7. TEACHING POINTS: MEDICATION ABORTION

EXERCISE 7.1

  1. I live 4 hours away. Can I still get the abortion pill?
    • Yes. Patients can undergo medication abortion if they live reasonably close to emergency medical care, and they have access to a phone and transportation.
    • Some protocols require a 2nd office visit, and others allow serial hCGs (baseline and follow-up) with telephone contact, and clinic visits with you or patient’s primary care provider as needed.
    • Telemedicine has been shown to be a safe and efficacious means of providing medication abortion in the right patient population, with high rates of patient satisfaction (Grossman 2011).
  2. What are my chances of needing an aspiration abortion?
    • Continuing viable pregnancy rate is ≤1% in most studies up to 63 days EGA, increasing to 3% in 64-70 days EGA. However, uterine aspiration may be needed for multiple reasons, including excessive bleeding/cramping, or by patient request. The total incidence of aspiration after medication abortion is 2-4% of cases up to 63 days EGA, and 6-9% of cases for 64-70 days EGA. (A second dose of misoprostol may be necessary to achieve these rates).
    • With continuing viable pregnancy (true drug failure), a second dose of misoprostol is >30% effective; alternatively, aspiration can be offered.
    • With a persistent gestational sac without evidence of development, a second dose of misoprostol can be offered, or the patient can be followed for several more weeks if stable.
    • In an asymptomatic patient with minimal bleeding or cramping who has echogenic material in the uterus but no ongoing pregnancy seen on ultrasound, no further treatment is necessary.
  3. How will I know if I’m bleeding too much?
    • After misoprostol, bleeding usually starts within 1 to 10 hours (average 4 hours).
    • Bleeding can be heavier than a normal period and accompanied by cramps and/or clots. Bleeding usually slows substantially after passing the pregnancy.
    • If the bleeding soaks more than 2 maxi-pads per hour for greater than 2 hours, that is more than normal; have patient call if they are concerned.
    • Hypovolemia symptoms warrant immediate evaluation (history, orthostatic vital signs, pelvic exam) and urgent uterine aspiration.
    • Hemoglobin or hematocrit can guide the need for iron or blood transfusion.
    • Blood transfusion is rarely needed (<0.2% of cases).
    • There is scant data regarding the optimal treatment for moderate bleeding. The efficacy of commonly used agents (such as a second dose of misoprostol, methylergonovine, or a tapered regimen of high-dose OC’s) is unknown.
  4. Will I see “the baby” when it comes out?
    • Up to 7 weeks EGA, tissue, blood, and clots are normally be visible to the naked eye.
    • At 7-9 weeks EGA, it is unlikely that a patient would inadvertently identify an embryo.
    • At 9-10 weeks EGA, fetus may be identifiable (Winikoff 2012), so counsel the patient accordingly.
    • If the patient is anxious about seeing the pregnancy tissue, they can be shown a drawing or counseled with information like “At X weeks of pregnancy, this is what the sac/embryo/fetus looks like. Would you like more information or do you want to go ahead with the medical abortion?” If they are not comfortable, they may prefer to have an aspiration abortion. .

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EXERCISE 7.2

  1. I took the misoprostol 2 hours ago. Now my temperature is 100.5° F and I feel like I have the flu. Should I be concerned?
    • No. Common side effects of MAB are temperature elevation, and flu-like symptoms. These are usually self-limited, and the body temperature should return to normal within a few hours. Have the patient recheck temperature again in 2-3 hours.
  2. I took the misoprostol 30 hours ago and passed the pregnancy 24 hours ago, but now my temperature is 101.5.
    • Persistent elevated temperature (>100.4° F) for several hours or > 24 hours after misoprostol warrants an office visit to evaluate for infection. Work-up should include:
      • Questions about pelvic pain, bleeding pattern, or odorous discharge
      • Review of systems to rule out other sources of fever
      • Pelvic exam
      • CBC to evaluate for leukocytosis.
    • Significant pelvic or cervical motion tenderness with fever suggests post-abortal endometritis, and appropriate antibiotics should be initiated. If US shows significant intrauterine material, uterine aspiration is also indicated.
    • If additional concerns arise for atypical infection, further evaluation may be warranted. In very rare cases, patients have presented with low-grade fever and nonspecific complaints (abdominal or pelvic pain, nausea, diarrhea, malaise) along with dramatic leukocytosis and hemoconcentration (Fjerstad 2011, Meites 2010) In patients with this presentation, a high index of suspicion is needed. Clostridium-mediated toxic shock syndrome may progress rapidly to fulminant sepsis and death. If atypical infection is suspected, refer for inpatient sepsis management with infection disease consultation.
  3. I used the medication vaginally, but I think one of those pills just fell into the toilet (or vomited if using buccal, sublingual, oral misoprostol). What should I do?
    • If the pills are vomited (or fall out if taken vaginally) less than 30 minutes after misoprostol, the patient may need to return for a second misoprostol dose. The active ingredient will have had adequate time to be absorbed, even if the pill appears undissolved. They may choose to wait a few hours to see if appropriate bleeding begins.
  4. I took mifepristone in clinic yesterday and started to bleed (like a period) this morning. I have not taken the misoprostol yet. What should I do?
    • Mifepristone alone may cause bleeding but is often inadequate for successful abortion; misoprostol significantly increases the efficacy – and therefore the safety of the regimen.
    • Many providers counsel patients to use the dispensed misoprostol regardless of post-mifepristone bleeding to improve chances of success.
    • Advise the patient to take misoprostol now.

