PERSPECTIVE ON MEDICINE : 2 Drugs, 1 Abortion--Maybe : A method that allows women to change their mind midway could cause a new generation of ‘thalidomide babies.’
My grandfather used to tease me by asking, “How would you like to buy a bridge?”--meaning, of course, “How do you think you can get something for (practically) nothing?”
When I read recently about the drug combination of methotrexate and misoprostol to induce early abortions, Grandfather’s warnings to a gullible child popped into my mind. Here’s why.
As a physician, I’d been aware that this combination of drugs was being tested as the newest agent in the arsenal of chemical abortion technology. Both drugs are already licensed and in common use, making them far easier to procure than RU-486. But nothing comes cheap, and if society deems that this combination is the easy way out of a night of foolish love, it had better look again.
Methotrexate is an old drug, initially used in cancer chemotherapy and expanded to treat severe cases of psoriasis and rheumatoid arthritis. The class of drugs to which it belongs has a long history as an elective human abortifacient, cited as such in the American Journal of Obstetrics and Gynecology as early as 1952. In addition to side effects ranging from impaired fertility to fatal liver disease, it is also a teratogen. Teratogens are agents that damage a developing fetus. Lederle, the drug company that produces methotrexate, cites two studies that estimate the risk of severe fetal deformities at birth at somewhere between one in 14 and one in 29.
Just what kind of damage does methotrexate cause? The most common kind seems to be malformation of the skull, ears and eyeballs, coupled with a failure of the child to grow normally in the womb. A small dose can cause great damage: One fetus was severely damaged by the amount recommended for a scant three days’ treatment for rheumatoid arthritis. Methotrexate and its chemical sibling aminopterin also are associated with malformed extremities. Remember thalidomide?
Now you may be saying that malformations are moot in a baby slated for termination in the first place. And you would be right--provided that the mother went through with all the steps of termination and expulsion. But the way the drug combination is given leaves itself open to what we in medicine loosely call “noncompliance.” The teratogenic drug methotrexate is given a full week before the second drug, misoprostol, which is necessary to complete the abortion. This leaves a week for the woman to change her mind.
Having been in family medicine for a decade and a half, I can tell you that many women are deeply conflicted about abortion and would waver over their decision. Other women are basically careless, which is why they got pregnant in the first place. And just as with the paradoxical observation that the teen-agers most likely to use birth control are also the ones most likely to defer sex in the first place and therefore have less a need for contraception, so the women most likely to get pregnant are most likely to forget to come back on time for their second dose. Are we to have squads to go out and look for these noncompliant ones? And if they don’t come back, or change their minds about having an abortion in the week they have to collect their wits, will we experience a wave of births of deformed babies? Are you willing to wager your tax money on universal compliance with a double-drug, time-gap abortifacient?
The woman most likely to comply with the time and emotional demands of the methotrexate- misoprostol combination would be a woman aware of her body’s rhythms, who could detect a pregnancy very early in its course. Sophistication and a close relationship with her personal physician and/or abortionist would help. But many women seeking abortions do not meet this profile. With 1.5 million abortions a year, the widespread use of methotrexate-misoprostol by clinics that are less research-oriented and less committed to follow-up than the institutions where the initial studies have been done may leave society quite vulnerable to failed completion of abortion and the births of many damaged children.
I would urge everybody who is committed to choice to take a close look at this new abortion combo. If you believe in the fallibility of human behavior, this combination has inherent problems. For some, the problems will last a lifetime.
