Elective Abortion Medication

  • Author: Suzanne R Trupin, MD, FACOG; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Jan 31, 2012
 

Medication Summary

A surgical abortion is usually performed under local anesthesia. For those modestly tolerant of pain, either intravenous sedation or a preoperative antianxiolytic agent can be administered. Nonsteroidal anti-inflammatory drugs (NSAIDs) have also been used for preoperative preparation. Narcotics can be used for pain control but are usually not necessary. A variety of agents may be useful for contracting the uterus postprocedure, although in a typical first-trimester procedure, these are not necessary. Agents useful to control bleeding include oxytocin, methylergonovine, or prostaglandins. Mechanical devices (typically intrauterine insertion of a Foley catheter) to control hemorrhage can also be useful. Now specific devices are available that allow for more fluid and coverage of larger uteri.

Postprocedure pain and cramping are effectively treated with a variety of analgesic agents (ie, NSAIDs, Tylenol, codeine, Vicodin).

Dinoprostone (Cervidil, Prepidil, Prostin E2) is a prostaglandin administered vaginally and is approved specifically for the use at term in labor for cervical preparation. It works almost as well as misoprostol, but it is very expensive and not used for abortions for this reason alone.

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Prostaglandins

Class Summary

Abortifacient drugs of various types can be used for medical termination or treatment of ectopic pregnancy. Rarely, they are used to complete an incomplete surgical abortion. This class of drugs includes misoprostol, gemeprost, and PG05 (15MF2 alpha prostaglandin).

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Misoprostol (Cytotec)

 

Not approved for use in pregnancy, yet is an invaluable medication widely used for cervical preparation for abortion, labor induction, and as a medical abortifacient. Provides safe, passive method of cervical dilatation and should be considered for preabortion ripening. In patients with a history of prior uterine or cervical surgery (ie, LEEP, cesarean delivery), prostaglandins are known risk factors for uterine perforation during surgical abortion. Can be administered PO or vaginally. Some studies show premoistened tabs placed vaginally helps absorption. Patients can be instructed in self-administration to help time the dose in synchrony with their abortion procedure.

In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the cervix of 8 mm or greater after 3 h of postintravaginal misoprostol at 400 mcg, whereas only 16.7% of women achieved this after 2 h at 600 mcg. The 600-mcg group had slightly greater adverse effects (eg, bleeding, abdominal pain, fever >38°C). Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of 100-400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical dilatation.

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Carboprost tromethamine (Hemabate)

 

Prostaglandin similar to F2-alpha (dinoprost) but has longer duration and produces myometrial contractions that induce hemostasis at placentation site, which reduces postpartum bleeding.

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Local anesthetics

Class Summary

A few patients can tolerate cervical dilatation and suction curettage with no anesthesia and also through relaxation techniques. Paracervical blockade provides some additional cervical compliance in the dilatation phase and all the anesthetic necessary for early abortion procedures.

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Lidocaine (Xylocaine)

 

Used for paracervical block to keep the patient comfortable during procedure. Local anesthetic blocks nerve impulses by decreasing sodium influx across neuronal cell membranes. Alternatively, chloroprocaine (Nesacaine) may be used.

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Antiprogesterones

Class Summary

Antiprogesterone class of drugs used for medical termination. Other potential uses include postcoital contraception, leiomyomatas, endometriosis, endometrial cancer, breast cancer, ovarian cancer, glaucoma, myomas, and Cushing syndrome. Antiprogesterones do not effectively treat ectopic pregnancy and should not be used for this indication.

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Mifepristone (Mifeprex, RU-486)

 

Progesterone receptor antagonist that has 5-times greater affinity for the receptor than progesterone. By blocking progesterone, the hormone that maintains pregnancy, abortion can be completed. Cervix is softened and dilated; decidual necrosis and detachment of the pregnancy at the endometrium and uterine contractions ensue.

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Antimetabolites

Class Summary

Methotrexate has been used for more than 15 years for the medical treatment of early, unruptured ectopic pregnancies. Success rate for this indication is greater than 90%. Adverse effects are minimal and regimens are cost effective. This offers effective destruction of rapidly dividing placental cells. Used for medical termination of pregnancy, although for complete expulsion, usually must be administered in conjunction with prostaglandin.

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Methotrexate (Folex PFS, Rheumatrex)

 

Antimetabolite that works by blocking enzyme dihydrofolate reductase, thereby inhibiting folate production and, thus, DNA synthesis. Primarily affects rapidly dividing cells first, such as trophoblast cells.

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Uterotonics

Class Summary

The rapid and complete emptying of the uterus usually provides a natural uterine contraction process that successfully halts postabortion blood loss and eventually leads to normal uterine blood loss and normal uterine involution back to the prepregnant state. The uterotonic medications are typically used to enhance this process or to halt immediate postabortion bleeding. In some cases, these drugs can be inducers of uterine activity that are potent enough to lead to abortion without other drugs or regimens.

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Oxytocin (Pitocin)

 

Produces rhythmic uterine contractions and can stimulate the gravid uterus. Also has vasopressive and antidiuretic effects. Can also control postpartum bleeding or hemorrhage. When used as in labor protocols, can induce second-trimester abortion.

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Ergot alkaloids

Class Summary

Also in the category of uterotonics and used almost exclusively for treatment of postabortal bleeding, atony, or hemorrhage.

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Methylergonovine (Methergine)

 

Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens third stage of labor. Administer IM during puerperium, delivery of placenta, or after delivering anterior shoulder. Also may be administered IV, over no less than 60 s, but should not be administered routinely because it may provoke hypertension or a cerebrovascular accident. Monitor BP closely when administering IV.

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Sedatives

Class Summary

During surgical abortion, relaxation techniques and local anesthetic is typically all that is required for adequate pain relief. In some patients, the use of IV, PO, or SL sedatives can enhance this effect.

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Midazolam (Versed)

 

Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Also useful for its amnestic effects.

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Antiemetics

Class Summary

Antiemetics are not typically necessary unless patients have preexisting nausea and vomiting of pregnancy or have nausea and vomiting in reaction to general anesthesia.

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Prochlorperazine (Compazine)

 

May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.

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Promethazine (Phenergan)

 

Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

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Antibiotics

Class Summary

Most antibiotics are used prophylactically to prevent postoperative endometritis. Some institutions have used dosages that would cover chlamydia and gonorrhea because patients often cannot be contacted after an abortion.

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Doxycycline (Vibramycin)

 

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Prophylaxis of postabortion infections. If contraindicated, use erythromycin or ampicillin. Suspected cervicitis for chlamydia.

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Erythromycin (E-Mycin, Ery-tab, Eryc, Erythrocin)

 

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. Prophylaxis of postabortion infections. Use if doxycycline is contraindicated.

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Immune globulins

Class Summary

Pregnancies past 5 weeks of gestation may have an established fetal blood system, and Rh sensitization can occur without administration. Typically, no preadministration antibody screens are performed in this patient population.

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Rh0(D) immune globulin (RhoGAM)

 

Given to Rh(-) mothers to avoid sensitization to Rh(+) fetal blood.

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Metronidazole (Flagyl)

 

Recommended as an alternative for endometritis prophylaxis.

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Contributor Information and Disclosures
Author

Suzanne R Trupin, MD, FACOG  Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Steven David Spandorfer, MD  Assistant Professor, Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Cornell Medical College

Steven David Spandorfer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

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