Counseling has played a critical role in the development of efficient and acceptable abortion services.¹⁵ Whether abortion is accomplished in a clinic, a physician’s office, or a surgical center, the functions of a counselor must be fulfilled to ensure quality patient care. These include help with decision making, provision of information about the procedure, obtaining informed consent, provision of emotional support for the patient and her family before, during, and after the procedure, and providing information about contraception.¹⁶ These responsibilities can be carried out by a physician, nurse, psychologist, social worker, or a trained lay person.

The counselor must be able to make judgments about duration of gestation using the last menstrual period and reports from other clinicians, must be aware of referral opportunities for prenatal care and adoption, must know about the abortion procedure itself, must be skilled and sensitive at obtaining informed consent after presenting understandable estimates of risk, must be able to give preoperative and postoperative instructions and serve as a contact person for problems that arise during these periods, and must provide realistic information about contraception. Informed consent is important both for the patient’s understanding of the risks of first-trimester abortion and for the legal protection of the clinician when outcomes are unsatisfactory.

Each clinic or office should have a first-trimester abortion informed consent document that defines in terms the patient can understand risks such as incomplete abortion, infection, and in the case of a surgical procedure, uterine perforation, transfusion, laparotomy, ectopic pregnancy, and failed abortion. Patients should always be asked about their intentions for future child bearing and the response recorded. The counselor should document that all responsibilities have been discharged.

Nearly half of induced abortions in the United States are repeat abortions.¹⁷ Repeat elective abortions are more common in older women, in women using a method of contraception, and in women reporting alcohol or drug abuse. Counseling after elective abortions should emphasize effective, long-term methods of contraception such as the intrauterine device (IUD), implants, or sterilization.

Aspiration surgical abortion is safe and effective, but it is not available everywhere, and some women find it difficult to undergo a surgical procedure or to go to a clinic where they may be subject to loss of privacy or harassment. Nonsurgical methods make abortion available to more women and improve the circumstances under which pregnancies are terminated. Both the progesterone antagonist mifepristone (RU 486) and the antimetabolite methotrexate have been demonstrated to effectively induce abortion early in pregnancy when combined with a prostaglandin. Both medical and surgical first-trimester abortions do not increase risks in future pregnancies, including ectopic pregnancy, spontaneous miscarriage, preterm birth, or low birthweight.¹⁸ Although both medical and surgical abortion methods have a very low rate of serious complications, medical abortion is associated with more discomfort, bleeding, and incomplete abortion.¹⁹,²⁰

France and China were the first countries to approve the marketing of the medical abortifacient mifepristone, a synthetic relative of the progestational agents in oral contraceptives. Mifepristone acts primarily, but not totally, as an antiprogestational agent. Both progesterone and mifepristone form hormone-responsive element-receptor complexes that are similar, but the mifepristone complex has a slightly different conformational change (in the hormone-binding domain) that prevents full gene activation. The agonistic activity of this progestin antagonist is due to its ability to activate certain, but not all, of the transcription activation functions on the progesterone receptor. The dimethyl (dimethylaminophenyl) side chain at carbon 11 is the principal factor in its antiprogesterone action. There are three major characteristics of its action that are important: a long half-life, high affinity for the progesterone receptor, and active metabolites.

A single oral dose of mifepristone has been followed a day later by the administration of a prostaglandin analogue. Several analogues have been used, but the most widely available and best tolerated was misoprostol, 800 µg administered vaginally.²¹ The combination allowed a reduction in dose of both agents. When administered in the first 8 weeks of pregnancy, this medical termination carried success and complication rates similar to that achieved with vacuum curettage.²²,²³

Misoprostol is a stable, orally active synthetic analogue of prostaglandin E₁, available commercially for the treatment of peptic ulcer. Combined with mifepristone, it provides an effective, simple, inexpensive, method that can be administered at home.²³,²⁴,²⁵,²⁶,²⁷ In the large U.S. trial of 600 mg mifepristone followed by 400 µg misoprostol orally, there was a 1% failure rate under 7 weeks of pregnancy and 9% from 8 weeks to 9 weeks.²⁸ Termination occurred in 50% of the women within 4 hours after misoprostol administration and 75% within 24 hours.

