Open Journal of Obstetrics and Gynecology, 2011, 1, 234-237
doi:10.4236/ojog.2011.14046 Published Online December 2011 (http://www.SciRP.org/journal/ojog/
OJOG
).
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG
Unsupervised medical abortion with misoprostol among
adolescent—what is the prospect of demedicalise
abortion in Sub-Saharan Africa?
Adebiyi Gbadebo Adesiyun1, Austin Ojabo2
1Department of Obstetrics & Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria;
2Department of Obstetrics and Gynaecology, Benue State University, Makurdi, Nigeria.
Received 20 October 2011; revised 21 November 2011; accepted 6 December 2011.
ABSTRACT
Objective: To find out clinical presentation and out-
come of unsupervised use of misoprostol as aborti-
facent among adolescents presenting with abortion
complications. Methods: Case series of thirty one a-
dolescents that presented with abortion complications
following unsupervised use of misoprostol. Results:
Over a period of 3 years, 31 adolescents were seen,
with median age of 17 years. Twenty nine (93.5%)
were unmarried and 22 (71%) were in secondary s-
chool. Pregnancy duration was 3months and above in
23 (74.2%) of the patients. The cumulative dose of
misoprostol tablet ingested was 2 (400 µg) in 17
(54.8%) of the patients. Twenty three (74.2%) pa-
tients presented with incomplete abortion with mild
sepsis while the remaining 8 (25.8%) patients were
admitted and managed with incomplete abortion wi-
th severe sepsis. Treatments offered were manual va-
cuum aspiration in 23 (74.2%) patients, evacuation of
retained product of conception under anaesthesia in 7
(22.6%) patients and 1 (3.2%) patient had laparo-
tomy with uterine repair following inadvertent uteri-
ne perforation complicating curettage for incomplete
abortion. Complications encountered were anaemia
67.7%, uterine perforation 3.2%, blood transfusion
9.7% and diarrhoea in 8 (25.8%) patients. Conclu-
sion: Demedicalise abortion with misoprostol due to
improper dosing protocol may be associated with in-
complete abortion and its sequelae in an uninformed
adolescent population. Establishment of adolescent f-
riendly medical centre that offers post abortion care
will go a long way in alleviating this problem.
Keywords: Demedicalise Abortion; Misoprostol; Ado-
lescent; Medical Abortion
1. INTRODUCTION
The current generation of adolescents are more than a
billion and they will be the largest generation in history
making the transition from children to adulthood [1].
The transition period of adolescence is characterized by
the onset of sexual relationships, marriage and child bea-
ring. However, the biological and social impact of sexual
activity in adolescence is associated with more cones-
quences in females than their male peers [1]. These con-
sequences have been shown to conspicuously and unto-
wardly shape the future of the female adolescent.
The changes in population dynamics resulting in mi-
gration to urban settlements and postponement of child-
bearing to allow for career attainment, has made preg-
nancy and childbearing at very early ages an unfavorable
and an uncherish tradition contrary to what it was gen-
erations ago. The resultant delay in marriage coupled
with low contraceptive prevalence typical of most de-
veloping countries, results in unwanted pregnancy [2]. It
is estimated that nearly 70,000 women die annually from
complications of unsafe abortion around the world. Over
69,000 of these deaths occur in developing countries while
23,000 occur in sub-Saharan African countries alone, re-
presenting an estimated 680 deaths per 100,000 abortion
procedures in Africa [3].
Misoprostol, an orally active prostaglandin E1 analog
was introduced into Nigeria medical practice for the
management of peptic ulcer disease and lately for the
prevention of postpartum haemorrhage. However, other
countries have extended its use to some women prob-
lems like abortion, uterine evacuation and labour induc-
tion [4]. In Nigeria, the restrictive abortion law in place
may encourage unsupervised use of misoprostol as an
abortifacient. With this background, we studied adoles-
cents presenting with complications of abortions fol-
lowing the use of self prescribed misoprostol in an at-

A. G. Adesiyun et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 234-237 235
tempt to induce an abortion.
2. METHODS
This was a descriptive observational case series of 31 a-
dolescents that presented with complications of abortion
following unsupervised use of misoprostol as an aborti-
facient. The patients were managed in Ahmadu Bello
University Teaching Hospital, 345 Aeromedical Hospital
and Alba Hospital, all located in Kaduna city, Northern
Nigeria. The patients were seen between January 2005
and December 2008. All the patients obtained misopros-
tol medication without prescription. The cases were di-
vided into 2 categories; mild and severe complications.
