Pregnancy and Abortion with Pills

Information adapted from Women on Web.

Is an abortion with pills safe and is it effective?

Medical abortion within the first trimester (first 12 weeks) is 98% effective. It is a safe procedure with few risks of complications. These risks are the same as when a person has a natural miscarriage and can easily be treated by a doctor. 

Medical abortion is safer than childbirth and the use of antibiotics or Viagra. In countries where childbirth is safe, 1 in every 15,000 women dies during childbirth. The risk of fatal anaphylaxis with penicillin has been estimated to be around 1 in 100 000. The mortality rate of people using drugs that treat erectile dysfunction, including Viagra, is approximately 4 in 100,000 users.

Mortality of medical abortion is less than 1 per 100,000.

Medical abortion with Mifepristone and Misoprostol is used in most European countries. In France alone, more than 2,000,000 abortions have been done with Mifepristone and Misoprostol since 1992 and no deaths have occurred. Mifepristone and Misoprostol are listed on the Core Model List of Essential Medicines of the World Health Organization.

According to the World Health Organization (WHO), individuals can safely and effectively self-manage their abortions within 12 weeks at home without the direct support of a healthcare provider.

What is an abortion with pills?

An abortion with pills is a non-surgical termination of a pregnancy. The safest, most effective type of medical abortion requires the use of two different pills. These medicines, called Mifepristone and Misoprostol, provoke the expulsion of the pregnancy from the uterus. Mifepristone blocks the hormone progesterone, which is required to sustain a pregnancy. Without this hormone, the attachment of a fertilized egg to the uterine wall is disrupted, and the uterus contracts. Misoprostol enhances contractions and helps to expel the products of conception from the uterus.

Is it difficult to do an abortion with pills yourself?

Abortion pills are easy to administer and can be taken in the privacy of your home.

A medical abortion does not need to take place in a hospital or first aid clinic in order to be safe. The World Health Organization suggests that individuals can self-manage their abortions until 12 weeks without the support of a health-care provider.

Using Mifepristone and Misoprostol is no more complicated than using other medications. Organisations like Women on Web will provide you with step-by-step instructions on how to use the pills, what to expect, and when you need to see a licensed medical practitioner should you experience any complications.

A medical abortion resembles a miscarriage and can occur safely at home. The process is very similar, and the effects are the same as those of a miscarriage. About 15% of all pregnancies end in a miscarriage, most of which do not happen in a hospital. Most people will deal with miscarriages by themselves and only seek medical attention in case of problems, such as prolonged, heavy bleeding or fever.

Medical abortion is highly safe and effective. Out of every 100 people who do medical abortion, 2 to 3 will seek further medical care. When you do medical abortion, please ensure that you are less than 12 weeks pregnant and live within 1 hour from a hospital (this is not an issue in Malta and Gozo as hospitals are always less than an hour away).

How do you know if you are pregnant, and how long you have been pregnant?

Most individuals determine that they are pregnant if they are sexually active and have missed a period. Nausea, breast soreness and fatigue are also common symptoms in early pregnancy. However, pregnancy tests or ultrasound are the only ways to be sure that you are pregnant.

You can do a pregnancy test from the first day of your missed period. Some high sensitivity tests, like Clearblue, can give you a result up to six days before your period is due.

If you do an ultrasound, the doctor can tell you exactly how long you have been pregnant. The ultrasound, however, will only show the pregnancy from about a week after you missed your expected period.

You can make an approximate calculation of how long you have been pregnant by calculating from the first day of your last menstrual period (LMP) to the present.

How many weeks into your pregnancy can you do an abortion with pills?

You can safely do an abortion with pills at home up to 12 weeks of pregnancy.

What happens if you take abortion pills after twelve weeks?

If you have been pregnant for longer than 12 weeks and do a medical abortion, the medicines will still work and cause an abortion. However, the risk of complications increases and it is more likely that you will need to receive treatment from a medical professional afterwards (see below to determine the exact amount of increased risk).

Medical abortion feels like having a miscarriage and there are no physically significant differences between having a medical abortion and spontaneous miscarriage. The symptoms and treatment are the same. Please be aware that after 12 weeks of pregnancy you will lose a lot of tissue and blood, and also a fetus (the size depends on the duration of the pregnancy) can be quite distressing to see.

Medical abortion after 12 weeks of pregnancy is still a safer option than resorting to unsafe methods to induce an abortion, such as inserting sharp objects into the vagina, ingesting toxic chemicals such as bleach or causing trauma by punching the abdomen. You should never use these dangerous methods!

