Medical Abortion - Side Effects & Complications

Adapted from information provided by “Level J” Wellington Hospital.

Side effects are an expected part of medical abortion (Kruse, Poppema et al. 2000). Some arise from the abortion process itself and some from the medication. Complications of medical abortion usually represent an extreme or severe side effect.

 

MANAGEMENT OF THE SIDE EFFECTS AND COMPLICATIONS OF EARLY MEDICAL ABORTION

(Gestations <49 days)

 

PAIN

  1. 90% of women experience abdominal cramps (Spitz, Bardin et al. 1998), (Schaff, Eisinger et al. 1999) but the severity varies from patient to patient. In El Rafaey’s study of 100 women, 67 patients did not request any form of pain relief, 33 had oral analgesia and 9 parenteral (El-Rafaey and Templeton 1994).
  2. Pain is modified by such factors as fear and anxiety. Full preliminary information and support during the procedure can modify the pain.
  3. Women can be offered pre-misoprostol pain relief, oral paracetamol and codeine or alternatively can be offered p.r.n. – there are side effects, particularly from codeine (light-headedness or dizziness, sedation, nausea and vomiting).
  4. Despite Mifegyne data sheet, current research suggests that there is no contraindication to use of NSAIDs such as Ibuprofen, which is used in USA clinical practice.
  5. Oral analgesics or NSAIDs will be sufficient to control the pain in most women but some may require a parenteral narcotic such as Pethidine 75-100 mg i.m. or Fentanyl 100 i.v. if cannulated.
  6. For severe persistent pain, it is important to exclude other causes such as ectopic pregnancy.

BLEEDING

This is a normal consequence of the abortion process, but may exceed the woman’s previous experience of bleeding. (Harper, Winikoff et al. 1998). As with pain management, informing the patient in advance of what to expect is essential.

Surgical intervention for excessive bleeding is required in less than 1% of 1 st trimester medical abortions. Two large studies using mifepristone 200mg 800mcg (Ashok, Penny et al. 1998), (Schaff, Eisinger et al. 1999) report 0.4% requiring emergency curette for bleeding; and Ashok (1998) (Ashok, Penny et al. 1998) report 0.2% receiving blood transfusions.

PRACTICAL CONSIDERATIONS

  1. The heaviest bleeding usually occurs at the time of expulsion of the sac/foetus. In a proportion of women this will be within the 48 hours following the Mifegyne administration (2% in Ashok et al’s study (Ashok, Penny et al. 1998)). Women need to be warned that this may occur and that 50% of women will experience some bleeding during this time.
  2. On admission to the ward, the abortion may take place within 30 minutes of the administration of misoprostol or it may be delayed for 4-6 hours. Most women are able to recognise the passage of the foetal sac.
  3. Excessive bleeding at this time will usually respond to oxytocics, 1.5% use in Ashok’s study (Ashok, Penny et al. 1998). If the bleeding soaks through two thick, full-sized sanitary pads per hour for two consecutive hours, further clinical assessment is essential. Depending on the clinical state of the patient and the progress of the abortion, a medical assessment may be indicated.
  4. Published accounts suggest that the likelihood of intervention decreases as providers gain more experience with medical abortion.
  5. Indications for surgical evacuation may include one or more of the following: (Kruse, Poppema et al. 2000):

BLEEDING AT HOME POST TOP

  1. Bleeding after medical TOP is commonly more prolonged than after surgical (Harper, Winikoff et al. 1998). Studies show a mean duration of bleeding from 9 –17 days with a range from 1 – 69 days. Despite this, a clinically significant drop in Haemoglobin rarely occurs. (Harper, Balistreri et al. 2001).
  2. Women should be told to initiate contact if bleeding soaks through two thick full-size sanitary pads per hour for two consecutive hours (Creinin and Aubeny 1999). The size of the clots and the accompanying symptoms must be factored into the assessment.
  3. Depending on these variables, the clinician may advise prompt admission to hospital for evaluation.
  4. Some providers use T/V ultrasonography to assist the decision whether or not to intervene. U/S findings of intrauterine heterogeneous echoic material are normal and expected after medical abortion. (Creinin and Aubeny 1999), Surgical aspiration is therefore warranted only if the clinical impression indicates an acute bleeding emergency.

