12.

2 Avortement médicamenteux
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12.2.1 Précautions

12.2.2 Protocole

12.2.3 Soins aux patients

12.2.4 Informations sur les patients

12.2.5 Suivi des patients

L'avortement médicamenteux est une méthode de ToP sûre et efficace. Le risque de

complications graves est inférieur à 0,1 % et le taux de réussite est de 97 à 98 %.

L'association mifépristone + misoprostol est plus efficace que le misoprostol utilisé seul
et réduit le nombre de doses de misoprostol nécessaires, réduisant ainsi ses effets
indésirables. Le misoprostol constitue cependant une option efficace et sûre, même
lorsqu’il est utilisé seul.

12.2.1 Précautions
Troubles de la coagulation : l'AMIU est privilégiée, si un avortement médicamenteux
est pratiqué il doit être réalisé sous observation.
Insuffisance surrénalienne chronique et asthme sévère non contrôlé : utiliser le
misoprostol seul.
En cas de 2 cicatrices utérines antérieures ou plus, compte tenu du risque de rupture
utérine :
Utilisez de préférence le régime combiné mifépristone + misoprostol, car moins
de doses de misoprostol sont nécessaires.
De 13 à 22 semaines LMP : admettre le patient en observation ; réduire la dose de
misoprostol à 200 microgrammes ; respecter un intervalle minimum d'un jour
entre la mifépristone et le misoprostol.

A noter : la mifépristone et le misoprostol ne sont pas indiqués pour l'interruption d'une

grossesse extra-utérine ou molaire.
12.2.2 Protocole
Avant 13 semaines LMP Entre 13 et 22 semaines LMP

mifépristone PO : 200 mg dose mifépristone PO : 200 mg dose unique

unique Puis 1 à 2 jours plus tard :
Puis 1 à 2 jours plus tard : misoprostol par voie sublinguale ou
misoprostol par voie sublinguale ou vaginale : 400 microgrammes toutes les 3
[1] heures jusqu'à l'expulsion fœtale et
vaginale : 800 microgrammes [2]
placentaire
Si l'expulsion n'a pas eu lieu dans les 24
heures, administrer une deuxième dose Si la mifépristone n'est pas disponible ou
de 800 microgrammes de misoprostol. est contre-indiquée : administrer du
misoprostol seul comme ci-dessus.
Si la mifépristone n'est pas disponible
ou est contre-indiquée :
misoprostol par voie sublinguale ou
vaginale : 800 microgrammes toutes les
3 heures (même si les saignements
débutent après la première ou la
[2]
deuxième dose) ; maximum. 3 doses.

ET

An analgesic or a combination of analgesics:

ibuprofen PO: 800 mg every 8 hours (max. 2400 mg daily); start with misoprostol
and continue as needed after expulsion, up to 3 days max.
If needed, add: codeine PO: 30 to 60 mg every 6 hours (max. 240 mg daily) or
tramadol PO: 50 to 100 mg every 6 hours (max. 400 mg daily).
Use one of these 2 drugs alone if ibuprofen is contra-indicated.

Notes
Notes:
All these doses may be used in adults and adolescents over 12 years.
Depending on the patient's specific constraints, mifepristone and misoprostol can be
taken simultaneously.
In the event of nausea/vomiting (not routinely): metoclopramide PO: 5
mg per dose for women < 60 kg; 10 mg per dose for women > 60 kg. The interval
 between each dose of metoclopramide should be at least 6 hours.

12.2.3 Patient care

Before 13 weeks LMP
Medication abortion is performed on an outpatient basis. A single visit is organized to
provide information and counselling on ToP and the medication used for that purpose
as well as on contraception and the specific method chosen by the patient.
Mifepristone is usually given under direct observation but it is not mandatory. The
woman can choose to take all medications at home.
Misoprostol is taken at home 1 to 2 days later (4 tablets of 200 micrograms for the
first dose). Bleeding and cramping are expected to start within 3 hours. In the vast
majority of cases this treatment is successful. If expulsion has not occurred within 24
hours, a second dose (4 tablets of 200 micrograms) should be taken. Women can
choose come back in consultation to take the misoprostol rather than taking it home.
If misoprostol only regimen is used, provide the patient with the total number of
doses (4 tablets of 200 micrograms every 3 hours; a total of 12 tablets).
Ibuprofen is given to the patient to be taken once cramping starts. Provide quantity to
cover 3 days of treatment.
All contraceptive methods can be started that same day (implant is inserted or
injection given during the consultation, oral contraceptive is given for a minimum of 3
months) except the IUD which can only be inserted after expulsion.

Between 13 and 22 weeks LMP

Due to an increased risk of complications, admit patient for observation after 12
weeks LMP, however, between 13 and 16 weeks LMP the woman can choose to take
the treatment at home, unless there is a risk of uterine rupture (Section 12.2.1).
As gestational age increases, expulsion takes more time and is more painful (ensure
pain management accordingly).
The foetus is more developed and is usually stillborn. In exceptional cases, transient
spontaneous breathing and/or movements may be observed. This may be
emotionally difficult for both the woman and medical staff.
The disposal of the dead foetus must be handled discreetly and respectfully.
For women 13-16 weeks LMP who chose to take the treatment at home,
provide necessary information and counselling as above, including considerations
regarding the disposal of the foetus.
For misoprostol, give sufficient doses to ensure treatment for 24 hours (2 tablets of
 200 micrograms every 3 hours; a total of 16 tablets). Advise the woman to stop
misoprostol as soon as expulsion has taken place.

12.2.4 Patient information

Before administering medications, the patient should be informed that:
Medical abortion is effective and safe. Only 2 out of 100 women will need vacuum
aspiration to end the pregnancy. Complications are rare.
Misoprostol may have teratogenic effect (this information should be known, in case
she changes her mind after taking the drugs or if the regimen fails).
During abortion, she will experience cramping, bleeding, expulsion of blood clots,
and between 13 and 22 weeks LMP, expulsion of the foetus and placenta.
Most often there will be no cramping and bleeding after taking
mifepristone. Cramping and bleeding start 1 to 3 hours after taking misoprostol and
usually slow down within 24 hours. They should not exceed 48 hours. Light bleeding
may last up to 1 month.
The abortion will be usually completed within 24 to 48 hours.
Misoprostol, especially when several doses are taken, can cause nausea, diarrhoea,
chills and fever that should not persist longer than 24 hours after taking the
medication.
Severe pain, heavy bleeding (soaking 2 pads per hour for 2 consecutive hours), foul
smelling discharge and fever lasting more than 24 hours are signs requiring
immediate medical attention.
Menstrual periods will resume within 4 to 8 weeks but fertility returns rapidly;
ovulation can occur as early as 10 days post-abortion. It is recommended to start
contraception immediately.

12.2.5 Patient follow-up

No routine post-abortion consultation is required.
The woman is encouraged to come back at any time if she has concerns,
complications or questions.
The woman is invited to return for contraception if she did not start a method
immediately at the time of the abortion.

In the event of incomplete abortion, see Chapter 2, Section 2.1.3.

In the event of ectopic pregnancy, see Chapter 2, Section 2.2.3.

In the event of ongoing pregnancy before 13 weeks LMP, perform a vacuum aspiration
(Chapter 9, Section 9.5).

References
1. World Health Organization. Medical management of abortion, 2019.
https://apps.who.int/iris/bitstream/handle/10665/278968/9789241550406-eng.pdf?ua=1

2. IPAS. Clinical Updates in Reproductive Health. April 2019.

https://ipas.azureedge.net/files/CURHE19-april-ClinicalUpdatesInReproductiveHealth.pdf