Abstract

• In France, women are entitled to request a termination of their pregnancy. Medical abortion is permitted in a hospital setting until 9 weeks of gestation, i.e. 9 weeks after the first day of the last menstrual period. In a community setting, it is permitted until 5 weeks after conception (7 weeks of gestation). It is carried out by a doctor or midwife, in their office or a health centre. How effective is medical abortion and what are its adverse effects? How is it undertaken in the community setting in France? We reviewed the available evidence using the standard Prescrire methodology.
   
• Medical abortion is based on sequential administration of two oral drugs: first the progesterone antagonist mifepristone, followed 24 to 48 hours later by the prostaglandin analogue misoprostol. Before 7 weeks of gestation, medical abortion is effective (complete abortion with no need for an additional procedure) in about 96% of cases. Incomplete abortion sometimes requires surgical evacuation.
   
• Vaginal bleeding starts within hours after taking misoprostol and sometimes even before it is taken. It is accompanied by potentially intense abdominal or pelvic pain. These symptoms are an inherent part of induced abortion. Ibuprofen is the first-choice analgesic.
   
• The abortifacient drugs used have mainly gastrointestinal adverse effects. Genital tract, haemorrhagic or infectious complications are rare. Abortion has no known long-term adverse effects. There have been few studies on its psychological effects.
   
• In 0.5% of cases, the pregnancy remains viable. When this occurs, the fact that the woman has taken misoprostol carries a risk of severe fetal malformations.
   
• Some situations preclude the use of medical abortion, in particular when these abortifacient drugs must be avoided or when the woman cannot safely undergo this method of abortion.
   
• In France, the law requires 1 or 2 consultations before medical abortion, 2 consultations for administration of the drugs, and 1 follow-up consultation. In practice, some of these consultations are often combined.
   
• When a woman requests an abortion, a consultation with a doctor or midwife is essential in order to discuss and explain the procedures, so that she can choose the most appropriate method with full knowledge of the facts. If the date of conception permits the use of medical abortion, the woman must request it in writing. Her Rhesus status is checked so that prophylaxis can be arranged if necessary to prevent alloimmunisation.
   
• Women should be clearly informed of the symptoms to expect and those that require medical consultation.
   
• The consultation 14 days to 21 days after the medical abortion is to verify there is no ongoing pregnancy.
   
• In practice, medical abortion provided in a community setting before the end of the 7th week of gestation is an effective method with few serious complications, provided the woman fully understands the advantages and risks of the method and makes an informed choice.

 ©Prescrire 1 November 2017

"Medical abortion in the community setting. The procedures and legal restrictions should be clearly explained to women" Prescrire Int 2017; 26 (187): 269-273. (Pdf, subscribers only)