Medical Abortion		Surgical Abortion
Advantages	Disadvantages	Advantages	Disadvantages
Avoid surgical and anesthetic risk	Longer waiting period for completion	Shorter time to completion	More serious risk involved
Increases choice	Requires multiple visits	Fewer visits	Limited access
Less painful than surgical with local anesthetic	Not available after 7 weeks (with US Food and Drug Administration regimen) or 9 weeks (with alternative regimen)	Can be performed at later gestations	Requires more equipment and investment
Offered earlier in pregnancy	Expensive	Pathologic confirmation	Providers more vulnerable to risk
More patient control over procedure	Slightly less effective	Shorter bleeding duration	Less patient control over procedure

	Mechanism of Action	Side Effects	Contraindications	Pharmacokinetics
Prostaglandins[10,40,41]
Misoprostol       400-800 mcg PO or PV	Interact with myometrial cell receptors causing strong myometrial cell contractions leading to expulsion of embryonic or fetal tissue. Also causes cervical softening and dilatation.	Diarrhea, vomiting, nausea, uterine cramping, bleeding	Glaucoma, sickle cell anemia, hypotension, mitral stenosis, pregnancy not intended for termination, hypersensitivity to misoprostol	Half life = 30 min.
				PO:
				Time to peak plasma concentration = 30 min.
				Onset of uterine tonus = 8 min.
				Time to peak uterine tonus = 25 min.
				PV:
				Time to peak plasma concentration = 80 min.
				Onset of uterine tonus = 21 min.
				Time to peak uterine tonus = 46 min.
Antiprogesterones[10,42]
Mifepristone (RU-486)       200-600 mg PO	Five times greater affinity for progesterone receptors. Binds to progesterone receptors and blocks progesterone from binding, thus inhibiting its action and leading to increased uterine contractility. Also softens and dilates cervix.	Abdominal pain, uterine cramping, nausea, vomiting, diarrhea	Severe anemia, adrenal disease, chronic corticosteroid administration, severe kidney disease, severe liver disease, severe pulmonary disease, cardiovascular disease, inherited porphyries, clotting disorder, anticoagulant therapy, ectopic pregnancy, undiagnosed adnexal mass, IUD in place, hypersensitivity to mifepristone	Time to peak serum levels = 90 min.
				Half life = 30 hours
				Percent protein bound = 98%
				Oral bioavailability = 69%
Antimetabolites[10,40-44]
Methotrexate       50 mg/m2 IM       25-50 mg PO	Blocks dihydrofolate reductase, thus inhibiting folate production and DNA synthesis. Affects rapidly dividing cells first (including trophoblast cells).	Nausea, vomiting, diarrhea, hot flushes, headache, uterine cramping, dizziness	Severe anemia, inflammatory bowel disease, clotting disorder, acute liver or kidney disease, alcoholism, immunodeficiency syndrome, bone marrow hypoplasia, leukopenia, thrombocytopenia, hypersensitivity to methotrexate	Time to peak serum levels = _ - 2 hours
				Terminal half life = 10-12 hours
				Percent protein bound = 50%

PO, orally; PV, vaginally; IUD, intrauterine device; IM, intramuscularly

	Regimen	Days From LMP	Complete Abortion Rates
FDA-approved regimen	Mifeprex 600 mg PO followed by misoprostol 400 mcg PO, see Table 4 for details[12,13]	< 49	98%
Lower dose of Mifeprex	Mifeprex 200 mg vs 600 mg PO followed by 400 mcg misoprostol PO[14]	< 63	Similar complete abortion rates
	Mifeprex 200 mg PO followed by misoprostol 800 mcg PV[15]	< 49	98.5%
		< 50-63	96.7%
			96% to 98%
Misoprostol administered vaginally	Misoprostol 800 mcg PV vs PO after Mifeprex 600 mg PO.[16]	< 63	95% PV
			87% PO
			Fewer side effects with vaginal route
Home administration of misoprostol	Misoprostol, either PV or PV, administered at home instead of at the office.[17-19]		Equal efficacy with home vs clinic administration
Up to 63 days after LMP	Mifeprex 200 mg po followed by misoprostol 800 mcg PV 48 hours later[15]	< 63	98%

LMP, last menstrual period; FDA, US Food and Drug Administration; PO, orally; PV, vaginally

	Studies*	Days From LMP	Complete Abortion Rates	Abortion Rates Within 24 hr of 1st, 2nd, or 3rd Misoprostol Dose
Methotrexate 50 mg/m2	Methotrexate dose followed by misoprostol 3 vs 7 days later[20,45]	< 56	83% in 3-day group	65% (1st, 2nd)
		< 49	98% in 7-day group	68% (1st, 2nd)
		50-56	90% in 3-day group
			96% in 7-day group
			75% in 3-day group
			100% in 7-day group
	Methotrexate dose followed by misoprostol dose 3 vs 4 vs 5 days later[21]	< 63	92% to 93% in all groups	78% (1st)
				89% (2nd)
				92% (3rd)
	Methotrexate dose followed by misoprostol dose 3 days later[22]	57-63	60% (10 patients total involved in study)
Methotrexate 75 mg IM	Methotrexate dose followed by misoprostol dose 5-6 days later[23]	< 49	95%	71% (1st, 2nd)
Methotrexate PO	Methotrexate 50 mg PO dose followed by misoprostol dose 5-6 days later[24]	< 49	91% Increased side effects compared with IM	78% (1st, 2nd)
	Methotrexate 50 mg PO vs 25 mg PO followed by misoprostol dose 7 days later[25]	< 56	91% in 25-mg group
			90% in 50-mg group

*	All methotrexate regimens reported here are followed by misoprostol 800 mcg PV, repeated approximately every 48 hours for up to 3 doses total.

LMP, last menstrual period; IM, intramuscularly; PO, orally

Visit 1: Day 1 Counseling and signing of informed consent Medical history and physical exam Blood samples taken for determination of hemoglobin level and Rh factor Pregnancy dating with sonogram or hCG level if no gestational sac is seen Administer RhoGAM if patient is Rh negative Administer 3 mifepristone (200 mg each) tablets for a total dose of 600 mg orally Instruct on self care and clinic emergency contact information Schedule next visit

Visit 2: Days 3-4 Use sonogram to check if patient has aborted (6% may abort prior to misoprostol) Administer 2 misoprostol tablets (200 mcg each) for a total dose of 400 mcg orally Observe patient in the office for 4 hours (~50% will abort during this time period) Give a prescription for pain medication Instruct patient on self care for expectant cramping, bleeding, and gastrointestinal side effects Schedule next visit

Visit 3: Days 12-20 Confirm abortion by sonography or hCG level (> 50% decrease) Assess level of bleeding and cramping since last visit Administer birth control of patient's choice

	US Trials (%)	French Trials (%)
Abdominal/Uterine cramping	96	83
Nausea	61	43
Headache	31	2
Vomiting	26	18
Diarrhea	20	12
Dizziness	12	1