Mild cases include those ≥ with temperature less than
100 F with absence of rigors, shock or generalized peri-
tonitis. Severe cases are those with impending/early en-
dotoxic shock, temperature greater than 100 F or sub-
normal, generalized peritonitis and evidence of bowel or
bladder injury. For this study, anaemia was defined as
hemoglobin level less than 10 grams per deciliter. The
patients all had ultrasound examination to confirm in-
complete abortion. Duration of pregnancy expressed in
months was based on patient’s estimation from last men-
strual period.
The patients were either managed as out-patient or in-
patient basis. Out-patient management was offered to tho-
se with mild cases and these include: uterine vacuum as-
piration, oral antibiotic, analgesia, and oral haematinics
for those with mild anaemia. Those with severe condi-
tions were managed as in-patient. In-patient manage-
ment included evacuation of retained product of concep-
tion under anaesthesia, intravenous fluids, parenteral anti-
biotics and blood transfusion depending on the severity
of anaemia. Results are presented in numbers and per-
centages.
3. RESULTS
Over a period of 3 years, 31 patients with incomplete
abortion following unsupervised use of misoprostol as
abortifacient were seen. The median age was 17 years
with age range of 14 to 19 years. Twenty nine (93.5%)
were single and 2 (6.5%) are married. The 2 married
patients were both less than 6 months into marriage.
Twenty two (71.0%) were secondary school students and
9 (29.0%) were apprentice learning a vocation (Table 1).
Range of pregnancy duration was I to 6.5 months. Of
the 31 patients, 17 (54.8%) used an oral cumulative dose
of 2 (400 microgram) misoprostol tablets, followed by 1
(200 microgram) tablet in 8 (25.8%) patients and 3 (600
microgram) tablets in 6 (19.4%) (Table 1). The peak du-
ration of pregnancy before ingesting misoprostol was 3
months (17 patients, 54.8%), followed by 4 months or a-
bove in 6 (19.4%) patients (Figure 1).
Table 1. Profile of patients.
VARIABLE N = 31%
AGE (YEARS)
<13
14 - 16
17 - 19
0
13
18
0
41.9
58.1
MARITAL STATUS
Single
Married
29
2
93.5
6.5
OCCUPATION
Secondary School
Apprentice
22
9
71.0
29.0
TOTAL DOSE OF MISOPROSTOL USED
1 tablet
2 tablets
3 tablets
8
17
6
25.8
54.8
19.4
0
2
4
6
8
10
12
14
16
18
MON TH S
1Month
2Month
3Month
≥4Mont h
Figure 1. Bar chart of number of patients
versus duration of pregnancy in months.
At presentation, based on the criteria, 23 (74.2%) pa-
tients were classified to have mild incomplete septic
abortion and 8 (25.8%) patients with severe incomplete
septic abortion (Table 2). None of the patients had been
on antibiotics before presenting to the hospital. Time
interval between ingestion of misoprostol to presentation
in the hospital was between 10 and 20 days in 21 (67.7%)
patients and 30 to 40 days in 10 (32.3%) patients (Table
2). In-patient management was offered to the entire 8
(100%) patients with severe case and the 23 patients
with mild case were managed as an out-patient.
Definitive treatment offered was uterine vacuum as-
piration for 23 (74.2%) patients, evacuation of retained
product of conception under anaesthesia for 7 (22.6%)
patients and laparotomy/uterine repair for 1 (3.2%) pa-
tient that had uterine perforation complicating uterine
curettage done in an unsafe environment before present-
ing to the hospital. The patient that had laparotomy was
a married secondary school student. Morbidities encoun-
tered were pyrexia 31 (100%), anaemia 21 (67.7%), ute-
rine perforation complicating uterine curettage 1 (3.2%)
and diarrhoea in 8 (25.8%) patients (Table 2). There was
no mortality recorded.
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Table 2. Presentation, management and complications.
Varia bl e N = 31 %
Mode of presentation
Mild incomplete septic abortion 23 74.2
Severe incomplete septic abortion 8 25.8
Interval between ingestion of
misoprostol and presentation
10 - 20 days 21 67.7
30 - 40 days 10 32.3
TREATMENT
MVA 23 74.2
ERPC under anaesthesia 7 22.6
Laparotomy 1 3.2
MORBIDITY
Anaemia 21 67.7
Uterine perforation complicating curettage 1 3.2
Blood transfusion 3 9.7
Diarrhoea 8 25.8
MVA: Manual Vacuum Aspiration; ERPC: Evacuation of Retained Product
of Conception.
