is no scientifically valid support or evidence for the so-called "post-abortion syndrome" of psychological trauma or deep depression. The most frequent response women report after having ended a problem pregnancy is relief, and the majority of women are satisfied that they made the right decision for themselves.


First-Trimester Abortion: A Comparison of Procedures


Mifepristone

Mifepristone, taken orally, blocks the action of progesterone, which causes the uterine lining to thin and the pregnancy to detach. It also causes the cervix to soften and dilate, and increases the production of prostaglandins, which cause uterine contractions. Misoprostol, a prostaglandin analogue taken either orally or inserted vaginally within a few days of mifepristone, induces uterine contractions and increases the effectiveness of mifepristone to approximately 95-98%.


Advantages

- Usually avoids the use of surgical instruments, thus avoiding the risk of injury to the cervix or uterus from instrumentation.
- Anesthesia not required.
- High success rate (95-98%).
- Resembles a "natural miscarriage."
- May offer women more privacy.
- Both drugs can be administered orally.
- Can be used very early in pregnancy.
- Procedure completed within 24 hours of the misoprostol administration in 90% of women.
- Approved by the FDA for early abortion.



Disadvantages

- Requires at least 2 visits.
- Effectiveness decreases with use after 7 weeks in regimens using oral misoprostol. Efficacy remains high up to 9 weeks with vaginal misoprostol.
- Takes days or, rarely, weeks to complete.
- Post-procedure bleeding may last longer than with surgical abortion.
- Women may see blood clots and pregnancy tissue.


Methotrexate

Methotrexate, given by injection, or occasionally orally, stops the ongoing process of implantation of an early pregnancy. Misoprostol, a prostaglandin analogue inserted vaginally several days after the methotrexate, causes uterine contractions and increases the effectiveness of methotrexate to approximately 95%.

Advantages

- Usually avoids the use of surgical instruments, thus avoiding the risk of injury to the cervix or uterus from instrumentation.
- Anesthesia not required.
- High success rate up to 7 weeks (95%).
- Resembles a "natural miscarriage."
- May offer women more privacy.
- Can be used very early in pregnancy.
- Can be used to treat ectopic pregnancy.
- Methotrexate and misoprostol are both FDA-approved for other uses.


Disadvantages


- Requires at least 2 visits.
- Effectiveness decreases with use after 7 weeks.
- May require several doses of misoprostol.
- Takes several days or weeks to complete.
- Post-procedure bleeding may last longer than with surgical abortion.
- Women may see blood clots and pregnancy tissue.

Vacuum Aspiration

Cervix is gradually opened with tapered rods. A cannula (straw-like tube), which is attached to a suction apparatus (either an electric machine or hand-held syringe), is inserted through the cervix into the uterus. The contents of the uterus are emptied by suction. Vacuum aspiration is approximately 99% effective.

Advantages

- Usually only requires one visit to the provider.
- Procedure is usually completed within minutes.
- Allows for sedation if desired.
- High success rate (approximately 99%).
- Can be used early in pregnancy.


Disadvantages

- Involves a surgical procedure.
- May seem less private to some women than aborting at home.

Facts About Mifepristone (RU-486)

What is Mifepristone?

Mifepristone (formerly known as RU-486) is a medication that blocks the action of the hormone progesterone. Progesterone is needed to sustain a pregnancy. Mifepristone has been used, in combination with other medications called prostaglandins, for medical abortion since 1988 in France and China, and since the early 1990's in the United Kingdom and Sweden. It has been licensed for use in 37 countries including the United States where it was approved in September 2000. Millions of women worldwide have safely used mifepristone regimens to end their pregnancies.



How mifepristone works to end pregnancy

Mifepristone blocks the action of progesterone, which is needed to sustain a pregnancy. This results in:

•Changes in the uterine lining and detachment of the pregnancy
•Softening and opening of the cervix

•Increased uterine sensitivity to prostaglandin
In the U.S., mifepristone is used in combination with another medication, a synthetic prostaglandin called misoprostol. Misoprostol causes the uterus to contract, and helps the pregnancy tissue to expel.



How effective is the combination of mifepristone and misoprostol in terminating an early pregnancy?

Depending on the prescribing physician's protocols, mifepristone and misoprostol can be used for early abortion up to 63 days after the start of the last menstrual period. Approximately 95-98% of women will have a complete abortion when using mifepristone/misoprostol. Success rates may depend on the treatment regimen and the duration of the pregnancy. The remaining women will need a suction procedure, either because of ongoing or excessive bleeding, an incomplete abortion (tissue remains in the uterus but there is no growing embryo), or an ongoing pregnancy (a viable growing pregnancy, which occurs in less than 1% of cases).



Treatment regimen with mifepristone/misoprostol

Clinical studies have shown that several variations in mifepristone/misoprostol treatment regimens are safe and effective. Generally, however, once a woman has decided to have a medical abortion, there are three steps in the process of a medical abortion:

Step One (at the medical office or clinic)

•A medical history is taken and a clinical exam and lab tests are performed.
•Counseling is completed and informed consent is obtained.
•If eligible for medical abortion, the woman swallows the mifepristone pill(s).

Step Two (at the office/clinic or at home depending on the treatment regimen)

•This step takes place within about 2 days of step one.
•Unless abortion has occurred and has been confirmed by the clinician, the woman uses misoprostol. Misoprostol tablets may be swallowed, placed between cheek and gum, or inserted into the vagina, depending on the treatment regimen.

