6 - TERMINATION OF EARLY PREGNANCY
Although all pregnancies up till about 22 weeks can be terminated
by aspiration or D & E, alternative methods may be considered for
the very young pregnancy if the equipment for aspiration is not
available. The morning after pill is included although it prevents
rather than terminates a pregnancy. The abortion pill RU 486 is now
available in most european countries, and in the USA at last as well.
1.MORNING AFTER PILL
Oral administration of a large dose of estrogen's will prevent
nidation of the fertilized ovum. Four pills of the normal
contraception pill strip contain enough estrogen.
Like an IUD it prevents rather than terminates a pregnancy. If
taken within 72 hours post coitum a pregnancy will be prevented.
Originally a daily dose of 25 or even 50 mg stilboestrol during 5
days was given. Invariably this caused nausea and in many cases some
of the tablets were vomited, making the method uncertain. Later a
reliable method using a combination of estrogen's and progesterone
was developed. The total ingestion of hormones in his method is so
low that no discomfort is experienced. It must be stressed that the
MAP (emergency contraception) has no effect on a well established pregnancy, however young. It
is not a method of abortion. Constantly new preparations are
marketed. E.g. Ulipristal acetate since february 2010.
The MAP is meant as an emergency measure after an unprotected
coitus. Every doctor should have it ready for this purpose (also for
her patients). It is unsuitable as a means of birth control for women
who have regular intercourse. But a woman with no regular sex life
may be well advised to have a few MAP's with her for incidental
contacts. In case of rape the first measure should be to give the
victim a MAP course.
Within 72 hours after an unprotected coitus (in most cases the
following morning, hence the name), a combination of 0.5 mg of levo
norgestrel (or 1 mg of racemic norgestrel) and 0.1 mg of ethinyl
estradiol is taken. This dose is repeated 12 hours later. Nausea or
vomiting is very rare, in most cases the woman will have not the
slightest discomfort. This very simple and reliable protocol may
prevent many abortions. The contraconceptive pill eg OVRAL® (the
white tablets only) contains both hormones in the proper quantity. So
the very simple protocol of two white OVRAL pills after intercourse,
repeated twelve hours later, will prevent a pregnancy.
2. INSERTION OF AN IUD - Insertion of a
copper containing IUD within 7 days after an unprotected intercourse
will almost certainly prevent a pregnancy since the device prevents
nidation. This is also a means to prevent an abortion and, if the IUD
is left in the uterus, a very reliable means to prevent further
pregnancies. Insertion when a pregnancy is already established mostly
has no effect and may be dangerous because it may cause infection in
a pregnant uterus.
3. RU 486 - THE ABORTION PILL - , or
Mifegyn®, developed by Roussel, France, is an anti-progestational
compound. Progesterone is necessary to maintain the pregnancy. This
hormone is initially produced by the corpus luteum, from the seventh
week onwards the placenta gradually takes over (luteo-placental
shift). In the presence of RU 486 part of the cell receptors which
normally combine with progesterone are blocked by combining with this
compound. This blocking is proportional with the concentration of RU
486. By taking 600 mg of RU 486 by mouth a young pregnancy may be
Eric Schaff proved that smaller doses,
like 200 mg had the same effect, so we do not see the advantage of
600 mg considering the high costs of the drug.
With the onset of the luteo placental shift the effect gradually
diminishes because of the rising concentration of progesterone. Under
seven weeks pregnancy the abortive effect is high, after ten weeks or
so it is nil. In clinical trials it is found that in these young
pregnancies about 80% of the women aborted spontaneously, the
remaining 20% had an incomplete abortion and had to be treated by
aspiration. In all cases bleeding started before day 5 and lasted one
to two weeks. This, by no means proves that the treatment is
successful, as despite the bleeding the pregnancy may continue. Most
women experience mild abdominal pains, in a few cases nausea or
dizziness are reported. In more advanced pregnancies the
effectiveness declines rapidly while the side effects become more
marked. In pregnancies of 8 to 10 weeks duration in only 30 % of the
cases a spontaneous abortion will occur while in 70 % an aspiration
has to be done. Blood loss is more abundant and in ± 1.5 % of
the cases a blood transfusion is necessary. A case of fatal blood
loss has been reported (Lancet 337/1993, page 969). Between these
limits administration of RU 486 leads to instability of the pregnancy
and blood loss which may be abundant. Since Swedish investigators
promote the combination with a prostaglandin to improve the efficacy
of the procedure the combination with misoprostol 400 mcg/buccally(or vaginaly) on day 2 or 3
became the method of choice.
