Medication termination of early pregnancy

Unwanted pregnancy - what to do? If a surprise takes you by surprise in the early stages, then you can use pills for medical abortion. It is indicated for many women, but first you need to consult a specialist.

This is a safe and effective method of artificial termination of pregnancy that does not require surgical intervention. It is allowed no later than 7 weeks from the moment of successful conception. The fact is that from the 8th week, placental vessels form, which can cause severe bleeding, dangerous to life and health.

Advantages:

• efficiency 99%;
• low risks of ascending infection;
• without injury to the pelvic cavity organs;
• without anesthesia;
• there is no risk of infection with hepatitis, HIV and other blood-borne diseases;
• universality - the procedure is recommended for everyone, including primigravidas;
• the psychotraumatic factor is minimized.

The procedure does not require a long hospital stay. After taking the prescribed medications, the patient is sent home and treatment is prescribed.

Pharmacodynamics and pharmacokinetics

Misoprostol is a synthetic derivative of prostaglandin E1 . It is capable of inducing contraction of the smooth muscles of the myometrium and dilation of the cervix, which facilitates the process of excretion of the contents of the uterine cavity. Due to its weak stimulating effect on the smooth muscles of the gastrointestinal tract, large doses inhibit the secretion of gastric juice , and the tablets act as an antiulcer agent .

Misoprostol as an active substance does not have a significant clinical effect on:

• prolactin;
• gonadotropin levels ;
• thyroid-stimulating hormones;
• growth hormones;
• thyroxine;
• cortisol;
• creatinine;
• platelet aggregation.

Pharmacokinetics

Oral administration leads to rapid absorption (max concentration - 6.08±1.64 mg/ml). When taken with meals, especially fatty ones, the bioavailability of the drug decreases without affecting the duration of absorption. In the walls of the gastrointestinal tract and liver, conversion occurs to the active diesterified metabolite - misoprostolic acid , the maximum concentration of which is reached after half an hour and is 499 mg/ml. The half-life is no more than 30 minutes; the substance does not accumulate in body tissues and is excreted primarily by the kidneys.

What is the difference between prostaglandins and antiprogestins?

Antiprogestins reduce the sensitivity of special receptor cells located on the surface of the uterus. The task of these cells is to take in the pregnancy hormone progesterone. After taking antiprogestins, the fetus dies, remaining in the uterus.

Prostaglandins act on smooth muscle receptors, stimulating the contractility of the myometrium (the muscular layer of the uterus), and thereby causing contractions. Under the influence of the medicine, the fertilized egg is rejected and comes out along with the endometrium (the inner layer of the uterus, which is renewed every monthly cycle).

At short stages of pregnancy, a medical abortion, carried out according to all the rules in compliance with the dosages of both drugs, proceeds like menstruation, but the discharge will be thicker and will contain blood clots.

Indications for use

• erosions , as well as erosive and ulcerative lesions of the gastrointestinal tract due to therapy with other drugs and prevention of their ulcerogenic effects (for example, prevention and treatment of NSAID gastropathy );
• peptic ulcer of the duodenum and stomach , including exacerbations;
• for early pregnancy of amenorrhea ).

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Contraindications

• hypersensitivity to the drug, as well as to other prostaglandins and analogues;
• liver dysfunction;
• cardiovascular or endocrine diseases;
• diabetes;
• severe form of renal failure ;
• contraindications for the use of prostaglandins – bronchial asthma , glaucoma , arterial hypertension ;
• reception of VPZ ;
• inflammatory processes in the intestines , including enteritis ;
• pregnancy , suspected ectopic pregnancy , lactation (breastfeeding);
• age group up to eighteen years.

When is the procedure contraindicated?

Pharmaboration cannot be carried out in the following cases:

• allergy to components;
• intrauterine insemination;
• impaired hemostasis;
• severe anemia;
• renal, hepatic and adrenal insufficiency;
• treatment with corticosteroids;
• serious inflammatory processes of the genital organs;
• lactation period;
• pathologies of the heart and blood vessels.

Misoprostol should never be taken without mifepriston. Some also make the big mistake of taking only one drug to speed up the abortifacient effect, which can lead to serious health consequences. Moreover, it only works in 30% of cases.

