Methods of Termination of Pregnancy

The document describes various methods for terminating a pregnancy in the first and second trimesters, including both medical and surgical options. Common medical first trimester termination methods include mifepristone and misoprostol, methotrexate and misoprostol, while surgical options include menstrual regulation, vacuum aspiration, and dilation and evacuation.

First Trimester Termination (Up to 12 Weeks)

Medical methods are safe, effective, non-invasive and have minimal or no complications. One of the primary regimens involves Mifepristone (RU-486) and Misoprostol. Mifepristone an analog of progestin (norethindrone) acts as an antagonist, blocking the effect of natural progesterone. Addition of low dose prostaglandins (PGE1) improves the efficiency of first trimester abortion. It is effective upto 63 days and is highly successful when used within 49 days of gestation.

Medical Protocols

The standard protocol involves the following steps:

• 200 mg of mifepristone orally is given on day 1.
• On day 3, misoprostol (PGE1) 400 μg orally or 800 μg vaginally is given.
• Patient remains in the clinic for 4 hours during which expulsion of the conceptus (95%) often occurs.
• Patient is re-examined after 10–14 days.

Alternatively, oral mifepristone 200 mg (1 tablet) with vaginal misoprostol 800 μg (4 tablet, 200 μg each) after 6–48 hours is equally effective. Contraindications: Mifepristone should not be used in women aged over 35 years, heavy smokers and those on long-term corticosteroid.

Another option is Methotrexate and Misoprostol. Methotrexate 50 mg/m2 IM (before 56 days of gestation) followed by 7 days later misoprostol 800 μg vaginally is highly effective. Methotrexate and misoprostol regimen is less expensive but takes longer time than Mifepristone and Misoprostol. Misoprostol has less side effects and is stable at room temperature unlike other PGs, which must be refrigerated.

Surgical Methods

Menstrual Regulation: It is the aspiration of the endometrial cavity within 14 days of missed period in a woman with previous normal cycle. The operation is done as an out patient or an office procedure. After introducing the posterior vaginal speculum, the cervix is steadied and 5–6 mm suction cannula (Karman’s) is then inserted and attached to the 50 mL syringe for suction. The operator should examine the aspirated tissue by floating it in a clear plastic dish over a light source. Placental tissue appears fluffy and feathery when floats in normal saline.

Second Trimester Termination (13–20 Weeks)

Procedures become more complex in the second trimester. Second trimester terminations may involve dilation and evacuation between 13-14 weeks or administration of hypertonic solutions after 14 weeks, along with oxytocin to induce labor. Intrauterine instillation of hyperosmotic solutions includes intra-amniotic hypertonic urea (40%), saline (20%) or extra-amniotic—Ethacrydine lactate, Prostaglandins (PGE2, PGF2a). Hysterotomy (abdominal) is less commonly done.

Summary of Methods