Medical Abortion

Expertise Understanding Discretion

MEDICAL ABORTION

What is a Medical Termination of Pregnancy (MTOP)

A medical termination is one where the woman takes two different drugs (mifepristone and misoprostol) that will end a pregnancy of up to nine weeks in a similar way to a miscarriage. These drugs have been used widely and safely on millions of women throughout the world, including France and China, UK, Sweden, USA and New Zealand. Mifepristone has only recently been approved for use by specialists in Australia.

In 2009 Dr Sue Brumby was granted permission to use mifepristone. Misoprostol has been approved to treat stomach ulcers in Australia. It is widely used in Australia and overseas in termination clinics.

How Does it Work?

Mifepristone is an anti-progesterone drug. Progesterone is a hormone that is necessary to maintain the early stages of pregnancy. Without progesterone, the lining of the uterus breaks down, the opening of the uterus softens and bleeding begins.
However, the uterus needs to contract and expel the pregnancy tissue, hence the need for misoprostol. This drug causes the uterus to contract and empty and is given to you to take at home 1—2 days later.

Most women will have a miscarriage anytime up to two days after misoprostol has been taken. This method is 95% successful at terminating the pregnancy and may be used up to and including pregnancies of nine weeks duration. The earlier the pregnancy, the more successful the drugs will be.

A minimum of two visits to the clinic is required approximately two weeks apart to ensure a successful termination.

Country patients who have difficulty returning to the clinic can be monitored by phone at two weeks. At one to two weeks from the miscarriage you will need to get a blood test to check your pregnancy hormones have significantly dropped. It is essential to ensure that you are no longer preganant.

If you have any of the following conditions you CANNOT have a medical termination (MTOP):

  • Chronic adrenal failure
  • Haemorrhagic/bleeding disorder
  • Inherited porphyria
  • Severe anaemia
  • Long-term anticoagulant therapy
  • Corticosteroid therapy
  • Confirmed or suspected ectopic (tubal) pregnancy
  • Allergy to mifepristone or misoprostol
  • IUD in place — this must be removed first
  • Irritable bowel disease or uncontrolled bowel disease (eg severe diarrhoea, Crohn’s disease)
  • Serious systemic illness (eg severe liver disease, heart disease, kidney failure, uncontrolled seizure disorders)
  • Serious pelvic infection
  • Unwillingness to undergo a surgical termination

Other Important Considerations

  • You can only have a medical termination if you are no more than 9 weeks pregnant.
  • You MUST —
    • Return to the clinic in two to three weeks.
    • Live within 30 minutes of a hospital and have reliable transport.
    • Have a reliable telephone.
    • Consent to a surgical termination if the medical termination fails (at no extra cost).

How do I make an appointment for Medical Abortion (MTOP)?

If you would like to make an appointment for an MTOP go to locations and contact the clinic nearest you. When you call allow 10-15 minutes for the receptionist to make your appointment.

You will need to bring along:

  • Your Medicare Card,
 Pension, or Health Care Card if you have one
  • Any current medications that you are taking
  • Proof of your blood type — we can perform a blood test at the clinc if you don’t have this
  • Any blood test results or ultrasound results that you may have
  • If you are between 14-16 years old, proof of age
  • If you are under 14, you must be accompanied by a parent or guardian who is required to give their written consent. If accompanied by a guardian, proof of guardianship is required.

It is not necessary to have a doctor’s referral in order to have a termination. 
Please reconfirm your appointment as requested by the receptionist.

How is an MTOP performed?

The first visit to the clinic

Mifepristone (one tablet of 200mg) is taken orally. Some women may start bleeding and miscarry with the abortion pill alone (30%) but misoprostol is usually needed to complete the process.

This visit includes:

  • Assessment and counselling
  • Ultrasound and testing to confirm the pregnancy.
  • If you have rhesus negative blood you will have an anti-D injection during this visit.
  • A base line pregnancy hormone test will be done.
  • You will be screened for Chlamydia.

At Home

The second drug, misoprostol (four tablets of 200mcg), is given to you at your first visit. The tablets should be taken 24 — 48 hours after the abortion pill by placing two tablets on either side of your mouth between your cheek and gum and allowing them to dissolve. The best results are from taking the tablets at 36 — 48 hours. Any remnants may be swallowed with water after 30 minutes.

Alternatively, the tablets may be moistened and inserted high in the vagina. After taking the four misoprostol tablets, you will have bleeding and cramps and may pass some pregnancy tissue. Most women will abort the pregnancy within four hours of taking tablets, some will take 24 hours, and 95% will have a complete abortion within one week.

The misoprostol can cause nausea, vomiting and diarrhoea in some women. These side effects are reduced if you put the tablets high up in your vagina. This is the best option if you are having severe vomiting from the pregnancy.