The longer the pregnancy is, the higher the risk of complications a medical abortion entails. According to the study by Hamoda et al. “Medical abortion at 64 to 91 days of gestation: a review of 483 consecutive cases”  published in the American Journal of Obstetrics and Gynecology, the percentage of people who needed further medical care as per the length of pregnancy is as follows:

 

Length of pregnancy and % who needed further medical care

0- 49 days (0-7 weeks) 2 %

40-63 days (7-9 weeks) 2.5%

64-70 days (9-10 weeks) 2.7%

71-77 days (10-11 weeks) 3.3%

77-84 days (11-12 weeks) 5.1%

85-91 days (12-13 weeks) 8%

What happens if you take abortion pills but are not pregnant?

Your health will not be harmed if you are not pregnant but take the medicines anyway. However, you may still experience the common side effects of the medicines, including nausea, vomiting, diarrhea, or a low fever for up to 24 hours.

Research has found that there is no medical harm and only few side effects when Mifepristone is used by nonpregnant individuals.  Misoprostol is used in nonpregnant people to prevent and treat ulcers.

What if you have a Rhesus negative (RH-) blood type and are doing an abortion with pills?

Usually individuals with RH- bloodtype who have a (surgical) abortion or miscarriage after 12 weeks or delivery are advised to have an injection of anti-D globuline. If the fetus has a positive blood-type and it is exchanged with the woman, the woman's body can produce antibodies that can potentially affect another fetus if she decides to have another baby.

However, research indicates that early medical abortion (in the first 12 weeks) and first trimester spontaneous abortions have no or very little exchange in blood between the pregnant woman and the fetus, and that the pregnant individual does not make a significant amount of antibodies that could affect the next fetus.

When should you NOT use abortion pills?

You should not use the medicines if:

  • Someone is forcing you to end your pregnancy

  • You are not sure about wanting to end your pregnancy

  • You have an allergy to Mifepristone, Misoprostol, or prostaglandins

  • You have one of the following diseases: Chronic adrenal failure, Hemorrhagic disorders or bleeding disorders/diseases, Inherited porphyries (it is highly unlikely that you have one of these diseases and do not know about it)

  • You have an ectopic pregnancy (a pregnancy outside the womb)

  • You cannot get to a hospital or first aid center within an hour

  • You are alone. You should ask a partner, friend or another trusted person to stay with you while you use the medicines.

Are there contraindications to abortion pills?

Contraindications are conditions or situations that may prevent you from being able to safely use Mifepristone-Misoprostol.

Individuals usually know if they have contraindications, like hemorrhagic disorders, or chronic adrenal failure, or if they are undergoing long-term corticosteroid therapy. Being pregnant for longer than 12 weeks is also a contraindication to using Mifepristone-Misoprostol at home.

 

Generally allergic reactions to these drugs are uncommon. In a study that accounted for 80,000 women who have used Mifepristone-Misoprostol, 6 women (0.008%) had mild allergic reactions (hives) after they took mifepristone. All of the women received treatment with an oral antihistamine and took the misoprostol with no further problems.

What is an ectopic pregnancy and is it affected by an abortion with pills?

An ectopic pregnancy is a pregnancy that grows outside the womb, usually in a fallopian tube. It is a life-threatening situation because if the pregnancy grows too large, it can cause the tube to burst. An ectopic pregnancy must always be treated with an operation or other medicines (Methotrexate). A medical abortion with Mifepristone and Misoprostol does not affect a pregnancy outside the womb.

You can make sure that your pregnancy is inside the womb by having an ultrasound. If you use Mifepristone and Misoprostol to end a pregnancy and you do not do an ultrasound first, there is a small chance that you could have an undetected ectopic pregnancy. If you do not pass tissue and blood after taking the Misoprostol, this might indicate an ectopic pregnancy. Some signs that you may have an ectopic pregnancy which has burst are sudden or ongoing severe pain, feeling light-headed or fainting, or pain in your shoulders. If you have these emergency symptoms, you should seek medical help immediately.

What if you are pregnant and have an IUD?

An individual who becomes pregnant with an IUD must have an ultrasound because when getting pregnant despite the IUD, the risk of an ectopic pregnancy is higher. The IUD makes the uterus and cervix inhospitable for a fertilized egg and therefore if a pregnancy does occur, it is more likely that it will occur outside the uterus. If the ultrasound shows that pregnancy is in the uterus, the IUD should be removed before doing an abortion with pills.

Can you use painkillers during an abortion with pills?

Non-steroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen and Diclofenac are the most effective painkillers for gynecologic pain management. If you cannot obtain those, Paracetamol can be used and/or combined with NSAID. Please read the package instructions of your painkillers carefully to know the maximum doses that you can take.

For some people, pain like uterine cramps may be intense, and not for others. It is difficult to know how strong the pain might be for you. As a precaution, we suggest that you take painkillers with food, approximately 1h before the Misoprostol. You can take another dose of painkillers 4 hours after the first one.