ON-CALL EVALUATION OF BLEEDING WITH MEDICAL ABORTION

FAILED ABORTION

Because of the New Zealand law, our protocol needs to ensure that products have been passed before the patients leave the clinic.

  1. Clinical observation
  2. Monitoring of all products passed – using a light box
  3. Examination of the vagina and cervix for products after six hours if none have been passed
  4. Suction curettage if the women leaves the clinic is required of the sac has not been seen

INCOMPLETE ABORTION

  1. As with the surgical suction curettage, a small percentage of women will have incomplete expulsion of the pregnancy tissue after an early medical termination.
  2. In the absence of excessive bleeding, these patients can be followed conservatively.
  3. Any decision to intervene would be based on the clinical state of the patient – see management of bleeding
  4. Symptoms can include prolonged and irregular bleeding episodes. T/V U/S helps to exclude a failed abortion but the presence of echogenic material is usual and as with U/S after surgical TOP, does not necessarily indicate clinically important retained products of conception (Wolman, Jaffa et al. 1996), (Dillon, Case et al. 1993).

GASTROINTESTINAL SIDE EFFECTS

Nausea and vomiting is common at this stage of the pregnancy. An increase in the nausea, with vomiting and diarrhoea are common after the misoprostol, although less common with the intravaginal doses. (El-Rafaey, Rajasekar et al. 1995). These symptoms are usually self-limiting.

Maxolon i.m. or i.v. or Buccastem are useful to manage severe nausea and vomiting.

In a recent publication Jain et al (Jain, Harwood et al. 2001) compared a group of patients who were given loperamide prophylactically before their misoprostol induced early TOP with a group of patients in whom it was not used. They showed less need for opiates and a significantly lower incidence of diarrhoea with no difference in the rate of complete abortion.

HEADACHE, DIZZINESS AND THERMOREGULATORY CHANGES

Headache and dizziness are usually mild and self-limiting.

Dizziness may be a side effect of any of the medications or a response to the abortion process. Unless associated with excessive bleeding this symptom is best managed with rest, hydration, slow position changes and assistance with ambulation (Kruse, Poppema et al. 2000).

Hot flushes and sensations of warmth or fever are also fairly common side effects of medical abortion. They can be a reaction to either mifepristone or misoprostol. These symptoms are usually short-lived and resolve spontaneously.

A Temperature exceeding 38ºC that persists for several hours warrants evaluation for infection.

ENDOMETRITIS

Endometritis is a rare complication of medical abortion, especially patients screened and treated for STI’s, as reported in large studies. However, Jensen et al comparing surgical with early medical TOP found no difference in the rates treated with antibiotics for presumed infection, mainly because of lower abdominal pain (Jensen, Astley et al. 1999).

Persistent pelvic pain with or without irregular bleeding or fever in the days after the pregnancy expulsion should be evaluated for possible Endometritis or incomplete abortion (Kruse, Poppema et al. 2000).

Either condition may cause the uterus to feel slightly enlarged, softened and tender. U/S may assist the diagnosis; a thin endometrial strip favours the diagnosis of infection, but retained products and infection may co-exist.

A full course of a broad-spectrum antibiotic is indicated for treatment of infection.

No data exists to support routine prophylaxis for medical abortion.

ECTOPIC PREGNANCY

An undiagnosed ectopic pregnancy is a most dangerous complication of early pregnancy. Mifepristone has not shown to be effective in treating ectopic pregnancy. Every effort must be made before the TOP to exclude an ectopic pregnancy. However, some will be missed. A pseudogestational sac may be present on ultrasound, which may mimic an early intrauterine pregnancy and may be wrongly reported by the ultrasonographer. (Only the presence of a yolk sac or a foetal pole confirms an intrauterine pregnancy). If no products are seen, either with medical abortion or on suction curettage, then follow-up to exclude ectopic must be done.

  1. Serial ßhCG’s 48 hours apart – results to be faxed/phoned to the appropriate physician.
  2. A repeat USS if ßhCG not falling.
  3. Advice to the patient about contacting the clinic or on call doctor urgently if she experiences severe or prolonged pain and an urgent response to such symptoms. (After the women leaves the clinic they should not experience prolonged or severe pain).
  4. A telephone call to the patients physician alerting her/him to the possibility of an undiagnosed ectopic pregnancy.

