Medical and Service Delivery Guidelines

Contents Introduction Section 1 Background information on Medabon® Section 2 Screening for Medabon® Section 3 Prescribing and administering Medabon® Section 4 Following up References Related Resources

Medabon® is a combination therapy for medical abortion in pregnancies through nine weeks, or up to and including 63 days since a woman’s last menstrual period (LMP). Medical abortion refers to the process of ending a pregnancy by taking medication, rather than through surgical intervention.* It may also be referred to as medication abortion, the abortion pill, non-aspiration abortion, or non-surgical abortion. The term “medical abortion” does not mean that a physician needs to be involved or that the procedure is performed out of medical necessity.

Medical abortion has been used by millions of women throughout the world. In 2006, the World Health Organization (WHO) released updated recommendations on medical abortion based on available evidence.¹ According to these recommendations, medical abortion through nine weeks’ gestation is safe and effective. The most effective and safest medical abortion regimen requires the use of two drugs, mifepristone and misoprostol. Medabon® packages contain mifepristone and misoprostol together.

This document on Medabon® has four sections that roughly correspond to the medical abortion process from a health worker’s perspective: background information, screening, administration, and followup. The protocol on page 9 provides an overview of the medical abortion process using Medabon®. This document was developed for an audience with a moderate amount of medical expertise. The level of technical detail and language may be adapted for the health providers who will be implementing services in a specific setting.

* The term “surgical abortion” is often used to refer to procedures such as vacuum aspiration (electric or manual) and sharp curettage, also known as dilatation & curettage (D&C).


1. Background information on Medabon®

Mifepristone and misoprostol are licensed separately in many countries. Medabon® offers the benefit of the drugs being licensed and packaged together in one medical abortion product.



Mifepristone acts by blocking progesterone receptors, leading to changes in the endometrial lining so that it ceases to support pregnancy, softening and dilation of the cervix, and increased uterine sensitivity to prostaglandins (such as misoprostol).²

Misoprostol is the preferred prostaglandin analog for use with mifepristone because of its efficacy, safety, low cost, and wide availability.³ Misoprostol softens the cervix and increases uterine contractility, and the contractions expel the pregnancy

Dosing and regimen

The Medabon® regimen consists of one 200-mg tablet of mifepristone given orally, followed one to two days (24 to 48 hours) later by four 200-μg tablets of misoprostol. This is the regimen recommended by WHO as a safe and effective method for medical abortion.¹

Medical abortion with Medabon® generally requires three steps:
1. Administration of mifepristone.
2. Administration of misoprostol one to two days later.
3. A follow-up assessment one to two weeks (generally 10–14 days) after mifepristone administration to confirm completion of abortion.

Effectiveness

An effective medical abortion is generally defined as a pregnancy terminated without need for another uterine evacuation method, such as vacuum aspiration or curettage. The Medabon® regimen has been shown to achieve complete abortion in about 98 percent of cases, and less than 1 percent of women using this regimen experience ongoing, viable pregnancies.^5,11

The rate of complete abortion for the Medabon® regimen can vary by provider. As provider experience increases, they are likely to be more comfortable with the method and less likely to perform unnecessary interventions. Following the regimen outlined in these guidelines will help ensure the highest rates of success. For example, adhering to the suggested interval between administration of misoprostol and a follow-up visit will help ensure that a woman’s abortion has had time to complete and will make unnecessary intervention less common. Of course, women should seek follow-up care sooner if they have problems or concerns.

Expected effects

Vaginal bleeding and cramping are normal and expected. The medical abortion process may feel like an intense, crampy, and long menstrual period, or similar to a spontaneous miscarriage.

Vaginal bleeding, often accompanied by the passage of clots, is usually heavier than a menstrual period. Bleeding sometimes begins after taking mifepristone, but most often starts one to three hours after misoprostol is taken. The amount and duration of bleeding varies: bleeding is generally heaviest for a few hours during the actual abortion and has the general pattern of diminishing over time, often lasting up to two to three weeks. Cramping is typically strongest in the hours after misoprostol is taken, then eases off after the pregnancy is expelled.¹²

After the pregnancy passes, which the woman may not be able to differentiate from other blood and/or clots, she will likely experience a persistent decrease of bleeding and cramps until the bleeding ends.

