What are the contraindications for medical termination of pregnancy?

Contraindications of Medical Termination of Pregnancy

Medical termination of pregnancy is contraindicated in patients with severe cardiovascular disease (especially pulmonary arterial hypertension), known hypersensitivity to mifepristone or prostaglandins, and in those taking CYP3A-metabolized drugs with narrow therapeutic ranges. 1, 2

Absolute Contraindications

• Confirmed or suspected ectopic pregnancy (medical termination will not be effective and could delay necessary treatment) 3
• Chronic adrenal failure (due to mifepristone's antiglucocorticoid effects) 1
• Concurrent long-term corticosteroid therapy (mifepristone may reduce effectiveness of steroids used for life-saving purposes) 1
• Inherited porphyrias (prostaglandins may precipitate attacks) 4
• Severe cardiovascular disease, especially pulmonary arterial hypertension (pregnancy termination in these patients should be performed surgically in centers with cardiac surgery capabilities) 2
• Known hypersensitivity to mifepristone or prostaglandins 1
• Patients taking CYP3A substrates with narrow therapeutic ranges (e.g., simvastatin, lovastatin) 1
• IUD in place (must be removed before medical termination) 5

Relative Contraindications

• Severe anemia (Hb <9 g/dL) (increased risk of complications from bleeding) 5
• Coagulopathy or anticoagulant therapy (increased risk of hemorrhage) 4
• Severe uncontrolled asthma (prostaglandins may exacerbate bronchospasm) 4
• Advanced gestational age (>9-10 weeks for standard medical regimens; efficacy decreases and complications increase with advancing gestation) 3, 6
• Multiple prior cesarean deliveries or uterine scars (increased risk of uterine rupture with prostaglandins) 5
• Severe liver or kidney disease (altered drug metabolism and clearance) 7

Method-Specific Considerations

First Trimester (≤12 weeks)

• Preferred method: Vacuum aspiration or medical termination with mifepristone followed by misoprostol 3, 8
• Dilation and evacuation (D&E) is the safest procedure in both first and second trimesters 2, 9
• Medical regimen: 200 mg mifepristone followed by 800 μg misoprostol 24-48 hours later (95-98% effective for pregnancies ≤49 days) 3, 5
• If mifepristone unavailable: Misoprostol-only regimens can be used but have lower efficacy 3

Second Trimester (>12 weeks)

• D&E is safer than medical methods with lower rates of hemorrhage (9.1% vs 28.3%) and infection (1.3% vs 23.9%) 9, 10
• Prostaglandin E1 (misoprostol) or E2 can be used if surgical evacuation not feasible 2
• Prostaglandin F compounds should be avoided as they can increase pulmonary arterial pressure and decrease coronary perfusion 2
• Saline abortion should be avoided due to risk of fluid overload, heart failure, and clotting abnormalities 2

Special Populations

Patients with Cardiovascular Disease

• Pulmonary arterial hypertension: Pregnancy termination is recommended as early as possible, preferably in the first trimester 2
• Pregnancy termination in the last 2 trimesters poses high risk to mothers with cardiovascular disease 2
• High-risk patients should be managed in centers with on-site cardiac surgery 2, 9
• Monitor systemic arterial oxygen saturation with transcutaneous pulse oximeter when using prostaglandins 2

Patients with End-Stage Renal Disease

• Increased risk of bleeding due to uremic platelet dysfunction 7
• Potential for fluid and electrolyte imbalances 7
• Higher risk of infection due to immunocompromised state 7
• Surgical evacuation may be preferred over medical termination due to lower risk of prolonged bleeding 7

Post-Procedure Care

• Antibiotic prophylaxis is recommended to prevent post-abortal endometritis (occurs in 5-20% of women not given antibiotics) 2, 10
• Rh-negative women should receive anti-D immunoglobulin to prevent alloimmunization 10
• Monitor for signs of infection, retained products, and excessive bleeding 10

Important Considerations

• First trimester termination is safest and should be performed in hospital rather than outpatient settings for high-risk patients 2
• Method selection should be based on gestational age, provider expertise, facility capabilities, and patient's medical conditions 9, 10
• Complete abortion rates are approximately 97% for surgical and 95% for medical termination in the first trimester 3