Unsafe methods of medical termination of pregnancy are a major cause of mortality among women in India, accounting for about 12 percent of maternal deaths. Needless deaths are only one grim facet of illegal terminations. For every one death, possibly hundreds are left wounded - sterile, castrated or both. There is a crying need for a safe and convenient method of abortion. Some method that can be administered even by health care professionals without access to sophisticated facilities. A method that makes it possible for women to make more personal, and private decision about abortion.
The drug most widely used for medical abortion internationally is mifepristone (or "RU - 486", as it was originally known in France) along with misoprostol. After its remarkable success in the West, the combination is now set to contribute to cutting down the deaths and damage related to abortions among Indian women.

MECHANISM OF ACTION
For successful medical abortion, mifepristone must be used in combination with misoprostol.
Mifepristone is an antiprogestin that competitively inhibits the progesterone receptor in the endometrium and causes detachment of implanted human embryo. It also softens the cervix to facilitate the expulsion of the pregnancy.
Misoprostol is a prostaglandin analogue, that accelerates the process of expulsion by stimulating uterine contractions and by softening the cervix.
As abortion induced by the two drugs is similar to spontaneous miscarriage, women tend to perceive it as a "natural" procedure.

DOSAGE AND ADMINISTRATION
The mifepristone - misoprostol combination is approved for termination of early pregnancy (less than 49 days). This regimen entails three clinic visits.
Day 1 : Eligibility screening, laboratory testing (to confirm pregnancy), counselling, physical exa-mination. Administration of 600 mg of mifepristone orally.
Day 3 : Administration of misoprostol 400 mcgm orally.
Day 14 : Confirmation of completion of medical abortion. If regimen has failed, the procedure must be completed by performing a surgical abortion.

EFFICACY STUDIES
1. International
In the largest trial involving 2015 pregnant women (up to 63 days gestation) seeking termination of pregnancy, mifepristone 600 mg orally was
administered on day one, followed by
misoprostol orally two days later.
a. Success was 92 percent in less than 49 days gestation.
b. Failure (need for surgical intervention) was less than one percent.
c. Incomplete abortion was five percent.
Termination occurred within four hours after the administration of misoprostol in 49 percent of the women and within 24 hours in 75 percent of the women. Vaginal bleeding ranged from spotting to heavy, with average duration of 13 days.
2. Indian Experience
A trial was carried out in 1500 patients in three centres in Pune and Mumbai to examine the feasibility of introducing medical abortion and to assess its potential as an alternative to surgical abortion, for termination of early pregnancy in India. Regimen used was 600 mg of mifepristone in first clinic visit followed by 400 mcg of oral misoprostol. Complete abortion occurred in 95 percent of patients, average duration of bleeding was nine days and pain was managed by administering paracetamol.

MANAGEMENT OF SIDE EFFECTS AND COMPLICATIONS
1. Bleeding along with passage of clots occurs as normal part of medical abortion, but it does not lead to significant drop in haemoglobin. Transfusion or surgery to control bleeding is required only if a woman soaks two thick full-size sanitary pads per hour for two consecutive hours. Average duration of bleeding is from 9 to 16 days.
2. Pain can be managed by prescribing paracetamol along with misoprostol.
3. Failed or incomplete abortion requires surgical abortion for the completion of the procedure.