Medical abortion in women with impaired renal function

Medical methods for pregnancy termination have revolutionized abortion care. They are of particular value in second-trimester abortion, being safer and less intrusive than surgery. There is a paucity of data on medical abortion in women with chronic diseases such as kidney disease—a MEDLINE search for medical abortion in women with renal disease revealed no published papers. Moreover, most research studies on medical abortion include renal function impairment in the exclusion criteria. Nevertheless, with advances in medical therapy, women with chronic diseases now live longer and can achieve a viable pregnancy. Guidelines indicate the necessity of therapeutic abortion in cases of severe kidney disease because the risks of maternal and fetal morbidity are high: up to 45% of pregnant women with severe kidney disease progress to end-stage renal disease and 80% of deliveries are preterm [1]. However, the ideal method of abortion is not described. Most women and their doctors opt for surgical abortion with no drug-induced adverse effects (SM et al., unpublished data), although—as in the present 3 cases—some women may present late in the second trimester, when surgical abortion carries its own risks. The 3 women in the present cases were aged 26, 34, and 32 years and had kidney disease of varying severity (Table 1). Two of the women were at 20 weeks or more of pregnancy and 1 was a primigravida at 15 weeks of pregnancy. Medical abortion was performed in all 3 cases after counseling and informed consent. In case 1, following dialysis, 100 μg of misoprostol was administered vaginally (2 doses every 4 hours); in case 2, 400 μg of misoprostol was administered vaginally (3 doses every 4 hours); and, in case 3, 200 mg of mifepristone was administered orally (single dose), followed by 400 μg of misoprostol vaginally (single dose) after 48 hours. Misoprostol is a prostaglandin E1 analog that causes softening of the cervix and uterine contractions, resulting in the expulsion of the conceptus [2]. Although originally developed as an oral drug for the prevention of peptic ulcers, misoprostol has been used via the vaginal, rectal, buccal, and sublingual routes in obstetrics and gynecology [3]. It is rapidly and extensively absorbed orally, and the shortest time to peak concentration, the highest peak concentration, and maximum bioavailability are achieved via the sublingual route [3]. The majority of misoprostol—80%—is excreted in the urine; therefore, its use is cautioned against in women with renal impairment. Although half-life, maximum plasma concentration, and bioavailability may be increased among these women, no correlation has been observed with degree of dysfunction [4]. It is uncertain whether misoprostol is removed via dialysis [4]. Thus, its use for medical abortion in women with renal disease has been a point of contention, with most obstetricians opting against use. However, in the present cases, misoprostol was used to achieve abortion in consenting women with impaired renal function, with no adverse effects. Larger studies are required to determine the optimum doses at different degrees of renal impairment. The authors have no conflicts of interest.