Mifepristone

Medication and procedural abortions before 13 weeks gestation and risk of psychiatric disorders. Steinberg, J. R., Laursen, T. M., Lidegaard, Ø., & Munk-Olsen, T. (2024).American Journal of Obstetrics and Gynecology, 231(4), 437.e1-437.e18. https://doi.org/10.1016/J.AJOG.2024.05.025

Background: The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders.

Objective: This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion.

Study design: Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history.

Results: Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93-1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86-1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1-2 years after=0.89, 95% CI: 0.80-0.98; PaIRR 1-2 years after=0.81, 95% CI: 0.88-1.05; MaIRR 2-5 years after=0.77, 95% CI: 0.71-0.84; PaIRR 2-5 years after=0.72, 95% CI: 0.67-0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53-0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50-0.58).

Conclusion: Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term.

Short-Term Adverse Outcomes After Mifepristone-Misoprostol Versus Procedural Induced Abortion : A Population-Based Propensity-Weighted Study. Liu, N., & Ray, J. G. (2023). Annals of Internal Medicine, 176(2). https://doi.org/10.7326/M22-2568

Background: Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada.

Objective: To compare short-term risk for adverse outcomes after early IA by mifepristone-misoprostol versus by procedural IA.

Design: Population-based cohort study.

Setting: Ontario, Canada.

Patients: All women who had first-trimester IA.

Measurements: A total of 39 856 women dispensed mifepristone-misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone-misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups.

Results: Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone-misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]).

Limitation: A woman prescribed mifepristone-misoprostol may not have taken the medication, and the exact gestational age at IA was not always known.

Conclusion: Although rare, short-term adverse events are more likely after mifepristone-misoprostol IA than procedural IA, especially for less serious adverse outcomes.

Mifepristone is also known as RU-486, the abortion pill, medical abortion, or chemical abortion

" Pain control in medical abortion", E Wiebe, Int'l J Gynecology & Obstetrics 74:275-280,2001

A Canadian study of abortion procedures using methotrexate and misoprostol reported that the mean pain

Score was 6.2 on a scale from 1-10. Severe pain (scores of 9 or 10) was reported by 23.4% of the women. Women experiencing severe pain were more likely to have a lower maternal age, lower parity, higher anxiety and depression, and less satisfaction with the procedure. The authors reported that pain medication given before the onset of the procedure did not reduce the amount of severe pain.

Mifepristone in South Australia Mulligan E, Messenger H. Australian Family Physician. MAY 2011.

The study found 3.3% of the women who used RU-486 in the first trimester of pregnancy reported to an emergency room compared with 2.2% who used a surgical method and •5.7% of the women who used RU-486 had to be re-admitted to hospitals compared with 0.4% of surgical abortion patients.

Additional information

Psychological distress symptoms in women undergoing medical vs. surgical termination of pregnancy. Lowenstein L, Deutcsh M, Gruberg R, Solt I, Yagil Y, Nevo O, et al. (2006), General Hospital Psychiatry, 28(1):43–47.

Compared to women choosing surgical abortion, those choosing chemical abortion had higher obsessive-compulsive symptoms, higher levels of guilt, higher interpersonal sensitivity scores, more paranoid ideation, and more general psychiatric symptoms.

A comparison of medical and surgical methods of termination of pregnancy: Choice, psychological consequences, and satisfaction with care. Slade, P., Heke, S., Fletcher, J., & Stewart, P. (1998). British Journal of Obstetrics and Gynecology, 105, 1288-1295.

Those who had a medical abortion rated it as more stressful and experienced more disruption in their lives. “One of the main differences between these two methods of termination is the consciousness and participation of the patient in the medical procedure in a process that involves blood, pain, and death.”

Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation. Ashok P.W., Hamoda, H., Flett, G. M. M., Kidd, A., Fitzmaurice, A., Templeton, A. (2005). Contraception, 71, 143-148.

46.8% of women undergoing a medical abortion experienced a significant decline in self-esteem 2-3 weeks following the abortion. This was a higher percentage than among those who had a surgical abortion (39.5%).

Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomized controlled trial, Kelly, T., Suddes, J., Howel, D., Hewison, J., & Robson, S. (2010). BJOG, 117, 1512-20.

Women who had chemical abortions had higher PTSD intrusion scores, such as nightmares, than women who had surgical abortions

Abortion Pill Reversal can be successful

Article regarding a medical protocol for women who change their minds to stop the RU-486 induced abortion.

Fatal Clostridium sordellii Infections after Medical Abortions N Engl J Med 2010; 363:1382-1383September 30, 2010

Clostridial toxic shock is a rare and largely fatal syndrome among reproductive-age women. Eight cases were reported after medical abortions using mifepristone and misoprostol between 2000 and 2009 bringing the risk of clostridial toxic shock to 0.58 per 100,000 medical abortions.