Side effects

In relation to various organs and systems, Misoprostol can cause the following adverse reactions:

• Gastrointestinal organs: abdominal pain , dyspepsia , flatulence , nausea , vomiting , diarrhea or constipation .
• Genitourinary system: various disorders of the menstrual cycle, postmenopausal bleeding from the vagina, hypermenorrhea , dysmenorrhea , heavy uterine bleeding , pain in the lower abdomen , most often caused by contractions of the myometrium. In the pre- and postmenopausal period - convulsions .
• Cardiovascular system: hypo- or hypertension .
• Skin: rash , itching .
• Allergic reactions and angioedema .
• Other reactions: dizziness , headaches , asthenia , changes in body weight, hyperthermia and/or chills .

Procedure for taking medications for Medical abortion

The procedure for taking medications consists of two stages .

• The first stage - taking Mifepristone
• Stage two – taking Misoprostol

First stage. Taking Mifepristone

Before the procedure, it is necessary to do an ultrasound of the pelvic organs to determine the duration of pregnancy and the location of the fertilized egg (to exclude ectopic pregnancy).

To begin the medical abortion procedure, the patient must take 200 mg of Mifepristone orally with water (at least 150 ml).

Most often, after taking the first drug (Mifepristone), a woman subjectively does not feel anything . THIS IS THE NORM! The main effect begins in the second stage - after taking Misoprostol.

And only in some cases may minor bleeding and aching pain in the lower abdomen begin. This is also normal, but much rarer.

Action of Mifepristone

Mifepristone is a progesterone blocker (this is the main hormone that maintains pregnancy). The main effect of the drug during medical abortion is to stop the development of pregnancy. Mifepristone also significantly increases the sensitivity of uterine cells to prostaglandins (in particular, Misoprostol).

Second phase. Taking Misoprostol

36-48 hours after taking Mifepristone, you must take the second drug from the complex - Misoprostol (Cytotec) in the following dose: 2 tablets of 200 mcg.

There are three ways to take Misoprostol:

• place under the tongue (sublingual);
• vaginally (deep into the posterior vaginal fornix) and
• buccally (place the tablet in the space between the cheek and gum) Source.

The strength of the effect is the same for all methods, but we strongly recommend dissolving one tablet under the tongue first, and then a second one after 40-60 minutes. At the same time, the likelihood of vomiting is significantly reduced, and the duration of the effect increases.

Action of Misoprostol (Cytotec)

Misoprostol against the background of the action of Mifepristone stimulates the contractile activity of the uterus, which leads to cramping pain in the lower abdomen, as well as the appearance (much more often) or intensification (if it appeared at the first stage) of bloody discharge. Against the background of these processes, the fertilized egg is separated from the walls of the uterus and released through the genital tract.

Instructions for Misoprostol (Method and dosage)

Misoprostol for abortion in combination with Mifepristone is taken according to the following scheme:

• 3 tablets (600 mg) of Mifepristone - orally on an empty stomach or two hours after a meal.
• After 36–48 hours - 2 tablets on an empty stomach. (400 mcg) Misoprostol.

Attention! If after taking there is no bleeding for 2 days, then taking the pills on your own is prohibited. To prescribe an additional dosage, you should consult a doctor - visit an obstetrician for 2-3 days.

Instructions for the use of Misoprostol as an antiulcer drug involve taking the tablets orally with meals. Dosage: 200 mcg 3-4 times a day, a single dose in the range of 200-400 micrograms, if the patient has hypersensitivity or renal failure - the dose is 100 micrograms. How to take it and for how long should be calculated depending on the indications and the observed clinical picture of treatment.

Medication termination of early pregnancy

One of the most important problems of modern healthcare is the preservation of women's reproductive health. Such close attention to this problem is connected, first of all, with the demographic situation in Russia. The measures taken, unfortunately, do not increase the birth rate in our country to the required level. The main way to solve the problem of preserving the reproductive function of women is to reduce the number of medical and criminal abortions and prevent unwanted pregnancies.

In the Russian Federation, abortion continues to be a common method of birth control and family planning (V.I. Kulakov, 1993). According to medical statistics, every year about 15-20 thousand women terminate their pregnancies. Until the last decade, surgical methods of abortion were used, such as vacuum curettage, vacuum aspiration (“mini-abortion”) and traditional curettage.

