Abortion Pills: Mifepristone with Misoprostol
Abortion pills are the colloquial term for medications used for a medical abortion mainly in the 1sttrimester to induce a “miscarriage”. The typical medications used in this context is a combination of mifepristone and misoprostol up until the 70th day of pregnancy.
Mifepristone is a progesterone receptor antagonist. Progesterone is one of the hormones responsible for maintenance of the uterine tissue during pregnancy. Thus, by blocking the actions of progesterone, mifepristone separates the placenta as well as softens and dilates the cervix. Furthermore, mifepristone also sensitizes the myometrium for misoprostol.
Misoprostol on the other hand is a synthetic prostaglandin E1. Prostaglandins are a group of hormone like chemicals that take key roles in body processes such as inflammation or pain. They’re also important for uterine contractions and birth. Misoprostol thus induces uterine contractions and promotes uterine evacuation.
Both medications are exceedingly safe and side effects are rare. The typical dosage of mifepristone is 200mg once typically, followed by under the cheek self-administered misoprostol in a dosage of 800mg. Historically Mifepristone had been given in the office, however, the FDA has removed the in-person dispensing requirement up to 10 weeks of gestation, and thus the use of telemedicine in this context is rapidly becoming the norm. Mifepristone is typically given with a beverage and crackers to minimize gastrointestinal side effects and if the patient vomits within 30 minutes of medication administration, the dose is repeated. The four 200mg pills of misoprostol are taken 24 to 48 hours after mifepristone. However, if a patient is at 9 to 11 weeks of gestation, a second dose of misoprostol is administered about 3 to 6 hours after the first dose to minimize the risk of ongoing pregnancy. Some providers however automatically provide a second dose of misoprostol only to be self-administered after instructions provided.
Mifepristone plus misoprostol is successful in almost 98% of the cases in terminating pregnancy. Risk factors for lower success rates include length of pregnancy, number of previous pregnancies as well as prior abortions. Prior cesarean sections however are not associated with an increased risk of abortion failure.
What to expect after taking abortion pills
As a patient, you can expect vaginal bleeding, abdominal pain as well as possible nausea and fever. Abdominal pain/cramps are also another common symptom following medication abortion. Older age and number of previous births lead to less pain, however, later stages of pregnancy lead to more pain. The pain is self-limited and peaks between the time after misoprostol is taken until the pregnancy is expelled. Of note, if your pain is not relieved by pain medicines or increases after bleeding starts decreasing, medical evaluation is urgently required. The pain typically responds to NSAIDs such as ibuprofen.
Finally, you may also expect GI discomfort as well as fever and chills. Although fever is relatively common, this is also self-limited and not severe. GI side effects on the other hand are more related to anxiety then medications themselves and if nausea becomes uncomfortable, your provider may prescribe an antiemetic.
Although previously suggested, most providers no longer require a follow up visit post abortion unless complications arise. First-trimester medication abortion is increasingly safe, and is not associated with any risks for future fertility or pregnancies. Furthermore, due to the SARS-CoV-2 pandemic as well as the overturning of Roe vs. Wade telemedicine is ever increasing in providing medication abortion, and effectiveness as well as patient satisfaction are comparable to in person visits. However, depending on your provider you may be seen again about a week or two later to confirm termination of pregnancy typically with a urine hCG test.
From a complication perspective, the first trimester medication abortion is extremely safe. A major study on over 200,000 patients, showed that only 200 needed treatment in the ER and a major adverse event only occurred in 320 of them. Most commonly seen complication is a failed abortion as well as an incomplete abortion. Failed abortion is the failure of abortion and continuation of ongoing pregnancy, while incomplete abortion is the failure of expulsion of all the products of conception. Both can present as continued cramping and spotting alongside with increased bleeding. If your provider confirms that this is the case, you’d need to either take an additional dose of misoprostol or undergo a surgical abortion, as both medications used for abortion are teratogenic.
If you continue to have fever and chills or pain that persists or a purulent discharge, you may have an infection. Although an infection can be severe, this is extremely rare. A study on over 45,000 patients demonstrated that the incidence of a serious infection was less than 0.01%.
Notwithstanding the fact that a mortal outcome is possible with a medical abortion, this is exceedingly rare. The mortality rate of a legal abortion is far less than the maternal mortality rate seen in those giving birth in the US. The largest study seen in this context demonstrated that out of 230,000 patients undergoing a medical abortion in 2009 and 2010, only one death had occurred leading to a mortality rate of 0.41 per 100,000. This is 40 times lower than the maternal mortality rate in the US of 16 per 100,000 or almost 30 times lower than the road traffic deaths of about 12 per 100,000 people annually indicating that driving to the provider is riskier than medication-based abortion.
All in all, medication-based abortion of first-trimester pregnancy is an exceedingly safe and effective procedure. You can expect to experience pain and bleeding although these are typically benign, self-limited and respond to simple treatments such as NSAIDs. If you’re seeing your provider in office, you’ll be provided the first medication, mifepristone and advised on taking misoprostol at home and unless you have complications will not be expected to see a provider or undergo testing again.
Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125(1):5-12.
Jatlaoui TC, Shah J, Mandel MG, et al. Abortion surveillance – united states, 2014. MMWR Surveill Summ. 2017;66(24):1-48.
Cleland K, Creinin MD, Nucatola D, Nshom M, Trussell J. Significant adverse events and outcomes after medical abortion. Obstet Gynecol. 2013;121(1):166-171.
Clark W, Bracken H, Tanenhaus J, Schweikert S, Lichtenberg ES, Winikoff B. Alternatives to a routine follow-up visit for early medical abortion. Obstet Gynecol. 2010;115(2 Pt 1):264-272.
Jones HE, O’Connell White K, Norman WV, Guilbert E, Lichtenberg ES, Paul M. First trimester medication abortion practice in the United States and Canada. PLoS One. 2017;12(10):e0186487.
Medical management of first-trimester abortion. Contraception. 2014;89(3):148-161.
Suhonen S, Tikka M, Kivinen S, Kauppila T. Pain during medical abortion: predicting factors from gynecologic history and medical staff evaluation of severity. Contraception. 2011;83(4):357-361.
Davis A, Westhoff C, De Nonno L. Bleeding patterns after early abortion with mifepristone and misoprostol or manual vacuum aspiration. J Am Med Womens Assoc (1972). 2000;55(3 Suppl):141-144.
Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med. 1998;338(18):1241-1247.
U.S. Food and Drug Administration. Information about mifepristone for medical termination of pregnancy through ten weeks gestation. Accessed January 9, 2023. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation