What is the recommended regimen, contraindications, and follow‑up for using a medical termination of pregnancy (MTP) kit in a confirmed pregnant patient who wishes to terminate a pregnancy up to 10 weeks gestation?

Medical Termination of Pregnancy (MTP Kit) Protocol

For pregnancies up to 10 weeks (70 days) gestation, the recommended regimen is mifepristone 200 mg orally followed by misoprostol 800 μg (buccally or vaginally) 24-48 hours later, achieving 95-98% efficacy with minimal complications. 1, 2, 3

Recommended Regimen

Standard Protocol (≤9 weeks/63 days)

• Mifepristone 200 mg orally as the initial dose 1, 4, 2
• Misoprostol 800 μg administered 24-48 hours later, either:
  • Buccally (placed between cheek and gum) 2, 3
  • Vaginally 1, 4, 3
• Home administration of misoprostol is safe and effective after the initial mifepristone dose 2, 3

Efficacy by Gestational Age

• ≤49 days (7 weeks): 92-98.8% success rate 5, 2
• 50-56 days (7-8 weeks): 83-98.8% success rate 5, 2
• 57-63 days (8-9 weeks): 77-95.5% success rate 5, 2
• Efficacy decreases with advancing gestational age, with the highest failure rates (ongoing pregnancy) occurring at 57-63 days 5, 2

Absolute Contraindications

Do not use medical abortion in these situations:

• Confirmed or suspected ectopic pregnancy 3
• Severe cardiovascular disease, especially pulmonary arterial hypertension - these patients require surgical termination in centers with cardiac surgery capabilities 6, 7
• Uncontrolled seizure disorder 3
• Acute porphyria 3
• Chronic adrenal failure or long-term corticosteroid therapy 8
• Known allergy to mifepristone or misoprostol 3

Relative Contraindications Requiring Caution

• Severe liver or kidney disease - may alter drug metabolism and clearance 6
• Inherited porphyrias 8
• Hemorrhagic disorders or anticoagulant therapy - increased bleeding risk 3
• Severe anemia (hemoglobin <9.5 g/dL) 3

Pre-Treatment Requirements

Essential Testing

• Confirm intrauterine pregnancy via ultrasonography or clinical dating 3
• Gestational age determination using ultrasound or reliable menstrual history 3
• Rh status testing - critical for post-procedure anti-D administration 1, 6
• Ultrasonography is mandatory when:
  • Gestational dating cannot be confirmed clinically 3
  • Risk factors for ectopic pregnancy exist 3

Patient Counseling (Must Be Expeditious)

• Timing is critical - delays directly impact success rates and complication risks 1, 9
• Discuss expected bleeding (average 9-16 days) and cramping 3
• Review signs of complications requiring immediate attention 3
• Provide contraception counseling covering safety, effectiveness, accessibility, affordability, and acceptability 1

Mandatory Post-Procedure Care

Antibiotic Prophylaxis

• Required for all patients to prevent post-abortal endometritis 1, 9, 6
• Without antibiotics: 5-20% infection rate 1, 9
• With antibiotics: 1.3% infection rate 1, 9

Rh Immunoglobulin

• Anti-D immunoglobulin is mandatory for all Rh-negative women to prevent alloimmunization 1, 9, 6

Follow-Up Assessment

• Clinical follow-up at approximately 7-14 days to confirm complete abortion 3
• Confirmation methods include:
  • Serial quantitative beta-hCG levels 3
  • Urine pregnancy testing 3
  • Ultrasonography 3
  • Clinical history alone may be sufficient in uncomplicated cases 3

Expected Effects vs. Complications

Normal Expected Effects

• Cramping and bleeding are expected - not complications 3
• Bleeding duration: average 9-16 days 3
• Low-grade fever, nausea, vomiting, diarrhea - manageable with NSAIDs or antiemetics 3
• Most expulsions occur within 4 hours (49%) to 24 hours (75%) of misoprostol administration 5

True Complications (Rare)

• Ongoing pregnancy: 1-9% depending on gestational age 5, 2
• Infection requiring hospitalization: 0.01% 2
• Hemorrhage requiring transfusion: 0.03% 2
• Undiagnosed ectopic pregnancy 3
• Need for unplanned uterine aspiration: 2-4% depending on gestational age 5

Critical Pitfalls to Avoid

1. Never delay counseling or procedure - timing directly impacts success rates and complication risks 1, 9
2. Never use prostaglandin F compounds - they cause adverse hemodynamic effects; use prostaglandin E1 (misoprostol) or E2 only 9, 6
3. Never omit antibiotic prophylaxis - infection rates increase from 1.3% to 5-20% 1, 9
4. Never forget anti-D immunoglobulin in Rh-negative women 1, 9, 6
5. Never use outdated FDA-approved dosing (600 mg mifepristone) - evidence supports 200 mg as equally effective 2, 3

Special Populations

High-Risk Cardiac Patients

• Women with pulmonary arterial hypertension should avoid pregnancy entirely - maternal mortality up to 50% 7
• If pregnancy occurs, termination should be performed as early as possible (first trimester preferred) in centers with cardiac surgery capabilities 7, 6
• Surgical methods preferred over medical methods in severe cardiovascular disease 6

Patients Requiring Chemotherapy

• First trimester chemotherapy is associated with 20% fetal malformation risk 7
• Pregnancy termination should be considered if chemotherapy cannot be delayed 7, 9