Side effects

Uterine contractions can be painful, and some women will experience side effects—including nausea, vomiting, diarrhea, headache, chills, shivering, and transient fever lasting less than a day. There are no long-term health effects of Medabon®, nor will the medication impact any future pregnancies.¹³

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Contraindications

Precautions

Women with these conditions should be treated with caution specific to their situation:
• Currently taking long-term systemic corticosteroid therapy for asthma or other conditions.^15,16 By contrast, the medicines in asthma inhalers are not systemically absorbed and women taking these medicines may use Medabon®.
• Chronic adrenal failure. It is possible that women with chronic adrenal failure may acutely develop dehydration, low blood pressure, or shock after taking mifepristone. Women with chronic adrenal failure should take an increased dose of glucocorticoids when using mifepristone and should be carefully monitored for signs and symptoms of shock.^15,16

Note: Women with multiple gestation¹⁷ and obese women¹⁸ may be given Medabon® in the same doses as other women. Additionally, women who have used Medabon® in the past may use it again with no decrease in efficacy.

Special considerations

• Women who are breastfeeding. Misoprostol enters breast milk soon after administration, and it is likely that mifepristone does as well. There is no evidence to suggest that either medication is harmful to infants. Women who are concerned about the effects of misoprostol on infants can take the medication immediately after nursing.¹⁹


• Women with an intrauterine device (IUD). Women with an IUD can be treated with Medabon® as long as the IUD is removed beforehand. See page 11 for information on reinitiating contraception after taking Medabon®.


• Women with sexually transmitted infections (STIs). Women with a confirmed STI should be treated concurrently with the initiation of medical abortion. Women with a suspected STI should be evaluated or referred and treated as appropriate for the health care setting; however, treatment of suspected STIs should not delay the abortion.

Given that Medabon® is only licensed for pregnancies through nine weeks, the likelihood of Rh-sensitization is very low. There is currently not enough evidence to recommend for or against Rh screening through nine weeks since LMP.²⁰ Depending on the prevalence of RhD-negative blood in the population and the ability to offer Rh-immune globulin, the country standard should be followed.

Confirming pregnancy and timing

Medabon® is licensed for women with pregnancies through nine weeks: in other words, a woman can take Medabon® through 63 days after the first day of her LMP. Duration of pregnancy can generally be confirmed by taking the woman’s history and with a physical examination. If signs of pregnancy are not clearly present, a blood or urine test confirming pregnancy may be required. Ultrasound is not necessary and should not be a prerequisite for abortion in settings where it is unavailable or makes the procedure overly expensive.^1,21 Where ultrasound is available, it may help to determine the length of pregnancy in cases of a discrepancy in dating, or to confirm an intrauterine pregnancy.

Choosing medical abortion or vacuum aspiration

Both medical abortion and vacuum aspiration have been found to be acceptable methods to women.^22,23,24 Women are more likely to find a method acceptable if they have chosen it themselves.^25,26

Women choose medical abortion or vacuum aspiration for a variety of reasons that reflect a woman’s specific circumstances and cultural context. Factors women consider in choosing between available methods include the length of gestation, the duration of the abortion process, where the abortion will occur, and what they are likely to experience.²³

Both medical abortion and vacuum aspiration are safe and effective methods with low complication rates.^11,27 There are, therefore, very few situations where a clear medical preference for either method exists.

Possible reasons to recommend medical abortion:
• Severe obesity. A surgical procedure may be more technically challenging.¹
• Uterine malformations, a fibroid uterus, or previous cervical stenosis.
• A wish to avoid an invasive procedure.

