Beginning in September of 1995, BSS
International began offering non-surgical abortion with
Methotrexate/Misoprostol as an alternative to traditional surgery in early
pregnancy. Currently we restrict this procedure to pregnancies seven weeks
or less as determined by transvaginal ultrasound. This relatively early
cut-off was based upon published reports which were later confirmed by our
own experience indicating that beyond this stage the failure rate is
greater than 50%. We feel this level is unacceptably high . When we first
began using this approach, we expected that it would be short-lived. At
that time, we all had reason to believe that RU-486, the much publicized "French
Abortion Pill", would be introduced into the US within a matter of
months. At the present time, it seems unlikely that it will be available
in the foreseeable future.
Methotrexate/Misoprostol abortion has one clear advantage over surgical
abortion: It simulates the process of spontaneous abortion (miscarriage).
Spontaneous abortion, a common event, is the mechanism which the body uses
to expel an abnormal or non-developing pregnancy. One disadvantage is that
the procedure is not always successful; and eventually a traditional
surgical procedure may be advisable. The major disadvantage is the
prolonged time framework. Ten to twenty days for completion of the
process is typical. Surveys have shown, however, that a significant
percentage of women prefer the concept of a non-surgical procedure.
There are at least two visits required for
methotrexate/Misoprostol. The first visit entails a medical history
followed by private counseling regarding the specifics of the process. An
ultrasound examination is then performed to establish the precise stage of
pregnancy. Blood tests are done as a reference point for methotrexate
suitability.
If the history and examination indicate
the patient to be an appropriate candidate, an injection of Methotrexate
determined by height and weight is administered in the buttock. Five to
seven days later, the patient is instructed to insert the Misoprostol
suppository which she recieved at the first visit. On the second visit a
repeat ultrasound examination is performed to determine if the pregnancy
has been expelled, or if not, if it has continued to develop. If the
pregnancy has been expelled, no further treatment is required. If it has
continued to develop, it is usually too late for Methotrexate to be
effective. Suction curettage is recommended in this situation. If the
pregnancy has ceased to develop, but persists, the options are to wait for
spontaneous expulsion, repeat the Misoprostol to expel the gestational
sac, or perform standard suction curettage. These options are a matter of
patient preference.
The mechanism of action
of Methotrexate and Misoprostol is of interest. Methotrexate is an old
line chemotherapeutic agent which is currently in wide use. It is
generally well tolerated in doses well beyond that used for pregnancy
termination and for much greater periods of time. It is felt to act as an
abortifacient (inducer of abortion) by damaging chorionic villi, the
actively growing root-like structures that attach the early pregnancy to
the uterus. The result is the detachment of the early pregnancy within the
uterus. Misoprotol is in a class of enzymes know as prostaglandins. Among
other actions it causes the uterus to contract vigorously. In this
situation, with the pregnancy separated from the wall of the uterus, the
result is expulsion of the pregnancy. The process is accompanied by
cramping and bleeding usually similar to a spontaneous abortion.
We encourage patients who are candidates for medical abortion to choose
the procedure only if it they feel it better suits their emotional needs.
Although the procedure appears perfectly safe, there is currently
inadequate data to suggest any medical benefits..