Step Three (at the office or clinic)

•This step takes place within about 2 weeks of step two.
•The clinician evaluates the woman to confirm a complete abortion. It is essential for women to return to the office/clinic to confirm that the abortion is complete.
•If there is an ongoing pregnancy, a suction abortion should be provided.
•If there is an incomplete abortion, the clinician will discuss possible treatment options with the woman. These may include waiting and re-evaluating for complete abortion in a number of days or performing a suction procedure.


Possible side effects of a mifepristone abortion

Side effects, such as pain, cramping and vaginal bleeding, result from the abortion process itself, and are therefore expected with a medical abortion. Other side effects may include nausea, vomiting, diarrhea, chills, or fever. Complications are rare, but may include infection, excessive vaginal bleeding requiring transfusion (occurs in approximately 1 in 500 cases), incomplete abortion or ongoing pregnancy which requires a suction abortion (see above). In exceedingly rare instances, as with miscarriage, suction abortion and childbirth, death may occur. Reports of death after medical abortion are very rare - less than 1 in 100,000 cases - a rate comparable to that for early surgical abortion and for miscarriage.1



What women can expect from a mifepristone abortion

•Medical abortion with mifepristone/misoprostol requires at least two visits to a medical office or clinic.
•Following established treatment regimens, approximately 95-98% of women using mifepristone/misoprostol will have a complete medical abortion.
•Complete abortion generally occurs more quickly when misoprostol is used vaginally rather than orally.
•In most cases, bleeding will begin within several hours of using vaginal misoprostol.
•Approximately two-thirds of women will have a complete medical abortion within 4 hours of using oral misoprostol.
•Approximately 90% of women will have a complete medical abortion within 24 hours of using oral misoprostol.
•On average, women may expect to have bleeding and/or spotting for 9-16 days.
•Women may pass clots, ranging in size.
•Some women may see whitish pregnancy tissue.

If the medications fail to end the pregnancy, a suction abortion should be provided. For this reason, a woman who chooses medical abortion must be willing to have a suction abortion if needed.

---------------------------------------------

Mifeprex (mifepristone) Information

Mifeprex is used, together with another medication called misoprostol, to end an early pregnancy (within 49 days of the start of a woman's last menstrual period). Since its approval in September 2000, the Food and Drug Administration has received reports of serious adverse events, including several deaths, in the United States following medical abortion with mifepristone and misoprostol. Each time FDA receives a report of a serious adverse event or death after medical abortion with these drugs, the agency carefully analyzes the available scientific information to determine whether or not the serious adverse event or death is related to the use of the drugs.

As previously reported by the agency, several of the women who died in the United States died from sepsis (severe illness caused by infection of the bloodstream) after medical abortion with mifepristone and misoprostol. Sepsis is a known risk related to any type of abortion. Most of these women were infected with the same type of bacteria, known as Clostridium sordellii. The symptoms in these cases of infection were not the usual symptoms of sepsis. We do not know whether using mifepristone and misoprostol caused these deaths.

Patients should contact a healthcare practitioner right away if they have taken these medications for medical abortion and develop stomach pain or discomfort, or have weakness, nausea, vomiting or diarrhea with or without fever, more than 24 hours after taking the misoprostol. These symptoms, even without a fever, may indicate sepsis. Patients should make sure their healthcare practitioner knows they are undergoing a medical abortion.

All providers of medical abortion and emergency room healthcare practitioners should investigate the possibility of sepsis in women who are undergoing medical abortion and present with nausea, vomiting, or diarrhea and weakness with or without abdominal pain. These symptoms even without a fever may indicate a hidden infection. Strong consideration should be given to obtaining a complete blood count in these patients. Significant leukocytosis with a marked left shift and hemoconcentration may be indicative of sepsis.

FDA recommends that healthcare practitioners have a high index of suspicion for serious infection and sepsis in patients with this presentation and consider immediately initiating treatment with antibiotics that includes coverage of anaerobic bacteria such as Clostridium sordellii.

FDA does not have sufficient information to recommend the use of prophylactic antibiotics for women having a medical abortion. Reports of fatal sepsis in women undergoing medical abortion are very rare (approximately 1 in 100,000). Prophylactic antibiotic use carries its own risk of serious adverse events such as severe or fatal allergic reactions. Also, prophylactic use of antibiotics can stimulate the growth of “superbugs,” bacteria resistant to everyday antibiotics. Finally, it is not known which antibiotic and regimen (what dose and for how long) will be effective in cases such as the ones that have occurred.

These recommendations are consistent with warnings in the Prescribing Information and information for the patient in the Medication Guide for Mifeprex.

The approved Mifeprex regimen for a medical abortion through 49 day’s pregnancy is:

Day One: Mifeprex Administration: 3 tablets of 200 mg of Mifeprex orally at once

Day Three: Misoprostol Administration: 2 tablets of 200 mcg of misoprostol orally at once

Day 14: Post-Treatment: The patient must return to confirm that a complete termination has occurred. If not, surgical termination is recommended to manage medical abortion treatment failures.

The safety and effectiveness of other Mifeprex dosing regimens, including use of oral misoprostol tablets intravaginally, has not been established by the FDA.

--------------------------------------

Full Details:




[HIDE]
Code:
http://www.janani.org/protopdf/manual1tri.pdf
[/HIDE]



[HIDE]
Code:
http://medind.nic.in/maa/t05/i2/maat05i2p151.pdf
[/HIDE]


[HIDE]
Code:
http://medind.nic.in/iad/t03/i3/iadt03i3p212.pdf
[/HIDE]


[HIDE]
Code:
http://www.janani.org/protopdf/manual1tri.pdf
[/HIDE]


------------------------

Hi Guys !

Did you find this Article useful to you?



.