Medical Abortion with Methotrexate and Misoprostol

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Medical Abortion with Methotrexate and Misoprostol

• David Blair Toub, M.D.
• Department of Obstetrics and Gynecology
• Pennsylvania Hospital

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Historical Perspective

• 1985 and earlier Misoprostol
• 1988 Mifepristone (RU-486) / Sulprostone
• 1994 MTX / Misoprostol
• 1996 RU-486 conditionally approved by FDA
• 1997 Misoprostol for early pregnancy failure

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Methotrexate Applications

• Molar Pregnancy / GTN
• Ectopic Pregnancy
• Cancer Chemotherapy
• Rheumatoid Arthritis
• Psoriasis
• First Trimester Abortion

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Misoprostol Applications

• Peptic Ulcer Disease
• Induction of Labor
• First and Second Trimester Abortion
• Treatment of Early Pregnancy Failure

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MTX / Misoprostol Abortion

• Most Effective in Early Pregnancy
• ( 56 days LMP)
• 90-97 Effective
• Requires Compliant Patient, Several Visits
• Not Yet Covered By Most Insurers

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MTX / Misoprostol Side Effects

• MTX
• Stomatitis
• Gastritis
• Alopecia
• Elevated LFTs

• Misoprostol
• Diarrhea
• Nausea

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Advantages / Disadvantages of Medical Abortion

• Advantages
• Avoids Clinic Harassment
• Avoids Surgical Risks
• Relatively Inexpensive
• Empowers Patient
• Extends Abortion Access
• May Treat Undiagnosed Ectopic Pregnancy (MTX)
• Allows Early Termination

• Disadvantages
• Multiple Visits
• 3-10 Require DE
• Not Covered By Insurers
• Bleeding May Be Unpredictable
• Must Be Less Than 49-56 Days From LMP
• May Be Completed With Karmen Cannula in Office

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Advantages / Disadvantages of Suction Curettage

• Advantages
• Brief Procedure
• Bleeding and Cramping Relatively Predictable
• Requires Minimal Visits
• Covered By Many Insurers
• Safe High Success Rate

• Disadvantages
• Infrequent (But Occasioally Serious) Surgical
  Risks
• More Often Performed in Targeted Outpatient
  Clinics
• Availability Limited
• At Times Restricted to 8 Weeks LMP

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Patient Selection

• 56 Days LMP
• Compliant, with Reliable Phone Contact
• No h/o Blood Dyscrasia, Liver Disease
• No Significant Contraindications to DE

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Misoprostol Alone is a Weak Abortifacient
400 mcg misoprostol PO, 56 days LMP (Norman et
al, 1991)
Percent
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MTX / Misoprostol vs Misoprostol
(Crenin and Vittinghoff JAMA 2721190-1195, 1994)
Percent Complete Abortion
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Abortion Rates by Misoprostol Routine (IM MTX)
(Schaff, et. al. 1996)
Percent Abortion
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Evidence-Based Medicine

• Class I At Least One Proper RCT
• Class II Cohort Studies or Nonrandomized Trial
• Class III Case Reports
• A Good Evidence Exists
• B Fair Evidence Exists
• C Insufficient Evidence

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Grimes Evidence-Based Summary

• 800 mcg Misoprostol on Day 7 gt Day 3 (IA)
• MTX Misoprostol gt Misoprostol (IA)
• 800 mcg Misoprostol pv gt 600 mcg po (IIB)
• MTX Alone Effective But Slow (IIIA)
• Regimen Less Effective gt 56 Days LMP (IIIA)

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Suggested Protocol
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Patient Experiences(Adapted From Creinin and
Park, 1995)

• 86 MTX/Misoprostol Patients, lt56 Days LMP
• 85/86 (99) Completed Questionnaires
• 48 Had Previous DE
• 49 Cited Negative Experience with DE
• 67/86 (79) Medical Abortion Positive
• 12/86 (14) Negative Experience
• 89 Would Choose Medical Abortion Again

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Conclusions

• Medical Abortion with MTX and Misoprostol is
  Effective for Early ( 56 Days LMP) Gestations
• The Timing and Route of Misoprostol
  Administration Influences Success Rates
• Patient Satisfaction is Generally Favorable
• MTX and Misoprostol is an Available Alternative
  to Progesterone Antagonists (e.g. RU-486)

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Future Dimensions

• Increase Availability of Medical Abortion
• Establish Absolute Upper Gestational Age Limit
• Compare RU-486 with MTX
• Work with Insurers to Establish Coverage

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Thank You!
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