Medical abortions can be done until 11 weeks of pregnancy and are 98% successful in terminating a pregnancy. They are popular because they are relatively safe and easy to administer. As of 2021, patients can get these medications via mail or pharmacy.
Contraindications for medical abortions include ectopic pregnancies, pregnancy > 11 weeks, adrenal insufficiency, renal failure, liver failure, cardiac disease, and coagulopathy.
Medical abortions are typically performed using Mifepristone and Misoprostol. Mifepristone blocks progesterone, preventing the pregnancy from progressing. Misoprostol, a synthetic prostaglandin E1, induces uterine cramping to help expel the pregnancy (think: misoprostol, like prostaglandin). Misoprostol should be taken 24-48 hours after mifepristone and patients should expect to have some bleeding but it should not exceed 2 pads/hr for 2 consecutive hours (think: rule of 2s). Patients are encouraged to take a repeat pregnancy test at 4 weeks or get an US to confirm termination after taking these medications.
Mifepristone dose: 200 mg PO
Misoprostol dose: 800 mcg x1-2 buccally or transvaginally.
If given buccally, the patient will place two 200 mcg pills in each cheek and let them dissolve.
Given the stigma and laws prohibiting safe abortions, many people are now seeking alternative means for abortions, such as medications they find on the internet. Some medications marketed as misoprostol are not regulated and contain other dangerous substances.
Misoprostol toxicity is very rare, however, due to more limited access to these medications people are at increased risk for harmful side effects. Normal doses of misoprostol in safe abortions are 200-1000 mcg depending on the route. This may cause a slight fever, chills, cramping, nausea, vomiting, or diarrhea, but symptoms typically improve quickly. Toxic doses are in the 3-8 mg range; these patients may have severe GI issues, high fever, chills, severe myalgias with rhabdo, bradycardia, hypoxia, AMS, and hypotension. Doses as high as 12 mg may result in multisystem organ failure and death. Symptoms develop very quickly after ingestion as it is completely absorbed from the stomach in 90 mins. Treatment involves removing any tablets from the vaginal canal, rectum, maybe stomach, and supportive care/symptomatic management until symptoms resolve (usually 12 hours).
Thanks for reading!
Ariella
Resources:
https://www.who.int/news-room/fact-sheets/detail/abortion
https://www.emrap.org/episode/emrap2022july1/postabortion
https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-01889-6
Graber, D. J., & Meier, K. H. (1991). Acute misoprostol toxicity. Annals of emergency medicine, 20(5), 549-551.
Henriques, A., Lourenço, A. V., Ribeirinho, A., Ferreira, H., & Graça, L. M. (2007). Maternal death related to misoprostol overdose. Obstetrics & Gynecology, 109(2), 489-490.