Abortion Care - Other Services

Making Your Choice -
Medical or Surgical Abortion

Your decision to have an abortion or continue a pregnancy is not a simple or easy one.  It is important to take the time you need to make the choice that is best for you.  Talking with family members, friends, and loved ones whom you trust can help.  There are also counsellors who can help as you make your decision.  Remember, women choose abortion for many reasons.
If you choose to end your pregnancy, and it has been 9 weeks or less since your last period, you may be able to have a medical abortion.  The following information may help you decide if it is right for you.

What is Medical Abortion?

A medical abortion uses two medicines to end a pregnancy.  The first one mifepristone (Ru486) weakens the attachment of the pregnancy to the uterus.  A second medication misoprostol swallowed or put into the vagina two days later, makes the uterus cramp and causes bleeding to expel the pregnancy.

When is Medical Abortion Used?

Before any abortion can be done, a doctor must confirm that a woman is indeed pregnant and determine how long she has been pregnant.  The length of a pregnancy is usally 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 as 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.
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.
B) Misoprostal.  Two days after taking mifepristone the 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. The doctor can help a woman decide whether medically induced abortion is the right option for her.

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.  About 95% will have a complete abortion within a week.  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, (the second drug) 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.

Women can 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 included: 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. Misoprostol causes cramping pain and bleeding, usually within a few hours of using the tablets.  Pain can range from mild, period-like pain to severe, disabling pain.  For most women the pain can be managed with pain relievers such as Nurofen, Naprogesic, Panadol, Panadeine.  It is important to use pain relief early in the treatment for it to have the best effect.

Bleeding can be light spotting through to very heavy with blood clots.  If you are soaking 2 large pad per hour for 2 consecutive hours you should contact the clinic.  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% of women will have a successful medical abortion.  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 theses cases, this heavy bleeding occurs 3-5 weeks after taking the medications.  Rarely, in approximately one in 500 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 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 medications because the medications can cause birth defects in the pregnancy.

Infections

Seven deaths in North America have been reported in women following the use of mifepristone/misoprostol, out of more than 1.1 million cases. One death was the result of an ectopic pregnancy (a pre-existing condition not related to mifepristone/misoprostol use), and six other have been attributed to sepsis. Uterine infection (endometrits) is rare and studies suggests that infection rate is approximately 0.9%.  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.

Uterine Rupture
Another concern about the use of medical abortion regimens using misoprostol is the risk of uterine rupture, especially in women with previous uterine scarring.  Case reports of uterine rupture are rare in the first trimester medical abortion.

 Who cannot have medical abortion?
A medical abortion may be suitable for most pregnancies up to 9 weeks but there are conditions that may prevent women from choosing this method.  These conditions are listed below:

>> Women wish to minimize participation in their abortion

>> Those who are anxious to have the abortion over quickly

>> Can not return for follow up visits

>> Can not communicate easily with provider because of language or comprehension barriers

>> Unable to access phone services or Emergency medical treatment

>> Unwillingness to undergo a surgical procedure should the medical method fails, or incase of incomplete abortion, heavy bleeding.

The following medical conditions also make her unsuitable.

>> Allergy to mifepristone or misoprostol

>> Severe anaemia

>> Bleeding disorders

>> Inherited porphyria (rare blood disorder)

>> Long term anti-coagulant therapy (blood thinning agents) (Warfarin,Heparin)

>> Chronic adrenal failure

>> Corticosteroids therapy (eg. Prednisone, cortisone)

>> Irritable bowel disease (chronic diarrhea and Chrones disease)

>> Serious systemic illness (eg. Heart disease, severe liver disease, kidney failure, uncontrolled seizures)

>> Serious pelvic infection

>> Confirmed or suspected ectopic pregnancy (Pregnancy growing outside uterus)

>> Presence of an intrauterine device. This must be removed before proceeding with abortion.

Once a woman has decided to have a medical abortion, there are three steps in the process of medical abortion:

Step one - at the clinic

>> At the clinic a medical history is taken and a clinical exam with ultra sound and lab tests are performed

>> Counseling is completed and informed consent is obtained

>> If eligible for medical abortion, the woman swallows the mifepristone pill

>> Take home misoprostol tablets

Step Two – at home

>> This step takes place 2 days after step one

>> The woman uses misoprostol.  Misoprostal tablest may be swallowed, placed between cheek and gum or in the vagina.

Step Three – at the clinic

>> This step takes place in about 2 weeks of step two. ( earlier if any concern)

>> It is essential for women to return to the 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 clinic doctor 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.

>> If there is a persistent heavy bleeding – the woman will need uterine suction curettage procedure.

Medical abortion particularly suits women with obesity or congenital abnormality of the uterus.

Surgical abortion

In the first 12 weeks of pregnancy, surgical abortion is usually done by a method called vacuum aspiration. With a vacuum aspiration (also called suction), the cervix (opening to the uterus) is stretched open slightly. The pregnancy is then removed through a small tube using suction. Vacuum aspiration is usually done in the medical clinic and the procedure takes 5 to 10 minutes. For a short time afterward, women may have strong cramping. Spotting or bleeding like a period may last for a few days or weeks. Complications are rare, but include infection, excessive bleeding, a tear in the cervix or uterus, incomplete abortion, or a continuing pregnancy.

>> High success rate (about 99%)

>> Instruments inserted into the uterus

>> Can be done in one visit

>> Procedure is completed in 5-10 minutes

>> May be used in early pregnancy

>> Anaesthesia /sedation can be used

>> Procedure is done in a clinic

>> The Doctor performs the procedure

For additional information visit www.prochoice.org

Other Services

• Pregnancy Testing and Counseling
• Contraceptive advice
• IUD insertion
• Implanon Insertion and Removal
• IUD removal
• Sexually Transmitted Infection - Management
• Ultrasound