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03 / 03 / 2009 - Should GPs REALLY be handing out abortion pills that made this woman bleed to death?
Manon Jones was just 18 when she took pills to abort an unwanted baby six weeks into her pregnancy.
The bright and bubbly A-level student went with her mother to Southmead Hospital in Bristol to terminate the baby, after deciding that continuing the pregnancy would cause too much trouble with her boyfriend's family.
What obstetricians describe as a 'low tech' procedure and abortion charities argue is a 'more natural' way for women to terminate a pregnancy than surgical intervention should have been relatively straightforward.
Just like thousands of women before her, Manon swallowed the first pill and took the second two days later.
Her mother Llywela held her hand as the pregnancy was terminated. Had everything gone smoothly, Manon should have recovered from the cramps - which usually start within four hours of taking the second pill - and got on with her life.
But the abortion was actually incomplete - part of the placenta which had attached itself to her womb wall had not been expelled from her body. This meant that the clotting procedures which should happen after a termination did not occur. Her blood was leaking away from inside her womb, which was also open to infection.
Warning signs were there when Manon, from Caernarfon, in Gwynedd, returned to hospital three days later complaining of heavy bleeding and light-headedness, but she was reassured by a scan which came back 'normal'. Four days later, she went on holiday with friends, but returned home early after feeling unwell and admitted herself again to Southmead Hospital.
Within days, her condition was critical and she was in a coma. Her family decided to turn off her life support machine on June 25, 2005, 13 days after the procedure, after it became clear she would not recover.
As heard at a coroner's inquest last year, a tragic series of events meant that Manon's life-threatening blood loss and toxic shock was not acted upon quickly enough.
Although the inquest concluded there was no failure of care by the NHS, she waited four hours for a blood transfusion because of another emergency, and suffered a heart attack and seizures which left her in intensive care.
Huge blood loss, or hypovolemia, can kill within an hour, but with retained placenta after an early pregnancy the bleeding can take longer to become life-threatening.
Blood infections can also be extremely dangerous, causing the body suddenly to weaken and vital organs to fail, leading to heart attacks, or liver and kidney failure.
Manon's mother said: 'It seemed such an unnecessary tragedy - a mother's worst fears come true.'
The abortion pill uses two drugs - mifepristone, which blocks the action of the pregnancy hormone, and misoprostol, taken up to 48 hours later, which causes bleeding to complete the abortion.
Most women using the abortion pill take it before nine weeks of pregnancy, but it can be used in hospital up to 13 weeks, in a higher dose.
Doctors tell women to expect period-like pain, which can usually be controlled with painkillers like ibuprofen. This is followed by heavy bleeding, during which the foetus will be passed from the body.
Bleeding can be heavy for up to 24 hours, but should then be more like a period, which may last for two weeks or more, experts say.
The relative ease of this abortion method means it is becoming increasingly popular - it now accounts for 35 per cent of all abortions, a rate which has increased six-fold since 1995.
Now, health ministers are making it even easier for women up to nine weeks pregnant to get this pill. Within weeks, six GP surgeries are due to start handing out the drugs, previously available only in hospitals and licensed abortion clinics.
The Government-funded BPAS (formerly the British Pregnancy Advisory Service), which provides abortions, is to be involved in running the pilot schemes.
Details of how the service will run are still being worked out by the Department of Health.
But there are concerns that the full risks of using the abortion pill are only just beginning to emerge, and taking abortion into the community could sweep away essential safeguards for women's health.
Waste: Manon's death is one of 13 due to the abortion pill reported worldwide
GP Dr Trevor Stammers, chairman of the Christian Medical Fellowship, says: 'Uterine rupture is a possibility with the abortion pill, as is incomplete abortion where the woman keeps bleeding, with potentially fatal results.
'Moving them into a GP setting is a bad move. There will be a lack of continuity of care which will affect patient safety.'
Manon's death is the only known fatality linked to the abortion pill in the UK, and one of 13 deaths reported worldwide, yet the Government's Medicines And Healthcare Products Regulatory Agency (MHRA) officials admit the number of serious complications linked to the abortion pill is probably vastly under-reported.
Many of these deaths involved teenagers - could their relative inexperience or desire not to make a fuss make them more vulnerable if things do go wrong?
Because there is no need for a general anaesthetic, the abortion pill is still seen as a safer option.
The alternative surgical method involves suction of the foetus from the womb, which can affect future fertility. The abortion pill is also less costly overall for the NHS and private abortion providers.
Although the official costs to NHS trusts of using the abortion pill compared with the suction method show little difference (around £600 for the pill, £680 for the suction method), this does not take into account the likelihood of a woman needing to stay in hospital overnight.
As Dr Kate Guthrie, spokeswoman for the Royal College of Obstetricians and Gynaecologists, says: 'It is safer in that you don't have the risk of anaesthesia and the surgical risks, although these are small. You also don't have the costs setting up and staffing a theatre.'
Although both drugs in the pill are recommended for use in early medical abortion by the Royal College of Obstetricians and Gynaecologists, the second drug, misoprostol, is licensed only for the prevention of gastric ulcers.
This 'off label' use - when a drug is prescribed for a use different from the one it is licensed for - means that when things go wrong, the MHRA may find it harder to trace it back to the drug.
According to the MHRA, there have been only nine serious suspected adverse drug reaction reports where misoprostol and mifepristone have been used for this purpose since 1973.
One recent case was reported in the British Journal of Obstetrics and Gynaecology. A 39-year-old woman, who was terminating her 13-week pregnancy for a severe abnormality using the abortion pill, had to have emergency surgery.
Medics found a 5cm tear caused by the pill because of the strength of the contractions it induced.
Staff at the University Hospital of Wales in Cardiff, where the termination was carried out, say the incident is significant because the woman had none of the known complications which could have led to a womb rupture, such as a Caesarean scar.
However, Ann Furedi, chief executive of BPAS, said: 'No outcome of any pregnancy is risk-free. The authors wrote up this case because it was so unexpected and had never been seen in medical literature.'
Michaela Aston, from the campaigning charity LIFE, says: 'Given there are still big questions over the safety of the mifepristone pill and growing evidence of the trauma suffered by so many women after their abortions, this move trivialises abortion and the huge decision it is for women.'
However, supporters of the pill say such criticisms are motivated by moral considerations alone.
Meanwhile the Department of Health insists that providing the abortion pill in a community setting is about 'increasing choice and improving early access to abortions, as evidence shows earlier abortions carry less risk of complications'.
One can only hope that if women given the pill at GP surgeries experience an incomplete abortion like Manon Jones, their symptoms will be spotted in time to save lives.
Source: Beezy Marsh - DAILY MAIL