MIFEPRISTONE/MISOPROSTOL ABORTION: STEP BY STEP

FIRST OFFICE VISIT – DAY 1

Determine Patient Eligibility:

  1. Confirm intrauterine pregnancy and determine gestational age: If using ultrasound a pre-medication sonogram should be obtained, or if using clinical evaluation, LMP plus bimanual exam may be sufficient.
  2. Rule out contraindications from medical history:
    • IUD in place (must be removed prior to administration of the medications)
    • Allergy to prostaglandins or mifepristone
    • Chronic adrenal failure or long-term systemic corticosteroid therapy
    • Known or suspected ectopic pregnancy
    • Hemorrhagic disorders or concurrent anticoagulant therapy
    • Inherited porphyria

Counseling and Informed Consent:

  1. Address pregnancy options, early abortion options (medication vs. aspiration), and patient’s concerns (see Chapter  2).
  2. Confirm confidential phone number and transportation access for follow-up.
  3. Discuss the safety of medication abortion and review risks (see Table):
    • Need for aspiration or additional misoprostol doses (up to 5% < 63 days and 9% at 64-70 days). Briefly review the safety and risks of aspiration in case indicated later.
    • Heavy or prolonged bleeding (up to 3%; uterine aspiration may be required)
    • Endometritis (<1%) and the very rare risk of atypical infection
    • Mifepristone alone has not been associated with teratogenic effects, although it may cause abortion in 60-80% of cases
    • Once misoprosol taken, abortion must be completed due to potential misoprostol teratogenicity (associated with increased congenital deformities, Mӧbius syndrome)
  4. Review and sign required consents and agreements:
  5. Compare the FDA-approved regimen with evidence-based alternatives
  6. Review use of medications:
    • Mifepristone:
      • Stops the pregnancy from growing
      • One 200 mg tablet is administered by mouth
    • Misoprostol:
      • Stimulates the uterus to contract and empty
      • Help the patient choose the optimal route for home administration:
      • Vaginal: place four 200 mcg tablets as high as possible in the vagina
      • Sublingual: place 2-4 200 mcg tablets under the tongue for 30 minutes. Swallow any remaining fragments after 30 minutes
      • Buccal: place four 200 mcg tablets between gum and cheek for 30 minutes. Swallow any remaining fragments after 30 minutes
    • Rho(D)-IG: 50 mcg dose IM within 72 hours of mifepristone if Rh negative
    • NSAIDs and opiates: prescribed for pain control. See Chapter 4 for specifics.
      • Hydrocodone/Acetaminophen 5mg/325mg q4-6h or equivalent
      • Ibuprofen 600-800 mg q6-8h or equivalent
    • Antiemetics: may be offered to improve patient comfort and increase the likelihood that medications will be absorbed
    • Prophylactic antibiotics: may be considered[1]
  7. Provide anticipatory guidance for the abortion process and medication side effects:
    • Cramping/pain occurs in >90% of patients, varies in intensity, peaks after misoprostol dose, and is typically improved by NSAIDs and/or opioids.
    • Nausea, vomiting, diarrhea, low-grade fever, chills and myalgias are common side effects of misoprostol, and usually resolve within 6 hours of use
    • If pills are vomited (or fall out) <30 min after misoprostol, consider a repeat dose
    • Vaginal bleeding is usually heaviest within 4-6 hours after misoprostol, often heavier than normal menses and accompanied by the passage of clots
    • Average bleeding duration is 9 days (range 1-45 days); clinically significant drop in hemoglobin is rare
    • A heavy first menses is common following medication abortion
    • Out-of-cycle bleeding following the first menses may indicate retained POC or other material, and should be evaluated (depending on post-abortion contraceptive method and other signs/symptoms)
    • Suggest the patient has a calm environment and a support person available.
  8. Review plans for initiating post-abortion contraception if desired: Advise patient that it is possible to get pregnant again right away
    • Implant: placement at time of mifepristone enhances patient satisfaction and does not appreciably increase MAB failure rates (Raymond 2016)
    • IUD: place at follow-up; may have slightly increased risk of expulsion (Sääv 2012)
    • Sterilization: sign consents, refer and offer an acceptable bridge method
    • Injection: provide at follow-up visit or sooner
    • Hormonal contraceptives: initiate within 5 days of misoprostol
    • Barrier methods: initiate immediately
    • Provide emergency contraception (dispense or prescribe) if desired for future need

Diagnostic Tests:

  1. Rh status (from lab, donor card, or patient chart)
  2. Hemoglobin or hematocrit (consider safety of MAB when baseline hemoglobin <10)
  3. Chlamydia/gonorrhea screen (as indicated; see Chapter 4 Diagnostic Tests)
  4. If using serial hCG protocol to assess for success, draw baseline serum hCG
    • (see hCG  follow-up below)

Additional Home Instructions

  1. Discuss how and when to reach provider on call, especially if the patient has:
    • No bleeding within 24 hours of misoprostol (second dose 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, “feeling sick”, nausea, vomiting or diarrhea more than 24 hours after taking misoprostol
    • Plans to go to a hospital/ emergency department (facilitating the patient’s visit may reduce the likelihood of unnecessary aspiration)

FOLLOW-UP – UP TO DAY 14

Medication abortion success must be assessed by ultrasonography, by serial hCG testing, or by clinical means in the office, or by telephone (NAF CPG 2016). If the patient fails to follow up as planned, the clinic must document multiple attempts to reach the patient.

  1. When ultrasound is used, success is determined by demonstrating the absence of the previously identified pregnancy (gestational sac or embryo, depending the US findings prior to MAB). Residual echogenic material and endometrial thickening are normal findings, and require no intervention unless accompanied by pain or excessive bleeding (i.e. treat the patient and not the ultrasound).
  2. When the serial hCG protocol is used, a decrease from baseline hCG of 60% in 6-10 days of initiating treatment correlates with a successful MAB (NAF CPG 2016).
  3. When telephone follow-up has been used, it has been shown to be non-inferior to standard office follow up, although ongoing research is underway (Oppegaard 2015).
  4. Review patient’s course since medications, including timing and extent of bleeding and cramping, and any ongoing symptoms.
  5. Review interpretation of diagnostic results with patient
  6. Review previously-initiated contraceptive method, or initiate contraception
  7. Review how to contact clinic in the event of late-onset bleeding (heavy or persistent) or other concerns warranting evaluation and treatment.

 

Proposed Criteria for Aspiration after Medication Abortion
Emergent

  • Excessive active bleeding with orthostatic hypotension or significant drop in hemoglobin/hematocrit

Non-emergent

  • Continuing pregnancy (may consider second misoprostol dose prior to aspiration)
  • Symptomatic problematic bleeding / cramping unresponsive to medical treatment
  • Patient preference

 


  1. Although some providers routinely give antibiotic prophylaxis prior to MAB, several organizations say the evidence is insufficient to support universal prophylactic antibiotic use during MAB (Ipas 2016, NAF 2016, SFP 2014, WHO 2012, ACOG 2009).  In contrast, there is compelling evidence to support universal antibiotic prophylaxis prior to aspiration abortion.