Introduction

The number of induced abortions in India in approved centers is estimated to be 6,20,472 and the maternal mortality due to unsafe abortions is 8% as reported in the Family Welfare Statistics 2011 [1]. The actual number of induced abortions is greatly underestimated as a high percentage of them go unreported and also because there is a rampant and irresponsible practice of self-administration of abortion pills throughout the country.

Medical abortion with mifepristone and misoprostol is a very safe option for termination of pregnancy when consumed under medical supervision with a success rate of 92-97% [2]. Clear guidelines have been formulated by organizations like WHO and in India by FOGSI regarding the use of abortion pills. WHO guidelines indicates the necessity of pre abortion care for women requesting abortion to confirm pregnancy,

to estimate the correct gestational age and to locate the site of pregnancy as either intra or extra uterine. It also emphasizes the need to obtain a detailed medical history to rule out contraindications for medical abortion such as bleeding disorders, uncontrolled seizure disorder, chronic adrenal failure etc and the importance of bimanual examination to assess the size of the uterus and a basic laboratory workup [3]. Both FOGSI & WHO consider that ultrasound is not mandatory but where it is available can be used to exclude an extra uterine pregnancy and to diagnose nonviable pregnancies.

Medical abortion is restricted for use in the early first trimester (up to 63 days) the dose being 200 mg of Mifepristone (oral) followed by 400 mcg of Misoprostol after 48 h vaginally or orally for < 49 d. Between 49–63 d, Mifepristone 200 mg orally and M isoprostol 800 mcg vaginally or orally after 48 h is recommended [2]. The patient has to be educated with details of the procedure like correct administration of the drug, the expected duration of bleeding, complications like excessive bleeding and pain, the possibility of failure and the need for surgical evacuation if necessary. A follow up visit on day14 to ensure completion of the process and to discuss contraception is recommended. In addition to the contraindications mentioned above, FOGSI also discourages medical abortion in patients with Hb < 8 g and if they lack access to 24 h emergency services. It also recommends anti-D injection to Rh negative mothers following medical abortion but routine use of antibiotics is not recommended [2].

The MTP act of India permits that abortion pills be prescribed by only registered medical practitioners and not by non allopathic doctors or by pharmacists. WHO recommends that the person or facility prescribing abortion pills should have a backup health care facility in case of failed or incomplete abortion [3].

Inspite of such clear guidelines and recommendations, self-administration of these drugs by pregnant women without any medical consultation or supervision has become highly prevalent due to availability of these drugs over the counter without any prescription. Many women depend on medical abortion and consider it as a method of spacing between pregnancies [4]. Due to unrestricted availability of these drugs the society considers this to be an extremely safe option of termination of pregnancy. Life threatening complications like excessive hemorrhage, sepsis and deaths due to undiagnosed ectopic pregnancies are not uncommon in women administering these drugs by themselves.

This retrospective observational study was carried out in Sri Manakula Vinayagar Medical College and Hospital to study the implications of self-administration of abortion pills by pregnant women to induce abortion.

Materials and Methods

This study was a retrospective observational study carried out in Sri Manakula Vinayagar Medical College & Hospital after due permission from the hospital authorities. All case records with the diagnosis of abortion whether spontaneous or induced were analysed between the period of July 2013 – June 2014 from medical records department and data was collected from case sheets in which pregnant women had given a history of induced abortion following self-administration of abortion pills and its complications. By self-administration we mean that these pregnant women had no medical consultation with a registered medical practioner and has taken abortion pills which was purchased from the pharmacy without any prescription either by self or by some close relative. The following data was collected. Age, marital status, parity, duration of pregnancy as perceived by the women, confirmation of pregnancy, duration between pill intake and visit to hospital, whether any intervention done elsewhere, any known medical or surgical complications, Hb level on admission, whether patient was in shock, USG findings of incomplete abortion, complete or failed abortion, evidence of sepsis like fever and tenderness on pelvic examination, blood transfusion, treatment given and duration of hospital stay. Management was based on whether patient was bleeding profusely, when surgical evacuation was performed whereas when bleeding was less and the amount of retained products as assessed by ultrasound was minimal medical methods were used.The abortion pills The abortion pills The abortion pills The abortion pills The abortion pills The abortion pills  The abortion pills The abortion pills

Results

The total number of abortions in our institution including spontaneous and induced abortions between the period of July 2013 – June 2014 was 128 of which 40 women had given a history of self-medication with abortion pills obtained without prior medical consultation. In our study we found that 85% were married, 12.5% were unmarried and one woman was a widow. The youngest patient was 15-year-old and all 4 (10%) patients between the age group of 15-19 were unmarried. 92.5% of the women belonged to rural population whereas 4.5% were from urban areas. The percentage of parous women who had self administered abortion pills was 75% and 25% were primigravida.

The gestational age at the time of consumption of abortion pills is shown in [Table/Fig-1].

The finding that 27.5 % of patients had consumed abortion pills after 9 wk of pregnancy is significant, as medical abortion is permitted only upto 63 d of gestation. The maximum period of gestation of self-administration was done was at 20 wk of pregnancy and this patient presented with shock following expulsion of the fetus and came with retained placenta and underwent subsequent surgical evacuation.

Pregnancy was confirmed by 39 women with urine pregnancy test and 1 woman had undergone USG along with UPT. The interval between pill intake and hospital visit is shown in [Table/Fig-2].