Possible reasons to recommend surgical abortion (usually vacuum aspiration):
• Contraindications to medical abortion.
• Time or geographical constraints preclude follow-up to confirm that medical abortion is complete.
• A woman has made the free and informed choice that she would like to be sterilized or have an IUD inserted, and the procedures can be carried out at the same time.
• Suspected ectopic pregnancy (so tissue can be examined to verify complete abortion).

Each woman who chooses medical abortion should be clearly informed:
• What will be done at each visit and what she will experience or do at home.
• What the medical abortion may feel like.
• What the common side effects are.
• How long the process may take.
• What the potential risks and complications are.
• What pain medications are available and how to use them.
• That she must plan to complete the abortion process once she starts it.
• When she will be able to resume her normal activities, including sexual intercourse.
• When she needs to seek medical attention.
• What contraceptive methods are available and how to get/start them.

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3. Prescribing and administering Medabon®

Scheduling medical abortion with Medabon®

The full medical abortion process should be taken into consideration when health providers and women schedule clinic visits. For most women, expulsion will happen within four to six hours of taking misoprostol.³¹ Bleeding and cramping will likely be heaviest at this time. If misoprostol is administered in a clinic setting, it is advisable that a woman stays in the clinic until she feels comfortable and able to return home. Women should be informed of this in advance so that they can plan for misoprostol administration around travel time, work and family needs, and the ability to have someone there with her if she chooses.

Women should have access to emergency care during the medical abortion process. Providers and women should make a plan for where to seek emergency care in the rare event of a serious complication.

Medabon® administration

Step 1. Woman swallows one mifepristone pill. If a woman vomits within 30 minutes of taking mifepristone, she will need to take another mifepristone pill.
Step 2. Four 200-μg misoprostol tablets are administered one or two days (24–48 hours) later (see box “Misoprostol administration,” page 3).

Vaginal administration: The woman or health worker should use their finger to push the four tablets one at a time into the vagina as far as they are able.

Health workers who administer misoprostol vaginally should follow the instructions on the package insert and wear clean gloves. If women administer misoprostol vaginally themselves, either at home or in the clinic, they should be advised to wash their hands first.

Sublingual administration: Women should place two tablets of misoprostol under their tongue and wait for them to dissolve. As soon as they have dissolved, two more tablets can be taken in the same way. If the first two tablets have not dissolved after 20 minutes, women can swallow any remaining fragments and take the final two tablets.

Some women may prefer to take all four tablets at once. In that case, women should place all four tablets under the tongue and wait for them to dissolve. If they have not dissolved after 20 minutes, women can swallow any remaining fragments.

Swallowing the tablets whole (oral administration) is less effective than placing them under the tongue until they dissolve or for 20 minutes.⁵

More information on Step 3, the follow-up visit, is provided on page 12.

Resuming normal activities

Women should have clear expectations regarding when they will or can resume normal activities. For example:

• Showering and bathing are fine at any time in the medical abortion process. Vaginal douching is not recommended.³²
• Women may ask when they are able to resume sexual activity. There is no evidence base to suggest ideal timing, but women should be encouraged to wait until they feel comfortable and ready (see below).
• Women can ovulate, and therefore get pregnant, before menstruation returns to normal. Women who want to prevent pregnancy should use a contraceptive method during sexual relations after taking Medabon®. Women have been found to ovulate as early as ten days following abortion. See page 11 for more information about contraceptive options.
• The return of menses following medical abortion will generally occur after about five weeks.³³

Medabon® Clinic Visits and Protocol

STEP 2. Misoprostol administration (24–48 hours later)
In the clinic: • Administer misoprostol vaginally or sublingually. • Make pain medication available. • Review signs of serious complications and confirm woman has printed materials. • Review plans for follow-up visit. • Review side effects and management
At home: • Woman administers misoprostol vaginally or sublingually.