Based on worldwide experience, the regimen with the least side effects and cost, but equally good efficacy, was a combination of a lower dose of oral mifepristone (200 mg), followed 48 hours later by the vaginal administration of 800 µg misoprostol at home.²³,²⁶,²⁷,²⁹,³⁰,³¹,³² The vaginal administration of misoprostol allowed medical abortion up to 63 days after the last menstrual period.²³ Repeated doses of misoprostol have been recommended for the management of delayed expulsion. However, because of a problem with infection, the protocol for medical abortion changed.

In 2005, the Centers for Disease Control and Prevention reported four cases of fatal toxic shock syndrome in California associated with Clostridium sordellii that occurred within 1 week after medical abortions (induced with 200 mg of oral mifepristone and 800 µg of vaginal misoprostol).³³ This prompted many clinicians and the Planned Parenthood Federation to switch to buccal administration of misoprostol, recognizing that Clostridium species are present in a small percentage of vaginal cultures.

Beginning in 2006, Planned Parenthood Federation clinics changed to a protocol that administered 800 µg misoprostol buccally 24 to 48 hours after 200 mg mifepristone and either to screen with vaginal cultures, especially for sexually transmitted infections (STIs), and treat appropriately or to provide prophylactically doxycycline 100 mg b.i.d. for 7 days beginning on the day of mifepristone. In 2008, the protocol was again changed, requiring prophylactic doxycycline treatment. The routine use of antibiotics was associated with a greater reduction in serious infection compared with the method of screen and treat. Following these changes, the number of serious infections decreased from 93 to 6 cases in 100,000 medical abortions, a decline of 93%.³⁴ The buccal misoprostol protocol provides comparable efficacy up to 63 days’ gestation, an expected outcome because the pharmacokinetics of misoprostol are essentially the same with either buccal or vaginal administration.³⁵,³⁶ The buccal route of administration of misoprostol is now the recommended method.

Fatalities with Clostridium species have been associated with spontaneous miscarriages, the postpartum period, after trauma or surgical procedures, and even when buccal misoprostol was used.³⁷ The best prevention of fatal toxic shock with this rare infection is awareness of the possibility and early recognition. Abdominal cramping as a presenting complaint makes the diagnosis difficult because this is a common symptom following medical abortion. Unique characteristics include: the absence of fever, markedly elevated white counts, fluid effusions sufficient to produce hemoconcentration, and eventually tachycardia and hypotension. Specific antibiotics with demonstrated efficacy against C. sordelli have not been identified, although doxycycline inhibits Clostridium growth in vitro. Early recognition of this rare infection would mandate consideration of aggressive surgery with hysterectomy, a lesson learned from the experience with septic abortions in the years before legalized abortion.

It is likely that abortion with mifepristone is the result of multiple actions. Although mifepristone does not induce labor, it does open and soften the
cervix (this may be an action secondary to endogenous prostaglandins). Its major action is its blockade of progesterone receptors in the endometrium. This leads to a disruption of the embryo and the production of prostaglandins. The disruption of the embryo and perhaps a direct action on the trophoblast lead to a decrease in human chorionic gonadotropin (hCG) and a withdrawal of support from the corpus luteum. The success rate is dependent on the length of pregnancy—the more dependent the pregnancy is on progesterone from the corpus luteum, the more likely that the progesterone antagonist, mifepristone, will result in abortion. The combined mifepristone-prostaglandin analogue method is usually restricted to pregnancies that are not beyond 9 weeks’ gestation. However, a regimen using a higher dose of misoprostol (administered vaginally) achieved a 95% complete abortion rate in women at 9 to 13 weeks’ gestation.³⁸ Other progesterone antagonists have been developed, but only mifepristone has undergone extensive abortion trials.

