Published Jun 2023
Authors: Natalie deQuillfeldt, MD, MA¹; Yaa Asare, MD¹; Michelle Cleeves, MD²; Nicole Soiseth, MD³; Anandi Ramaswami, MD; Paige Kendall, MD4; Aaron Lazorwitz, MD5; Michael Belmonte, MD4
Section Editor: Adelaide McClintock, MD6
Executive Editor: Yilin Zhang, MD7
1Resident, Department of Medicine, University of Colorado
2Associate Professor, Department of Medicine, University of Colorado
3Assistant Professor, Department of Medicine, University of Colorado
4Fellow, Complex Family Planning, Department of Obstetrics and Gynecology, University of Colorado
5Assistant Professor, Department of Obstetrics and Gynecology, University of Colorado
6Assistant Professor, Department of General Internal Medicine, University of Washington
7Assistant Professor, Department of General Internal Medicine, University of Washington – Valley Medical Center
Objective(s)
- Identify relative and absolute contraindications to medication abortion
- Counsel patients on options for medication abortion and correct administration of medications
- Identify adverse effects of medical abortions and when patients should be referred for emergency care or procedural abortion
- Locate your local laws and institutional guidelines regarding prescription of medication abortion
Teaching Instructions
Plan to spend at least 30-60 minutes preparing for this talk. Read through the instructions below, ensure QR codes and links continue to work. There is a pre-test and post-test survey (QR code) that can be used to assess baseline knowledge of medical abortion.
Anticipated time to deliver the talk without cases or other features: 20 minutes; anticipated time with cases: 45 minutes.
Review your local/institutional guidelines and consider creating an additional slide or handout for learners listing sites where medication abortion may be prescribed, who to refer patients to for complications, and any restrictions or limitations that may be present. To find out local/state laws, please visit the Guttmacher Institute at https://www.guttmacher.org/state-policy/explore/overview-abortion-laws.
Print out copies of the Learner’s Handout so they may follow along during the presentation and take notes as you expand on the decision tree and apply it through the practice cases. Begin with reviewing the objectives for the session.
Introduction/ Impact:
When Roe v. Wade was overturned June 24, 2022, hundreds of thousands of women* (in this talk the term refers to people with uteruses) lost access to vital reproductive healthcare. This led healthcare workers predominantly in the fields of OB-Gyn and family medicine to scramble to find ways to prescribe medication and procedural abortion to their patients while also protecting their medical licenses. Lack of access to abortion disproportionately impacts people of color and lower socioeconomic status.
As internal medicine providers, adults with uteruses account for 50% of the patients we treat. By learning how to prescribe just two medications, we can respond to the urgent need to help patients retain autonomy over their bodies and join the fight for reproductive justice alongside our colleagues. Please keep in mind the information on this topic is continually changing so for updated information consult the Guttmacher Institute.
In this talk, we will be discussing the medications used for abortion, side effects, complications, and indications for surgical referral. Allow space for any of your learners, who may be uncomfortable with these topics, to excuse themselves if needed.
Objective 1: Identify relative and absolute contraindications to medical abortion. (Approach)
Medication abortion can safely be used up to 11 weeks, although use beyond 10 weeks is considered off label.
- Step 1: Confirm pregnancy with urine hcg and estimated gestational age (EGA) using the first day of the last menstrual period (LMP).
- If LMP is unknown, ultrasound may aid in confirming gestational age though it is not necessary if the patient is certain of their LMP and they were not using hormonal contraception.
- Ultrasound is also helpful if ectopic pregnancy is suspected in patients with prior ectopic pregnancy, tubal surgery or pathology, current IUD use, and use of in-vitro fertilization for the current pregnancy.
- Step 2: Choose the appropriate medication regimen. The combination of mifepristone and misoprostol is most effective (95-99% effective) and is the recommended treatment for medical abortion. For patients with relative or absolute contraindications to mifepristone or in practice settings where mifepristone is not available, misoprostol can be used alone for medical abortion. However, misoprostol alone is only 76-88% effective).
- Step 3: Assess for medical contraindications.
- While anemia (Hgb <9.5g/dL) is not a strict contraindication, the safety of abortion in this patient population is unknown. They may pursue an abortion if they are willing to have closer follow up. Transfusion rate for medication abortion is less than 0.1% so unless there is a concern for anemia, testing Hgb is not necessary.
- Absolute contraindications to medication abortion include ectopic pregnancy, presence of an IUD, known coagulopathy, and anticoagulant therapy.
- Certain medical conditions such as heart failure, cancer, and uncontrolled lupus may increase the risk of morbidity and mortality due to pregnancy. If a patient wishes to proceed with pregnancy in the setting of a high-risk condition, offer referral to maternal fetal medicine (MFM).
