FIRST TELEHEALTH OR OFFICE VISIT – DAY 1
- Introduce and build rapport with the patient
- Address pregnancy, abortion options (medication vs. aspiration), and patient concerns
- Reassure patient that abortion is safe, and does not interfere with ability to get pregnant and stay pregnant in the future if so desired.
- Determine pregnancy dating and medication abortion eligibility by one of the following:
- LMP <77 days from anticipated date of mifepristone use (within 1 week of certainty)
- Regular menses with no hormonal contraception use for 2 months prior to LMP
- First positive pregnancy test less than 6 weeks ago
- No ectopic risk factors (previous ectopic, history of PID, IUD in place at the time of conception, bleeding since LMP, or unilateral pelvic pain).
- LMP plus physical examination including bimanual exam as needed.
- Limited ultrasound not required (except as indicated below).
- LMP <77 days from anticipated date of mifepristone use (within 1 week of certainty)
- Review medical history for absolute and relative contraindications to medication abortion:
- IUD in place (must be removed prior to administration of the medications)
- Allergy to a medication (eg mifepristone or misoprostol)
- Chronic adrenal failure or long-term use of systemic corticosteroid therapy
- Known or suspected ectopic pregnancy
- Hemorrhagic disorders or concurrent anticoagulant therapy or symptomatic anemia
- Inherited porphyria
- No severe or unstable chronic condition that increases risk of outpatient procedure
- Confirm confidential phone number, email and/or transportation access for follow-up.
- Discuss safety of medication abortion and review risks (see Complications Table):
- Overall, early medication abortion is at least tenfold safer than continuing a pregnancy to term, although the magnitude of safety varies in global settings.
- Need for additional misoprostol doses or aspiration with its risks, if needed later.
- Heavy or prolonged bleeding can occur in up to 3% of cases; Management options include misoprostol, high-dose NSAIDs, and non-urgent uterine aspiration. Rarely emergent uterine aspiration or transfusion indicated.
- Endometritis (<1%) is very uncommon. Atypical infection with Clostridium is extremely rare.
- Mifepristone is not associated with teratogenicity.
- There is no evidence-based regimen for mifepristone reversal; Not taking misoprostol after mifepristone may be associated with heavy bleeding (Grossman 2015, Creinin 2020).
- Advise patient about the potential teratogenicity of misoprostol (associated with increased congenital deformities, Mӧbius syndrome, and limb defects)
- In the U.S., patients must review and sign required consents and agreements:
Counseling on Abortion Process
- Provide anticipatory guidance for the abortion process and medication side effects
- Ask if the patient wants to have a support person available.
- Some patients may experience vaginal bleeding after mifepristone, and should be advised to continue to use misoprostol as directed.
- Cramping/pain occurs in >90% of patients, varies in intensity, peaks after misoprostol dose, and is typically improved by NSAIDs and heat.
- Common side effects of misoprostol include: nausea, vomiting, diarrhea, low-grade fever, chills and myalgias, and usually resolve within 6 hours of use.
- If mifepristone or misoprostol are vomited (or fall out) <15-30 min after use, consider repeat dosing. Antiemetic medications can be used ahead of medications if patient has significant degree of pregnancy-related nausea.
- Vaginal bleeding is usually heaviest within 4-6 hours after misoprostol, often heavier than normal menses and accompanied by the passage of large clots.
- Average bleeding duration is 9 days (range 1-45 days); but clinically significant drop in hemoglobin is rare. Intermittent spotting may last for up to one month.
- A heavy first menses is common following medication abortion.
- Patients bleeding heavier than two pads per hour for over two hours need to be evaluated.
- Review use of medications:
- Assists in detaching pregnancy from the uterine lining, preparing the uterus to expel the pregnancy
- One 200 mg tablet is swallowed
- Stimulates uterus to contract and expel the pregnancy
- Describe options for misoprostol so patient can choose their optimal route for home administration:
- Buccal: place four 200 mcg tablets between gum & cheek for 30 minutes. Swallow remaining fragments. Patients may place 24-48 hours after mifepristone.
- Vaginal: place four 200 mcg tablets as high as possible in the vagina. Patients may place 6-48 hours after mifepristone.
- Sublingual: place 2-4 200 mcg tablets under the tongue for 30 minutes. Swallow remaining fragments
- If >63 days LMP, a second dose of 800mcg misoprostol 4 hours after the first dose can be considered; and if >70 days LMP, a second dose is recommended.
- If ≥ 56 days LMP and Rh negative, give Rho(D)-IG: 50 mcg dose IM within 72 hours of mifepristone. (See Chapter 5).
- Pain control
- NSAIDs are mainstay: Ibuprofen 600-800 mg PO q6-8h or equivalent.
- Data does not support the addition of opiates for medication abortion when compared to NSAIDS alone (Colwill 2019). Some providers may choose to use a limited prescription of opiates in select situations (eg, medication allergy or intolerance to NSAIDs).
- Antiemetics may offer ondansetron, promethazine, or metoclopramide for patient comfort and medication absorption.