Vacuum curettage is the most common method of artificial abortion in many countries of the world, including Russia. The advantages of this procedure are the simplicity and short duration of the procedure for complete evacuation of the contents of the uterine cavity through a slight dilatation of the cervix. The operation is easily performed under local anesthesia on an outpatient basis.

When using this method of abortion, allergic reactions to the medications used, perforation or atony of the uterus, convulsions or cardiac arrest, etc. are possible.

Artificial termination of pregnancy using vacuum aspiration for the purpose of birth control has become widespread in many countries of the world. The widespread use of this method is due to the fact that the operation can be performed on an outpatient basis using relatively simple medical equipment, subject to the rules of asepsis and antisepsis, without the use of local anesthesia. After the operation, patients return to normal activities within 1 hour. Despite the advantages of this method, diagnosing the initial stages of pregnancy and excluding ectopic pregnancy pose some difficulties.

Traditional curettage is an artificial abortion operation, which is currently used less and less. Medical abortion often leads to serious complications in the early postoperative period (bleeding, infection, remnants of the fertilized egg, etc.). At a later date, inflammatory diseases of the female genital organs, miscarriage, infertility, and ectopic pregnancy develop. The complicated course of subsequent pregnancy, childbirth and the postpartum period (V.I. Kulakov et al., 1991; T.N. Melnik et al., 2001) adversely affects the condition of the fetus and newborn (T.S. Cherednichenko, 2001).

Among the modern gentle methods of terminating an unplanned pregnancy, we can mention the medication method. Its development began back in the 70s. XX century. During this period, a program to create steroids with antihormonal effects was implemented in France. In 1980, mifepristone was introduced, which is a synthetic steroid drug for oral use and is an antagonist of progesterone and glucocorticoids.

The medical method of terminating an unplanned pregnancy using the drug mifepristone (Mifegin, Pencrofton) has been used abroad since 1980, and in Russia since 1998 (E. N. Karaeva et al., 1999).

Mifepristone (mifegin, pencrofton, mifeprex) is a synthetic steroidal antiprogestogenic agent (blocks the action of progesterone at the receptor level). The mechanism of action of the drug is based on interaction with the hormone-binding domain of the target cell receptor, which causes an “ineffective” conformation and blockade of the effects of the natural steroid.

Mifepristone increases the contractility of the myometrium, stimulating the release of interleukin-8 in choriodecidual cells, increasing the sensitivity of the myometrium to prostaglandins (to enhance the effect, it is used in combination with synthetic analogues of prostaglandins (E. N. Karaeva et al., 1999)). As a result of the action of the drug, desquamation of the decidua and the removal of the fertilized egg occur.

After a single oral dose of 600 mg of mifepristone, the maximum concentration is reached after 1.5 hours. The absolute bioavailability of the drug is 69%. In blood plasma, mifepristone is 98% bound to proteins: albumin and acidic alpha-1-glycoprotein. After the distribution phase, elimination is slow at first, the concentration decreases by half between 12-72 hours, then the elimination process accelerates. The half-life is 18 hours.

During a pathomorphological study of the material from miscarriages (T. N. Melnik et al., 2001) after the use of mifepristone, they found that the line of rejection of the developing placenta passed along the terminal ends of the anchor villi and residual fragments of the basal membrane, consisting of layers of cytotrophoblast and decidual cells. In the cavity of the embryonic sac, preserved fragments of the embryo, amniotic membrane and yolk sac were found. There was a complete correspondence of the structure of the villi, as well as the wall of the embryonic sac, which was explained by the short period from the moment of taking the drug to the rejection of the embryonic sac. The immediate mechanism of rejection was the formation of a hematoma in the thickness of the basal lamina with its transition to the nearby intervillous space. The local nature of hemorrhagic disorders (at the border of the endo- and myometrium), their acute occurrence and the short duration of the process did not create prerequisites for the release of thromboplastic masses and, consequently, for changes in hemostasiological parameters of the blood, which was confirmed by a study of the blood coagulation system.

The current indication for the use of mifepristone (mifegin, pencrofton) is termination of intrauterine pregnancy in the early stages (42 days of amenorrhea). However, there are studies (R. A. Hatcher, 1993; R. A. Manusharova, E. I. Cherkezova, 2002), during which these drugs were used before 9 weeks of pregnancy. In addition, literature data indicate the effectiveness of using mifepristone for the preparation and induction of labor during full-term pregnancy. Currently, mifepristone is used in France, the USA, Sweden, China, Russia, Great Britain, India and other countries.

