Detailed information for executing a safe and effective medical abortion in Pakistan, in the comfort of your home.
Introduction
Credit: Mural in Zone 5, Guatemala, April 2018. By UN Women/Ryan Brown
Abortion is legal in Pakistan only in very specific cases: to save a woman's life due to pregnancy complications, or to provide "necessary treatment" (this vague term is up to interpretation, and almost never even considered).[1]
As a consequence of this suppression of basic women's right, millions of women each year go through unguided abortion attempts, many of which end up with serious health complications due to lack of proper guidance, information, and availability of the correct medicines.[2]
We are here to provide the necessary information in context of Pakistan, and even the required drugs to execute a safe medical abortion of pregnancies up to 12 weeks.
Before proceeding, the first thing you should do is be absolutely sure that you are pregnant.
Do not make any guesses based on the symptoms, or if you miss your periods.
You have 2 options:
The best way would be to get a "Beta hCG levels" blood test done.
This test is also known as: Quantitative Serum beta-HCG, hCG serum test, or HCG Blood test.
You can get this test done from any laboratory. Charges vary from Rs. 500 - Rs. 1500.
Reports are usually available within 24 hours
You do not need a prescription or a doctor's note to get this test.
Make sure that the laboratory gives the result as a range of values, not just a "positive" or "negative"
Use urine pregnancy test strips.
These are available at almost every pharmacy.
Price ranges from Rs. 20 - Rs. 100 per strip
The higher priced strips are not better, even the digital ones. They all contain the same strip inside. Just get the cheapest ones.
Get many strips, as they are not very reliable.
Also get clean disposable cups to test in.
For reliable results, try to use it on the first urine of the day.
There should be instructions on the back of the pack to read the result.
If you get an invalid result (blurry or half line), try again.
If you had unprotected intercourse recently (less than 3 weeks), it may be too early to detect the pregnancy. Keep testing every other day with the pregnancy test strips.
The blood test is much more reliable for early pregnancies.
How to prepare for a medical abortion at home?
Make sure you can be at a safe space for at least 24 hours.
Take a few days off from work, studies, etc.
Also make sure you will have someone with you during this period to take care of you and to assist you.
Read this to make sure you don't have an ectopic pregnancy.
This procedure does not work on ectopic pregnancies. If you are sure your pregnancy is ectopic, seek medical attention.
Only proceed if you have:
confirmed the pregnancy via multiple home-based pregnancy tests, or blood test.
made sure you can stay at safe space for 24+ hours.
made sure your pregnancy is not ectopic.
researched on the closest hospital, in case of a complication.
Complications are rare, but you should be prepared for the possibility
Read more about this below
arranged the required medicines.
read this guide completely, and thoroughly.
Which medicines are required for medical abortion in Pakistan?
2 primary drugs are required for the procedure:
12 tablets of Misoprostol 200mcg:
More commonly known as Pfizer Cytotec.
Locally available as Breeky, ST Mom, Arthrotect, etc.
These variants should NOT be used for medical abortion.
For some reason, we have seen inequitable failures when using ST Mom & Breeky. It's better to not take the risk and just not use them.
Some of these have an enteric coating which prevents it from being slowly absorbed, which is mandatory for this procedure.
Some of these also have a core of Diclofenac Sodium, which is also an issue.
Non-coated Misoprostol is not available in local pharmacies in Pakistan.
Only imported Pfizer Cytotec should be used for medical abortion.
12 tablets of Letrozole 2.5mg OR 2 tablets of Mifepristone:
Mifepristone is also known as RU-486, Mifeprex, etc.
Mifepristone is not available in Pakistan, and is currently impossible to source. Which is why we will be focusing on Letrozole for the rest of this guide.
Letrozole suppresses estrogen production.
Letrozole comes under the brands Aromek, Femara, Leena, Letara, Lezra, Losiral, etc.
Letrozole might also be hard to find in pharmacies in Pakistan.
Highest quality Letrozole would be imported Novartis' Femara - try to get this.