Do NOT use anti-spasmodics like Buscopan (Hyoscine). As the Misoprostol makes your uterus contract in order to push out the pregnancy, anti-spasmodics might interfere with the abortion process by relaxing the uterus.

How is an abortion with pills carried out?

To end a pregnancy up to 12 weeks, the medicines should be taken as follows:

  • First, one tablet of Mifepristone (200 mg) is swallowed.

  • 24 hours later, 4 tablets of Misoprostol (200 mcg each) are placed under the tongue and and kept there for 30 minutes, until the tablets are dissolved. You can swallow your saliva. After 30 minutes, you can spit out any remains of the tablets. If you use Misoprostol 400mcg, instead of Misoprostol 200mcg, the number of Misoprostol pills needed per dose should be halved.

Misoprostol can also be placed in the vagina, but if it is placed under the tongue no remains of the pills can be found in the event that you need to go to a hospital. There are no blood tests that can show that you have taken Misoprostol, so there will be no way to prove that you tried to do an abortion.

If you have less bleeding than expected and are concerned the medication has not worked, 3 hours after using the Misoprostol, you can put another 2 tablets of Misoprostol (200 mcg each) under your tongue for another 30 minutes.​ You can repeat this up to maximum 5 doses of Misoprostol in total until you are sure that abortion has occurred.

 

What happens if you take Misoprostol later than recommended?

The World Health Organization advises a regimen that starts with Mifepristone 200mg and is followed 1-2 days later by 800 mcg of Misoprostol. The minimum recommended interval between the use of Mifepristone and Misoprostol is 8 hours.

Research has shown that for women with pregnancies of 8 weeks or less, Misoprostol works with the same efficacy whether it is taken at 12 hours, 24 hours, 48 hours, or as much as 72 hours after Mifepristone. 

What happens if you do not take Misoprostol after Mifepristone?

If, for some reason, you take the Mifepristone and then decide that you will not take the Misoprostol part of the medical abortion regimen, be aware no reversal regimen exists. Below a few possible scenarios that might take place:

  1. You might experience a complete abortion without ever taking Misoprostol.

  2. You might experience a missed abortion, which means that the fetus is no longer viable, but the products of pregnancy (blood, tissue) do not leave your body. This has to be treated with a vacuum aspiration in hospital.

  3. It is also possible that your pregnancy might continue. If you decide you want to keep the pregnancy at this point, it is unlikely that the Mifepristone will cause later fetal malformations.

Is it safe to have more than one abortion with pills?

Yes. Individuals can be fertile for about 40 years. They may need more than one abortion for several reasons because, for example, their method of contraception fails, or they don’t have access to contraception at all. Having one or more than one safe abortion, has similar risks on woman's health or ability to have children later on than having a spontaneous miscarriage.

Can you eat and drink during an abortion with pills?

You should not drink any alcohol or use drugs prior to, during, and after using the medicines, as it can affect your judgment. You can eat food and drink liquids as you normally would. However, as some women experience nausea from the Misoprostol, you may want to eat lightly.

When does bleeding usually start during an abortion with pills?

Mifepristone alone usually does not cause any side effects before taking Misoprostol, although some women may experience light bleeding or nausea.

After using Misoprostol, you should expect bleeding and cramps. Bleeding usually starts within four hours of taking the pills, but it sometimes starts later.

For some people, the bleeding and cramping and other side effects like nausea, vomiting, diarrhea, headache, dizziness, and hot flashes or fever may occur shortly after taking Misoprostol.

Bleeding is often the first sign that the abortion has begun. If the abortion continues, bleeding and cramps become more severe. Bleeding is often heavier than a normal menstruation, and it is normal to have clots. The longer the pregnancy has developed, the heavier the cramps and the bleeding will be.

 

The heaviest bleeding typically occurs 2-5 hours after using Misoprostol and usually slows down within 24 hours. The most intense cramping and bleeding generally lasts for 3-5 hours, but these times may vary. Some women bleed heavily for up to 48 hours and may pass clots days or even weeks after taking Misoprostol. This is common and not necessarily dangerous, unless you soak through more than two maxi pads per hour for 2 hours or more, or when you pass clots bigger than an orange.

You will continue to bleed lightly from one to three weeks after the abortion, but times may vary. Your normal menstrual period usually returns after four to six weeks.

How will you know the abortion has been successful?

Many women can often tell when the abortion is successful because the symptoms of pregnancy (nausea, tender breasts, need to urinate) start going away. By having an ultrasound, you can learn whether the medicines have worked and if your pregnancy has ended within a few days after the abortion. It is best to wait for an ultrasound for 10 days after using Mifepristone, as only 23% of abortions are fully complete after 7 days.

