EXERCISES: MEDICATION ABORTION

The exercises refer to mifepristone and misoprostol regimens unless otherwise stated.

EXERCISE 4.1

Purpose: To practice responses to questions that may arise during counseling.

What would you tell patients who ask the following questions?

1. I live 4 hours from the clinic. Can I still get the abortion pill? Can it be delivered?

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2. What are my chances of needing an aspiration abortion?

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3. How will I know if I’m bleeding too much?

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4. What will I see when the pregnancy passes?

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5. My partner wants me to keep this pregnancy. Will they know that I had an abortion?

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6. I got a judicial bypass and my parents don’t know I’m pregnant and having an abortion. Is this the right method for me?

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7. I took abortion medications that I ordered online from a website. Does my provider have to report it?

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8. I had a positive pregnancy test – a surprise because I am on testosterone which I’m taking as a transgender male. I am unsure of my LMP due to irregular spotting. I am interested in abortion pills being delivered to my home.
   • Do I qualify for a telemedicine medication abortion?
   • What additional workup do I need?
   • I received the medications in-person after an US showed a 6 wk pregnancy. I get telemedicine follow up in 1 week. In addition to confirming abortion completion, what else will I need?

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EXERCISE 4.2

Purpose: To practice responding to follow-up questions that may arise by telephone.

How would you respond to the following questions?

1. a. I took the misoprostol 2 hours ago. Now my temperature is 100.5° F and I feel like I have the flu. Should I be concerned?
   b. I took the misoprostol 30 hours ago and passed the pregnancy 24 hours ago, but now my temperature is 101.5 ° F.

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2. I used the medication vaginally, but I think one of those pills just fell into the toilet (or vomited if using buccal or sublingual misoprostol). What should I do?

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3. I took the mifepristone in the clinic yesterday and started to bleed like a period this morning. I have not taken the misoprostol yet. What should I do?

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4. I vomited three hours after using the mifepristone, what should I do?

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5. I am having new really heavy vaginal bleeding. It has been 4 weeks since my medication abortion. What should I do?

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EXERCISE 4.3

Purpose: To practice follow-up and management of complications after medication abortion.

How would you manage the following situations?

1. A 29 year-old G3P1 patient requests medication abortion and is 6 weeks by LMP. Serum hCG level is 782 IU/L. Following mifepristone and misoprostol, the patient has moderate bleeding and cramping. When the patient returns on Day 4, serum hCG level is 5530 IU/L.

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2. A 25 year-old G2P1 patient returns for follow-up after taking mifepristone and misoprostol. They report moderate bleeding and cramping a few hours after taking misoprostol, and have had no complaints since then. On a follow-up ultrasound, there is a moderate amount of heterogeneous debris in the endometrial cavity.
   1. What management would you suggest for uterine debris?
   2. How would you manage this patient differently if they were symptomatic with ongoing moderate vaginal bleeding and/or cramping?

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3. A 19 year-old G4P0 patient who took mifepristone 4 days ago and took misoprostol 3 days ago returns today because of very heavy vaginal bleeding. They state they have soaked 5 maxi-pads in the last 3 hours.
   1. What should you assess first?
   2. What diagnostic work-up would you initiate?
   3. What management options would you offer this patient?
   4. What are indications for a uterine aspiration after medication abortion?

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