Methotrexate and misoprostol to terminate early pregnancy

Abstract

Background: Although medical termination of pregnancy is available in Europe and China as an alternative to surgical termination, political and social factors have blocked medical approaches to pregnancy termination in the United States. Methotrexate, which is toxic to trophoblastic tissue, has been used safely to treat unruptured ectopic pregnancies. This report describes the use of a single low dose of methotrexate followed by intravaginal misoprostol for the medical termination of early pregnancy.

Methods: Women seeking termination of pregnancy were selected for this study on the basis of their good general health, emotional stability, and a pregnancy of 63 days or less in duration. Each woman received an intramuscular dose of methotrexate (50 mg per square meter of body-surface area). Five to seven days later, 800 micrograms of misoprostol was administered intravaginally. If abortion did not occur after seven days, the women was offered a second dose of misoprostol or vacuum aspiration. Successful abortion was defined as a complete termination of pregnancy within seven days after the first or second administration of misoprostol.

Results: A total of 171 of the 178 women enrolled in the study (96 percent) had successful medical abortions. Twenty-five women (14 percent) did not have an abortion after the first dose of misoprostol and received a second dose. Eighteen subsequently had complete abortions, but seven required suction curettage. In all seven women who required suction curettage, there was histologic evidence of disruption in the conceptus. No important side effects or complications were noted.

Conclusions: The combination of methotrexate and misoprostol represents a safe and effective alternative to invasive methods for the termination of early pregnancy.

PIP: Methotrexate, which is toxic to trophoblastic tissue, has been used safely to treat unruptured ectopic pregnancies. This report describes the use of a single low dose of methotrexate followed by intravaginal misoprostol for the medical termination of early pregnancy. Women seeking termination of pregnancy at the Mount Sinai Medical Center, New York City, were selected on the basis of their good general health, emotional stability, and a pregnancy of 63 days or less in duration. Each woman received an intramuscular dose of methotrexate (50 mg per square meter of body-surface area). 5-7 days later, 800 mcg of misoprostol (4 x 200 mcg) was administered intravaginally. If abortion did not occur after 7 days, the woman was offered a 2nd dose of misoprostol or vacuum aspiration. Successful abortion was defined as a complete termination of pregnancy within 7 days after the 1st or 2nd administration of misoprostol. A total of 171 of the 178 women enrolled in the study (96%) had successful medical abortions. 25 women (14%) did not have an abortion after the 1st dose of misoprostol and received a 2nd dose. 18 subsequently had complete abortions, but 7 required suction curettage. In all 7 women who required suction curettage, there was histologic evidence of disruption in the conceptus: trophoblastic changes that ranged from mild hydropic degeneration to almost complete dissolution of the trophoblast. On the basis of the women's reports, 88% appeared to have had abortions within 24 hours, which claim was confirmed by vaginal ultrasound examination. More than 75% of the women had little pain or only moderate pain (or= 2 on a scale from 0 to 4+). No important side effects or complications occurred. The patients overwhelmingly preferred the medical termination of pregnancy to the surgical method. The combination of methotrexate and misoprostol represents a safe and effective alternative to invasive methods for the termination of early pregnancy.