- Mifepristone specific: Patients on corticosteroids or with history of adrenal insufficiency should not take mifepristone as it is a synthetic steroid. At higher doses it blocks the effect of cortisol at the glucocorticoid receptor, potentially blocking the effect of exogenous corticosteroids and precipitating adrenal insufficiency. While experienced clinicians may still prescribe mifepristone for these patients, they would require close monitoring for development of hypokalemia, hypotension, or other signs of adrenal insufficiency so would likely be safer receiving procedural abortion instead.
- Misoprostol specific: Patients with porphyria are discouraged from taking misoprostol. Patients should also not take magnesium-containing supplements simultaneously with misoprostol due to risk of worsened GI side effects.
- Step 4: Obtain informed consent and review how to refer a patient for uterine aspiration or blood transfusion if needed. Ensure prescriber and patient agreements are signed and include after-care instructions in your patient’s visit summary (see supplemental materials for these). Patients should be aware that…
- Taking medication abortion pills does not adversely affect future fertility or pregnancy outcomes.
- Rh testing is no longer recommended for abortion under 12 weeks, even for those who are known to be Rh neg as there is minimal risk of enough maternal-fetal blood mixing to induce alloimmunization.
- Alternatives to medication abortion include procedural abortion, carrying pregnancy to term, and adoption after birth.
- Over 90% of patients are confident in their choice and do not regret it. Once taken, there is no reversal agent. Due to the teratogenicity of misoprostol, patients with incomplete abortions should be referred for uterine aspiration.
- Some states require 24+ hours of waiting after counseling which can delay care and make it more difficult to access abortion due to need for multiple days off from work, childcare, and other hurdles. Case 2 contains a QR code where learners can access laws pertaining to mandatory waiting periods by state which is updated frequently.
Objective 2: Counsel patients on options for medication abortion and correct administration of medications (Medications for Abortion)
- Mifepristone available: In patients who are able to take mifepristone and in practice settings where this is available, the conbination of mifepristone and misoprostol is recommended. Mifepristone is a progesterone receptor modulator that promotes placental separation, cervical dilation, and sensitization of the myometrium to prostaglandins such as misoprostol. Misoprostol is a prostaglandin E1 analogue that causes cervical softening and uterine contractions.
- An oral dose of mifepristone is taken, followed by misoprostol buccally or vaginally 24-48 hours later.
- It is very important that the patient waits at least 24 hours after mifepristone dose for optimal efficacy. If the patient vomits less than 30 minutes after the dose of mifepristone, another must be taken.
- Between 9 and 11 weeks of gestation, a second dose of misoprostol must be taken 3-6 hours after the first dose.
- The combination of mifepristone and misoprostol is 95-98% effective at inducing abortion up to 11 weeks, whereas efficacy for misoprostol alone ranges from 78-93%.
- Mifepristone not available: If the patient has a contraindication to mifepristone, they may take misoprostol monotherapy with repeated dosing every 3 hours for up to 3 doses. There are less GI side effects when misoprostol is taken vaginally.
Objective 3: Identify adverse effects of medical abortions and when patients should be referred for emergency care or procedural abortion (Follow-up, Side Effects)
Follow-up: Ask your learners what follow-up may be needed at “1-2 weeks” and at “4 weeks” and click to reveal the answer.
According to 2020 practice guidelines from the National Abortion Federation, patients should be offered follow up within 14 days though they may also opt for self-assessment. Assess for ongoing pregnancy symptoms such as breast tenderness, fatigue, and morning sickness 1-2 weeks after the misoprostol dose. Patients may also consider lab or home urine pregnancy testing at 4-6 weeks, but not prior to 4 weeks.
If the patient continues to have symptoms of pregnancy and is still <11 weeks EGA, they may take another dose of vaginal misoprostol prior to proceeding to aspiration. Alternatively, a pelvic ultrasound to confirm an empty gestational sac can be performed at 1-2 weeks after taking the medications.
It is important to emphasize that absence of a gestational sac confirms success of the medication abortion, as some radiologists may be overly cautious when evaluating for retained products of conception. While there is no endometrial thickness cutoff, it would be appropriate to have a patient follow-up with a family planning clinic if there are concerns, rather than moving directly to repeat intervention.
Side Effects and Complications: Ask your learners what expected side effects and complications you may see after a medical abortion. Click on each side effect/complication for more information.
The expected effects of medication abortion include:
- Severe cramping and bleeding: Bleeding is heavier than menses. This often begins 2.5-4 hours after the misoprostol dose, and lasts about an hour, though it can last up to 24 hours.