Contraindications to the use of the drug are: a history of hypersensitivity to mifepristone, adrenal insufficiency and long-term glucocorticosteroid therapy, acute or chronic renal and/or liver failure, porphyria, uterine fibroids, presence of a uterine scar, anemia, hemostasis disorders (including as a result of previous treatment with anticoagulants), inflammatory diseases of the female genital organs, the presence of severe extragenital pathology. Mifepristone should not be used in women over 35 years of age who smoke without first consulting a physician. In addition, contraindications to the use of the drug for the purpose of abortion are suspected ectopic pregnancy; pregnancy not confirmed by clinical studies; exceeding 42 days after the cessation of menstruation; occurring during the use of intrauterine contraception or after discontinuation of hormonal contraception.

The drug should be prescribed with caution for chronic obstructive pulmonary diseases (including bronchial asthma), severe arterial hypertension, cardiac arrhythmias and heart failure. Patients with prosthetic heart valves or infective endocarditis should be treated with prophylactic antibiotics while receiving mifepristone.

Breastfeeding should be stopped for 14 days after taking mifepristone. The use of this drug requires all preparatory measures related to abortion.

Among the side effects associated with the termination procedure, it should be noted: bloody discharge from the genital tract, pain in the lower abdomen, exacerbation of inflammatory processes of the uterus and appendages.

Side effects associated with taking mifepristone are a feeling of discomfort in the lower abdomen, weakness, headache, nausea and vomiting, dizziness, hyperthermia. Taking mifepristone in a dose of up to 2 g does not cause adverse reactions. In cases of drug overdose, adrenal insufficiency may occur.

When performing a medical abortion using the drug mifepristone, you should avoid prescribing non-steroidal anti-inflammatory drugs, as they weaken its effectiveness. If on the 10th–14th day there is no effect from the use of the drug, the pregnancy must be terminated in another way, since the formation of congenital malformations in the fetus is possible.

Studies conducted back in the 80s showed that the effectiveness of the isolated use of mifepristone is 85%. Therefore, it was subsequently proposed to combine mifepristone with prostaglandins. According to the literature, the effectiveness of this combination reaches 96-98% (R. A. Manusharova, E. I. Cherkezova, 2002). It has also been shown that the effectiveness of the combined use of mifepristone (at a dose of 400 mg) and Cytotec (800 mcg) is 96%.

We observed 200 women aged from 18 to 41 years (36.7+2.3 years). For 37 of them, it was their first pregnancy; 28 had terminated their second pregnancy (the first ended in an induced abortion), the rest had a history of childbirth (37) or childbirth and abortion (98). According to gynecological examination and ultrasound, the average gestational age was 5.2±0.2 weeks with an average diameter of the ovum of 10.5+0.5 mm.

Gynecological diseases were present in 42.1% of patients (asymptomatic small uterine fibroids - 4.1%; cervical erosion - 20.9%; chronic adnexitis - 15%; paraovarian cyst - 4%; ovarian dysfunction - 5%; genital endometriosis - 3.1%).

Mifegin was prescribed once in the form of tablets at a dose of 600 mg (3 tablets of 200 mg each), and after 36-48 hours the patients took a prostaglandin - misoprostol (Cytotec) at a dose of 400 mcg (2 tablets of 200 mcg each) and after 3 hours - another 400 mcg (2 tablets). The drugs were taken in the presence of a doctor after obtaining the patient's consent. Observation was carried out for 2-3 hours, after which women could leave the medical facility after receiving the necessary recommendations. The ability to work was completely preserved.

The effectiveness of the method was assessed on the basis of a positive outcome, confirmed by data from an objective examination, bimanual examination, and ultrasound (absence of the fertilized egg, as well as its elements in the uterine cavity on the 10-14th day).

Expulsion of the ovum in 180 out of 200 women occurred after the combined use of Mifegin and Cytotec, in 11 patients - without additional use of Cytotec. In 9 patients with a gestational age of 8.5-9 weeks. 12-24 hours after taking mifegin, bleeding from the genital tract was observed, for which they were hospitalized and the uterine mucosa was curetted. Expulsion of the gestational sac occurred on the first day after taking Cytotec in 95.3% of women, and on the second day in 4.7% of women. Clinically, this was manifested by bloody discharge from the genital tract (scanty or moderate intensity) on the first day after taking mifegin - in 38% of women; 62% of patients did not experience any bleeding from the genital tract on the first day after taking mifegin. 40–55 minutes after taking Cytotec, bleeding from the genital tract intensified in the vast majority of women and in 60% of cases was accompanied by cramping pain in the lower abdomen and expulsion of the ovum.