Managing effects of the abortion

Bleeding
Bleeding can be managed similarly to a very heavy menstrual period or a spontaneous miscarriage (e.g., with sanitary pads or cotton wool). It will be heaviest after taking misoprostol—often during expulsion of the products of conception—and light bleeding may last two weeks or longer. It is not uncommon for bleeding to stop and then start again. Some women, up to 20 percent in one study, may continue to have bleeding or spotting 35–42 days after the initiation of a medical abortion.³⁴ If bleeding is heavy, prolonged, or causes anemia (or symptoms of anemia, such as dizziness, faintness, or significant loss of energy), then vacuum aspiration, fluid replacement, or transfusion might be required. The risk of bleeding requiring intervention (transfusion and/or aspiration) ranges from 0.02 to 1.8 percent.^35–37

Cramping and pain
Women are most likely to feel pain in the first few hours after administration of misoprostol.1 Women should receive medicines (or where they are unavailable, prescriptions or recommendations for medicines) to manage pain and have the pain medicine available when taking the misoprostol. Nonsteroidal anti‑inflammatory drugs (NSAIDs) like ibuprofen (400–800 mg) have been shown to be more effective than paracetamol (500–1,000 mg)³⁸ and can be taken at the same time as misoprostol, but not before. If possible, women should have access to or at least a prescription for a narcotic pain medicine in the event they need it; codeine 30–40 mg may be added to either NSAIDs or paracetamol. Women should be advised of other comfort measures, such as use of hot water bottles.

Seeking care for possible complications

When educating women about the use of Medabon®, it is important to stress that serious complications are rare, but that they should be on the look-out for the following signs and symptoms, and seek help (ideally from their original provider) if they experience:

• Persistent, heavy bleeding to the point where they feel sick or weak, or if they soak more than two pads per hour for more than two consecutive hours.
• Fever of 38°C/100.4°F or higher continuing for more than the day following misoprostol use.
• Persistent vomiting or diarrhea for more than the day on which misoprostol was administered.
• Very severe, continuous, or increasing abdominal pain that is unrelieved by medication, rest, a hot water bottle, or a heating pad.

Little to no bleeding 24–48 hours following misoprostol is not an emergency, but is cause for seeking follow-up care as it may be a sign of continued pregnancy.

Infection after medical abortion procedures is rare. Women should, however, be informed of the symptoms of infection and encouraged to seek follow-up care should symptoms of infection occur. The severity of the infection should determine what treatment is provided; oral antibiotics are used for most treatment of infection or presumed infection.³⁹

Women should always be given printed information on signs of complications to take home (see the sample patient brochure in these materials). As noted previously, providers and women should discuss a plan for emergency care prior to the medical abortion process. Ideally, women should seek care for complications from their original providers. If the original provider is not available, accessible, or cannot provide the necessary follow-up, providers should work with women to identify an alternative in advance. Women should be encouraged to take their informational materials with them if they seek emergency care elsewhere, in case the facility is unfamiliar with medical abortion and associated complications.

Most back-up care is similar to that needed by women having a spontaneous abortion, and many communities have a health care facility already in place to provide such care. In rare cases, serious complications do occur that require emergency follow-up (see the “Medical Guidelines for Providers of Emergency Care” included in this packet).

Contraceptive counseling and services

Women taking Medabon® should be offered contraception. Women can become pregnant within ten days of the abortion if they are not using an effective method of contraception.⁴⁰ Evidence supports the use of any modern contraceptive method after an uncomplicated abortion.^41,42 Women can begin taking hormonal methods, whether combined (estrogen and progestin) or progestin-only, on the same day as misoprostol administration, when expulsion of the products of conception generally occurs.⁴³ These methods include oral contraceptives,^44–46 injectable methods, implants, and the contraceptive patch. For women taking the misoprostol at home, they can be given any patient-initiated hormonal methods and told to start them on the day they take misoprostol. They may see a provider for injectable contraception or implants. The vaginal contraceptive ring can be started when bleeding slows down after expulsion of the pregnancy.

Condoms, spermicides, the cervical cap, and the diaphragm can be used as soon as women start having sex again.¹ If a woman would like to have an IUD inserted or undergo sterilization, these procedures should be performed after an assessment confirms that the woman is no longer pregnant and the products of conception have been expelled. Natural family planning or fertility-awareness methods cannot be initiated until a woman’s regular cycles have resumed, and she may need to use a barrier method— like a condom or a diaphragm—in the meantime.

