Medical abortion: overview and management.

Medical abortion regimens are safe, effective, and offer a new range of choices for patients and providers. In September 2000, the US Food and Drug Administration (FDA) approved a regimen of mifepristone and misoprostol, which effects abortion by luteolysis, uterine contractions, and expulsion of the products of conception without surgical instrumentation. The regimen requires that a provider be capable of diagnosing ectopic gestations and be able to make arrangements for a surgical abortion in the case of failure or medical emergencies. With a medical abortion, the pregnancy is passed spontaneously, and there may not be tissue obtained for confirmation. Physicians must be aware of their state requirements with regard to expulsed tissue examination. Completion of the procedure can be established by ultrasound or by measurement of serum levels of human chorionic gonadotropin (hCG). The FDA-approved protocol allows for use up to 49 days after the first day of the last menstrual period (LMP) and consists of mifepristone 600 mg orally on day 1, misoprostol 400 mcg orally on day 3, and a follow-up appointment on days 12-20. Half of all patients pass their pregnancy in the first few hours after the second visit. It is important to be able to determine the difference between expected bleeding, 14 days on average, and the complication of hemorrhage, as 2% to 10% of patients require a surgical abortion. Continuing viable pregnancies are rare. Several other regimens can safely expand options and reduce expense, including protocols using methotrexate. Medication indications and contraindications, management strategies for patients undergoing treatment with these regimens, and safety issues are reviewed.