TERATOGENICITY

This in an issue if a woman changes her mind after either Mifegyne or Mifegyne and misoprostol. There is as yet no evidence for the teratogenicity of Mifegyne.

Evidence suggests that misoprostol may result in congenital anomalies when used during the first trimester of pregnancy. Both limb abnormalities and Möbius sequence (mask-like faces with bilateral sixth and seventh cranial nerve palsy and frequently coincident micrognathia) (Gonzalez, Vargas et al. 1993).

FOLLOW-UP

Because of the current interpretation of the New Zealand law women cannot leave AMAC until the medical staff have observed that the pregnancy tissue has been expelled, i.e. that the abortion is complete.

There is therefore, no indication for the routine ultrasound follow-up that is required in counties where many or all of the women abort at home and it is necessary to check that the abortion has completed successfully.

The AMAC MTOP Doctor will carry a mobile phone and can be contacted for advice or in emergency situations. Women should be encouraged to report such symptoms as severe and persistent pain, fever or heavy bleeding.

All women must return to their referring doctor for a routine assessment two weeks after the medical termination as with surgical termination.

References:

Ashok, P.W., G.C. Penney et al. (1998). “An effective regimen for early medical abortion: a report of 2000 consecutive cases.” Hum Reprod13(1O): 2965-5.

Creinin, M and E. Aubeny (1999). Medical Abortion in early pregnancy. A clinician’s guide to medical and surgical abortion. P. Stubblefield. New York, Churchill Livingstone: 91-106.

Creinin, M. D. and T. Schulman (1997). “Effect of the nonsteriodal anti-inflammatory drugs on the action of misoprostol in a regimen for early abortion.” Contraception56(3): 165-8.

Dillion, E. H., C Q. Case, et al. (1993). “Endovaginal US and Doppler findings after first-trimester abortion.” Radiology186(1): 87-91.

El-Rafaey, H., D. Rajasekar, et al. (1995). “Induction of abortion with mifepristone (RU486) and oral or vaginal misoprostol.” N Engl J Med332(15): 983-7.

El-Rafaey, H, and A. Templeton (1994). Early induction of abortion by a combination of oral mifepristone and misoprostol administered by the vaginal route.” Contraception49(2): 111-4.

Gonzalez, C. H., F. R. Vargas, et al. (1993). “Limb deficiency with or without Möbius sequence in seven Brazilian children associated with misoprostol use in the first-trimester of pregnancy.” Am J Med Genet47(1): 59-64.

Harper, C., E. Balistrei, et al. (2001). “Provision of hormonal contraceptives without a mandatory pelvic examination: the first stop demonstration project.” Fam Plann Perspect33(1): 13-8.

Harper, C., B. Winikoff, et al. (1998). “Blood loss with mifepristone—misoprostol abortion: measures from a trial in China, Cuba and India.” Int J Gynaecol Obstet63(1): 39-49.

Jain, J. K., B. Harwood, et al. (2001). “Early pregnancy termination with vaginal misoprostol combined with loperamide and acetaminophen prophylaxis.” Contraception63(4): 217-21.

Jensen, J. T., S. J. Astley, et al. (1999). “Outcomes of suction curettage and mifepristone abortion in the United States. A prospective comparison study.” Contraception59(3): 153-9.

Kruse, B., S. Poppema, et al. (2000). “Management of side effects and complications in medical abortion.” Am J Obstet Gynecol183(2 Suppl): S65-75.

Schaff, E. A., S. H. Eisinger, et al. (1999). “Low-dose mifepristone 200 mg and vaginal misoprostol for abortion.” Contraception59(1): 1-6.

Spitz, I. M., C. W. Bardin, et al. (1998). “Early Pregnancy termination with mifepristone and misoprostol in the United States.” N Engl J Med338(18): 1241-7.

Wolman, I., A. J. Jaffa, et al. (1996). “Transvaginal sonohysterography: a new aid in the diagnosis of residual trophoblastic tissue.” J Clin Ultrasound24(5): 257-61.

Adapted from information provided by “Level J” Wellington Hospital.

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