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4. Following up

A follow-up visit is desirable approximately two weeks (10–14 days) after taking Medabon®. During this visit, the clinician confirms that the woman is no longer pregnant and that bleeding patterns are within the expected range, ensures contraception is provided if desired, and answers her questions. Confirmation that the pregnancy has been terminated is possible by pelvic examination, bleeding and symptom history, or by ultrasound, if necessary. The following scenarios represent the most likely situations encountered at the follow-up visit:

Successful medical abortion

The woman reports she no longer feels pregnant, has taken the medications as instructed, and had bleeding and cramping consistent with a successful medical abortion. This is the most common outcome.

Problematic bleeding

Problematic bleeding encompasses a range of bleeding patterns that may be tiresome or problematic for the woman, or, in rare cases, are true emergencies. In the case of problematic bleeding, the pregnancy is not growing, but the woman’s bleeding pattern is not gradually diminishing. The pelvic exam is consistent with a small or non-pregnant uterus. Treatment options, unless indicated otherwise below, are: 1) waiting longer for bleeding to stop; 2) an additional dose of misoprostol, which may help the uterus contract and expel residual tissue or a persistent empty sac; or 3) uterine evacuation.

Various patterns of problematic bleeding requiring specific interventions are:

Persistently heavy bleeding
The woman may have been bleeding continuously—like during a heavy menstrual period—since she took misoprostol. If the woman feels weak from bleeding, a uterine aspiration is recommended. If she is clinically stable and feels well, a repeat dose of misoprostol may be offered as long as the woman is willing and able to return two days to one week later, depending on the duration and amount of problematic bleeding, to assess whether bleeding is diminishing.45 Although providing a second dose of misoprostol is a practice used by some providers to increase uterine contractility and expel residual tissue, its use has been studied for expulsion of a persistent sac or unexpelled embryo47; providing a repeat dose of misoprostol has not been studied for alleviation of problematic bleeding.

Erratic bleeding
Some women have days of very little bleeding, no bleeding, or spotting, and erratically experience very heavy, gushing bleeding. If a woman is symptomatic for anemia, perform uterine aspiration.

Hemorrhage
Hemorrhage causing hemodynamic instability is an emergency and is treated with an immediate uterine evacuation to empty the uterus. If the hemorrhage has been very serious, blood or fluid transfusion should be considered. If transfusion services are not available, the woman should be transported to the nearest facility providing these services.

Continued pregnancy

The woman reports continued pregnancy symptoms and the uterus is larger than on previous exam. Uterine evacuation is recommended at this time.

