INTRODUCTION Millions of women worldwide have safely terminated their pregnancies with medication since mifepristone—or RU 486—was first introduced in the late 1980s. Research in the past two decades has identified several highly effective regimens for early medical abortion.1 Whether taken in a health center or at home by women themselves, regimens using pills offer an option that many women prefer to surgical abortion procedures such as manual vacuum aspiration or dilation and curettage (D&C).
Because mifepristone is a registered abortion drug, its sale and use are not permitted in most countries with restrictive abortion laws. In contrast, misoprostol is an anti-ulcer medication, and is registered under various trade names worldwide.2,3 Research has found that misoprostol alone is about 75-85 percent successful in inducing abortion in the first trimester when used as recommended. Although less effective alone than when combined with mifepristone, misoprostol offers a safe and accessible alternative for women.
GUIDELINES FOR USING MISOPROSTOL TO INDUCE ABORTION
Misoprostol is typically sold in pharmacies in tablets of 200 mcg. Four tablets are recommended to initiate an early abortion, and four (or, rarely, eight) more may be required for its completion. It is best to use misoprostol within nine weeks since the last menstruation; that is, fewer than 63 days counting from the first day of the last regular period. The earlier in pregnancy misoprostol is administered the better, because it is safer, more effective, and less painful. Misoprostol can be used later in pregnancy but the risks of complications are higher (see below). Women with an intrauterine contraceptive device (IUD) in place should have it removed before using misoprostol.
GUIDELINES FOR PREGNANCIES UP TO 12 WEEKS: 4
Step 1: Place four 200-mcg tablets (or their equivalent) in the mouth under the tongue or in the cheek pouch. Hold tablets in the mouth for 20-30 minutes to allow them to dissolve, and then swallow the remaining fragments.
During this process, you may experience bleeding that is somewhat heavier than for a period. That is normal. You should have a supply of thick sanitary napkins on hand.
Bleeding and uterine contractions (cramping) may begin as quickly as 30 minutes following this first step. If bleeding and contractions do not start within 3 hours, see Step 2 (below).
Bleeding itself does not mean that an abortion has occurred. Close inspection of the sanitary pad or other receptacle can reveal whether the pregnancy has been terminated. This will be difficult to detect in the very early stages of pregnancy, however, because the embryonic tissue is indistinguishable from the normal clotting of menstrual blood. For example, six weeks into pregnancy (that is, six weeks from the first day of the last menstrual period), the embryonic sac is only about the size of a short grain of rice. By the eighth week it is more visible, about the size of a kidney bean. For terminations from 10-12 weeks, the fetus is 30 mm to 8 cm in length (1+ to 3+ inches) and it will be very clear when it has passed.
If it is not clear that the pregnancy has been terminated within three hours of taking the first dose—for example, if the embryonic sac is not visible on the sanitary pad, or if cramping continues without diminishing—go to Step 2.
Step 2: Place four more 200-mcg tablets under the tongue or in the cheek pouch and hold them there for 20-30 minutes until they dissolve.
Step 3: If the pregnancy has not been terminated three hours after using the second set of pills and bleeding, take four more 200 mcg tablets of misoprostol.
The majority of pregnancies up to 12 weeks duration are terminated within hours of the first administration of misoprostol. Generally, more than three-quarters of women experience an abortion within the first 24 hours, although it sometimes takes longer.4 If unsuccessful, the entire process may be repeated.
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