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8/13/2023

Medication Abortion

Editor’s Note: This article is accurate and current as of the publication and review date. Practitioners need to be aware of the laws concerning this subject, and the variability of those laws and regulations across the country, which are subject to change at any time. Practitioners should frequently check for updates and changes in their local jurisdiction.

Medication or medical abortion (MAB) is a safe and effective option for pregnancy termination. MAB allows care to occur at earlier gestational ages, thus decreasing risks of pregnancy termination. The standard (and US Food and Drug Administration [FDA]–approved) regimen is oral mifepristone followed by misoprostol 6 to 48 hours after pending route of administration. Misoprostol only is an acceptable alternative (see Table). The FDA restricts mifepristone use under a risk evaluation and mitigation strategy (REMS) program, requiring provider registration and, historically, in-clinic patient disbursement. During the COVID-19 pandemic, the FDA permanently removed the in-person dispensing requirement. Telemedicine protocols have since been developed. Telemedicine is as effective as in-person visits, with rare adverse effects such as incorrect dating or ectopic pregnancies. MAB via telemedicine is safe, is associated with high patient satisfaction, and improves access to early abortion care.

 

Table. Medication Abortion Regimens (adapted from the American College of Obstetricians and Gynecologists)

 

Regimen	Mifepristone dose	Misoprostol dose	Interval between drugs
Preferred
Combination (FDA approved)	200 mg orally	800 mcg buccally	24 to 48 hours*
Combination (World Health Organization recommended)	200 mg orally	800 mcg (vaginally, buccally, sublingually)	24 to 48 hours*
Alternative
Misoprostol only	NA	800 mcg (vaginally, buccally, sublingually)	Repeat every 3 hours for up to 3 doses

*Recent data suggest that misoprostol up to 6 hours after mifepristone is just as effective.

 

Pregnancy confirmation options include serum hCG testing or home urine hCG testing, ultrasonography, or history-based last menstrual period gestational age dating. In 2020, the American College of Obstetricians and Gynecologists stated that gestational age dating based on last menstrual period without ultrasonography is acceptable and approved for MAB up to 70 days gestational age. Recent data support use of MAB for last menstrual period–based dating up to 77 days. Only 1% of patients who report sure last menstrual period within 1 week have ultrasonography that confirms gestational age of more than 77 days. MAB should not be offered to patients who have suspected or confirmed ectopic pregnancies, blood disorders, adrenal failure, or allergies to mifepristone or misoprostol. Patients who are unable to understand care instructions or follow-up should not obtain MAB.

Bleeding is typically much heavier with MAB than with menses, and severe cramping is possible. Patients should be given bleeding precautions. Most complications such as need for dilation and curettage or blood transfusion occur within 24 hours of misoprostol administration. Antibiotics and routine laboratory tests, including Rh status and hemoglobin levels, are not required. Research suggests that risk of Rh sensitization is negligible in early abortions.

Follow-up is recommended 1 to 2 weeks after treatment. Telemedicine follow-up is a reasonable option given that if both the patient and clinician agree that expulsion occurred based on symptoms, they are correct 96% to 99% of the time. A home urine pregnancy test should be obtained 4 weeks later.

For in-person follow-up, ultrasonography, serum hCG measurement, or urine pregnancy testing may be done if deemed necessary. Ultrasonography should only be used to determine the presence or absence of a gestational sac. If no gestational sac was ever present, a serum hCG level decrease of 80% or more 1 week after treatment indicates success. Mifepristone is not teratogenic; however, misoprostol use during the first trimester may cause anomalies that patients should be counseled about if pregnancy continues. If a retained gestational sac or prolonged irregular bleeding is present 2 weeks after MAB, another misoprostol administration, dilation and curettage, or expectant management may be offered. If there is cardiac activity after a repeated misoprostol administration, dilation and curettage should be performed. MAB failure rates are 0.5% when performed at less than 7 weeks gestational age and 3.4% when performed at less than 10 weeks gestational age.

Providers who have the skill set to diagnose and discuss pregnancy options, evaluate for ectopic risks, and counsel on the regimen are appropriate MAB providers. Providers should be able to manage or refer patients should complications arise.

Further Reading:

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology, Society of Family Planning. Medication Abortion Up to 70 Days of Gestation: ACOG Practice Bulletin, Number 225. Obstet Gynecol. 2020 Oct;136(4):e31-e47. doi: 10.1097/AOG.0000000000004082. PMID: 32804884.

Raymond EG, Grossman D, Mark A, Upadhyay UD, et al. Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception. 2020 Jun;101(6):361-366. doi: 10.1016/j.contraception.2020.04.005. Epub 2020 Apr 16. PMID: 32305289; PMCID: PMC7161512.

Initial publication June 2023

Final editing of initial publication performed by The Medical Pen, LLC.

 

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