Both of these medicines can be hard to arrange. Which is why we have partnered with one of Pakistan's oldest importers to have both of these drugs readily available, for easy delivery across Pakistan.
How to get Cytotec & Femara for abortion in Pakistan?
Both of these medicines are not easily available in pharmacies in Pakistan.
You can contact your local pharmacy and request them to make it available, however that may be difficult because you can't really trust the pharmacies and they would know for what purpose these medicines are used.
Which is why we have requested PinkPk to import these drugs, and use their existing private delivery network to deliver them.
How to use Cytotec & Femara for a medical abortion?
The whole process will take 4 days to complete.
Days 1-3: Letrozole/Femara
Properly using Letrozole before Misoprostol increases the rate of success by over 55%![3]
You need to take 10mg (4 tablets of 2.5mg each) for 3 days before using Misoprostol.
Day 1: Take 2 tablets of Femara 2.5mg in the morning, and 2 tablets of Femara 2.5mg in the evening.
Day 2: Same as Day 1.
Day 3: Same as Day 1.
Day 4: Cytotec
On this final day of the procedure, the bleeding should happen and you need to be absolutely free for 24+ hours.
We are going to use 1PM as the starting time for this example. You can take the first dose whenever convenient for you.
1:00PM: Put 4 tablets of Cytotec 200mcg under the tongue.
1:30PM: If anything remains of the tablets, spit them out.
4:00PM: Again put 4 tablets of Cytotec 200mcg under the tongue.
4:30PM: If anything remains of the tablets, spit them out.
7:00PM: Again put 4 tablets of Cytotec 200mcg under the tongue.
7:30PM: If anything remains of the tablets, spit them out.
Fig.1 - How to put Cytotec under the tongue
Keep moving the tablets around to help them slowly mix with the saliva.
You can eat/drink between dosages, when you don't have the tablets under the tongue.
Avoid heavy meals. We recommend high-energy, easy to digest foods, such as fruits, smoothies, nuts, bread, etc.
If the bleeding starts after the 1st or 2nd dosage, do not skip the rest of the dosages! Try to finish the tablets as instructed.
What to expect
Bleeding should start within 2-12 hours of the first dosage.
You may experience the following symptoms, as soon as right after the first dosage:
Nausea and/or diarrhea. You may have the urge to throw up. Try to resist, but do it if you can't. It's okay.
Pain & cramps.
You can take Ibuprofen (Brufen) for these.
Do not take any other painkillers.
If taking Ibuprofen, do not exceed total 3200mg (8 tablets of 400mg) in 24 hours
Chills. This the body's normal response to Cytotec.
These symptoms are related the the length of the pregnancy; the longer the pregnancy, more intense these symptoms will be.
If you don't experience any of these symptoms within 24 hours, confirm the following:
You are using authentic, properly imported, Pfizer Cytotec & Novartis Letrozole.
You took the tablets exactly as instructed.
Your pregnancy is not ectopic. This procedure is not effective on ectopic pregnancies.
This procedure is up to 95% effective. You can try again after 3 days, if you are sure you took the medicines properly, and if the medicines you are using are authentic.
Confirming whether the medical abortion was successful.
So you have taken all the medicines according to the instructions, great!
Now you need to confirm whether the procedure was successful or not.
Some notes:
Bleeding is not a necessary indicator of success. In some cases, there is bleeding but the abortion was not completed.
An incomplete abortion can lead to serious health risks for the mother, and can lead to serious birth defects.
Urine test strips will show false positives for up to 5 weeks, even if the procedure was successful.
Follow these steps to confirm that the medical abortion completed:
Get the "Beta hCG levels" blood test done as soon as possible after using the tablets.
Wait at least 4 days.
Get the same "Beta hCG levels" blood test done again.
You should try to get confirmation as soon as possible so that in case you have to reattempt, it's not delayed too much.
If the body is processing the miscarriage, the Beta hCG values should start to drop. This is why you need to get it done twice, to see if the levels are falling or rising.