Possible birth defects if pregnancy continues

References

1. World Health Organization (WHO). Frequently Asked Questions about Medical Abortion: Conclusions of an International Consensus Conference on Medical Abortion in Early First Trimester, Bellagio, Italy. Geneva: WHO; 2006. Available at: www.who.int/ reproductive-health/publications/medical_abortion/.
2. Creinin M. Medical abortion regimens: historical context and overview. American Journal of Obstetrics & Gynecology. 2000;(2Suppl):S3–S9.
3. Foster A. Medication Abortion: A Guide for Health Professionals. Cambridge: Ibis Reproductive Health; 2005. Available at: www.ibisreproductivehealth.org/downloads/Medication_ abortion_A_guide_for_health_professionals_English.pdf.
4. Tang OS, Chan C, Ng E, Lee S, Ho P. A prospective, randomized, placebo-controlled trial on the use of mifepristone with sublingual or vaginal misoprostol for medical abortions of less than 9 weeks gestation. Human Reproduction. 2003;18(11):2315–2318.
5. Raghavan S, Comendant R, Digol I, et al. Two-pill regimens of misoprostol after mifepristone medical abortion through 63 days’ gestational age: a randomized controlled trial of sublingual and oral misoprostol. Contraception. 2009; 79(2):84–90.
6. Hamoda H, Ashok PW, Dow J, Flett GM, Templeton A. A pilot study of mifepristone in combination with sublingual or vaginal misoprostol for medical termination of pregnancy up to 63 days gestation. Contraception. 2003;68(5):335–338.
7. Jvon Hertzen H, Piaggio G, Wojdyla D, et al. Two mifepristone doses and two intervals of misoprostol administration for termination of early pregnancy: a randomized factorial controlled equivalence trial. British Journal of Obstetrics and Gynaecology. 2009;116(3):381–389.
8. Winikoff B, Dzuba IG, Creinin MD, et al. Two distinct oral routes of misoprostol in mifepristone medical abortion: a randomized controlled trial. Obstetrics & Gynecology. 2008;112(6):1303–1310.
9. Fjerstad M, Sivin I, Lichtenberg ES, Trussel J, Cleland K, Cullins V. Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days. Contraception. In press.
10. Middleton T, Schaff E, Fielding S, et al. Randomized trial of mifepristone and buccal or vaginal misoprostol for abortion through 56 days of last menstrual period. Contraception. 2005;72(5):328–332.
11. Ashok PW, Templeton A, Wagaarachchi PT, Flett GM. Factors affecting the outcome of early medical abortion: a review of 4132 consecutive cases. British Journal of Obstetrics and Gynaecology. 2002;109(11):1281–1289.
12. Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. New England Journal of Medicine. 1998;338(18):1241–1247.
13. Virk J, Zhang J, Olsen J. Medical abortion and the risk of subsequent adverse pregnancy outcomes. New England Journal of Medicine. 2007;357:648–653.
14. Cable EE, Pepe JA, Donohue SE, Lambrecht RW, Bonkovsky HL. Effects of mifepristone (RU-486) on heme metabolism and cytochromes P-450 in cultured chick embryo liver cells, possible implications for acute porphyria. European Journal of Biochemistry. 1994;225(2):651–657.
15. Sitruk-Ware R. Mifepristone and misoprostol sequential regimen side effects, complications and safety. Contraception. 2006;74(1):48–55.
16. Davey A. Mifepristone and prostaglandin for termination of pregnancy: contraindications for use, reasons and rationale. Contraception. 2006;74(1):16–20.
17. Hayes JL, Achilles S, Reeves MF, Creinin MD. Outcomes of medical abortion through 63 days in women with twin gestations. Contraception. 2008;78(2):168–169.
18. Strafford M, Mottl-Santiago J, Savla A, Soodoo N, Borgatta L. Relationship of obesity to outcome of medical abortion. American Journal of Obstetrics & Gynecology. 2009;200(5): e34–36.
19. Vogel D, Burkhardt T, Rentsch K, et al. Misoprostol versus methylergometrine: pharmacokinetics in human milk. American Journal of Obstetrics & Gynecology. 2004;191(6): 2168–2173.
20. Fiala C, Fux M, Gemzell-Danielsson K. Rh-prophylaxis in early abortion. Acta Obstetricia et Gynecologica Scandinavica. 2003;82(10):892–903.
21. World Health Organization (WHO). Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO; 2003. Available at: www.who.int/reproductive-health/publications/ safe_abortion/. References
22. Creinin, MD. Randomized comparison of efficacy, acceptability and cost of medical versus surgical abortion. Contraception. 2000;62(3):117–124.
23. Winikoff B, Irving S, Kurus J, et al. Safety, efficacy, and acceptability of medical abortion in China, Cuba, and India: a comparative trial of mifepristone-misoprostol versus surgical abortion. American Journal of Obstetrics & Gynecology. 1997;176(2):431–437.
24. Tang OS, Miao BY, Lee SW, Ho PC. Pilot study on the use of repeated doses of sublingual misoprostol in termination of pregnancy up to 12 weeks gestation: efficacy and acceptability. Human Reproduction. 2002;17(3):654–658.
25. Henshaw RC, Naji SA, Russell IT, Templeton AA. Comparison of medical abortion with surgical vacuum aspiration: women’s preferences and acceptability of treatment. British Medical Journal. 1993;307(6906):714–717.
26. Slade P, Heke S, Fletcher J, Stewart P. A comparison of medical and surgical termination of pregnancy: choice, emotional impact and satisfaction with care. British Journal of Obstetrics and Gynaecology. 1998;105(12):1288–1295.
27. Hakim-Elahi E, Towell HM, Burnhill MS. Complications of first trimester abortion: a report of 170,000 cases. Obstetrics & Gynecology. 1990;76(1):129–135.
28. Seeber B, Barnhart K. Suspected ectopic pregnancy. Obstetrics & Gynecology. 2006;107:399–413.
29. Rossing M, Daling J, Voigt L, Stergachis A, Weiss N. Current use of an intrauterine device and risk of tubal pregnancy. Epidemiology. 1993;4(3):252–258.
30. Pisarka M, Carson S, Buster J. Ectopic pregnancy. The Lancet. 1998;351:1115.
31. El-Refaey H, Templeton A. Early induction of abortion by a combination of oral mifepristone and misoprostol administered by the vaginal route. Contraception. 1994;49(2):111–114.
32. Tsai CS, Shepherd BE, Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. American Journal of Obstetrics & Gynecology. 2009;200(1):38.e1–8.
33. World Health Organization Task Force on Post-ovulatory Methods for Fertility Regulation. Comparison of two doses of mifepristone in combination with misoprostol for early medical abortion: a randomized trial. British Journal of Obstetrics and Gynaecology. 2000;107(4):524–530.
34. Davis A, Westhoff C, De Nonno L. Bleeding patterns after early abortion with mifepristone and misoprostol or manual vacuum aspiration. Journal of the American Medical Women’s Association. 2000;55(3Suppl):141–144.
35. Ashok PW, Penney GC, Flett GM, Templeton A. An effective regimen for early medical abortion: a report of 2000 consecutive cases. Human Reproduction. 1998;13(10): 2962–2965.
36. Hausknecht R. Mifepristone and misoprostol for early medical abortion: 18 months experience in the United States. Contraception. 2003;67(6):463–465.
37. Schaff E, Stadalius L, Eisinger S, Franks P. Vaginal misoprostol administered at home after mifepristone (RU486) for abortion. Journal of Family Practice. 1997;44(4):353–361.
38. Livshits A, Machtinger R, David LB, Spira M, Moshe-Zahav A, Seidman DS. Ibuprofen and paracetamol for pain relief during medical abortion: a double-blind randomized controlled study. Fertility and Sterility. 2009;91(5):1877–1880.
39. Shannon C, Brothers LP, Philip NM, Winikoff B. Infection after medical abortion: a review of the literature. Contraception. 2004;70(3):183–190.
40. Boyd EF Jr, Holmstrom EG. Ovulation following therapeutic abortion. American Journal of Obstetrics & Gynecology. 1972;113(4):469–473.
41. Mittal S. Contraception after medical abortion. Contraception. 2006;74(1):56–60.
42. World Health Organization (WHO). Medical eligibility criteria for contraceptive use. Third edition. Geneva: WHO; 2004.
43. Martin CW, Brown AH, Baird DT. A pilot study of the effect of methotrexate or combined oral contraceptive on bleeding patterns after induction of abortion with mifepristone and a prostaglandin pessary. Contraception 1998;58(2):99–103.
44. Tang OS, Gao PP, Cheng L, Lee SW, Ho PC. A randomized double-blind placebo-controlled study to assess the effect of oral contraceptive pills on the outcome of medical abortion with mifepristone and misoprostol. Human Reproduction. 1999;14(3):722–725.
45. Tang OS, Xu J, Cheng L, Lee SW, Ho PC. The effect of contraceptive pills on the measured blood loss in medical termination of pregnancy by mifepristone and misoprostol: a randomized placebo controlled trial. Human Reproduction. 2002;17(1):99–102.
46. Royal College of Obstetricians and Gynaecologists (RCOG). The Care of Women Requesting Induced Abortion: Evidencebased Clinical Guideline Number 7. London: RCOG Press; 2004.
47. Reeves M, Kudva A, Creinin M. Medical abortion outcomes after a second dose of misoprostol for persistent gestational sac. Contraception. 2008;78(4):332–335.
48. Exelgyn. Mifepristone - Investigators Brochure. Paris, France: Exelgyn S.A.; 2008.

