Event: Best Medical Practice with Mifepristone: UK and international perspectives

Jennie Bristow reports from a conference held at St Thomas’s hospital, London, on 14 October.

Back in the 1980s, those working in abortion services would not have dreamed of a time when women could safely and effectively manage their own abortions, through swallowing two drugs, provided widely and at low cost, and taken in the privacy of their own homes. But thanks to the ‘abortion pill’ – a combination of mifepristone and a prostaglandin (most commonly, misoprostol), home abortion in the first trimester of pregnancy has become a reality: at least, in some parts of the world.

The challenge for Britain is to work out how to make this reality happen here, where legal regulations actively prevent the use of best practice in early medical procedures.

This conference, funded by Nordic Pharma UK, offered perspectives on best practice with mifepristone from Mr Kamal Ojha MD, MRCOG, Consultant Gynaecologist at St George’s Hospital in London; Dr Christian Fiala MD, PhD, Medical Director of the Gynmed Clinic for Contraception and Abortion in Austria; and Dr Raha Shojai MD, Consultant in Obstetrics and Gynaecology at the North University Hospital of Marseille, France.

Introducing the conference, Kamal Ojha discussed the major difference that Early Medical Abortion (EMA – also known as the ‘abortion pill’ ) has made to the gestations at which abortions are performed in the UK. In 2010, three quarters of abortions in England and Wales were performed at under 9 weeks’ gestation, and as an abortion method EMA is growing in popularity relative to vacuum aspiration.
Some important safety and efficacy issues with EMA are continuing pregnancy following administration of mifepristone. On the first point, Mr Ojha explained, there are three issues: failed medical abortion, whether both mifepristone and the prostaglandin have been given; interrupted medical abortion, where mifepristone only is given; and a partially completed surgical abortion, where mifepristone has been given to soften the cervix prior to the procedure. The failure rate of EMA is low – 0.3%-1.5% of cases. The other issues relate to a small number of reported cases, but highlight some interesting aspects of the widespread use of mifepristone.

For example, Christian Fiala’s talk began with a discussion of how mifepristone works. Its only effect, he explained, is that it stops the progesterone hormone from doing its job, thus making the uterus more sensitive to the prostaglandins used to open to the cervix, and separating the gestational sac from the uterine wall. For this reason it is effective more effective, he suggested, than misoprostol at cervical priming; which in turn, indicates its usefulness in areas such as IUD fitting.

Dr Fiala also argued that mifepristone has no teratogenic effect, and no feticidal effect. In later gestations, the fact that mifepristone is a gentler way of beginning the process of labour induction than the alternatives means that there can be a greater risk that the fetus may exhibit signs of life.

Dr Fiala stressed the synergistic activity of the two drugs used in EMA, which means that the dosage of mifepristone and misprostol should be discussed together. He spoke about the advantages of using a 600mg of mifepristone, in terms of reducing the pain of contractions induced by misoprostol. He went on to discuss the evidence about the clinical settings in which misoprostol should be administered, which he summarised as: 1) in the clinic, and the woman stays for two hours; 2) in the clinic, and the woman goes home immediately afterwards; and 3) at home. There is no evidence of benefit for the first two recommendations, he argued, while there is lots of evidence about the benefits of home use, and this is standard practice in the USA, Sweden and Austria.

Dr Fiala went on to discuss the question of whether there should be a lowest gestational age for EMA, arguing there is no reason to wait until it is possible to see a gestational sac on ultrasound and that β-hCG tests can be used to confirm that the procedure is successful. Ultrasound is often used because of concerns about ectopic pregnancy, but ‘we can handle this rationally’, he argued: a woman needs to be booked for a follow-up appointment anyway, so even in the rare cases where there is an ectopic pregnancy, no harm is done by starting on the EMA procedure provided care is taken one week later to ensure that the woman is no longer pregnant.

For Dr Fiala, we should handle patients presenting for very early ‘in the same way we do those with a miscarriage’. This is a recurrent theme in the EMA debate, as the experience of an early medical abortion is very similar to that of an early miscarriage, and there are similarities in the drugs used to manage it. For example in the UK, while it is illegal to give women misoprostol to take at home if she is undergoing an abortion, it is routine practice to give misoprostol to women who have experienced a miscarriage.

The management of home abortion was the theme of Dr Raha Shojai’s discussion of the clinical experience of, and guidelines relating to, EMA in France. Dr Shojai discussed some features of the abortion law in France, where it has been legal since 1975, and is available up to 14 weeks from the woman’s last menstrual period. There is a seven-day ‘cooling off’ period which can be reduced to 48 hours in cases where waiting may push women over the gestational limit – in practice, Dr Shojai implied, this loophole is widely used.

Medical abortion up to 49 days’ gestation is licensed in France to be performed outside of hospitals, meaning that provision has shifted away from hospitals to GPs’ surgeries and to the woman’s home. This has had many advantages in terms of reducing the waiting lists for abortion, and the cost of provision. Women at these gestations can be orientated towards a hospital, clinic, office or home use: since 2005, said Dr Shojai, about 15% of abortions have taken place at home; and the results in terms of safety, acceptability, and patient choice have been highly positive. Practice has evolved such that women are often given both mifepristone and misoprostal to take at home.

Closing the conference, Mr Kamal Ojha discussed the recommendations relating to Early Medical Abortion in the forthcoming new guidance to be published by the Royal College of Obstetricians and Gynaecologists (RCOG), and chaired an open forum for discussion of the issues of the day.

Also read: Abortion Review topic archive: Early Medical Abortion

Source: http://www.abortionreview.org