If the numbers fall a few days apart, that means the body is processing the miscarriage. If the numbers are rising, that means the body resisted the miscarriage and you will have to reattempt.
Fig.2 - An example of Beta hCG test results of a successful medical abortion
How to reattempt in case of a failed medical abortion.
If the values are rising, you can attempt the medical abortion again right away.
You don't need to use Letrozole again, when reattempting. Just skip "Days 1-3" described above, and take 12 tablets of Cytotec again as described above on "Day 4".
What to do in case of complications while attempting a medical abortion in Pakistan?
Complications are extremely rare if you have followed the above instructions, while using the correct medicines.
But they are still a possibility, and you should be prepared for them.
Signs of a complication, which would require medical intervention:
Heavy bleeding, without the feeling of pressure.
Though bleeding is a normal outcome, heavy bleeding can be dangerous.
This bleeding would feel like the tap is open, you would be easily able to tell it apart from regular bleeding.
Normal bleeding should not fill up more than 2 sanitary pads, for more then 2 consecutive hours.
Very high fever: exceeding 39°C.
Prolonged fever: less than 39°C, but lasting for more than 24 hours.
Constant very high pain, lasting for more than 3 days after using the tablets.
If you have any of these symptoms, go to a hospital!
The symptoms & treatment of a medical abortion complication and a miscarriage are the same.
The medical staff at almost all hospitals is experienced with dealing with miscarriages, and would be able to administer the appropriate treatment.
You don't have to tell the staff or the doctor about the medical abortion. Just say you suspect you might be having a miscarriage.
The tablets can not be detected in the blood.
Steps to take after a successful medical abortion.
After you have confirmation of the success of the medical abortion, and you have recovered, you should schedule an appointment with a OB/GYN or obstetrician or gynecologist.
Again, you only need to mention that you have had a miscarriage.
The doctor might prescribe a blood test, and/or do an ultrasound to confirm whether the uterus is empty.
In case the uterus is not empty, a dilatation and curettage (D&C) might be required.
The doctor may prescribe supplements or other medicines, even if the uterus is empty and everything is fine.
Frequently Asked Questions.
General
Can I get pregnant again after doing a medical abortion?
Yes. Generally, a medical abortion has no affect on your future possibilities of conceiving, as long as it's done properly.[4]
Dosage
My pregnancy is only at 4 weeks. Can I just take 4/6/8 tablets of Cytotec?
No. Even if your pregnancy is of 2 weeks, DO NOT change the dosages. Take all the dosages as instructed, for all pregnancies up to 12 weeks.
We repeat: DO NOT change or modify the dosages on your own.
Reducing the dosages will not make the procedure more comfortable or avoid the side effects. It will only fail, cause complications, and waste your time.
My doctor said only 4 tablets are required if I take them vaginally?
You will hear differing opinions and dosages from each doctor. There are hundreds of ways of using these tablets for a medical abortion.
The instructions we have described above are the most safe and have the highest chance of success, empirically tested. You can go through the references at the bottom to see the comparison of different methods of usage.
Do not risk your health and valuable time, while trying to save a few thousand rupees.
Meta
Who made this website? Why?
Why, because the country is in dire need of a safe medical abortion guide, as explained in the introduction.
All the research & interviews were done by students & faculty of a leading medical university in Pakistan. Identifiable information can not be mentioned because of obvious reasons.
All of the work was done gratis and some by volunteers. The website is hosted for free, and should be online for a long time.
No sponsorship or aid was provided for this project.
How can I be of help?
The most helpful thing you can do is spread this website as much as you can. Post on your social media, forums, other local communities.
If you know someone who needs this procedure done and can't afford it, consider paying for their medicines.
References
United Nations Population Division, Abortion Policies: A Global Review, New York: United Nations, 2002.
Population Council, Unwanted Pregnancy and Post-Abortion Complications in Pakistan: Findings From a National Study, Islamabad, Pakistan: Population Council, 2004.
American College of Obstetricians and Gynecologists. Practice Bulletin No. 143: Medical management of first-trimester abortion. Obstetrics & Gynecology, 2014.
