What is the recommended regimen for medical termination of pregnancy (MTP) at 7-14 weeks gestation?

Medical Termination of Pregnancy at 7-14 Weeks Gestation

For pregnancies between 7-14 weeks gestation, the recommended regimen is mifepristone 200 mg orally followed by misoprostol 800 mcg (buccal or vaginal route) administered 24-48 hours later, with surgical dilation and evacuation (D&E) being the preferred alternative method in the second trimester (≥12 weeks) due to superior safety profile. 1, 2

Medical Regimen (7-9 Weeks)

First Trimester Protocol (Up to 9 Weeks/63 Days):

• Administer mifepristone 200 mg orally as the initial dose 3, 4
• Follow with misoprostol 800 mcg administered 24-48 hours later 3, 5
• Buccal route is preferred over oral for misoprostol, as it achieves higher success rates (96.2% vs 91.3%), particularly at advanced gestational ages 5
• Success rates are highest at 29-42 days gestation (98.8%) and decline to 95.5% at 57-63 days 3
• The complete abortion rate with this regimen is approximately 95-97% 3, 4

Route-Specific Considerations:

• Buccal misoprostol maintains efficacy >94% even at 57-63 days gestation 5
• Oral misoprostol efficacy drops below 90% (85.1%) after 8 weeks, with significantly higher ongoing pregnancy rates (7.9% vs 1.7% with buccal) 5
• Vaginal administration is an acceptable alternative to buccal route 6, 4

Transitional Period (9-12 Weeks)

At gestational ages beyond 9 weeks:

• Medical abortion becomes less effective and requires repeated doses of misoprostol 4
• Consider transitioning to surgical management as efficacy decreases with advancing gestation 4
• Hospital-based setting with close monitoring is recommended 1

Second Trimester (12-14 Weeks)

Dilation and evacuation (D&E) is the safest and preferred method for termination at 12-14 weeks gestation 1, 2:

• D&E has dramatically lower complication rates compared to medical methods 1, 2
• 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
• Should be performed in hospital setting by experienced providers 1, 2
• Most procedures performed under sedation or general anesthesia 1, 2

If medical method is chosen for second trimester:

• Mifepristone followed by prostaglandin E1 (misoprostol) or E2 2
• Avoid prostaglandin F compounds as they increase pulmonary arterial pressure and may decrease coronary perfusion 2
• Requires repeated prostaglandin doses at 3-6 hour intervals 6

Essential Supportive Care

Antibiotic Prophylaxis:

• Recommended for all patients to prevent post-abortal endometritis 1, 2
• Without prophylaxis, infection occurs in 5-20% of women; with prophylaxis, risk drops to 1.3% 1, 2

Rh Immunoglobulin:

• All Rh-negative women must receive anti-D immunoglobulin to prevent alloimmunization 1, 2

Pain Management:

• Adequate analgesia should be provided 2
• Fetal analgesia is not indicated as there is no evidence of fetal pain awareness before 24-25 weeks gestation 1, 2

Critical Timing Considerations

Gestational Age-Specific Success Rates:

• 29-42 days: 98.8% success 3
• 43-56 days: ~97% success 3
• 57-63 days: 95.5% success (medical method) 3
• Beyond 63 days: Consider surgical approach as first-line 1, 2

Special Populations and Contraindications

High-Risk Patients:

• Severe cardiovascular disease, especially pulmonary arterial hypertension, is a contraindication for medical termination 7
• These patients require surgical termination in centers with cardiac surgery capabilities 7
• First trimester termination is safest and should be performed in hospital settings for high-risk patients 7

Cancer Patients:

• If chemotherapy or radiotherapy is required during first trimester, pregnancy termination is advised due to high risk of fetal malformations 1
• Chemotherapy can be administered with reasonable safety during second trimester if termination is not performed 1

Common Pitfalls to Avoid

• Do not use oral misoprostol beyond 8 weeks as efficacy drops significantly; switch to buccal or vaginal route 5
• Do not delay counseling or procedure as this directly impacts success rates and increases complication risks 1
• Do not use prostaglandin F compounds in any patient, particularly those with cardiovascular concerns 2
• Do not perform medical abortion beyond 9 weeks without repeated misoprostol doses and close monitoring 4
• Do not choose medical method over D&E in second trimester unless surgical expertise is unavailable, as D&E has superior safety profile 1, 2