What is the recommended regimen for medical termination of pregnancy (MTP) before 9 weeks?

Medical Termination of Pregnancy Before 9 Weeks

The recommended regimen is mifepristone 200 mg orally followed by misoprostol 800 mcg administered vaginally 24-48 hours later, which achieves a 96-98% complete abortion rate. 1, 2

Medication Regimen

Standard Protocol

• Mifepristone 200 mg orally as the initial dose 3, 4
• Misoprostol 800 mcg vaginally administered 24-48 hours after mifepristone 1, 3, 2
• This combination is effective up to 63 days (9 weeks) of gestation 3, 5, 2

Route of Administration Matters

• Vaginal misoprostol (800 mcg) is superior to oral administration, with complete abortion rates of 96% versus 84-92% for oral routes 2
• If vaginal administration is not feasible, oral misoprostol 800 mcg can be used, though efficacy is reduced 2, 4
• Buccal administration of misoprostol 800 mcg is an acceptable alternative to vaginal route 3

Alternative Regimen

• Simultaneous administration (mifepristone and misoprostol given at the same time) achieves 95.1% complete abortion rate, which is noninferior to the 24-hour interval regimen 6
• This may be preferred when immediate treatment is desired, though gastrointestinal side effects (nausea, diarrhea) are more common 6

Clinical Management

Pre-Treatment Requirements

• Confirm gestational age using ultrasonography or reliable menstrual history 3
• Ultrasonography is mandatory when dating cannot be confirmed clinically or when ectopic pregnancy risk factors exist 3
• Gestational age must be ≤63 days (9 weeks) for this regimen 3, 2

Expected Effects and Side Effects

• Cramping and bleeding are expected, with bleeding lasting an average of 9-16 days 3
• Gastrointestinal symptoms (nausea, diarrhea) occur in up to 50% of women 4, 6
• Low-grade fever is common and can be managed with NSAIDs 3
• Antiemetics can be used for nausea management 3

Follow-Up Protocol

• First follow-up visit at 4-8 days after mifepristone administration 2
• Confirm complete abortion using clinical history combined with serial quantitative beta-hCG levels, urine pregnancy testing, or ultrasonography 3
• If ongoing pregnancy is present, administer a second dose of misoprostol 800 mcg vaginally 2
• Second follow-up before day 15 if repeat dosing was needed 2

Essential Supportive Care

Antibiotic Prophylaxis

• Prophylactic antibiotics are recommended to prevent post-abortal endometritis, which occurs in 5-20% of women without antibiotics versus 1.3% with prophylaxis 1, 7

Rh Immunoglobulin

• All Rh-negative women must receive anti-D immunoglobulin to prevent alloimmunization 1, 7

Efficacy and Safety

Success Rates

• Complete abortion rate: 96-98% with vaginal misoprostol after single administration 2
• After second dose if needed: 98% complete abortion rate 2
• Overall efficacy comparable to surgical vacuum aspiration (97% vs 95%) 4

Rare Complications

• Ongoing pregnancy requiring surgical intervention: <5% 2, 4
• Hemorrhage requiring intervention: <5% 4
• Infection: <1% with antibiotic prophylaxis 1
• Undiagnosed ectopic pregnancy: rare but must be excluded 3

Important Clinical Pitfalls

Gestational Age Considerations

• Efficacy decreases beyond 9 weeks, requiring repeated misoprostol doses and potentially different protocols 4
• Always confirm gestational age accurately before initiating treatment 3

When to Avoid Medical Method

• Severe cardiovascular disease, especially pulmonary arterial hypertension, requires surgical termination in specialized centers 7
• Severe liver or kidney disease may alter drug metabolism and requires careful consideration 7