Questioner: marilyn
Subject: medical abortion failed, incomplete abortion, aspiration procedure, abortion pill, cytotec
Date Asked: 2009-10-19
Date Answered: 2009-10-19 on allexperts.com

Question:
QUESTION: I’m very anxious about having an aspiration abortion..please respond ASAP.
I was 6 weeks pregnant when i came in for a medical abortion. They did the vaginal ultrasound and i’m qualified for the pill but the doctor check my pelvic and he said that i have an inverted uterus. There might be a chance that the pill not going to work but i can try. I got my first pill (Ru-468) in the office and 44 hours later, i took 4 tablets of cytotec BUCALLY. I started to bleed 1 hour later and continue for to pass tissue and large clots for 6hours and continue to bleed for a week. I came back for the follow-up  at the office on week after i took the first pill (Ru-468) and they did the vaginal ultrasound and the nurse said i haven’t completely passed all the tissue. My endometrium still thick so they give me 4 more tablets of Cytotec (800mcg total) and asked me to inserted RECTALLY this time instead of BUCALLY. After i inserted rectally, i got cramp for about 1 hour but barely i bled anything. The next day, i didn’t bled at all. Today is the third day since i had the second dose of cytotec and i just rarely spot anything…but if i do spot…just dark brown discharge came out (look like a string of blood) ..very little but thick. They asked me to come back to the office 1 week later for the follow up. So my questions are: Can cytotec be given RECTALLY for medical abortion? I hardly bleed after the second round of cytotec, does this means i have to have aspiration surgery because i still didn’t expel enough tissue? Is it possible for me to have another round of  Cytotec (800mcg) given BUCALLY this time? Do you think another round of cytotec (800mcg) would work?
thanks for all your help!!!!

ANSWER: Dear Marilyn,
I’m glad you asked these excellent questions.  Here are my thoughts regarding your situation:
1) If you are no longer pregnant, one option is to DO NOTHING.  It is common and normal to have some tissue remaining after a miscarriage or the abortion pill.  This happens more commonly if you have an inverted uterus.  So, one option is to do nothing.  Things that can help cause your uterus to contract and expel the tissue naturally are taking baths, and massaging your lower belly or pelvic area; having sex stimulates the uterus to contract; heat to your lower abdomen and massage.  Eventually, it will pass.  There is no additional risk of infection.  You should only choose this option if this will not cause you emotional distress.  If you are concerned about the tissue, you should get it resolved.
2) If you want to follow up with the doctor and you both decide you want to try again to intervene, you should know that taking misoprostol rectally is no more effective than taking it buccally.  You can take it another time to see if it works.  It is completely safe.
3) The Aspiration Procedure is the safest and most simple method to treat incomplete abortion, miscarriage, and early abortion.  There is nothing to be afraid of.  I have been an advocate of this procedure for over a decade, and I am thrilled that you are being offered this option.  Unfortunately it is very hard to find a doctor who does it, so I would love to know where you are getting your medical care.  It is especially easy to complete the Aspiration Procedure in the situation of a miscarriage or incomplete abortion, because your cervix is already dilated.  The procedure only takes a few minutes.  There is no scraping, no electric suction, no heavy sedation, so there are no major complications. I would recommend the Aspiration Procedure over misoprostol because in a few minutes, the problem is resolved, and you will not have to keep following up and getting examinations.

I hope this is helpful,
Doctor Joan
New York City
———- FOLLOW-UP ———-

QUESTION: Dear Dr. Joan…
I’m very thankful that you responded to my email so quick.
I’m getting my medical care in U.S. and abortion is legal in my state.
Aspiration procedure was the first option the the doctor recommended but i turned it down b/c i don’t like anything invasive. So i chose the pill  instead.
Dr. Joan, i do have some more questions to ask you:
Last week, i came back for the follow up at the clinic after 7 days since i took the first pill (Ru-486). They did the vaginal ultrasound and said i still retained some tissue as well as my endometrium lining is not thin enough the way they want it to. Therefore, the nurse offered me the second set of 800mcg of cytotec taken rectally.
So my questions are:
1)Does every clinic measure the thickness of your endometrium to determine if the abortion is complete or incomplete? I look up alot clinical studies and it shows that there’s no correlation between incomplete pregnancy and thickness of uterus. The clinic i’m going now look at my endometrium lining to determine if the pregnancy is complete or not
2) Is the thickness of uterus have to do with progesterone level? i know that the progesterone in the body decrease after the abortion. So do i have to bleed alot in order to decrease the thickness of the uterus or automatically the thickness would decrease as the progesterone decrease in your body after abortion?
2)Based on your recommendation from above, if my vaginal ultrasound shows that i’m no longer pregnant and still retained some tissue the option is DO NOTHING. But what happen if my doctor force me to do the aspiration procedure. Can i just said NO? Before i did the pill, the clinic asked me to sign a form said that if the abortion is incomplete i have to do the surgery! Is it legal for me to say NO if i don’t want to do the Aspiration procedure?…i just want to pass it naturally..
Please help..thank you so much for answering all these questions. Dr. Joan without u idk what to do..You are awesome GREATLY APPRECIATE !!!!

Answer:
Dear Marilyn,
You have excellent questions. I am always impressed with women who do their research when they need to get an abortion.  Most women do not know all of their options in the area of early abortion.

Here are my thoughts on your questions:
1) No – measuring the thickness of the endometrium DOES NOT correlate with retained products or incomplete abortion.  The only reason to do an aspiration abortion procedure after a medical abortion is if 1) there is a continuing pregnancy; 2) the pregnancy is over but a sac remains, and the women does not want to pass it naturally. 3) A woman experiences lengthy or heavy bleeding or continued cramping.  I would not recommend a procedure for just a small amount of remaining tissue, because in my experience it will pass on its own.  In fact, “retained products” or incomplete abortion is not defined by seeing something on ultrasound.  It is defined by a patient’s symptoms of unusual bleeding and cramping, and this corresponds with an ultrasound.  It is a common mistake with doctors who are less experienced with medical abortion.

2) Doing a procedure for thickened endometrium is not indicated, because thickened endometrium is normal at this stage.  It will go back to normal after the abortion.

3) You can absolutely do nothing.  The paper you signed said that you would do a procedure if the pregnancy CONTINUES. This is in the contract because the abortion pill causes birth defects, and for a very small number of women who fail, some women want to continue the pregnancy.  This would not be an option.

Now, I hope this helps you let go of the idea that there is something wrong, and let your body come back to it’s natural state as it will in its own time.

Doctor Joan

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