(There is some debate among doctors about risks of a rare systemic infection with the vaginal route. See the Comparison and Risks page for more information on this.)

The pain is like bad period cramps and will hurt the most during the miscarriage. After the tissue is expelled the pain subsides.

You can take painkillers like Nurofen, Naprogesic, or Panadiene before, during or after the process. It is best to take them one hour before the misoprostol. We will also give you some anti-nausea tablets and a very strong painkiller.

Most women bleed for 9 —15 days but some have bled for up to 70 days. However, if you haven’t started to bleed within 24 hours, you should take another four tablets of misoprostol after you call Dr Brumby on 0408 618 226. These extra tablets will be given to you at your first visit. Some women develop very heavy bleeding on the first day, or after a few weeks. The spare tablets can contract the uterus and push out blood and tissue that can be causing the heavy bleeding. Phone Dr Brumby on 0408 618 226 before you take any more tablets.

Occasionally, some women will need to return to the clinic for a third dose of misoprostol. A surgical termination (STOP) may be required if the third dose doesn’t work.

You must return your unused tablets to the clinic when you attend for your checkup visit. These drugs must not be left in your home or given to anyone else as they can cause miscarriage and foetal abnormalities.

The Second Visit

You must return to the clinic two to three weeks after the first visit to ensure that the MTOP has been successful. This is confirmed by vaginal ultrasound. If there is a continuing pregnancy, a surgical termination will be organised free of charge. The abortion pill is not known to increase the risk of foetal malformations but misoprostol may do so. Therefore it is essential that the termination be completed surgically if the MTOP fails.

What should I expect after an MTOP?

Bleeding

The bleeding may be light, like a heavy period, or heavier than a normal period. It may last for two weeks or more and there can be clots. The heavy bleed usually settles after a few hours. It can begin thirty minutes after taking the misoprostol tablets and it may (rarely) last as long as 70 days. The next period is usually expected four to eight weeks after the miscarriage. This period may be heavier, more painful, more prolonged than your usual one. Haemorrhage requiring blood transfusion is reported with overall rates of approximately 1 — 2 in 1,000 women.

Cramping is a natural component of the miscarriage process and may be worse than a normal period. Pain is most intense during expulsion. It may only last an hour or two or, it may last for twenty four hours.
Simple pain relief medication is usually all that is required, eg Nurofen, Naprogesic. It is best to take pain killers about an hour or two before you take the misoprostol. We will also give you medication for stronger pain relief (Panadiene Forte).

We can’t say exactly when your miscarriage will happen. Most women will miscarry within four hours of taking misoprostol. You need to choose the right time in your daily routine to take the misoprostol and pain relief.
You may be able to see the pregnancy tissue once it has passed. It may be a small sac of greyish looking tissue. It is possible but unlikely that you will see a foetus.

Other side effects

  • Nausea, diarrhoea, vomiting, headache, fever, chills, shivering, dizziness and fatigue are other side effects of misoprostol.
  • Infection is uncommon with an overall rate of <1%, however, there have been very rare fatal cases of toxic shock syndrome in USA.
  • After a successful MTOP, pregnancy symptoms will go away. Nausea subsides quickly over the next few days but breast enlargement and tenderness may take a few weeks to go.

Ovulation may occur from ten days after the MTOP so you should use contraception as soon as the miscarriage has finished. If you would like to use the contraceptive pill, you should take it on the same day as the misoprostol, or the day after.

Breastfeeding

We don’t know what effects mifepristone and misoprostol have on a breastfed infant. We recommend that misoprostol should be taken immediately after a feed and the next feed should not take place until six hours later.

Medical Terminations (MTOP)

Surgical Terminations (STOP)

High success rate 95% Very high success rate > 99%
Usually avoids the use of surgical instruments thus avoiding risk of injury to cervix and uterus. Instrumentation of cervix and uterus required.
Anaesthesia not required (however there is a small failure rate and a surgical termination may be necessary). A needle will be used to take a blood sample. Anaesthesia required. Intravenous sedation is most commonly used and this is very low risk. Local anaesthetic (awake) is also available.
Resembles a miscarriage. Pain and bleeding are variable but usually more than an STOP. A doctor performs the procedure while you are asleep unless you have chosen a local.
The pregnancy is usually passed within 24 hours of taking the second drug. The blood and tissue that remains may take days or weeks to pass. The procedure is completed within 5 — 10 minutes.
Bleeding may last for up to 40 days (rarely 70) and patients may see pregnancy tissue and blood clots. Pain is usually moderate to severe for a few hours. Some women have only mild pain. Post procedural bleeding rarely lasts more than two weeks. For most women it is light to moderate and lasts about three to four days. Post op pain is mild to moderate.
Requires a minimum of two visits to the clinic two  weeks apart. Only one visit to the clinic is required usually lasting about three hours.
Can only be performed in early pregnancy up to nine  weeks from last period May be performed in early pregnancy up to 18 weeks at our clinic.
The miscarriage may occur at home. You have to fast for five hours before the procedure and you can’t drive yourself home. You can drive home if you have chosen a local.

