What is the recommended approach for medical termination of pregnancy?

Medical Termination of Pregnancy: Recommended Approach

The recommended approach for medical termination of pregnancy depends critically on gestational age: for pregnancies ≤49 days (7 weeks), use mifepristone 200 mg followed by misoprostol 400-800 mcg buccally; for second-trimester terminations, dilation and evacuation (D&E) is the safest method and should be strongly preferred over medical approaches. 1, 2

First Trimester Medical Termination (≤49 Days/7 Weeks)

Medication Regimen

• Administer mifepristone 200 mg orally, followed 36-48 hours later by misoprostol 400-800 mcg buccally 1, 3
• The 400 mcg dose of buccal misoprostol is equally effective as 800 mcg (96% success rate for both) and causes significantly less vomiting and fever/chills 3
• Success rates are highest at ≤49 days gestation (92-98%), declining to 77-83% at 50-63 days 4, 5

Critical Safety Requirements

• Pregnancy must be excluded before initiating mifepristone treatment, as it is a potent progesterone antagonist that will terminate pregnancy 6
• Obtain negative pregnancy test prior to treatment or if treatment is interrupted for >14 days in reproductive-aged women 6

Expected Timeline and Outcomes

• Termination occurs within 4 hours in 49% of women and within 24 hours in 75% 5
• Follow-up assessment should occur 12-15 days after mifepristone administration 3
• Failure rates (requiring surgical intervention) increase from 1% at ≤49 days to 9% at 57-63 days 5

Second Trimester Termination (≥14 Weeks)

Strongly Preferred Method: Dilation and Evacuation (D&E)

• D&E is dramatically safer than medical methods for second-trimester termination and should be the default choice 1, 2, 7
• Hemorrhage risk: 9.1% with D&E vs 28.3% with medical methods 1, 2
• Infection risk: 1.3% with D&E vs 23.9% with medical methods 1, 2
• Must be performed in hospital setting by experienced providers 1, 2, 7
• Most procedures performed under sedation or general anesthesia 1, 2

Alternative Medical Method (When D&E Unavailable)

• Use prostaglandin E1 (misoprostol) or E2 for medical termination 1
• Avoid prostaglandin F compounds due to adverse hemodynamic effects (increased pulmonary arterial pressure, decreased coronary perfusion) 2
• Monitor systemic arterial oxygen saturation with pulse oximetry during prostaglandin administration 2, 7

Essential Post-Procedure Care (All Methods)

Infection Prevention

• Administer prophylactic antibiotics to all patients - reduces post-abortal endometritis from 5-20% to 1.3% 1, 2, 7

Rh Immunization Prevention

• Give anti-D immunoglobulin to all Rh-negative women 1, 2, 7

Monitoring Requirements

• Watch for signs of infection, retained products of conception, and excessive bleeding 1

Counseling Framework for High-Risk Patients

Timing and Content

• When pregnancy termination is indicated, counseling should be performed as expeditiously as possible to optimize choices and outcomes 8
• Provide nondirective counseling covering: short- and long-term maternal health risks, risks/benefits of pregnancy continuation vs termination, and treatment options 8
• Reassess continuously throughout pregnancy as health status can change rapidly 8

Patient Satisfaction Factors

• Women define satisfaction based on receiving adequate information about termination options and having autonomy to decide on method consistent with their personal values 8
• If termination elected, provide postabortion counseling to normalize feelings and identify supportive resources 8

Special High-Risk Situations

Cardiac Disease/Pulmonary Hypertension

• First-trimester termination is safer than second-trimester for high-risk cardiac patients 1
• Manage in experienced centers with on-site cardiac surgery capabilities 1, 2

Oncology Patients

• First-trimester pregnancy termination is advised if chemotherapy or radiotherapy required - these treatments carry high risk of fetal malformations in first trimester 1

End-Stage Renal Disease

• Mifepristone can be used up to 7 weeks gestation as alternative to surgical evacuation 1
• Consider high-risk and manage in experienced centers with emergency support 1

Critical Pitfalls to Avoid

• Do not delay counseling or procedure - gestational age directly impacts success rates and complication risks 8, 5
• Do not use prostaglandin F compounds - they cause dangerous hemodynamic effects 2
• Do not omit antibiotic prophylaxis - infection rates are unacceptably high without it 1, 2, 7
• Do not perform second-trimester medical termination when D&E is available - complication rates are substantially higher 1, 2