Clinics and hospitals currently wait for an ultrasound to confirm a pregnancy inside the uterus before proceeding with a medication abortion. However, recent research from a large international study led by Karolinska Institutet suggests that this treatment can be just as effective and safe even before the sixth week of pregnancy. The findings are published in The New England Journal of Medicine.
In 2023, Sweden recorded 35,550 abortions, with more than 60% occurring before the end of the seventh week of pregnancy. Typically, the abortion process is delayed until a vaginal ultrasound confirms that the pregnancy is intrauterine to rule out ectopic pregnancies, which occur when the embryo implants outside the uterus, usually in the fallopian tubes. Ectopic pregnancies cannot be terminated with a medication abortion and can pose serious risks to the woman’s health. An ultrasound can typically detect a pregnancy by weeks five to six.
“Many women find out about their pregnancy quite early, and a significant number also decide quickly that they want an abortion, often wishing for it to take place as soon as possible,” says Karin Brandell, the study’s lead author and a gynaecologist at Karolinska University Hospital, who is also pursuing her doctorate at the Department of Women’s and Children’s Health at Karolinska Institutet, Sweden. “Previous observational studies have shown mixed results regarding effectiveness, so we aimed to investigate whether very early abortions are as effective and safe as waiting.”
Women from nine countries
The VEMA (Very Early Medical Abortion) study involved more than 1,500 women across 26 clinics in nine different countries who sought an abortion prior to ultrasound confirmation of an intrauterine pregnancy. Participants were randomly assigned to either a delayed abortion after confirmation of intrauterine pregnancy (around weeks 5 to 6) or an early abortion (around weeks 4 to 6). Both groups were administered two medications – mifepristone and misoprostol.
Initially, all participants were within six weeks of pregnancy and showed no signs or symptoms of ectopic pregnancy (like abdominal pain or bleeding) or any risk factors for such a condition (including becoming pregnant while using an IUD or having a history of ectopic pregnancies). The main measurement of success was a completed abortion.
“Conducting medical abortion at a very early stage was found to be equally effective and safe, even in cases of undiagnosed ectopic pregnancy,” remarks Kristina Gemzell-Danielsson, a professor of obstetrics and gynaecology at Karolinska Institutet, who is also a senior physician at Karolinska University Hospital and the project leader for the VEMA study.
A political issue
In both groups, over 95% of the women achieved a complete abortion, but the few instances of incomplete procedures varied between the groups. In the delayed treatment group, 4.5% of cases were incomplete and necessitated additional vacuum aspiration (surgery). In 0.1% of cases, the pregnancy continued. Conversely, in the early group, 3% experienced ongoing pregnancies, while 1.8% required surgical intervention due to incomplete abortions. A total of 1% of all participants had an ectopic pregnancy.
Women in the early treatment group reported less discomfort and bleeding. Additionally, participants in both groups expressed a strong desire to have the abortion performed at the earliest opportunity.
“Abortion is both a political and medical matter,” Dr. Brandell observes. “In Sweden, a woman can undergo another procedure a week after a failed early abortion. However, in Texas, where abortions are prohibited after the sixth week, this option is not available. It was therefore essential to demonstrate that early abortion is as effective as the standard procedures performed later in pregnancy.”
Improving abortion methods and contraceptives
The researchers plan to explore a new combination of medications for early abortions to see if it could also be effective for ectopic pregnancies. They are also working on new contraceptives based on one of the components used in current medical abortions, mifepristone.
“It could be administered in a lower dose than that used for abortions to prevent unwanted pregnancies, possibly in the form of one tablet each week, or as needed,” says Professor Gemzell-Danielsson.
The study received funding from various organizations, including the Swedish Research Council, research funds from the Hospital System of Helsinki and Uusimaa, the European Society of Contraception and Reproductive Health, the Nordic Federation of Societies of Obstetrics and Gynecology, the Gothenburg Society of Medicine, and an ALF grant (Karolinska Institutet/Region Stockholm). Full disclosures regarding the researchers’ conflicts of interest are detailed in the study.
