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.
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.
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. The FDA-approved dosage regimen consists of a single PO dose of mifepristone on Day 1, followed 24-48 h later by a single buccal dose of mifepristone.
Prostaglandins
Class Summary
Some agents in this category can stimulate uterine contractility and result in expulsion of the fetus. They can be used to induce abortion between 13-20 weeks of pregnancy.
Misoprostol (Cytotec)
Not approved for use in pregnancy, yet is an invaluable medication widely used for medical abortion, cervical preparation for abortion, and labor induction. Provides safe, passive method of cervical dilatation and should be considered for preabortion ripening in later first trimester cases or in cases of cervical stenosis. There is some association with uterine rupture when using misoprostol for labor induction in patients with prior cesarean section so it should be used with caution.
The FDA-approved dosage regimen consists of a single PO dose of mifepristone on Day 1, followed 24-48 h later by a single buccal dose of mifepristone. Because most women will expel the pregnancy within 2-24 hr of taking misoprostol, discuss with the patient an appropriate location for her to be when she takes the misoprostol.
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.
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.
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.
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.
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.
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.
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.
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. As the majority of oxytocin receptors develop in the late second to early third trimester, oxytocin is less effective than misoprostol for labor induction in the second trimester. However, high dose oxytocin protocols may be used where prostaglandins are not available. (Labor induction abortion in the second trimester, Society of Family Planning Clinical Guidelines, Contraception 2011.)
Ergot alkaloids
Class Summary
Also in the category of uterotonics and used almost exclusively for treatment of postabortal bleeding, atony, or hemorrhage.
Methylergonovine (Methergine)
Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding. 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.
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.
Midazolam
Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Also useful for its amnestic effects.
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.
Prochlorperazine (Compazine, Compro)
May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.
Promethazine (Phenergan, Promethegan, Phenadoz)
Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.
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.
Doxycycline (Vibramycin, Morgidox, Adoxa, Monodox, Oracea)
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.
Erythromycin (Ery-tab, Erythrocin, E.E.S. 400, PCE)
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.
Metronidazole (Flagyl, Metro)
Recommended as an alternative for endometritis prophylaxis.
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.
Rh0(D) immune globulin (RhoGAM, HyperRHO S/D, Prophylac, WinRHO SDF)
Given to Rh(-) mothers to avoid sensitization to Rh(+) fetal blood.
Analgesics
Class Summary
NSAIDs are readily available, relatively inexpensive, and have a low side effect profile when used cautiously and in those who have no contraindications. Diclofenac, ibuprofen, ketoprofen, meclofenamate, mefenamic acid, and naproxen are some of the NSAIDs approved by the US Food and Drug Administration (FDA) to treat pain. A variety of opioids can also be used to treat cramping.
Naproxen (Naprosyn, Aleve, Anaprox)
Naproxen is available in both prescription and nonprescription doses. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. The daily cost is approximately $3.00, compared with $0.14 for generic ibuprofen.
Ibuprofen (Advil, Motrin, NeoProfen)
Ibuprofen is available in both prescription and nonprescription doses. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. If not contraindicated, it is the drug of choice for treatment of mild to moderate pain.
Diclofenac (Cataflam, Voltaren XR, Cambia, Zipsor)
Diclofenac is one of a series of phenylacetic acids that have demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis.
Because diclofenac can cause hepatotoxicity, liver enzymes should be monitored in the first 8 weeks of treatment. Diclofenac is rapidly absorbed; metabolism occurs in the liver via demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate-release form is diclofenac potassium. Diclofenac carries a relatively low risk of bleeding gastrointestinal (GI) ulcers.
Ketoprofen (Nexcede)
Ketoprofen inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Smaller initial dosages are particularly indicated in the elderly and in those with renal or liver dysfunction. Doses higher than 75 mg do not improve therapeutic response and may be associated with a higher incidence of adverse effects.
Meclofenamate
Meclofenamate inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Compared with other NSAIDs, it is associated with a higher incidence of diarrhea.
Mefenamic acid
Mefenamic acid inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, thereby decreasing prostaglandin synthesis. Compared with other NSAIDs, it is associated with a higher incidence of diarrhea.
Acetaminophen (Tylenol, Aspirin Free Anacin Extra Strength, Acephen, Cetafen)
This is the drug of choice (DOC) for treating pain in patients with documented hypersensitivity to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), who are diagnosed with upper gastrointestinal disease, or who take oral anticoagulants.
Codeine/acetaminophen (Tylenol #3, Tylenol #4, Tylenol with Codeine)
Acetaminophen and codeine combination is used for the treatment of mild to moderate pain.
Hydrocodone/acetaminophen (Anexsia, Hycet, Lorcet)
This combination is used for the relief of moderate to severe pain.
Oxycodone/acetaminophen (Endocet, Percocet, Primlev)
The combination of oxycodone and acetaminophen is used for the relief of moderate to severe pain. It is the DOC for aspirin-hypersensitive patients.