Risks Associated with a Medical Termination of Pregnancy (MTOP)

Approximately 5% of women will have a failed medical termination and require a curette. Serious complications are rare but any medical or surgical procedure has potential complications.

Excessive Bleeding

Bleeding is expected with medical terminations. It is most likely to occur within four hours of taking the four misoprostol tablets. It may be much heavier than a normal period. We check your haemaglobin and if it is low, monitor your blood loss.The average bleeding lasts nine to fifteen days but can last as much as 40 days. Haemorrhage requiring a blood transfusion can occur with rates of 1 — 2 in 1000. There is a risk of death if severe blood loss is not treated urgently.

Retained Products of Conception

This complication causes very heavy vaginal bleeding with cramping pain. It happens when the pregnancy tissue has not been completely expelled from the uterus (5%). Extra misoprostol can often help the uterus to expel the rest of the tissue. If not a curette may be required to remove the remaining tissue. We will do this at no extra cost.

Continuing Pregnancy

Occasionally the pregnancy may continue and a curette is necessary. This is less common with early pregnancies and the rate is one in a hundred. An assessment with an ultrasound is made two weeks after the initial consultation to ensure that a successful abortion has occurred. A curette will be organised if the medication has been unsuccessful.

Infection

Pelvic infection after medical abortion is uncommon. The symptoms of infection are abdominal pain, elevated temperature and vaginal discharge with or without bleeding. When properly treated, future fertility is not affected. There is an ongoing debate about the risks with vaginal application of the four misoprostol tablets. In the USA, there have been deaths from septicemia (toxic shock) associated with vaginal application. There has been one death in Australia. The incidence is quoted as 1:100,000 — very rare. This has also happened with oral application but it is even less common. It is possible that these deaths were coincidental and not related to the MTOP. There have been no deaths in Europe where millions of women have had MTOPS.

Our Advice

The risk with vaginal application is very low or zero. However, it is better to be on the safe side and use the oral route. But if you are very nauseated or vomiting from the pregnancy, the vaginal route is less likely to increase these symptoms and should be used. Some women get nausea, vomiting and diarrhea from the misoprostol and this can be exacerbated with the oral route.
Symptoms of septicemia are feeling very very unwell (“run over by a truck”), and a high temp over 38 degrees. If you have any concerns, call the clinic or go to hospital.

Ectopic Pregnancy

About 1 in 200 pregnancies grow in the tube and not in the uterus. Medical abortion is not possible with this kind of pregnancy. If you have an ectopic pregnancy you will be admitted to hospital for treatment. Ectopic pregnancies are very serious and may cause death. If we think you are at risk we will give you a special information sheet.

Psychological Effects

Major emotional or psychological problems after an MTOP are uncommon. They are more likely if you have a pre-existing problem or are pushed into a termination against your will. The clinic can arrange a referral to appropriate counsellors if necessary.

Foetal Abnormalities

Birth defects are normally 2 – 3%. The abortion pill is not known to increase the risk of birth defects, but foetal malformations have been reported after first trimester use of misoprostol. Therefore, you have to complete the abortion once the procedure has begun. You cannot change your mind.

Other Complications

Allergic reactions to the mifepristone or misoprostol are very rare.

ABORTION
  • What Happens when I have an abortion?
  • How do I prepare?
  • What will I need to bring?
  • What else do I need to know?
  • What can I expect?
  • What happens next?
MEDICAL ABORTION
  • What is a Medical Termination of Pregnancy (MTOP)?
  • How does it Work?
  • Conditions where you will not be able to have a MTOP
  • Other Considerations
  • How do I make an appointment for (MTOP)?
  • What to bring.
  • What Happens Afterwards
  • MTOP vs STOP Comparison
  • Risks Associated
CONTRACEPTION
  • Condoms
  • Diaphragm
  • Pills
  • The Nvaring
  • LARCS
  • The Injection
  • Sterilisation
WOMEN’S HEALTH
  • Women’s Checks
  • Pap Smears
  • Breast Checks
  • Vaginal Problems
  • Menopause
  • Contraception
  • IUD & IUS Insertion and Removal
  • Pregnancy Counselling
  • Pregnancy Terminations
  • Sexually Transmitted Infection
VASECTOMIES
  • Information
  • Questions
  • Risks
  • After Care
OTHER INFORMATION
  • Meet our Doctors
  • STI’s
  • Pregnancy
  • Counselling
  • Support
  • Men’s Issues
  • Coping
  • Risks
  • Articles
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