Induced (Safe) Abortion

Introduction

Induced abortion otherwise known as safe abortion refers to the deliberate termination of pregnancy.
Termination of pregnancy is requested for and done for reasons permissible by law either through a surgical procedure or by pharmacological means.
In most countries, an induced abortion may be carried out legally only under the following conditions:

  • in case of rape
  • defilement or incest
  • threat to the physical and mental health of the mother
  • presence of foetal abnormality and
  • mental retardation of the mother.

Patients given a pharmacological option for abortion will need to be monitored closely for completeness of the abortion process.
They should be informed to report back immediately in cases of profuse or heavy vaginal bleeding, fever or offensive vaginal discharge.
We have different types of abortion which include complete abortion, septic abortion, safe abortion, missed abortion, inevitable abortion, incomplete abortion, threatened abortion etc.

Investigations

  • FBC
  • Blood group and Rhesus factor
  • Special Investigations for medico-legal indications e.g. rape (DNA, HIV status etc.)

Treatment

Treatment objectives

  • To ensure that legal requirements for termination are met
  • To ensure safe abortion
  • To provide family planning counselling and services as needed
  • To prevent risk of Rhesus incompatibility in future pregnancies

Non-pharmacological treatment

  • Manual Vacuum Aspiration (4-12 week gestation)
  • Dilatation and curettage (4-12 week gestation)
  • Cervical ripening followed by Dilatation and Evacuation (D&E) (> 12 weeks gestation)

Pharmacological treatment

A. Medication Abortion

Evidence Rating: [A]
Mifepristone
Then
Misoprostol 

Dosage regimes for Mifepristone and Misoprostol for various gestational ages

Gestational
age
Mifepristone and Misoprostol
(Evidence Rating A)
Misoprostol Only
(Evidence Rating A)
4-8 weeks Mifepristone 200 mg stat. plus
followed 24-48 hours later by
Misoprostol, 800 micrograms (oral,
vaginally) stat followed if needed by 2 repeat doses of 800 micrograms
vaginally or sublingually every 3-12 hourly (max. 3 doses)
Misoprostol only: 800 microgram stat. vaginally
followed by 2 repeat doses of
800 microgram vaginally or
sublingually if needed every 3-12 hourly (max. 3 doses)
9-12 weeksMifepristone 200 mg orally, plus 36
-48 hours later:
Misoprostol 800 microgram vaginally, follow with up to 2 additional doses
of Misoprostol 400 microgram sublingually or vaginally at 3 -12 hour intervals (max. 3 doses)
Misoprostol 800 microgram
vaginally stat.,
Followed by 2 repeat doses
of 800 microgram every 3-12 hours if needed (max. 3 doses
13-24* weeksMifepristone 200 mg orally, plus 36-48 hours later:
Misoprostol 800 microgram vaginally, Follow by repeated dose of Misoprostol 400 microgram every
3-4 hourly vaginally (or sublingually if there is significant bleeding from
earlier vaginal misoprostol administration) until expulsion.
(max. 5 doses)
Misoprostol 800 microgram
vaginally followed by 400 microgram vaginally (or sublingually if there is significant bleeding) at 3-6
hourly intervals.

Repeat dosing until expulsion
(max. 5 doses)
24 -28*
weeks
Mifepristone 200 mg orally, plus
36-48 hours later:
Misoprostol 100- 200 microgram
vaginally or orally every 4 hours,
Repeat dosing until expulsion (max. 5 doses. Decrease dose of misoprostol with increasing gestational age
Misoprostol 100-200 microgram vaginally or orally
every 4 hours.

Repeat dosing until expulsion
(max. 5 doses.
Decrease dose of misoprostol with increasing gestational age.

Note

Uterine sensitivity to Misoprostol increases with gestational age.
Lower doses of misoprostol are therefore used for older gestations.

*Medication Abortions in second trimester should only be done by doctors

Referral Criteria

For all types of abortion, refer early for specialist care if the uterus is suspected or found to be perforated or if complications e.g. infection or
profuse bleeding are severe.