CHAPTER 4 TEACHING POINTS: MEDICATION ABORTION

The following exercises refer to mifepristone and misoprostol regimens unless stated otherwise.

EXERCISE 4.1

On the day of mifepristone:

  1. What history do you need before administering mifepristone?
    • LMP, history indicating pregnancy is ≤ 77 days (11 weeks)
    • No contraindications to medication abortion
      • Allergy to a medication (eg mifepristone or misoprostol)
      • Known or suspected ectopic or molar pregnancy
      • Hemorrhagic disorders or concurrent anticoagulant therapy or symptomatic anemia
      • Chronic adrenal failure or long-term use of systemic corticosteroid therapy – mifepristone blocks steroid effect at receptor and may worsen disease. Too unpredictable to recommend MAB with increasing steroid dose to compensate.
      • Inherited porphyria (rare heme metabolism disorder) – mifepristone worsened the condition in animal studies. Data is lacking in humans.
      • IUD in the uterus (must be removed prior to administration of the medications)
    • No severe or unstable chronic condition that increases risk of outpatient procedure
    • Certain of desire to have abortion and willing and able to follow up as planned
    • Of note, the following are not contra-indications: asthma on steroid inhalers, obesity, breastfeeding, HIV / AIDs, multiple gestations, or STIs.

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  1. What physical exam and testing do you need before administering mifepristone?
    • No labs or ultrasound required, unless:
      • Rh: if 56 days LMP and Rh unknown (can be ascertained by donor card, chart, patient report, or lab).
      • Hemoglobin or hematocrit: consider if history or symptoms of anemia. Rare for clinically significant drop in hemoglobin after medication abortion.
      • Chlamydia/gonorrhea screen: if symptoms or risk factors. Avoid delaying abortion provision while awaiting results.
      • Testing based on follow-up plan:
        • None if using clinical history +/- home urine hCG(s)
        • or serum hCGs (day of mifepristone and after misoprostol)
        • or ultrasound if using serial ultrasounds

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  1. What topics do you discuss with a patient who would like a medication abortion?
    • When and how to take the mifepristone and misoprostol
      • Every patient has different circumstances. Consider discussing the following as applicable: privacy, child care, work / school responsibilities, access to bathroom, support person availability 
    • How to manage cramps (with ibuprofen and comfort measures)
    • Number to call if
      • Soaking 2 maxi pads/hour for 2 consecutive hours
      • Nausea or malaise > 24 hours after misoprostol
      • Fever > 24 hours after misoprostol
      • No bleeding at all 24 hours after misoprostol
    • No long-term adverse effects on health or fertility

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At the time of follow-up:

  1. How do you assess whether the medication abortion regimen worked?
    • Symptoms of abortion completion assessed by phone or electronic messaging alone (NAF 2020, Perriera 2010), or paired with urine pregnancy testing.
    • Urine pregnancy tests: High sensitivity, low sensitivity or a multi-step approach with both can be utilized depending on your setting.
      • Remember for regimens > 63 days LMP, hCG may be falling naturally in continuing pregnancies. High sensitivity tests may be preferred.
      • High sensitivity urine pregnancy tests should not be used < 1 month after medication abortion, as may remain positive even after a successful medication abortion.
    • Alternatively, either of the following can be used:
      • Serum beta hCG quantitative confirming a drop of:
        • 50% by 72 hours
        • 60% by 4-5 days (Pocious 2016).
        • 80% by 7 days (Fiala 2003)
          • As hCG has physiologic decline in later first trimester, assess patient’s symptoms in conjunction with their hCG results if clinical suspicion for ongoing pregnancy.
      • Ultrasound.  Note a thickened endometrial stripe common normal finding after medication abortion, and only requires management if patient is symptomatic with bleeding and / or cramping).

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  1. What symptoms or signs require evaluation or treatment?
    • Soaking 2 maxi pads/hour for 2 hours in a row. Excessive bleeding with signs of acute hemorrhage or significant drop in hematocrit are very rare; only 0.03-0.6% of patients who take mifepristone need transfusion (Chen 2015).
    • Nausea, malaise, weakness, fevers, or tachycardia >24 hours after taking misoprostol. It is important to evaluate for other infectious etiologies of a patients symptoms and avoid delaying treatment for common medical conditions.
      • Need for IV antibiotics is extremely rare (0.006% to 0.093% of patients). However, toxic shock due to Clostridium Sordelli can be fatal requiring prompt evaluation of tachycardia, hypotension, leukocytosis, or hemo-concentration without fever (Fjerstad 2009).
    • Persistent bleeding/cramps – may need exam, labs +/- ultrasound to r/o:
      • Continuing pregnancy [Rare; 1.2-3.5%] (Chen 2015, Abbas 2015).
      • Retained tissue [can offer another dose of misoprostol, < 4% require a procedure] (Chen 2015).
      • Endometritis [Rare; 0.01-0.5% treated for infection] (Chen 2015).
      • Ectopic or molar pregnancy [Rare; < 0.6%] (Abbas 2015).
    • No significant bleeding – after misoprostol need US to r/o:

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EXERCISE 4.2

  1. I live 4 hours away. Can I still get the abortion pill?
    • Yes. Patients can have a medication abortion if they live reasonably close to emergency medical care, and they have access to a phone and transportation. 
    • Studies have demonstrated safety, effectiveness, efficiency, and acceptability of direct-to-patient telehealth provision without any in-person visits (Raymond 2019), though U.S. restrictions still prevent this from being implemented beyond the research setting.
    • Some protocols allow for follow up via phone or telehealth visit (with or without follow up urine hCG or serial blood hCGs drawn at a location in close proximity to the patient), while others require a follow up office visit.

