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: 20 mg | Oral
  • Misoprostol: 800 micrograms | Buccal
  • Interval between drugs: 24 to 48 hours
• Combination WHO recommended
  • Mifepristone: 20 mg oral
  • Misoprostol: 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: