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 pregnancy.

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 and height.
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 be necessary.

Women's Health Center
Kendall
Miami, Florida
(305) 595-4963

Women's Medical Center
DownTown Miami
(305) 595-4963