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Related resources

Castleman L, Winikoff B, Blumenthal P. Providing abortion in low-resource settings. In: Paul M, Lichtenberg S, Borgatta L, Grimes D, Stubblefield P, Creinin M, eds. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care. Wiley-Blackwell; 2009.

Creinin MD and Gemzell Danielsson K. Medical abortion in early pregnancy. In: Paul M, Lichtenberg S, Borgatta L, Grimes D, Stubblefield P, Creinin M, eds. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care. Wiley-Blackwell; 2009.

Gynuity Health Projects and Reproductive Health Technologies Project (RHTP). Frequently asked questions about fatal infection and mifepristone medical abortion: technical version [fact sheet]. New York: Gynuity Health Projects and RHTP; 2006. Available at: www.gynuity.org/ resources/info/faqs-on-fatal-infection-and-medical-abortiontechnical- version/. Also available in Spanish and Turkish.

Hyman AG, Castleman LD. Woman-centered abortion care: Reference manual. Chapel Hill, NC: Ipas; 2005. Available at: www.ipas.org/Publications/Woman-centered_abortion_ care_Reference_manual.aspx. Also available in French, Portuguese, and Spanish.

Hyman AG, McInerny T, Turner K. Woman-centered abortion care: Trainer’s manual. Chapel Hill, NC: Ipas; 2005. Available at: www.ipas.org/Publications/Woman-centered_abortion_ care_Trainers_manual.aspx. Also available in French, Portuguese, and Spanish.

Ibis Reproductive Health. Medication Abortion: A Training Module for Health Professionals. Cambridge, MA: Ibis Reproductive Health; 2003. Available at: www.ibisreproductivehealth.org/downloads/Medication_ Abortion_Training_Module.ppt. Also available in Arabic.

International Consortium for Medical Abortion (ICMA). The ICMA Information Package on Medical Abortion: Information for Health Care Providers. Available at: www.medicalabortionconsortium.org/articles/for-healthcare- providers/. Also available in Arabic, French, Hindi, Portuguese, Romanian, Russian, and Spanish.

Ipas. Best practices in medical abortion: starting contraception after first-trimester abortion [fact sheet]. Chapel Hill, NC: Ipas; 2007. Available at: www.ipas.org/ Publications/asset_upload_file685_2890.pdf. Also available in German, Russian, and Spanish.

McInerny T, Baird TL, Hyman AG, Huber AB. A Guide to Providing Abortion Care. Chapel Hill, NC: Ipas; 2001. Available at: www.ipas.org/Publications/asset_upload_file207_2447.pdf. Also available in Romanian and Russian.

Paul M, Stewart FH, Weitz TA, Wilcox N, Tracey JM. Early Abortion Training Workbook. San Francisco, CA: University of California, San Francisco Center for Reproductive Health Research & Policy; 2003. Available at: www.teachtraining.org/ Workbook.html.

Philip NM, Shannon C, Winikoff B, eds. Misoprostol and Teratogenicity: Reviewing the Evidence. New York: Gynuity Health Projects and Population Council; 2003. Available at: www.gynuityorg/resources/info/misoprostol-andteratogenicity- reviewing-the-evidence/. Also available in Spanish.

Talluri-Rao S, Baird TL. Information and Training Guide for Medication-Abortion Counseling. Chapel Hill, NC: Ipas; 2003. Available at: www.ipas.org/Publications/asset_upload_ file24_2449.pdf. Also available in Portuguese and Russian.

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