The urine home pregnancy test should be done 3 weeks after taking the medicines, because before 3 weeks, the pregnancy hormones are still in your body and the test might show a falsely positive result. Your body might need several days or weeks (until your next menstrual period) to expel the tissue and blood completely.

How do you know if you have a complication and what should you do?

If performed in the first 12 weeks, a medical abortion carries a very small risk of complications. This risk is the same as when a woman has a miscarriage and can be easily treated by a doctor or trained medical practitioner. Out of every 100 women who do a medical abortion, 2 to 3 women will seek further medical care.

Please see the list below for possible complications, symptoms, and treatment:

Heavy bleeding (occurs in less than 1% of medical abortions)

  • Symptom: Bleeding that lasts for more than 2 hours and soaks more than 2 maxi sanitary pads per hour. Feeling dizzy or light-headed can be a sign of too much blood loss. This is a serious health risk and requires medical attention.
  • Treatment: a vacuum aspiration.  Very rarely (less than 0.2%) a blood transfusion is needed.

Incomplete abortion

  • Symptoms: heavy or persistent bleeding and/or persistent severe pain.
  • Treatment: another 2 tablets of misoprostol and/or a vacuum aspiration.

Infection

  • Symptom: If you have a fever (more than 38 degrees Celsius) for more than 24 hours, or you have a fever of more than 39 degrees, there might be an infection that needs treatment.
  • Treatment: antibiotics and/or vacuum aspiration.

If you think you might have a complication you should seek medical attention immediately. If you live in a place where abortion is illegal and you don’t have a doctor who you trust, you can still access medical care. You do not have to tell the medical staff that you tried to induce an abortion; you can tell them that you had a spontaneous miscarriage. Doctors have the obligation to help in all cases and know how to handle a miscarriage.

The symptoms of a miscarriage and an abortion with pills are exactly the same and the medical practitioner will not be able to see or test for any evidence of an abortion, as long as the pills have completely dissolved. If you took the Misoprostol under the tongue the pills should have dissolved within 30 minutes. If you took the pills vaginally, you can check with your finger to make sure that they are dissolved. Traces of the pills may be found in the vagina up to four days after inserting them.

Less than 1% of women experience ongoing pregnancy. This can be determined by a pregnancy test after 3 weeks or an ultrasound. If the medical abortion treatment failed, there is a slight increase in the risk of birth defects such as deformities of the hands or feet, and/or problems with the nerves of the fetus. In these cases you will have to repeat a medical or surgical abortion.

Do you need to have an ultrasound after an abortion with pills?

If you do not have symptoms of a complication, or doubts whether the pregnancy was terminated, it is not necessary to have an ultrasound after a medical abortion.

By having an ultrasound, you can determine whether the pregnancy has ended, especially if you are unsure whether the abortion was successful. It is best to wait for 10 days after using Mifepristone before having an ultrasound.

 

You can also have a home urine pregnancy test about 3 weeks after taking the medicines. If you take the home urine pregnancy test before waiting for 3 weeks, the result may show up as false positive, as there are still pregnancy hormones in your body.

Medical abortion, like miscarriage, is a process that takes place over time and the body might take several weeks to fully expel all the tissues and products from the uterus. This is completely normal.

Do you need psychological counselling before or after an abortion?

Most persons do not need any psychological help before or after an abortion.

Feelings of regret after abortion are rare. In fact, the most common emotional response after abortion is relief. Transient feelings of guilt, sadness, or loss are common, but most women can overcome negative feelings that might affect them. It is normal to feel emotional after an abortion. While you may experience sadness or grief, these feelings usually go away after a few days. However, in countries where taboos and social stigma are prevalent, it is more common for women to suffer feelings of guilt and shame.

If it helps, you can read the stories of other women who have had an abortion in Malta on Break the Taboo.

Does an abortion with pills increase the risk of breast cancer?

No, having an abortion does not increase a person’s chance of developing breast cancer.

When can you become pregnant again after an abortion with pills?

Although your period may not come for several weeks after your abortion, you can ovulate (be fertile) at any time after the abortion. This means you can get pregnant right away, even if you are still having some light bleeding. If you want to avoid becoming pregnant, it is very important to start using contraceptives immediately.

You can use condoms and other birth control methods right away. An IUD can be put in place as soon as the abortion procedure is determined successful, 4-14 days after you have taken the Misoprostol, even if there is still light bleeding. You can also wait to insert an IUD until your next regular period, but you will need to use another contraceptive method in the meantime if you do not want to risk becoming pregnant.

You can start hormonal contraceptive methods (pills, patch, ring, injection, implant)  immediately after the first pill of the medical abortion. Oral contraceptive pills can also be started up to 3 days after using the Misoprostol. If you start birth control pills more than 3 days after using the Misoprostol, it is recommended that you use a barrier method (condoms) during the first 9 days, until the pills reach their full level of protection.