The duration of bleeding was in most cases from 7 to 14 days. In 4 patients, scanty bleeding was observed for up to 15-17 days. Bleeding that required conservative therapy for 1-2 days (dicinone, ascorutin, vikasol) was observed in 3 patients. Surgical intervention for the purpose of hemostasis was not required in any observation. It should be noted that severe cramping pain in the lower abdomen was observed in nulliparous women, and in women who gave birth they were weakly expressed or absent. Cramping pain in the lower abdomen was relieved by oral administration or parenteral administration of antispasmodic (no-spa) or analgesic (analgin, baralgin) agents.

We were unable to achieve a positive result after taking Mifegin in 3 cases. According to ultrasound data, the presence of remnants of the fertilized egg in the uterine cavity was recorded, for which the patients underwent diagnostic curettage. It should be noted that these women had a history of endometritis. Apparently, the lack of sufficient effect in these cases is due to impaired contractility of the uterus.

Mifegin was well tolerated. When taking Cytotec, 8 women experienced side effects (in the form of nausea, vomiting, dizziness, headache), which lasted for 30-45 minutes from the start of taking the drug and went away on their own.

Control ultrasounds performed on days 10-14 after expulsion of the ovum showed normal endometrial condition in 187 women. In 3 patients, expansion of the M-ECHO was noted in the presence of hypoechoic content. In one observation, heterogeneity of M-ECHO and echo-negative inclusions were revealed. These women were additionally prescribed duphaston at a dose of 10 mg 2 times a day for 10 days and an additional ultrasound was performed after the next menstruation. In all cases, the normal state of M-ECHO was established during control ultrasound.

Thus, the results of the study indicate that the combined use of the drugs Mifegin (mifepristone) and Cytotec is a highly effective means for terminating an unwanted pregnancy. If all necessary requirements are strictly observed, this method is well tolerated by women, has no significant side effects and can be used to terminate pregnancy at short notice (up to 7 weeks). The use of mifegin does not cause disruption of the menstrual cycle, the likelihood of affecting reproductive function is almost zero.

Medical termination of pregnancy almost completely eliminates the risk of ascending infection and associated complications. In addition, with this method of abortion, there is no psychogenic trauma, which most often accompanies traditional artificial abortion, which improves the woman’s quality of life.

For questions regarding literature, please contact the editor.

R. A. Manusharova , Doctor of Medical Sciences, Professor E. I. Cherkezova RMAPO, Andrology Clinic, Moscow

During pregnancy and lactation

Based on the type of effect on the fetus, the drug is classified in category (according to the FDA) - X.

Misoprostolic acid can pass into breast milk. Despite the fact that there is no information on the development of any adverse reactions in children, it is recommended to use Misoprostol during lactation with caution.

If the drug is used as:

• Gastroprotective agent: pregnancy or planning it is unacceptable, since increased uterine tone can cause miscarriage . The drug can be prescribed only after pregnancy test Taking Misoprostol is usually started 2-3 days after the start of the menstrual cycle ; a prerequisite is the use of reliable methods of contraception , for example, barrier ones.
• Uterotonic: use for the purpose of termination of pregnancy, otherwise the drug is contraindicated in case of planned pregnancy.

What do you need to know?

Medical abortion can only be prescribed by a doctor. Before this you need to go through:

• taking urine, blood, glucose, ECG tests;
• Ultrasound, which will exclude ectopic development;
• bimanual examination with collection of vaginal smears.

The doctor also measures blood pressure, checks pulse rate and breathing.

The method is suitable for frozen pregnancies of the gestational age allowed in the protocol. If problems with blood clotting are detected, then they undergo a coagulogram.

Reviews of Misoprostol

Reviews about Misoprostol can be found absolutely varied. Many note the drug as an effective means for terminating pregnancy, although they complain about side effects and negative consequences after use.

