Medical Termination of Pregnancy: Recommended Regimens
First Trimester (≤7 weeks gestation)
The standard regimen is mifepristone 200 mg orally followed by misoprostol 800 μg 24-48 hours later, achieving 92-98% success rates. 1, 2, 3
- Mifepristone 200 mg (or 600 mg) orally is administered first 2, 4
- Misoprostol 800 μg (or 400 μg) is given 24-48 hours later, typically vaginally, buccally, or sublingually 2, 4
- Success rates are highest at ≤49 days gestation (92-98%), declining to 77-83% at 50-63 days 2, 4
- If mifepristone is unavailable, misoprostol alone can be used but requires repeated doses and has lower efficacy 2
Surgical vacuum aspiration (manual or electric) is equally effective with ~97% complete abortion rates and remains an excellent alternative. 2
- Vacuum aspiration has lower infection risk (1.3%) compared to medical methods (23.9%) when prophylactic antibiotics are used 1
- Major complications occur in <1% of cases 2
- Pre-operative misoprostol administration can reduce complications 2
Second Trimester (14-27 weeks gestation)
Dilation and evacuation (D&E) is the safest procedure for second-trimester termination and should be the preferred method. 5, 1, 6
- D&E has significantly lower hemorrhage risk (9.1% vs 28.3% with medical methods) 1, 6
- Infection risk is markedly lower (1.3% vs 23.9% with medical methods) 1, 6
- Must be performed in a hospital setting by experienced providers 5, 1
- Most procedures require sedation or general anesthesia 1, 6
Medical Alternative for Second Trimester
If surgical evacuation is not feasible, use mifepristone-misoprostol regimen: 5, 7
- Mifepristone 200 mg orally followed by misoprostol (doses ≥200 μg, repeated as needed) 7
- Mifepristone significantly increases effectiveness compared to misoprostol alone 7
- Prostaglandin E1 (misoprostol) or E2 can be used to evacuate the uterus 5
Critical: Avoid prostaglandin F compounds as they significantly increase pulmonary arterial pressure and may decrease coronary perfusion. 5, 1
Essential Monitoring and Safety Measures
- Monitor systemic arterial oxygen saturation with pulse oximetry during prostaglandin administration 5, 1
- Administer prophylactic antibiotics to prevent post-abortal endometritis (occurs in 5-20% without antibiotics) 5, 1, 6
- Give anti-D immunoglobulin to Rh-negative women 1, 6
- High-risk patients require management in experienced centers with on-site cardiac surgery capabilities 5, 1, 6
Critical Timing Considerations
- First trimester is the safest time for elective termination 5
- Chemotherapy during first trimester carries 10-20% risk of major fetal malformations; termination should be discussed if treatment cannot be delayed 5, 6
- For cancer patients requiring immediate treatment, pregnancy termination is recommended in first trimester 5
- Fetal analgesia is not recommended as there is no evidence of fetal pain awareness before 24-25 weeks gestation 1, 6
Common Pitfalls to Avoid
- Do not use saline abortion (causes volume expansion, heart failure, and clotting abnormalities) 5
- Do not administer prostaglandin F compounds 5, 1
- Avoid medical termination beyond 9 weeks without repeated misoprostol doses due to reduced efficacy 2
- Ensure completion confirmation and exclude ectopic pregnancy, especially at very early gestations 2