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  1. What are my chances of needing an aspiration abortion?
    • Medication abortion is >97% effective in most settings. Continuing pregnancy rate is rare (≤1% to 3%, as above) regardless of pregnancy dating when using the recommended mifepristone with misoprostol regimens. Redosing misoprostol alone may be an effective management option for patients who wish to avoid aspiration (or mifepristone and misoprostol although with minimal evidence for efficacy).
    • Uterine aspiration may also be needed for excessive bleeding/cramping, or by patient request.
    • For >63 days LMP, the total incidence of aspiration after medication abortion is 2-9%, with the range decreasing to <1% to 3% when a second dose of misoprostol is used (NAF 2020).
    • For persistent gestational sac without evidence of development, a 2nd dose misoprostol can be offered, or the patient can be followed for several more weeks if stable.
    • For asymptomatic patient (minimal bleeding or cramping) with echogenic material and thickened endometrial stripe on ultrasound, no further treatment is necessary. 

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  1. 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.

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  1. What will I see when the pregnancy passes?
    • Below 63 days LMP, blood and clots are normally visible, and it is unlikely a patient would identify an embryo.
    • At > 63 days LMP, the fetus may be identifiable and the patient should be counseled accordingly. 
    • If the patient is anxious about seeing the pregnancy or fetal tissue, consider showing a drawing and counsel with information such as: “At X weeks of pregnancy, this is what the pregnancy / fetus looks like.  Would you like more information or do you want to go ahead with the medication abortion?” If they are not comfortable, they may prefer an aspiration abortion. 

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  1. My partner wants me to keep this pregnancy.  Will they know that I had an abortion?
    • The symptoms of an abortion with pills and a miscarriage (spontaneous abortion) are identical.  Miscarriage happens in 15-20% of all pregnancies

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  1. I got a judicial bypass and my parents don’t know I’m pregnant and having an abortion. Is this the right method for me?
    • Discuss the individual circumstance with the patient, to help them decide whether a medication or an aspiration abortion might be preferable.
    • Explore options for a safe location where the young person might be able to use the misoprostol; e.g. a supportive relative’s house, a friend’s house.

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EXERCISE 4.3

  1. a) 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 misoprostol 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.

b) I took the misoprostol 30 hours ago and passed the pregnancy 24 hours ago, but now my temperature is 101.5º.

    • Persistent elevated temperature (>100.4º F) for several hours or > 24 hours after misoprostol warrants an office visit to evaluate for infection. Work-up should include:
      • Evaluation for other etiologies of symptoms
      • 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.

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  1. 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 misoprostol pills are vomited (or fall out if taken vaginally) less than 30 minutes after placed, the patient may need to return for a second misoprostol dose. If >30 minutes has elapsed, there is no need to re-dose as the active ingredient will have had adequate time to be absorbed, even if the pill appears undissolved. They may choose to wait to see if appropriate bleeding begins, and re-dose if no bleeding occurs within 4 hours.

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  1.  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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  1. I vomited three hours after using the mifepristone, what should I do?
    • Nothing. There is no need to re-dose the mifepristone if ingested for >15 minutes.

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  1. I am having new very heavy vaginal bleeding. It has been 4 weeks since my medication abortion. What should I do?
    • Assess amount of bleeding, symptoms of hypovolemia to ensure no hemorrhage.
    • Review records for confirmation of MAB completion (symptom check with negative home urine pregnancy test, adequately down-trending serum hCG, or ultrasound).
    • If there has been little to no interim symptoms of prolonged bleeding and cramping, this new onset heavy bleeding may represent onset of menses.
    • If prolonged bleeding and cramping have been ongoing, consider evaluation and management with uterine aspiration as appropriate. 

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EXERCISE 4.4

  1. A 29 year-old G3P1 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.
    • If ectopic can be firmly ruled out, treatment options include aspiration, repeat misoprostol alone (second dose is about 30% effective), or repeat mifepristone with misoprostol (may be a patient-centered option, but no evidence base for efficacy).
    • If no intrauterine pregnancy is identified despite rising hCG, the patient must be evaluated and treated for presumed ectopic pregnancy.

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  1. A 25 year-old G2P1 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 2020).
      • 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.

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  1. A 19 year-old G4P0 patient took 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 (orthostasis or 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?
      • Urgent uterine aspiration is indicated
      • Uterotonics may be indicated
      • Initiate iron supplementation as needed
      • Blood transfusion is rarely needed but may be necessary.
    4. What are indications for a uterine aspiration after medication abortion?
      • Bleeding in hemodynamically unstable patient (emergent)
      • Continuing pregnancy: Persistent growth, cardiac activity, or persistent increase in hCG. Can offer:
        • Uterine aspiration
        • A second dose of misoprostol (completes expulsion in 35% patients with ongoing pregnancy <63 days; Reeves 2008), or
        • Repeat misoprostol and mifepristone (patient-centered but not evidence based approach, lacking data on efficacy), or
      • Symptomatic problematic bleeding / cramping unresponsive to medical treatment
      • Patient preference if declines repeat misoprostol

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EARLY ABORTION TRAINING CURRICULUM Copyright © 2020 by UCSF Bixby Center for Global Reproductive Health. All Rights Reserved.