What is the recommended regimen for medical termination of pregnancy?

Medical Termination of Pregnancy Regimen

The recommended regimen for medical termination of pregnancy is mifepristone 200 mg orally followed by misoprostol 600-800 mcg vaginally or 400 mcg orally 24-48 hours later, with effectiveness of 92-95% for pregnancies up to 49 days gestation.

Timing and Effectiveness Based on Gestational Age

Medical termination effectiveness varies by gestational age:

• ≤49 days (≤7 weeks): 92-95% effective 1, 2
• 50-56 days (7-8 weeks): 83% effective 1
• 57-63 days (8-9 weeks): 77% effective 1

First Trimester Protocol

Medications and Dosing

1. Mifepristone: 200 mg orally as a single dose
2. Followed by misoprostol:
   • 600-800 mcg vaginally OR 400 mcg orally
   • Administered 24-48 hours after mifepristone

Considerations

• Complete abortion typically occurs within 24 hours of misoprostol administration in 75% of cases 1
• Surgical backup should be available for incomplete abortion (3-5%) or ongoing pregnancy (1-2%) 2
• The first trimester is the safest time for elective pregnancy termination 3
• Procedures should be performed in a hospital setting with emergency support services available 4

Second Trimester Protocol (12-20 weeks)

Medications and Dosing

1. Mifepristone: 200 mg orally
2. Followed by misoprostol:
   • Initial dose: 800 mcg vaginally 36-48 hours after mifepristone
   • Subsequent doses: 400 mcg vaginally every 3 hours (maximum 4 doses in 24 hours)

Effectiveness

• 97.9% abortion rate within 24 hours
• 99.5% abortion rate within 36 hours
• Median induction-to-abortion interval: 6.7 hours 5

Alternative Methods When Medical Management Not Feasible

Surgical Options

• Dilatation and evacuation (D&E): Safest surgical procedure in both first and second trimesters 3
• Should be performed in a hospital rather than outpatient facility for high-risk patients 3

When Surgical Evacuation Not Feasible

If surgical evacuation is not feasible in the second trimester, prostaglandins E1 or E2 can be administered to evacuate the uterus 3.

Common Side Effects and Management

• Abdominal pain: 62% of women may not require analgesia 6
• Gastrointestinal effects: 24% experience vomiting, 7% experience diarrhea 6
• Bleeding: Typically heavier than menstrual bleeding
• Infection: Uncommon (1-3%) 4

Special Considerations

Cancer Patients

Pregnancy termination may be advised in cases requiring:

• Chemotherapy or radiotherapy during the first trimester
• Need for radical gynecological surgery
• Poor maternal life expectancy 3

Cardiovascular Disease

• High-risk cardiac patients should be managed in an experienced center with on-site cardiac surgery 3
• The method, including anesthesia needs, should be considered individually 3
• Prostaglandin F compounds should be avoided as they can significantly increase pulmonary arterial pressure 3

Contraindications and Cautions

• Mifepristone is contraindicated in patients with chronic adrenal failure, concurrent long-term corticosteroid therapy, or hemorrhagic disorders
• Saline abortion should be avoided due to risk of intravascular volume expansion, heart failure, and clotting abnormalities 3

Follow-up

• Follow-up visit recommended 14-15 days after mifepristone administration
• Confirm complete abortion through clinical examination and/or ultrasound
• Surgical intervention may be required for incomplete abortion or ongoing pregnancy

Medical termination of pregnancy offers a non-invasive alternative to surgical abortion with high success rates, particularly in early pregnancy, though effectiveness decreases with advancing gestational age.