4. DISCUSSION
Most developing countries like Nigeria have restrictive
abortion law limiting access to safe abortion. Adoles-
cents are more vulnerable to unwanted pregnancy and its
complications because of secrecy surrounding sex at an
early age due to peculiar socio-cultural background in
most African Societies. Globally, medical abortion offers
a new and better option to women seeking to terminate
their pregnancy [5]. Medical methods of abortion hold
the potential to improve women’s health and advance
their reproductive right [6]. With accessibility to medical
abortion, women will no longer have to rely on surgical
services considered to be less desirable and mostly un-
safe in developing countries.
Supervision of medical abortion in a clinical setting is
required at one stage or the other [1]; this makes the con-
cept unfavorable for countries with restrictive abortion
law. Supervision is paramount in low resource settings
where majority are less educated and uninformed. All
the patients managed in this study did not receive super-
vision before and/or after the use of misoprostol as abor-
tifacient. Although authors have reported the possibility
of “demedicalise abortion” that obligates medical super-
vision so long as easy access to medical care is available
in case any problem arose [5-7]. However, for successful
outcome of demedicalise abortion, women would need
to accomplish the following; recognize that they are pre-
gnant, estimate the duration of pregnancy, select appro-
priate regimen, adhere to the correct protocol, manage
adverse reactions and seek care for those that warrant
medical attention, possibly notice and cope with expul-
sion of the embryo, and recognize a complete abortion
[5]. Considering the aforementioned viz-a-viz the socio-
cultural and demographic characteristic obtainable in
most African setting, it will be difficult to fulfill the cri-
teria of demedicalise abortion in most resource con-
strained societies of Africa.
The peculiarities of the adolescent period especially in
the developing countries where enormous stigma is as-
sociated with unwanted pregnancy, makes accomplish-
ment of the above criteria almost impossible. Further-
more, the absence of adolescent friendly medical care
has not helped the situation in most resource poor coun-
tries. Over a period of time, several regimens have been
used for medical abortion. These include mifepristone-
gameprost, mifepristone-misoprostol and methotrexate-
misoprostol [5]. However in Nigeria, out of all the drugs
used for medical abortion, only misoprostol is easily a-
ccessible in terms of availability and cost. This attributes
may have increasingly favored misoprostol as a com-
monly used abortifacient. Furthermore, lack of enforce-
ment of drug prescription before dispensing policy in
most developing countries is a major demerit towards
the success of medical abortion .In this study, the preg-
nancies were either in the first or second trimester. In as
much as authors [8-11] have documented the safety and
efficacy of misoprostol alone in medical termination of
1st and 2nd trimester pregnancies. The route of admini-
stration and dosage regimen are of paramount impor-
tance. All the patients in this study used misoprostol ora-
lly. Oral route of administration have been associated
with low efficacy, with success rates between 5% and
11% in earlier studies [12,13]. On the contrary, vaginal
route have success rates of between 89% and 94%
[8,10,11,14,15].
Treatment protocol is an important variable in the
success rate of demedicalise abortion with misoprostol.
Dose regimen ranging from 200 µg to 800 µg, 8 to 12
hourly have been reported with good success [8,10,11,14,
15]. The adolescents in this series did not follow any
particular regimen, which may be responsible for the
low success rate and increase complication of incom-
plete abortion and its sequalae. Life table analysis esti-
mating efficacy of misoprostol for first trimester preg-
nancy termination revealed the overall complete abortion
rate of 88% to 93% with compliance to specific re-
gime/protocol and intervention rate as low as 9% [16].
The greatest percentage of deaths and serious morbidity
resulting from unwanted pregnancies occur in develop-
ing countries [17]. In this series, the complication was
mainly incomplete abortion and its sequalae like sepsis,
anaemia and blood transfusion. Limitation of this study
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A. G. Adesiyun et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 234-237 237
is that we did not rule out concomitant consumption of
local herbal agents with abortifacient property.
Even though induced abortion is a criminal act in Ni-
geria, a lot of clandestine termination of pregnancy takes
place on daily basis. Effort should be made towards set-
ting up medical centers that are adolescent friendly,
where counseling, routine medical assistance and care
for abortion related complications can be rendered to
patients. However, in other developing countries with
unrestrictive abortion law, factors contributing to three
tier delay in accessing health care must be considered in
the success of demedicalise abortion [18].
OJOG
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