Non-Surgical Abortion (Methotrexate)
MEDICAL TERMINATION OF PREGNANCY
Medical abortion may be an alternative to surgical
abortion for some women. In a surgical abortion the pregnancy is
removed by suction curettage. In a medical abortion, an injection
is used to stop the growth of the pregnancy and then pills are placed
in the vagina to cause the pregnancy to abort itself. Currently,
the two drugs used for early medical abortion are methotrexate and
misoprostol. Both are safe and approved by the Food and Drug Administration,
although for purposes other than abortion. Thousands of women have
used this method in clinical trials, and there have been no reports
of significant side-effects or long-term risks. The medical method
has a success rate of 95% or greater when given before 8 weeks of
Methotrexate has been used since 1982 in a single
low dose to safely and successfully treat ectopic pregnancies (pregnancies
occurring outside of the uterus, usually in the tubes). For use
in termination of pregnancies inside the uterus, it is also given
by injection in a single dose determined by each woman's weight
and height. Methotrexate stops cells of the placenta (afterbirth)
from being able to divide and multiply. In an early pregnancy, this
stops development of the embryo. If a pregnancy were to continue
after taking this drug, the fetus will show deformities. Side effects
of a single low dose are usually absent, and when present are mild
and short-lived. They might include nausea, diarrhea, abdominal
cramping and/or sores in the mouth. Less often, vomiting, headache,
dizziness, sleeplessness and/or vaginal bleeding may occur.
Misoprostol is commonly used to protect the stomachs of people who
need to take daily doses of anti-inflammatories. For use in abortion,
4 tablets are placed in the vagina eight days after the methotrexate
injection. In cases where there is little or no bleeding response,
it may be necessary to give a second dose of misoprostol. Misoprostol
acts on the uterus to create contractions and uterine bleeding.
When taken after methotrexate, it causes the uterus to expel the
small non-living embryo. The side-effects of misoprostol include
uterine cramping and bleeding, as the cramps and bleeding are necessary
to empty the uterus. The cramps and bleeding usually begin within
2-4 hours of inserting the tablets. Other possible side-effects
might include nausea, vomiting, diarrhea, abdominal pain, dizziness,
and/or hot flushes.
OVERVIEW OF PROCESS
The first visit consists of counseling and reviewing
of the consent form, a vaginal ultrasound, a urine pregnancy test
and blood tests for hemoglobin and Rh type. Methotrexate is then
given as an injection in a dose determined by each woman's weight
Certain foods contain Folic Acid, which can interfere with the action
of methotrexate. Therefore, the following foods should be avoided
in the week after the methotrexate injection: Dark green leafy vegetables
(iceberg lettuce is okay), Broccoli, Beans - especially kidney,
lima, black and lentils, Peas, Beets, Brewers yeast (including beer),
Whole grains, Wheat germ, Oranges and orange juice, Grapefruit and
grapefruit juice, Organ meats (including liver), and Bananas.
Certain medications may interfere with the action of the methotrexate
and misoprostol. Therefore, do not take any medications that contain
aspirin, ibuprofen drugs (such as Advil, Motrin), Nuprin or Aleve.
The patient will leave with 4 tablets of misoprostol
to insert by herself into her vagina in eight days. She will also
receive prescriptions for pain relievers. The second visit will
be scheduled for 14-18 days after the first visit and consists of
a gynecological exam, a vaginal ultrasound and possibly repeat blood
testing. If the medical abortion is complete, no further follow-up
is needed. If the medical abortion is found to be incomplete, the
patient may choose, in consultation with the clinician, either to
repeat steps in the process, or to schedule a surgical abortion.
INSTRUCTIONS FOR THE USE OF MISOPROSTOL
On the 8th day after your methotrexate injection,
four misoprostol tablets need to be placed into your vagina. Plan
to take the misoprostol at a time when you can lie down afterwards.
Try to eat lightly and get plenty of fluids the day before, because
nausea and vomiting can be worse with rich, spicy or fried foods
and with dehydration.
Wash your hands well, and using your middle finger
push the tablets (one at a time) deep into your vagina. Rest on
your back for at least 30 minutes. Expect cramping to begin in about
1-4 hours, although cramping may not start for 24 hours. You may
have cramping before the bleeding starts. Severe lower abdominal
cramps often mean that pregnancy tissue is passing down the cervix.
This type of cramping may occur in waves and will become more mild,
after the pregnancy tissue passes.
Bleeding usually starts with 1/2 to 24 hours after
the cramping has begun. At the start, the bleeding should be like
a heavy period and may include blood clots (some clots may be quite
large), but decreases after a few days to light flow, then spotting
which may continue for a couple of weeks.
After the pills are placed, continue to drink fluids steadily, and
eat lightly. You may take 1-2 acetaminophen with codeine (Tylenol
#3) when cramps begin, and 1-2 every 4-6 hours thereafter as long
as you do not need to drive or concentrate.
Contact the office if you have any question or
concerns, if vomiting or diarrhea is excessive, or if bleeding is
excessive. If bleeding has begun and all is going well, be sure
to keep your follow-up appointment. This visit will ensure that
the uterus is empty.
You may pass the pregnancy tissue at an unexpected
time or place. The embryo may be embedded in a blood clot or it
may be more recognizable as a small white form. The smaller the
pregnancy, the less likely the pregnancy tissue will be identified.
After the pills are placed in the vagina, avoid
sexual intercourse until your follow-up exam has determined that
the abortion is complete. You must use contraceptives for 3 months
after the Methotrexate injection. We will discuss your contraceptive
needs at the first visit, and make plans for how best to proceed
depending on the method that you have chosen.
It is rare to have an emergency, but important
to be prepared. It could be dangerous to delay care in the event
of an emergency, so it is necessary to contact us as soon as possible.
Please contact us if you have excessive bleeding;
severe pain not reduced by rest, pain medication, heating pad, or
hot water bottle; continued vomiting (unable to keep anything down)
for more than 4-6 hours; or fever greater than 101 degrees F.
If the pregnancy tissue does not pass completely
and there is continuous excessive bleeding, suction curettage may