Pencrofton and Misoprostol are used in combination for medical abortion , but it must be supervised by medical staff and supervised by a doctor. In addition, medical specialists usually prescribe Misoprostol for the treatment of erosive and ulcerative lesions of the gastrointestinal tract and to prevent the ulcerogenic effects of other drugs.

Conclusion

The drug Misoprostol is used for medical abortions only in combination with Mifepristone and its analogues strictly under medical supervision. Self-administration can lead to dangerous bleeding, incomplete abortion (retention of parts of the fertilized egg in the uterus) and overdose.

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Abortion and contraception clinic in St. Petersburg - department of the medical gynecological association "Diana"

Make an appointment, tests or ultrasound via the contact form or by calling +8 (812) 62-962-77. We work seven days a week from 09:00 to 21:00.

We are located in the Krasnogvardeisky district, next to the Novocherkasskaya, Ploshchad Alexander Nevsky and Ladozhskaya metro stations.

The cost of a medical abortion in our clinic is 3,300 rubles. The price includes all pills, an examination by a gynecologist and an ultrasound to determine the timing of pregnancy.

Mifepristone

The drug, which belongs to the group of sex hormones, antiprogestogens, is produced in tablets, each of which contains 200 mg of the active ingredient mifepristone.

Characteristics of the drug

After a single dose of the drug, the maximum concentration in the blood is reached after an hour and a half. After distribution, it is excreted very slowly over 12-72 hours. Excreted through the kidneys.

Mifepristone is a synthetic drug that blocks progesterone. Its action increases contraction of the uterus, resulting in fetal rejection.

Application

The drug is prescribed for abortion up to 49 days from the date of absence of menstruation. When terminating the pregnancy of a frozen fetus, as well as to stimulate a normal pregnancy if the period of contractions is prolonged.

Dosage

Admission is carried out exclusively as prescribed by the attending physician. To terminate a pregnancy, take a single dose of 200 mg of Mifepristone. There are no sensations after taking Mifepristone. The drug should be taken with 1 tablet with a glass of water. The effective dose of the drug is 200 mg; there is no need to take more. After about 24-36 hours, you must take Misoprostol according to the schedule and after 2 weeks you must undergo an ultrasound diagnosis. If there are leftovers, you can take another dose of Misoprostol. If there are no unpleasant symptoms, you need to wait for the next cycle.

Side effects

Taking the drug can cause uterine bleeding, pain in the lower abdomen, and increased body temperature. Sometimes complaints of nausea, dizziness or headache, stomach upset and skin reactions.

Very rarely, but there have been cases in women when the following effects were reported after termination of pregnancy:

• infectious and inflammatory diseases of the genital organs;
• specific redness of the skin caused by a large flow of blood to the capillaries;
• toxic shock.

Interaction with other drugs

The simultaneous combination of Mifepristone with non-steroidal anti-inflammatory drugs is unacceptable, as they sharply reduce the effect of the drug.

Features of the product

The patient must be familiar with the conditions of the procedure itself and with possible complications in the future. The medicine is used only under the supervision of a doctor. In most cases, fetal rejection occurs approximately 4-8 hours after ingestion. In very rare situations this happens within seven days.

Contraindications

Mifepristone is prescribed with great caution for:

• hypertension, unstable blood pressure;
• bronchial asthma;
• oncological diseases;
• endocrine pathologies;
• disorders of the heart and blood vessels;
• chronic liver and kidney diseases.

Cases of drug overdose

If prescribed correctly by a doctor, such cases do not occur. However, if symptoms such as intoxication, drowsiness, vomiting or renal colic appear, it is necessary to immediately take treatment measures - gastric lavage using activated charcoal and a saline laxative.

Preservation and shelf life

The drug should be stored in a dry place inaccessible to children for no more than 5 years. It is prohibited to use the medicine after the expiration date.

Of course, medical abortion is much safer for women than surgical intervention, but do not forget about possible unwanted side effects and consequences for the female body.

We also remind you to follow the rules for the safe use of Mifepristone and Misoprostol. Be sure to contact a specialized clinic for medical advice. Do not self-medicate on your own; consult your doctor. You should not take Mifepristone and Misoprostol without medical supervision.

To preserve your health and life, do not purchase any medicines in damaged or questionable packaging, so as not to stumble upon an expensive counterfeit. Original drugs Mifepristone and Misoprostol can only be purchased in pharmacies or on the premises of a medical institution.