Early abortion. Update and implications for midwifery practice

Abstract

Medical abortion using methotrexate and misoprostol and manual vacuum aspiration are two new methods for pregnancy termination during the first 8 weeks of gestation. Compared to the regimen of mifepristone (RU 486) and misoprostol, both methods offer high rates of complete abortion and acceptability to users. Limitations of the new two-drug regimen compared with mifepristone include a longer time to effect abortion, transient gastrointestinal side effects, and risk of potential teratogenicity from methotrexate's cytotoxicity. Compared to standard surgical abortion, both methods allow women to avoid surgery, are more privately performed, and may be more easily accessible. The safety of first-trimester abortion provided by nurse practitioners and physician assistants has been established. Whether midwives and either new method to their practices depends on several factors. These include obtaining appropriate training, overcoming legal restrictions, and meeting professional and personal challenges inherent in providing early abortion care.

PIP: This article reviews two new methods--combined methotrexate and misoprostol administration and manual vacuum aspiration--suitable for abortion during the first 8 weeks of pregnancy. This review discusses the pharmacology of methotrexate and misoprostol, summarizes research on the regimen's effectiveness and acceptability, and presents a sample protocol of its clinical use. The 2-drug regimen has a longer treatment-abortion interval than the mifepristone-misoprostol combination; other limitations include transient gastrointestinal effects and a risk of potential teratogenicity from methotrexate's cytotoxicity. However, the regimen has high efficacy and acceptability. Incorporation of abortion services into midwifery practices would expand the number of abortion providers in the US. Whether nurse-midwives become able to perform this function depends on obtaining adequate training, overcoming legal restrictions, and meeting the professional and personal challenges inherent in early pregnancy termination.