Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the various regimens for medication abortion
2. List the contraindications to medication abortion

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers:PIM Planners have nothing to disclose

Method of Participation and Request for Credit

Participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Designated for 0.5 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY: 

ACOG has reaffirmed guidance related to medication abortion up until 70 days of gestation. This guidance impacts multiple aspects of gynecologic care. Approximately 60% of abortions will occur before 10 weeks with current data suggesting that medication abortion constitutes 39% of all abortions. Combined mifepristone-misoprostol regimens are preferred due to increased effectiveness vs misoprostol only. Mifepristone is a selective progesterone receptor modulator and misoprostol is a prostaglandin E1 analogue.

Use in Patients with Prenatal and Medical Conditions

• May be used in patients with comorbidities but may require monitoring  
• Anemia
  • Risk for excessive bleeding is low but there may be more bleeding vs procedural abortion
• Asthma
  • Not contraindicated
  • Misoprostol does not cause bronchoconstriction
• Multiple gestation
  • Not contraindicated  
  • Treat twins like singleton

Evaluation Prior to Medication Abortion

Confirm Pregnancy and Estimate Gestational Age

• Regular menstrual cycles | Certain LMP within the prior 56 days | No signs, symptoms, or risk factors for ectopic pregnancy
  • Clinical examination or ultrasound examination is not necessary
  • If ultrasound is clinically indicated, transabdominal approach can be used  

Rh Testing

• Unknown Rh Status
  • Perform testing and Rh D immunoglobulin as indicated
• Rh testing and Rh D immunoglobulin administration are not available or will cause significant delay
  • Shared decision making is advised

Other Laboratory Evaluations

• Not routinely indicated clinically but may be a local or state requirement
• Suspected Anemia: Obtain hemoglobin or hematocrit

Medication Abortion Regimen

Preferred

• Combination FDA approved
  • Mifepristone: 200 mg | OralMisoprostol: 800 micrograms | Buccal
  • Interval between drugs: 24 to 48 hours
• Combination WHO recommended
  • Mifepristone: 200 mg oralMisoprostol: 800 micrograms | Buccal, vaginal, sublingual
  • Interval between drugs: 24 to 48 hours

Alternative: Mifepristone unavailable   

• Misoprostol: 800 micrograms | Buccal, vaginal, sublingual
• Repeat every 3 hours for up to 3 doses

Follow-Up

Counsel Patients Regarding the Following

• Bleeding and cramping may be more severe than menses
• Potential adverse effects (typically following misoprostol)
  • Nausea | Diarrhea | Headache | Dizziness | Thermoregulatory effects (e.g., fever, warmth, hot flushes, chills)
• Contact clinician
  • Heavy bleeding: Soaking >2 maxi pads per hour for 2 consecutive hours
  • <1% of patients will require intervention (e.g., aspiration) for excessive bleeding
  • Seek care at the nearest facility of care if emergency situation arises
• Routine in-person follow-up not necessary
  • If patient wishes clinical follow-up: Medical history | Clinical examination | Serum hCG
  • If ultrasound performed: “…sole purpose is to determine whether the gestational sac is present or absent. The measurement of endometrial thickness or other findings do not predict the need for subsequent uterine aspiration”

Medication Failure

Need for Uterine Aspiration Due to Ongoing Pregnancy or Retained Tissue

• Incomplete
  • Repeat dose of misoprostol or
  • Uterine aspiration or
  • Expectant management
• Ongoing pregnancy
  • Repeat dose of misoprostol or
• Uterine aspiration

Note: Management choices based on clinical situation and patient preference

Teratogenicity 

• Misoprostol in a teratogen associated with Möbius’ syndrome (facial paralysis)
  • Counsel regarding teratogenicity prior to providing medication abortion
• In case of unsuccessful medication abortion
  • Counsel regarding teratogen risk and all pregnancy options
• If patient opts to continue pregnancy
  • Monitor expectantly

KEY POINTS:

• Counseling prior to procedure  
  • Medication abortion failure rates requiring aspiration increase toward 10 week gestation (approximately 3 % ongoing pregnancy) but is still low
  • Contraception  
    • Can be initiated on day 1 (mifepristone intake) except for IUD and permanent contraception
    • All contraceptive methods are considered safe after successful medication abortion
    • Use of DMPA on day 1 may increase the risk of ongoing pregnancy
  • Medication abortion does not impact future fertility or pregnancy outcomes  
• Any clinician that can screen and provide follow-up can provide medication abortion
• Mifepristone can be taken at home and can be self-administered by patients
  • Medication abortion can be provided via telemedicine services
• Prophylactic antibiotics are not required
• Use NSAIDS for pain management

Note: ACOG has released a Practice Advisory on mifepristone and the FDA Risk Evaluation and Mitigation Strategy (REMS)

The FDA has permanently removed the in-person dispensing requirement and added a new pharmacy certification process, which will enable retail pharmacies that meet certain qualifications to dispense mifepristone directly to patients who have a prescription from a certified prescriber

All other previous mifepristone REMS requirements remain in effect, including the need for prescriber certification and completion of Prescriber and Patient Agreement Forms 

Primary Sources – Learn More:

ACOG Practice Bulletin 225: Medication Abortion Up to 70 Days of Gestation

ACOG: Updated Mifepristone REMS Requirements

Related ObG Topics:

Does Adding Mifepristone Prior to Misoprostol Improve Medical Management of Pregnancy Loss?

Managing Early Pregnancy Loss

Surgical vs Pharmaceutical Abortion: Comparing the Risks for Serious Adverse Events