Infection is another risk. One review of surgical abortion found a cumulative rate of 0.5 percent in those given prophylaxis compared with 2.6 percent in those given placebo (Achilles, 2011). In another review of nearly 46,000 irst-trimester abortions, the postoperative infection rate was <0.3 percent for either surgical or medical methods (Upadhyay, 2015).
Incomplete abortion may require reevacuation. For medical abortion, this neared 5 percent in one systematic review (Raymond, 2013). Reaspiration rates following surgical abortion are typically <2 percent (Ireland, 2015; Niinimaki, 2009).
In sum, first-trimester surgical abortion ofers higher e.cacy rates (96 to 100 percent) than medical abortion (83 to 98 percent). Medical abortion also carries a greater cumulative risk of complications, although diferences are small (Lichtenberg, 2013). hese are balanced against the greater privacy of medical abortion and the more invasive steps of curettage.
In appropriately selected women, outpatient medical abortion is an acceptable option for pregnancies with a menstrual age <63 days (American College of Obstetricians and Gynecolo gists (20 16c). Although suitable at later gestational ages, success rates are lower.
gestation, one third are completed medically in the United
States Qatlaoui, 2016). hree medications are used alone or in combination: mifepristone, methotrexate, and misoprostol. Of these, mifepristone augments uterine contractility by reversing progesterone-induced myometrial quiescence, whereas misopro scol directly stimulates the myometrium. Both also ripen the cervix (Mahajan, 1997; Tang, 2007). Methotrexate acts on tro phoblast and halts implantation. It is used less frequently now due to current availability of the more efective mifepristone.
Contraindications to medical abortion have evolved from exclusion criteria that were used in initial clinical trials. Cau tions include current intrauterine device; severe anemia, coagu lopathy, or anticoagulant use; long-term systemic corticosteroid liver, renal, pulmonary, or cardiovascular disease; or uncon trolled hypertension (Guiahi, 2012). Of note, misoprostol is suitable for early pregnancy failure in those with prior uterine surgery (Chen, 2008).
Methotrexate and misoprostol are both teratogens. Thus there must be a commitment to completing the abortion once these drugs are given (Aufret, 2016; Hyoun, 2012; Kozma, 2011). With mifepristone, for women who choose to continue their preg nancies after exposure, the ongoing pregnancy rate ranges from 10 to 46 percent (Grossman, 2015). The associated major mal formation rate was 5 percent in one series of 46 exposed preg nancies (Bernard, 2013).