Van den Bergh found that It also may be used as a means of contraception: by
taking one dose (this could be as small as 20 -50 mg) every month at
the time of the period a pregnancy will be terminated, if there is no
pregnancy it has no effect.
Since february 2000 the compound is available in most European
countries. Also in China and Cuba it is used in recognised clinics.
In somecases however, an aspiration must be done afterwards. In the
U.K. RU 486 is also used in the second trimester. The mifepristone
makes the uterus more sensitive for Pg's and thus this combination
seems to be promising.
4. PROSTAGLANDINS - Application of
dinoprostone is used for induction of labor when the patient is at or
near term. It may be used to terminate a pregnancy but the side
effects can be severe, especially in advanced cases. In the very
young pregnancy, if the period is not more than a week over time,
blood loss is less but discomfort is stronger than with aspiration.
The compound can be applied vaginally as a suppository or
intra-cervically as a gel. Clinically it can be applied as an IV
infusion. It has been promoted as a method of birth control: monthly
vaginal application of the compound terminates a possible pregnancy,
if there is no pregnancy nothing happens.
The use of Misoprostol (Cytotec®), a drug made by Searle to
prevent stomach ulcers caused by NSAID containing medication, has
become popular, particularly in parts of the world where abortion still is
illegal. Joeri van den Bergh as an 'abortion expert' on the American site 'Allexperts.com' develloped a sceme where the Cytotec® is taken divided over several hours and administered buccally.
In pregnancies less than 6 weeks the following scheme is advised:
take one initial tablet in the cheek and wait for one hour. If no
serious cramps occur, take 4 tablets, also buccal. (Do not swallow !)Then every 1-2
hours (depending on the contractions) 2 tablets till a total of 12
tablets is used. No more tablets should be taken in one trial as
hyperpyrexia and other complications may occur. If no miscarriage
follows,the treatment may be repeated after 1 day. A couple of years Joeri sent women all over the world his cytotec program, and if the women could neither obtain nor affort it, Cytotec as well. This internet abortionservice is now adopted by 'Women-on-Waves' : http://www.womenonwaves.org/set-274-en.html.
Specially in the later
trimesters heavy bleeding may occur and hospitalization is therefore
always needed. (Not a recommended procedure !!)
In general hospitals nowadays I.V.
infusion of Sulprostone (16-phenox-omega-17,18,19,20-tetranor
PGE2Methyl-sulfonylamide) are used to interupt unwanted
pregnancy's. After 20 -72 hours (or more) the fetus is expelled. In
Ljubljana 1mg of 15-Me PgF2a given intraamniotically proved to be
5. MENSTRUAL REGULATION - This was
introduced as a means to treat severe dysmenorrhoea. A thin flexible
catheter with side openings (Karman type) is brought into the uterus
shortly before the menstrual period. The endometrium is sucked out by
means of a hand operated 50 ml syringe with a locking device of the
plunger. The plunger is withdrawn till the locking device engages.
Then the catheter is moved up and down in the uterus so that the
endometrium is sucked away. The idea is that without endometrium no
menstruation occurs and therefore the patient will not feel any pain.
This method has been described as early as 1927 by the Russian E.
6. OVERTIME TREATMENT - Soon the
principle of Menstrual Regulation was adopted to terminate a very
early pregnancy. The procedure is done if the patient is 'over time',
hence the name. The terms Overtime Treatment and Menstrual Regulation
are used to avoid the word abortion if abortion is illegal. As
stated in Chapter 7 the force which sucks the tissues out of the
uterus is proportional with the vacuum and with the width of the
canula. Since even with a powerful pump retention in a young
pregnancy occurs if too thin a catheter is used, it is to be feared
that this methods has a high failure rate. If this method is
practiced the patient must be told that there is a real possibility
of failure and that she must come back after two weeks for a check up
examination with pregnancy test. That the reported failure rate is
limited is not contradictory. If the method is limited to women who
are less than a week over time some 50% of them are not pregnant at
all or will have a spontaneous abortion anyway.
Recently this procedure has become popular as a third world
method of abortion. Complete sterile packs (made and distributed by
IPAS) containing the special syringe and catheter are donated by WHO.
Midwives and Clinical Assistants are taught the technique, they can
do the bulk of patients without anesthesia and without severe
complications as long as sterility is maintained. The doctor and the
theater are only needed for failures.
- last revision spring 2010