- GI side effects: include nausea (43-46%) vomiting (23-40%), diarrhea (23-35%)
- Fever/flushing/chills (32-69%). Patients may also experience constitutional symptoms such as malaise.
Complications are rare but include:
- Prolonged or heavy bleeding: defined as soaking >2 pads per hour for 2 consecutive hours. Fortunately, only about 1% will need uterine aspiration for excessive bleeding, and of that, <0.1% need a transfusion.
- Incomplete or failed abortion: occurs in 5-7% of patients taking the mifepristone and misoprostol combination. There is an increased risk for this after 57 days (beyond 8 weeks) of gestation. The incidence is >7% for misoprostol alone and may be as high as 22%.
- Intrauterine infection: this is an extremely uncommon complication (1.2%) which is manifested by prolonged pelvic pain (>24h), abnormal vaginal discharge, and fevers/chills. Patients should be advised to seek immediate medical care if they experience any of the above complications.
Cases: Give learners a moment to read case information aloud followed by 2-3 minutes to discuss with a partner or group before presenting each answer.
FAQs by Learners
Q: How much does abortion cost (pills, in-clinic administration, and procedural)?
A: The cost of abortion varies widely from $600-2,000 depending on whether it’s in-clinic or procedural, however the cost of the medications alone on GoodRx.com is around $35 in Colorado, where this talk was developed.
Q: Can patients start contraception right away?
A: According to ACOG’s abortion guidelines all methods of contraception except IUD and sterilization can be initiated on day 1 of abortion.
Q: When can patients start having sex after abortion?
A: Although they may resume intercourse when they are comfortable, it is recommended that they avoid vaginal penetration until heavy bleeding has resolved in order to reduce risk of infection.
Q: Does abortion impact future fertility/pregnancy outcomes?
A: No, it does not.
Q: Where can I get additional training?
A: The Society of Family Planning has a training for medication abortion for Primary care providers https://abortionpillcme.teachtraining.org
Take Home Points
- Prior to prescribing medical abortion, confirm pregnancy, estimate gestational age, and investigate whether there is a mandatory waiting period in your state
- State laws surrounding abortion are currently in flux so you should always confirm your local laws prior to prescribing.
- Medical abortion can be considered for pregnancies up to 11 weeks gestation. Mifepristone + misoprostol combination therapy is more effective than misoprostol alone.
References
- McCann, Allison, et al. “Tracking the States Where Abortion Is Now Banned.” The New York Times, The New York Times, 24 May 2022, www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html.
- Bazelon, Emily. “Risking Everything to Offer Abortions across State Lines.” The New York Times, The New York Times, 4 Oct. 2022, www.nytimes.com/2022/10/04/magazine/abortion-interstate-travel-post-roe.html.
- CDC. Introduction USMEC. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/intro.html. Updated as of March 27, 2023. “Pregnancy Options Abortion.” Bedsider, www.bedsider.org/pregnancy_options/abortion.
- Public Policy Office. “Counseling and Waiting Periods for Abortion.” Guttmacher Institute, 19 Oct. 2022, www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion.
- Jain JK, Dutton C, Harwood B, Meckstroth KR, Mishell DR Jr. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of early pregnancy. Hum Reprod. 2002;17(6):1477
- Autry BM, Wadhwa R. Mifepristone. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557612/
- Carlsson I, Breding K, Larsson PG. Complications related to induced abortion: a combined retrospective and longitudinal follow-up study. BMC Womens Health. 2018;18(1):158. Published 2018 Sep 25. doi:10.1186/s12905-018-0645-6
- Ngoc NT, Blum J, Raghavan S, Nga NT, Dabash R, Diop A, Winikoff B. Comparing two early medical abortion regimens: mifepristone+misoprostol vs. misoprostol alone. Contraception. 2011;83(5):410. Epub 2010 Oct 18
- Committee on Practice Bulletins—Gynecology , et al. “Medication Abortion up to 70 Days of Gestation.” ACOG, Oct. 2020, www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation.
- Horvath S, Goyal V, Traxler S, Prager S. “Society of Family Planning Committee Consensus on Rh Testing in Early Pregnancy.” Contraception. July 2022;114:1-5. Available at https://www.contraceptionjournal.org/article/S0010-7824(22)00197-4/fulltext
- Coyaji K, Krishna U, Ambardekar S, et al. Are two doses of misoprostol after mifepristone for early abortion better than one? BJOG 2007; 114:271.
- NAF 2019 Clinical Policy Committee. Clinical policy 2020 guidelines for abortion care. https://prochoice.org/wp-content/uploads/2020_CPGs.pdf. Published 2020.
- Raymond EG, Harrison MS, Weaver MA. Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review. Obstet Gynecol. 2019;133(1):137-147. doi:10.1097/AOG.0000000000003017