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EXERCISE 7.3

  1. A 29 year-old G3P1011 patient requests medication abortion and is 6 weeks by LMP. Examination reveals a barely enlarged uterus, and serum hCG level is 782 IU/L. They take mifepristone 200 mg, followed 24 hours later by an appropriate dose of buccal, vaginal, or sublingual misoprostol. They have moderate bleeding and cramping during the next several hours. When the patient returns on Day 4, examination is essentially unchanged, and serum hCG level is 5530 IU/L.
    • This patient’s rapidly rising hCG level suggests continuing viable pregnancy, despite history of bleeding after misoprostol. Ectopic pregnancy should also be excluded.
    • Consider ultrasound, if available and the patient is able to follow up in the office.
    • Treatment options include aspiration or repeat misoprostol (second dose is about 30% effective).
  2. A 25 year-old G2P1011 patient who received mifepristone 200 mg 7 days ago and took misoprostol 800 mcg 6 days ago, returns to clinic today for a follow-up visit. They report moderate bleeding and cramping a few hours after misoprostol, and have had no complaints since then.  On a follow-up ultrasound, there is a moderate amount of heterogeneous material in the endometrial cavity. 
    1. What management would you suggest for heterogeneous uterine material?
      • If US is performed at the follow-up visit, the sole purpose is to determine if the patient is still pregnant (SFP 2014).
      • Endometrial thickness should not be used to guide management after MAB. The post-abortion uterus will normally contain sonographically hyperechoic tissue that consists of blood, blood clots, and decidua (Reeves 2009, 2008). In the absence of heavy bleeding or cramping, avoid unnecessary intervention for US findings (NAF CPG 2016).
      • Providers can monitor such patients based on symptoms (SFP 2014).
    2. How would you manage this patient differently if they were symptomatic with ongoing moderate vaginal bleeding and/or cramping?
      • An aspiration may be warranted for hemodynamic instability or for patient preference (SFP Clinical Guidelines 2014).
      • Clinicians providing MAB may wish to be trained in uterine evacuation procedures; alternatively, they may establish referral relationships with other providers trained in aspiration. Return to Exercises
  3. A 19 year-old G4P0 patient who received mifepristone 4 days ago and took misoprostol 3 days ago returns today because of very heavy vaginal bleeding. They state they have soaked 5 maxi-pads in the last 3 hours.
    1. What should you assess first?
      • Hemodynamic status (orthostatic vital signs)
      • Exam to assess active bleeding and uterine bogginess
    2. What diagnostic work-up may be of assistance?
      • Hemoglobin/hematocrit
      • Ultrasound (if available)
    3. What management options would you offer this patient?
      • Emergent uterine aspiration is indicated
      • If hemoglobin or hematocrit indicate that there has been substantial blood loss, even if the patient does not seem to be bleeding heavily at the moment, they should have a uterine aspiration.
      • If blood loss is severe (low hemoglobin or hematocrit), consider transfusion
      • Initiate iron supplementation as needed.
    4. What are indications for a uterine aspiration after medication abortion?
      • Bleeding in hemodynamically unstable patient (emergent)
      • Continuing pregnancy: Persistent growth and cardiac activity at follow-up, or persistent increase in hCG. Can offer a second dose of misoprostol prior to aspiration. Of note; in MAB clients < 63 days returning with persistent cardiac activity, a 2nd dose of miso led to complete expulsion in 36%; Reeves 2008)
      • Symptomatic problematic bleeding / cramping unresponsive to medical treatment
      • Patient preference

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