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MEDICAL TERMINATION OF PREGNANCY

WHAT IS MEDICAL TERMINATION OF PREGNANCY?

Medical Termination of Pregnancy (MTP) refers to non-surgical methods of terminating a pregnancy. So, instead of using a surgical procedure to terminate a pregnancy, various drugs are used.

The drugs used for MTP end an already established pregnancy, thus they are Abortifacients (they cause an abortion). This is in contrast to drugs used for birth control. These drugs prevent a pregnancy and have no effect on an established pregnancy.

Abortifacients terminate a pregnancy. Birth control prevents it.

There are many drugs and regimens used for MTP. The 6 main groups of drugs are listed in the next section. Only 3 of these drugs are routinely used for early terminations, meaning pregnancies up to 9 weeks (63 days). They are Misoprostol, Mifepristone (RU-486) and Methotrexate.

Early MTP drugs are often confused with drugs used for birth control, especially with drugs used for emergency contraception (EC). A more detailed look at the 3 early MTP drugs should help clear up some of the confusion.

Before we discuss the individual drugs, there is one very important point you must remember. Even though the drugs used for early pregnancy termination are easy to use and self-administer, they must be used only under direct and close medical supervision. This is because these drugs act on an already established pregnancy. A pregnancy, even an early one, can be associated with potentially deadly complications, like an ectopic pregnancy. This is in contrast to drugs used for EC that act before there is a pregnancy; this makes them safe to use without a prescription, or over-the-counter.

DRUGS USED FOR MEDICAL TERMINATION OF PREGNANCY

Oxytocin is a drug that causes uterine contractions and induces labor. High doses of oxytocin are given in small volumes of intravenous fluids.

2. HYPEROSMOTIC SOLUTIONS

Hyperosmotic solutions also induce labor. 20-25% Saline or 30-40% Urea solutions are injected into the amnionic sac (the bag of fluid).

3. PROSTAGLANDINS AND ANALOGUES

Prostaglandins are substances naturally produced in the body. They have many actions, including induction of labor. The drugs in this group can be used vaginally, as a shot, into the amnionic sac (the bag of fluid), and orally (by mouth).

Misoprostol belongs to this group. The brand name in the U.S. is Cytotec and it is used to induce labor and to treat stomach ulcers.

4. ANTIPROGESTERONES

Antiprogesterones are drugs that block the action of the body's hormone progesterone. This hormone is very important for pregnancy.

Mifepristone (RU-486), a pill, is a drug in this group. The brand name in the U.S. is Mifeprex.

The MTP regimen causes the lining of the uterus, together with the implanted egg, to shed.

In addition to the U.S., Mifepristone is also available in Austria, Belgium, China, Denmark, Finland, France, Germany, Greece, Israel, Luxembourg, the Netherlands, Norway, Russia, Spain, Sweden, Switzerland, Tunisia, Ukraine, the UK, etc.

5. PROGESTERONE PRODUCTION BLOCKERS

Progesterone production blockers, as the name implies, block the production of the hormone progesterone. Progesterone is very important for pregnancy.

Epostane, a pill, is an agent in this group.

The usual dose is 200 mg every 6 hours, for 7 days, and you can take it up to 7 weeks (49 days) from the date of your last normal menstrual period.

The rate of successful treatment with epostane is 87% - 90% , and it has a good safety profile.

The main side effects are nausea and vomiting.

The average length of vaginal bleeding with this regimen is 10.7 days. Once the treatment is complete, usually there is no delay in the resumption of normal periods.

Methotrexate is a folic acid antagonist, a drug that stops cells from dividing. It comes in the form of a pill, or a shot.

