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Enhancing the Safety of Medical Abortion

Buccal administration of misoprostol and routine antibiotic use were associated with lower rates of serious infections after medical abortions.

In response to reports of serious infections occurring after medical abortions in five North American women (JW Womens Health Jun 4 2009), Planned Parenthood Federation of America (PPFA) changed its medical abortion protocol to buccal rather than vaginal administration of misoprostol (following oral ingestion of mifepristone). All PPFA centers that provided medical abortions also adopted either routine administration of doxycycline or universal chlamydia screening. After reviewing subsequent trends in serious infections following medical abortions, PPFA mandated universal antibiotic administration for women who underwent the procedure. Now, investigators have assessed trends in incidence of serious infections after medical abortions in relation to the changes in PPFA’s protocols. Incidence was tracked during Period 1 (vaginal misoprostol; neither chlamydia screening nor antibiotic prophylaxis mandated), Period 2 (buccal misoprostol; either routine chlamydia screening with treatment as indicated or universal antibiotic prophylaxis), and Periods 3 and 4 (buccal misoprostol; universal doxycycline administration [periods differed only in maximum gestational age at abortion]).

From January 1, 2005, to June 30, 2008, almost 228,000 eligible women underwent medical abortions at PPFA centers, and 92 serious infections were reported. During the course of the study, rates of serious infection among PPFA medical abortion patients fell from 0.89 per 1000 to 0.06 per 1000, a relative decrease of 93% (P<0.05). Between Periods 1 and 2, the relative decline in infection rates was greater with routine antibiotic administration than with the screen-and-treat approach (P=0.04).

Comment: Routine antibiotic prophylaxis is associated with substantially lower infection rates after surgical abortion; these results show that such prophylaxis also is appropriate in conjunction with medical abortion. Because the transition from vaginal to buccal misoprostol administration was accompanied by simultaneous adoption of routine chlamydia screen-and-treat or universal antibiotic administration, specific benefits of buccal versus vaginal misoprostol cannot be distinguished; however, PPFA data have shown that these two routes of misoprostol administration have similar efficacy. Until more data become available, buccal administration of misoprostol should be considered the standard of care.

— Andrew M. Kaunitz, MD

Published in Journal Watch Women's Health July 8, 2009

Citation(s):

Fjerstad M et al. Rates of serious infection after changes in regimens for medical abortion. N Engl J Med 2009 Jul 9; 361:145.

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