Mifepristone is most noted for its abortifacient activity and the political controversy surrounding it. However, the combination of its agonistic and antagonistic actions can be exploited for many uses, including contraception, therapy of endometriosis, induction of labor, treatment of Cushing’s syndrome, and, potentially, treatment of various cancers. Doses of 2 to 5 mg/d inhibit ovulation and produce amenorrhea in over 90% of cycles, and in a pilot study of 50 women, there were no pregnancies.³⁹ A clinical trial indicated that a daily dose of 5 mg mifepristone would be an effective oral contraceptive.⁴⁰

Methotrexate was tested as an abortifacient in the same dose used to treat ectopic pregnancy, 50 mg intramuscularly per m² of body surface area.⁴¹ Later, a single 75-mg intramuscular dose was demonstrated to be as effective.⁴² Methotrexate has also been administered orally in doses of 25 or 50 mg.⁴³ As with mifepristone, a prostaglandin is added to promote expulsion of the uterine contents. The first trials demonstrated that if the prostaglandin (800 µg misoprostol vaginally) was given a week after the injection of methotrexate, this method could be almost as, but not as effective as mifepristone.⁴⁴ Efficacy diminishes with advancing gestation beyond 7 weeks since the last menstrual period.⁴⁵,⁴⁶,⁴⁷ Because methotrexate takes longer to act than mifepristone, the prostaglandin is used a week after the initial treatment and is repeated a day later if expulsion has not occurred. Methotrexate is easily available and inexpensive. It has been used in low doses to treat psoriasis and rheumatoid arthritis, as well as ectopic pregnancy, without adverse effects. It is, however, a known teratogen that can be deadly in high doses, and its use as an abortifacient results in prolonged bleeding and a prolonged time to abortion (up to a month in some cases). Mifepristone is preferred by clinicians who have experience with both methods, but there are no direct comparison studies of methotrexate and mifepristone.

Another approach uses the combination of tamoxifen and misoprostol. The administration of tamoxifen (20 mg daily for 4 days) followed by
misoprostol (800 µg vaginally, with a second dose if necessary 24 hours later) was associated with a 92% rate of complete abortion in 100 women with pregnancies less than 9 weeks’ gestational age.⁴⁸ Similar good results were obtained in a comparison of tamoxifen (20 mg b.i.d. for 4 days) with methotrexate.⁴⁹

The use of prostaglandin alone has also been pursued.⁵⁰ Relatively high success rates have been reported with multiple dosing,⁵¹ but the most effective regimen and the best method of administration remain to be determined.⁵² The administration of 800 µg misoprostol daily for 3 days has been reported to be very effective late in the first trimester (10 to 12 weeks).⁵³ In very early gestation, a single vaginal dose of 800 µg misoprostol or multiple doses within 24 hours is as effective as the usual combination of mifepristone and oral misoprostol.⁵¹,⁵⁴

One word of caution regarding misoprostol, the synthetic prostaglandin E₁ analogue: it is now recognized that infants born to pregnant women exposed to misoprostol have an increased risk of abnormal vascular development resulting in Möbius’s syndrome (congenital facial paralysis with or without limb defects) and defects such as equinovarus and arthogryposis.⁵⁵,⁵⁶,⁵⁷ Although the risk is low, this possibility must be considered in decision making when the various methods for first-trimester abortion are considered.

Careful prospective follow-up assessments can detect no health differences in women who have medical abortions compared with women who have abortions by vacuum aspiration.⁵⁸ Although women having medical abortions experience more bleeding and cramping, with appropriate counseling and support, women are equally satisfied with surgical and medical abortions.⁵⁹

The most widely used technique for first-trimester abortions is vacuum curettage.⁷,⁶⁰,⁶¹ The procedure is performed using local anesthesia (a paracervical block). Cervical dilation is accomplished with tapered Pratt dilators. Some surgeons recommend the preoperative insertion of cervical tents. These are osmotic dilators of dried seaweed or synthetic hydrophilic substances that are left in place from a few hours (synthetic) to overnight (seaweed).⁶² Mifepristone (RU 486), the progesterone antagonist, produces preoperative cervical dilation equally effectively, and the ease of its single oral dose makes it a more attractive choice, but oral mifepristone requires a long pretreatment (24 to 36 hours).⁶³ Buccal misoprostol (400 µg) dilates the cervix as effectively as laminaria when given 4 hours prior to the procedure, and it is relatively inexpensive.⁶⁴ After the procedure, the patient is observed for 1 to 2 hours before returning home.