The

n e w e ng l a n d j o u r na l

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m e dic i n e

clinical practice

A Request for Abortion Allan Templeton, M.D., and David A. Grimes, M.D. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.

A 22-year-old student presents to her primary care physician with an unintended pregnancy at 9 weeks of gestation and requests an abortion. She is aware of both medical (drug-induced) and surgical methods of terminating a pregnancy and wants to know which approach would be recommended. She also asks whether either method will affect her future reproductive health. What would you advise?

The Cl inic a l Probl em From the Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen, United Kingdom (A.T.); and the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill (D.A.G.). Address reprint requests to Dr. Templeton at the Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Aberdeen AB25 2ZD, United Kingdom, or at [email protected]. N Engl J Med 2011;365:2198-204. Copyright © 2011 Massachusetts Medical Society.

An audio version of this article is available at NEJM.org

Induced abortion is one of the most common medical interventions. In the United States, approximately 1.2 million abortions were performed in 2008.1 In the United Kingdom, more than 200,000 abortions are recorded annually.2,3 About one of three women will have had an induced abortion by the time she reaches menopause. Approximately 90% of abortions are performed in the first trimester because the pregnancy is unintended or unwanted. A small but important proportion (1 to 2%) of abortions are performed later because of a fetal abnormality (e.g., anencephaly, trisomy, or myelomeningocele)4 or serious illness (e.g., cancer or pulmonary hypertension) in the woman. Until recently, the main method of abortion was surgical, but since 1992 in the United Kingdom and since 2000 in the United States, medical abortion has become increasingly available. Medical abortion involves the combined use of the progesterone antagonist RU-486 (now known as mifepristone), which initiates the abortion, and a prostaglandin, which causes uterine contractions and empties the uterus.5 Of all abortions, medical abortions account for approximately 10% in the United States, 40% in England, and 70% in Scotland (Fig. 1). Easy access to safe, legal abortion services is important to the general health of women and their families.6 Women will seek abortion whether it is legal or not, and the morbidity and mortality associated with illegal abortion remain high. This review article does not address the debate over abortion or the adverse health effects associated with restricting access to abortion services, but it assumes a woman’s right to have her pregnancy terminated if the relevant legal requirements are met.

S t r ategie s a nd E v idence Medical Abortion

Medical abortion has evolved considerably since mifepristone was first licensed for use in Europe in the early 1990s. Whereas initial results with mifepristone alone were disappointing, effectiveness improved dramatically when a prostaglandin or prostaglandin analogue was administered 1 or 2 days after mifepristone.5 Today, the most commonly used prostaglandin is the prostaglandin E analogue misopro-

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The New England Journal of Medicine Downloaded from nejm.org on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved.

clinical pr actice

key Clinical points

first-trimester Abortion • Up to 9 weeks’ gestation, a choice of medical or surgical abortion should be offered, since both are safe and effective. • Medical abortion is associated with more pain and bleeding, and it carries a slightly higher risk of incomplete abortion (2 to 5%, vs. 1% with surgical abortion). • Surgical abortion may be associated with an increased risk of serious, but very rare, complications requiring major surgery. • Women can be reassured that the current evidence indicates that neither method of abortion is associated with an increased risk of harm to their future reproductive health or to their future mental health, as compared with continued pregnancy. • The insertion of an intrauterine device at the time of the abortion is the best reversible method of contraception to prevent another unintended pregnancy.

stol; its advantages include stability at room temperature (which facilitates short-term storage), possible administration by several routes (vaginal, buccal, sublingual, and oral), and low cost. Misoprostol (and other prostaglandin analogues) can be used alone as abortifacients but are less effective than mifepristone plus misoprostol.7 Similarly, in areas where mifepristone is still unavailable, such as Canada, methotrexate followed by misoprostol can be used, although this regimen is not as effective as the mifepristone–misoprostol regimen. Initially, misoprostol at a dose of 400 μg was administered orally, and this continues to be the preferred route of administration in France, although in the United Kingdom and United States, vaginal administration of misoprostol at a dose of 400 to 800 μg was shown to be more effective, particularly at gestational ages of more than 7 weeks.8 If needed, the administration of a second dose of misoprostol, either vaginally or orally according to the amount of vaginal bleeding, further increased the likelihood of complete abortion.9 Alternative routes of misoprostol administration, including sublingual10 and buccal,11 have been shown to be as effective as vaginal administration, although side effects of prostaglandin, which are mainly gastrointestinal, are more frequent.12 However, many women prefer the convenience of these approaches, which do not involve vaginal administration of tablets. The Food and Drug Administration–approved dose of mifepristone is 600 mg, but in a randomized trial, the effectiveness of a 200-mg dose was similar to that of a 600-mg dose for medical

abortion at all gestational ages.13 An initial vaginal dose of 800 μg of misoprostol is widely used; although a lower dose may be sufficient in many women and is associated with fewer side effects, there is no effective way to predict which women will require the higher dose. Some studies have indicated that the interval between administration of these two medications can be reduced to 24 hours or less, but most clinics wait 24 to 48 hours after mifepristone administration to administer misoprostol. Once medications have been administered, abortion can be completed at home. The safety and efficacy of medical abortion completed at home are similar to the safety and efficacy of medical abortion in the clinic,14 although ready access to emergency facilities is still required. This is now the usual approach to medical abortion in the United States and is increasingly common in Europe.15 Surgical Approaches

Since the 1970s, suction curettage, also known as vacuum aspiration, has been the standard method of abortion in the United States, where more than 80% of abortions in the first trimester are performed surgically (Fig. 1). Vacuum aspiration is a safe procedure that is associated with low rates (