Is mifepristone (RU-486) safe for medical termination of pregnancy in a patient with end-stage renal disease (ESRD)?

Safety of Mifepristone for Medical Termination of Pregnancy in End-Stage Renal Disease

Mifepristone can be used for medical termination of pregnancy in patients with end-stage renal disease (ESRD), but should be administered in a hospital setting with close monitoring due to potential complications related to the underlying renal condition. 1

Considerations for Medical Termination in ESRD

Safety Profile

• Mifepristone itself does not have specific contraindications related to renal disease, unlike many other medications that require dose adjustments in ESRD 2
• The European Society of Cardiology guidelines indicate that mifepristone can be used up to 7 weeks gestation as an alternative to surgical evacuation 1
• Patients with ESRD should be considered high-risk and managed in an experienced center with appropriate emergency support services 1

Recommended Approach

• First trimester is the safest time for elective pregnancy termination in high-risk patients 1
• The procedure should be performed in a hospital setting rather than an outpatient facility to ensure all emergency support services are available 1
• Dilatation and evacuation is considered the safest procedure in both first and second trimesters for high-risk patients 1

Monitoring Requirements

Before Procedure

• Baseline assessment of renal function and electrolytes 2
• Evaluation for potential bleeding risks, as patients with ESRD may have platelet dysfunction 1
• Consideration of potential drug interactions with other medications the patient may be taking for ESRD 2

During and After Procedure

• Close monitoring of vital signs and bleeding during the procedure 1
• Monitoring for signs of infection, as immunocompromised ESRD patients may be at higher risk 1
• Assessment of fluid status, as patients with ESRD have limited ability to handle fluid shifts 2

Potential Complications

Specific to ESRD Patients

• Increased risk of bleeding due to uremic platelet dysfunction 1
• Potential for fluid and electrolyte imbalances 2
• Higher risk of infection due to immunocompromised state 1

Management of Complications

• Have blood products available if needed for excessive bleeding 1
• Consider prophylactic antibiotics to prevent post-abortal endometritis, which occurs in 5-20% of women not given antibiotics 1
• Monitor for signs of volume overload, which can be particularly problematic in ESRD patients 2

Alternative Options

Surgical Options

• Dilatation and evacuation remains the safest procedure for high-risk patients, including those with ESRD 1
• Surgical evacuation has a lower risk of prolonged bleeding compared to medical termination, which may be advantageous in ESRD patients 3

If Medical Termination is Preferred

• Consider using mifepristone followed by a carefully monitored dose of misoprostol 1, 4
• When prostaglandin E compounds are given, systemic arterial oxygen saturation should be monitored with a transcutaneous pulse oximeter 1
• Avoid prostaglandin F compounds as they can significantly increase pulmonary arterial pressure and may decrease coronary perfusion 1

Common Pitfalls and Caveats

• Saline abortion should be strictly avoided in ESRD patients because saline absorption can cause expansion of intravascular volume, heart failure, and clotting abnormalities 1
• Patients with ESRD may have altered drug metabolism and elimination, requiring careful monitoring for drug effects and side effects 2
• The combination of mifepristone and misoprostol has higher success rates (95%) compared to mifepristone alone (80%), but may also have more side effects that need careful monitoring in ESRD patients 5