Rates of serious infection after changes in regimens for medical abortion

Abstract

Background: From 2001 through March 2006, Planned Parenthood health centers throughout the United States provided medical abortion (abortion by means of medication) principally by a regimen of oral mifepristone followed 24 to 48 hours later by vaginal misoprostol. In response to concern about serious infections, in early 2006 Planned Parenthood changed the route of misoprostol administration from vaginal to buccal and required either routine provision of antibiotics or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine treatment with antibiotics for all medical abortions.

Methods: We performed a retrospective analysis assessing the rates of serious infection after medical abortion during a time when misoprostol was administered vaginally (through March 2006), as compared with rates after a change to buccal administration of misoprostol and after initiation of additional infection-reduction measures.

Results: Rates of serious infection dropped significantly after the joint change to buccal misoprostol from vaginal misoprostol and to either testing for sexually transmitted infection or routine provision of antibiotics as part of the medical abortion regimen. The rate declined 73%, from 0.93 per 1000 abortions to 0.25 per 1000 (absolute reduction, 0.67 per 1000; 95% confidence interval [CI], 0.44 to 0.94; P<0.001). The subsequent change to routine provision of antibiotics led to a further significant reduction in the rate of serious infection - a 76% decline, from 0.25 per 1000 abortions to 0.06 per 1000 (absolute reduction, 0.19 per 1000; 95% CI, 0.02 to 0.34; P=0.03).

Conclusions: The rate of serious infection after medical abortion declined by 93% after a change from vaginal to buccal administration of misoprostol combined with routine administration of antibiotics.

Figure 1. Rates of Serious Infection after Medical Abortion among Patients in Two Groups of Planned Parenthood Health Centers

Period 1 ( January 1, 2005, through March 31, 2006) was the baseline period during which vaginal misoprostol and standard antiseptic measures were used for the abortion of fetuses through 63 days of gestation. During Period 2 (April 1, 2006, through June 30, 2007), buccal misoprostol was used through 56 days of gestation; some Planned Parenthood clinics used the infection-reduction measure of universal screening for sexually transmitted infections (STIs) and treatment when screening was positive, whereas others provided routine antibiotics consisting nearly uniformly of 100 mg of oral doxycycline twice a day for 7 days. During Period 3 ( July 1, 2007, through December 31, 2007), buccal misoprostol was used through 56 days of gestation and all health centers routinely provided the doxycycline regimen. During Period 4 ( January 1, 2008, through June 30, 2008) buccal misoprostol was used through 63 days of gestation, and all health centers routinely provided the doxycycline regimen. Group 1 comprises health centers that switched in Period 2 to universal testing for STI, and Group 2 comprises health centers that switched in Period 2 to routine provision of antibiotics. An asterisk denotes a significant decrease from the previous period. There were no serious infections in Periods 3 and 4 in Group 2.