Describe the abortifacient drugs and poisons with their dangers.

General Principles

• An abortifacient is a substance used to procure abortion. The governing fact about the whole group is that none of the traditional agents reliably empties the uterus in a dose the woman survives — they act by general toxicity, causing abortion only as a consequence of severe systemic illness. The woman is therefore poisoned before she aborts
• They are classified by mechanism — ecbolics, which act directly on uterine muscle; irritants of the gut and kidney, which act reflexly by producing violent purgation or renal irritation; and systemic and metallic poisons, which act by general toxicity

Medical Abortion and its Misuse

• Mifepristone with misoprostol is the modern regimen, and is genuinely effective and safe when used correctly: mifepristone, an antiprogestogen, followed after 24 to 48 hours by misoprostol, a prostaglandin analogue
• Its lawful use in India is restricted by the MTP Act and the Drugs and Cosmetics Rules to prescription by a qualified practitioner, at a registered facility, and generally up to 9 weeks
• The dangers of unsupervised use, which is now widespread — ectopic pregnancy is missed, and the woman attributes her pain and bleeding to the drug until the tube ruptures, which is the single most lethal consequence; the gestational age is not assessed, so the drug is taken far beyond the safe limit; incomplete abortion with continued bleeding and sepsis goes untreated; and the woman does not present because she believes she has done something unlawful
• Over-the-counter sale is illegal but common, and the kits are widely available; a woman presenting with bleeding after taking such a kit is a patient requiring assessment for ectopic pregnancy and for retained products, and should be treated without recrimination

Applied Aspects

• Exclude ectopic pregnancy in every woman who presents with pain or bleeding after taking an abortifacient; this is the commonest avoidable death in this group and the history of having taken a pill is precisely what delays the diagnosis
• Ask directly and without judgement about what was taken; a woman who fears prosecution will conceal it, and the answer determines the treatment
• Recognise the poisoning, not just the bleeding — the classical agents cause renal failure, gangrene, haemolysis and hepatic injury, and the pregnancy may be entirely intact
• Preserve the container, tablets or plant material for identification, and take viscera at autopsy; several of these agents are identifiable chemically or botanically
• Suspect Plumbago or Calotropis root in the cervix where there is a chemical ulcer and sepsis; the root may still be in place and should be recovered intact
• Treat and then report; the case is medicolegal and the police must be None of the traditional agents aborts safely; they act by general toxicity, so the effective dose is at or above the lethal one
• Ergot causes gangrene of the extremities at doses approaching those that would empty the uterus, and the peripheries should be examined
• Cantharides produces haemorrhagic nephritis and cystitis, and the renal findings may be the first clue to what was taken
• Recover a plant root intact if it is still in the cervix; botanical identification of Plumbago or Calotropis is possible and is decisive
• Informed, but the woman is a patient and the obligation to treat comes first