- Prophylactic antibiotics are not recommended
- Offer to discuss contraception, while remaining aware that some patients prefer not to discuss at time of abortion (Brandi 2018, Matulich 2014, Kavenaugh 2011). If interested, review options and timing for initiation. Reassure patients that abortion does not affect future fertility and that fertility can resume within a week of an abortion.
- Implant: placement at time of mifepristone enhances patient satisfaction without increasing MAB failure rates (Raymond 2016).
- IUD: place at follow-up visit; may have slightly increased risk of expulsion if done at 1 week (Sääv 2012).
- Sterilization: sign consents, refer and offer an acceptable bridge method
- Injection: may start at any time, may be provided IM in clinic or SQ for home use. Advise that injection at time of mifepristone is associated with slightly increased rate of continuing pregnancy on the order of 1-3% (Raymond 2016).
- Hormonal contraceptives: may start at any time (Tang 2002).
- Barrier methods: Can use as soon as patient resumes intercourse.
- Offer emergency contraception and dispense or prescribe if desired for future use.
- Home instructions: Discuss how to reach provider on call, especially if the patient has:
- No bleeding within 24 hours of misoprostol (a repeat dose of misoprostol or an ultrasound if not initially performed may be indicated)
- Soaked two or more maxi-pads for two or more consecutive hours
- Unmanageable pain despite taking analgesics prescribed
- Sustained fever >100.4° F or onset of fever >24 hours after misoprostol
- Abdominal pain, weakness, nausea, vomiting or diarrhea > 24 hrs after misoprostol
- Plans to go to a hospital or emergency department. Most patients’ concerns can be addressed with reassurance and anticipatory guidance. Many patients can wait to see you in the office rather than be referred to an ER. If ER is needed, facilitation may help improve the patient experience and reduce unnecessary interventions.
No Labs or Ultrasound Required, unless:
- Rh status: if ≥ 56 days LMP and Rh unknown (this can be ascertained by donor card if Rh negative, chart, patient report, or lab). Additionally, some protocols allow Rh testing to be omitted if a patient expresses a desire to decline Rhogam or states they do not desire future fertility.
- Hemoglobin or hematocrit: can be considered if history or symptoms of anemia. Rare for clinically significant drop in hemoglobin after medication abortion.
- Chlamydia/gonorrhea screen: if patient has symptoms or risk factors. Awaiting GC/CT results should not delay abortion provision.
- Means of assessing successful abortion:
- Not needed in the office if using clinical history plus home urine hCG test(s)
- Baseline serum hCG on day of mifepristone followed by another after misoprostol
- Baseline and follow-up ultrasound if using serial ultrasounds
(Source: Reproductive Health Access Project)
FOLLOW-UP TELEHEALTH OR OFFICE VISIT – DAY 7 – 14
- Review patient’s course since taking medications, including timing and extent of bleeding and cramping, and resolution of pregnancy symptoms. Symptoms requiring an in-person evaluation:
- No bleeding and cramping heavier than a period
- Continued heavy bleeding without improvement
- Patient does not feel that the pregnancy has passed
- Continued symptoms of pregnancy (nausea, breast tenderness)
- Significant pain unrelieved by usual measures
- Success of abortion must be assessed by a) clinical history in conjunction with home urine pregnancy tests, b) by serial hCG testing, or c) by ultrasound (NAF CPG 2020).
- Clinical history (assessing symptoms by telehealth or phone) is acceptable, when paired with home urine pregnancy test at ≥ one month (Grossman 2011, Oppegaard 2015, Schmidt-Hansen 2019). May give patient an additional pregnancy test so that they do not need to purchase one.
- When serial hCG protocol is used, a decrease from baseline hCG of 50% by 72 hours, 60% by 4-5 days (Pocious 2016), and 80% by 7 days from initiating treatment (Fiala 2003) is consistent with a successful MAB.
- As hCG has physiologic decline in later first trimester, assess symptoms in conjunction with hCG results if clinical suspicion for ongoing pregnancy.
- When ultrasound is used, success is determined by demonstrating the absence of the previously identified pregnancy (gestational sac or embryo).
- Review clinical course and results, if any, with patient. Have patient contact clinic for late-onset heavy bleeding or other concerns warranting evaluation and treatment.
- Review contraceptive plan if desired
- Because of the safety and efficacy of medication abortion, some providers consider follow-up optional. If planned follow-up is not completed, it is recommended to attempt to contact the patient and to document in accordance with your clinical protocols.
|Proposed Criteria for Aspiration after Medication Abortion|
- Data supports that the use of Rho(D)-IG is unnecessary prior to 56 days gestational age, as the degree of fetal-maternal hemorrhage shown to be well below threshold of sensitization in early abortion. Forgoing Rh testing and Rho(D)-IG for medication abortion under 70 days may also be considered. Studies are ongoing to further clarify this recommendation for gestational ages 56-70 days. (Mark 2019, Horvath 2020, Hollenbach 2019) ↵
- Several organizations say the evidence is insufficient to support universal prophylactic antibiotic use during MAB (Ipas 2020, NAF 2020, SFP 2014, WHO 2018). In contrast, there is compelling evidence to support universal antibiotic prophylaxis prior to aspiration abortion. ↵