Complication Clinical Presentation Management Options Occurrence Rate
Problematic bleeding and/or cramping
  • Prolonged cramping, pain and/or bleeding
  • Retained gestational sac or tissue may be seen on ultrasound; inappropriate decline in hCG
  • Expectant management
  • Repeat misoprostol
  • Uterine aspiration
(varies by study & GA)
Continuing Pregnancy
  • May have scant bleeding after medications, persistent pregnancy symptoms
  • Ongoing viable intrauterine pregnancy (growing gestational sac or cardiac activity on US; rapidly rising hCG)
  • Uterine aspiration
  • Repeat misoprostol¬†(800 mcg vaginally, 36% had complete expulsion and 29% no longer had cardiac activity at follow-up)1

<1% ‚ȧ63 d2

3% 64-70 d2

  • Typical endometritis: fever (>24 hours after misoprostol), pelvic/abdominal pain, vaginal discharge with odor, uterine/adnexal tenderness
  • Atypical endometritis:
    • Very rare: Incidence 0.58 per 100,000 in the US
    • Severe, often fatal
    • Etiology: Clostridium sordelii– or Clostridium perfringens-mediated toxic shock syndrome
    • Occurs 2-7 days after MAB
    • Symptoms: nausea, abdominal bloating, diarrhea, pain, malaise
    • Signs: usually afebrile, tachycardic, hypotensive, leukocytosis & increased HCT
  • Follow CDC guidelines for antibiotic therapy
  • Uterine aspiration if retained tissue present
  • Immediate hospitalization and aggressive treatment for atypical infection
< 10 case reports by CDC3
Ectopic Pregnancy
  • May be asymptomatic or present with minimal bleeding or inappropriate decline in hCG after misoprostol.
  • May present with pelvic/abdominal pain, history of bleeding or spotting during the pregnancy, shoulder pain, tachycardia/hypotension.
  • Treat or refer as appropriate
(in study of GA < 6 weeks)2
Excessive Bleeding
  • Heavy or prolonged vaginal bleeding, Hgb drop >2, orthostatic hypotension
  • True hemorrhage is life-threatening emergency; rare but can occur
  • May result from retained pregnancy tissue and may present 2-5 weeks after mifepristone
  • Uterine aspiration
  • FeSo4
  • Blood transfusion
  • FeSo4

1. Reeves 2008
2. SFP 2014 Clinical Guidelines
3. Meites 2010
4. NAF online 2016


Early Abortion Training Workbook Copyright © 2016 by UCSF Bixby Center for Global Reproductive Health. All Rights Reserved.