Position Statement on Self-Administered Misoprostol for Termination of Pregnancy

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Position Statement on Self-Administered Misoprostol for Termination of Pregnancy
Overview Across the United States, physicians are encountering patients who have attempted to self-abort their pregnancies using misoprostol as a single drug agent, without guidance from medical professionals. Women may be resorting to self-abortion strategies because of perceived or real barriers to accessing reproductive health services, because of increased availability through illegitimate outlets, or because they lack information about the potential health risks associated with self-abortion strategies. Note: In this document, unless otherwise stated, the term “misoprostol” refers to use of this drug as a single agent, not in combination with other drugs.
Background Misoprostol is a synthetic prostaglandin E1 analog that is FDA-approved for the prevention of gastric ulcers. It is also FDA-approved for medication abortion in combination with mifepristone (RU 486). Because of its potent effects on the cervix and uterus, misoprostol is commonly used for cervical priming and labor induction in obstetrics and gynecology and can also be used as an abortifacient on its own. In some communities in the United States and abroad, it is obtainable without a prescription, enabling women to use misoprostol for self-induced abortion without professional guidance.1,2,3 The combination of mifepristone and misoprostol is 95-98% effective in achieving complete abortion without surgery during the first nine weeks of pregnancy. The efficacy and safety of early medication abortion with the combined mifepristone-misoprostol regimen has been extensively documented in the medical literature.4 A number of investigators have examined the efficacy, safety, and side effects of a misoprostol-only regimen for first trimester abortion in trials employing a wide variety of doses, routes of administration, and clinical endpoints. Most of these studies are not randomized, controlled trials and generally do not meet the highest standards of scientific evidence. This literature shows that lower complete abortion rates occur with use of misoprostol as the sole agent compared to its use in combination with mifepristone. Even with repeated, high doses, the success rate in clinical trials is about 85% (range 84-96%).5 The safety profile of misoprostol abortion has been documented in clinical research settings, under physician supervision, in which investigators carefully assess women’s bleeding, monitor for infection, and intervene when complications occur. The risks of undergoing misoprostol abortion in the absence of such professional assistance remain unknown. Nonetheless, in many places around the world, self-
administered misoprostol provides women seeking early pregnancy termination an inexpensive option that is safer than other modes of illegal abortion. For this reason, women’s health advocates and clinicians around the globe have promoted the use of misoprostol for pregnancy termination. The lower efficacy of the misoprostol abortion regimen precludes its acceptance as a standard method of abortion care in the U.S., where surgical abortion services and mifepristone are legally available. Currently in the U.S., however, some women with unwanted pregnancies, particularly in immigrant communities, use misoprostol for self-induced abortion without guidance from healthcare providers. These women may lack information about the appropriate dose(s) or route of administration or may not have an accurate assessment of gestational age. Though data are lacking regarding the overall experiences and outcomes of women who self-abort using this method, anecdotal and published case reports from hospital emergency and obstetric and gynecology departments have documented misoprostol overdose with maternal organ failure, hemorrhage due to incomplete abortion, rupture of undocumented ectopic pregnancy, and complications of molar pregnancy.6,7,8,9 It is still unclear how many women who undergo misoprostol self-induction do not experience complications and do not require medical intervention. The occurrence of self-induced abortion with misoprostol may reflect the decreasing availability of safe, legal, accessible, affordable abortion care in this country.10 Legislative, judicial, and financial barriers to abortion services have reduced or eliminated access for women in some states, and any decrease in the number of abortion providers portends further reductions in access. The fact that women are utilizing misoprostol for self-abortion even in places like New York City—an urban area with numerous providers, in a state that provides publicly funded abortion for low-income women—suggests that real and perceived obstacles to abortion care may again create a public health crisis in the U.S. The climate of fear and stigma that surrounds abortion—fostered by decades of negative and biased public discourse—is dramatically affecting women’s ability to obtain necessary reproductive health services.
Conclusions • PRCH believes that all women—regardless of where they live, their immigration status, or their income—should have the ability to obtain the safest, most efficacious abortion care available, with the counsel of a licensed healthcare professional. • Misoprostol alone is less effective than combination drug regimens for termination of pregnancy, and the safety of self-administered misoprostol outside a medical setting is unclear, especially after the first trimester. Therefore, PRCH does not advocate use of a self-administered misoprostol regimen where more effective, safer methods are available. PRCH should continue to ensure, as its first priority, that all women have access to the safest, state-of-the-art care for reproductive health and abortion services, so that women do not resort to less effective or less safe means of family planning. In circumstances where abortion access is severely restricted, selfadministration of misoprostol may be reasonable as a less harmful alternative
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to the morbidity and mortality associated with illegal, clandestine abortion by other means. • PRCH should continue to advocate that all individuals have access to education about methods to avoid unplanned pregnancy, as well as knowledge about safe, effective, and legal means available for pregnancy termination.
The authors have no financial or other commercial relationships with products discussed in this report and present their opinions based on the best available evidence from the medical literature.
Approved March 2009
1. Lafaurie, M. M., D. Grossman, et al. Women’s perspectives on medical abortion in Mexico, Colombia, Ecuador, and Peru: a qualitative study. Reprod Health Matters. 2005;13(26):75-83. 2. Coles, M. S., and L. P. Koenigs. Self-induced medical abortion in an adolescent. J Pediatr Adolesc Gynecol. 2007; 20(2):93-95. 3. Rosing, M. A., and C. D. Archbald. The knowledge, acceptability, and use of misoprostol for self-induced medical abortion in an urban U.S. population. J Am Med Women’s Assoc. 2000;55(suppl 3):183-185. 4. Kulier, R., A. M. Gulmezoglu, et al. Medical methods for first trimester abortion. Cochrane Database Syst Rev. 2004; (1):CD002855. 5. Weeks, A. Misoprostol for reproductive health: dosage recommendations. Int J Gynaecol Obstet. December 2007; 99(suppl 2):S155-S206. 6. Nayki, U., C. E. Taner, et al. Uterine rupture during second trimester abortion with misoprostol. Fetal Diagn Ther. 2005;20(5):469-471. 7. Berghahn, L., D. Christensen, et al. Uterine rupture during second-trimester abortion associated with misoprostol. Obstet Gynecol. 2001;98(5 pt 2):976-977. 8. Lialios, G., A. Kallitsaris, et al. Uterine perforation as a rare complication of attempted pregnancy termination with misoprostol: a case report. J Reprod Med. 2006;51(7):599-600. 9. Filippini, A., G. Villa, et al. Acute hemolytic anemia with acanthocytosis associated with high-dose misoprostol for medical abortion. Ann Emerg Med. 2007;50(3): 289-291. 10. Guttmacher Institute. State policies in brief: state funding of abortion under Medicaid. 2008.
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