Review articleInfection after medical abortion: A review of the literature
Introduction
Over the past decade, medical abortion regimens have become more widely used to terminate first- and second-trimester pregnancies. From November 2000 to May 2002, an estimated 80,000 women received mifepristone for medical abortion in the United States [1] and over 15 million medical abortions were performed in China from 1992 to 2002 [2]. Regimens using mifepristone accounted for approximately half of the first-trimester abortions performed in France, Scotland and Sweden, and 18% of the first-trimester abortions in England and Wales from 1990 to 2000 [3]. These methods offer women safe, effective and acceptable alternatives to surgical procedures. It is important, however, to understand the frequency of complications after medical abortion and to develop proper management and treatment guidelines in order to provide high-quality care for patients seeking treatment.
Infections requiring oral or intravenous antibiotic treatment and/or hospitalization sometimes occur after surgical abortion, childbirth and invasive procedures involving the female genital tract. Postpartum infection is estimated to occur 6.0–7.4% of the time after cesarean sections and 5.5% after vaginal deliveries [4], and pelvic infections are the most common complication of surgical abortion procedures, with frequencies varying from 0.1% to 4.7% worldwide [5]. Risk of developing infection is a particular concern for providers, because they are keen to avoid serious complications that may jeopardize the health and future fertility of the predominately young and healthy women they treat.
Because medical abortion is a noninvasive procedure, there is an expectation that infection after medical abortion could be less frequent than after surgical abortion. Indeed, data from both Hausknecht [1] and Planned Parenthood (Mary Fjerstad, Planned Parenthood Federation of America, personal communication) suggest the frequency of infectious complications after mifepristone medical abortion is very low (considerably less than 1%). Based on US Food and Drug Administration (FDA) adverse event reports related to the use of mifepristone (Mifeprex®), a 2003 review by Hausknecht found reports from 10 (out of an estimated 80,000) women (0.013%) in the United States who underwent medical abortion treatment with mifepristone who were treated with antibiotics for infections, one of which was serious [1], [6]. A review of clinic-based data from the Planned Parenthood Federation of America found that 13 cases of endometritis requiring intravenous antibiotics and hospitalization were diagnosed among the 58,950 women receiving mifepristone medical abortion between January 1, 2001, and June 30, 2003 (0.022%) (Mary Fjerstad, Planned Parenthood Federation of America, personal communication).
Nonetheless, it is not possible to make accurate estimates about rates of infection after medical abortion from these data, because of two key but distinct issues. First, data based on regulatory reports are generally presumed to underestimate the true incidence of an event, as reporting is voluntary and unsolicited. Second, data from Planned Parenthood represent only one clinic system, and thus it is not possible to generalize from those results to the population of all medical abortion providers in the United States. The purpose of this review is to provide more systematic data on infectious complications after the five most common medical abortion regimens.
Section snippets
Materials and methods
In order to analyze the frequency of infection after medical abortion for early pregnancy termination, we searched the Medline database for articles written in English before July 2003 with the following indexing terms: medical abortion, mifepristone, misoprostol, methotrexate, abortion and pregnancy termination.
We used the following selection criteria for study inclusion: (a) sample size greater than 100 (although for randomized trials, the sample size for a particular study arm could be less
Results
Overall frequency of diagnosed and/or treated infection reported after medical abortion treatment was <1% (0.92%, N = 46,421). Infections were reported after treatment, with a range of 0.00% to 6.11% among studies. The most common type of postabortal infection reported was endometritis (49%, 210/429), followed by undefined “genital tract infection” (37%, 159/429). Both types of infections were usually diagnosed with no confirmatory tests and treated with no sequelae. In over 46,400 patients
Discussion
As this review of studies examining five types of medical abortion regimens clearly demonstrates, overall frequency of reported infection after medical abortion procedures (0.92%) is lower than that reported after either surgical abortion procedures or childbirth. The rate of women lost to follow-up was quite low (<5%) in most of the studies we reviewed. Therefore, it is unlikely that loss to follow-up affected the reported frequency of infection. Several other methodological issues, however,
Acknowledgements
The authors wish to thank Mary Fjerstad of the Planned Parenthood Federation of America for her contribution of clinic data. We thank the Packard Foundation for their support.
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