TWO MTP REGIMENS: A COMPARISON TABLE

REGIMENS	MIFEPRISTONE & MISOPROSTOL	METHOTREXATE & MISOPROSTOL	COMMENTS
How Does It Work?	Mifepristone: blocks the action of progesterone, causing the uterine lining to thin and detach. Misoprostol: causes uterine contractions that expel the embryo and placental tissue.	Methotrexate: stops cell division. Misoprostol: causes uterine contractions that expel the embryo and placental tissue.
When Does It Work?	1. Evidence-based: through 9 weeks (63 days) from the Last Menstrual Period (LMP) 2. FDA*-approved: through 7 weeks (49 days) from the LMP	Once pregnancy is confirmed, through 7 weeks (49 days) from the LMP.
Dose	1. Mifepristone 200 mg by mouth followed 1-3 days later by Misoprostol 800 mcg vaginally (self-administered, at home) 2. Mifepristone 600 mg by mouth followed 2 days later by Misoprostol 400 mcg by mouth	Methotrexate 50 mg by mouth or a 50 mg/m2 shot, followed 3-7 days later by Misoprostol 800 mcg vaginally (self-administered, at home)
How Well Does It Work?	1. ~97% 2. 92% to 97%	94% to 96%	If the drugs are unsuccessful, a surgical procedure is needed to complete the process.
Number of Doctor's Office Visits	1. Two 2. Three	Two	Depending on the individual case, more visits may be needed.
Side effects**	Nausea, vomiting, diarrhea, headache, dizziness, fever or chills, anemia (rare), blood transfusion needed (rarely).	Nausea, vomiting, diarrhea, headache, fever or chills, stomatitis (rare), anemia (rare), blood transfusion needed (rarely).	**Bleeding and cramping are expected effects of all termination procedures.
Expected bleeding	~ 13 days	~ 10-17 days
Can It Treat an Ectopic?	Not an effective treatment.	~ 90% effective for early, unruptured ectopic pregnancy (3.5 cm or less, initial beta hCG less than 5,000 mIU/ml)	An ectopic pregnancy, can be deadly. This is why the supervision of a qualified doctor is imperative.
Follow-up	Must return for confirmation of termination. If unsuccessful, surgical termination is necessary.	Must return for confirmation of termination. If unsuccessful, surgical termination is necessary.
Regulatory status U.S.	Mifepristone--approved for early medical termination Misoprostol--approved for ulcer treatment	Both drugs are approved.	Worldwide, these drugs have been safely used by millions of women for over 10 years.

*FDA is the U.S. equivalent of the Medicine Control Agency

MISOPROSTOL ALONE: SELF-ADMINISTRATION REPORTS

Misoprostol is not usually used as the only drug, or without medical supervision, for early pregnancy termination. However, reports of women using misoprostol on their own have been increasing.

While women are most likely to self-administer misoprostol in countries where legal termination is unavailable (e.g., Latin America), evidence suggests that U.S. women are also using this method.

The reported misoprostol-only regimens involve multiple doses, taken at 24-hour intervals. How well the regimen works depends on the time elapsed from the Last Menstrual Period (LMP) and the number of doses.

For example, 800 mcg misoprostol administered vaginally up to 49 days from the LMP, is 69.0% effective after one dose, 86.4% effective after two doses, and 91.7% effective after three doses. For the same dose administered vaginally up to 63 days from the LMP, the effectiveness is 78% after one dose, 91% after two doses, and 92% after three doses.

If you are using misoprostol on your own, please let your doctor know so that appropriate follow-up care or a referral for it can be provided to you, in case you need it.

MEDICAL TERMINATION OF PREGNANCY: FINAL NOTES

Medical Termination of Pregnancy is a safe and effective alternative to surgical procedures.

Medical Termination of Pregnancy (MTP) is not the same thing as Emergency Contraception (EC). MTP acts on an already established pregnancy, while EC has no effect on a one.

Medical Termination of Pregnancy allows one to have a termination much earlier, it affords more privacy, and a sense of greater personal control over the experience.

1. Williams Obstetrics 21st. Ed.

2. Stewart FH, Wells ES, Flinn SK, Weitz TA. Early Medical Abortion:Issues for Practice. UCSF Center for Reproductive Health Research & Policy: San Francisco, California (2001)