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CHAPTER 4 TEACHING POINTS: MEDICATION ABORTION

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

EXERCISE 4.1 (COUNSELING)

  1. I live 4 hours away from the clinic. Can I still get the abortion pill? Can it be delivered to me at home?
  • Yes, MAB medications can be delivered to them at home. At time of publication MAB is available via mail in all 50 states (provided by clinicians living in states with abortion Shield Laws; see PlanCPills.org)
  • Studies have demonstrated safety, effectiveness, efficiency, and acceptability of direct-to-patient telehealth provision without any in-person visits (Raymond 2019) with medications delivered to the their requested address
  • A follow up appointment is optional and may be done via telehealth (with or without follow-up UPT or serial quantitative blood hCGs).
  • People living in states with abortion restrictions or bans may consider using Shield Law telehealth providers. Shield Laws protect the providers who prescribe the medication, but legal questions still remain. Since Dobbs vs. Jackson Women’s Health in 2022, hundreds of thousands of Americans living in states with bans or restrictions have accessed abortion through Shield Law providers. For specific questions, please use If/When/How Repro Legal Helpline.

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  1. What are my chances of needing an aspiration abortion after medication abortion?
    • MAB is >95% effective in most settings, but may vary based on clinician’s likelihood to intervene. Continuing pregnancy rate is rare (≤1% to 3%) regardless of pregnancy dating when using the recommended mifepristone with misoprostol regimens. Management options include: redosing with misoprostol alone, with mifepristone and misoprostol (expert opinion; studies are lacking), or following the person without medical intervention for several more weeks if stable. Use shared decision-making regarding repeating MAB vs aspiration.
    • For 63-90 days LMP, the total incidence of aspiration after MAB is 2-9%, with the range decreasing to <1% to 3% when a second dose of misoprostol is used (NAF 2024).
    • Uterine aspiration may be needed for excessive bleeding/cramping or by a patient’s request.
    • For an asymptomatic person (minimal bleeding or cramping) with echogenic material and thickened endometrial stripe on an US (and absent gestational sac), no further treatment is necessary.

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  1. How will I know if I’m bleeding too much?
    • After misoprostol, bleeding usually starts within 4-6 hours.
    • Bleeding can be heavier than an expected period and accompanied by cramps and/or large clots. Bleeding usually slows substantially after passing the pregnancy.
    • If the bleeding soaks more than 2 maxi-pads per hour for more than 2 consecutive hours, that is more than normal; have the person repeat NSAIDs and misoprostol and plan to call them in the next 30-60 minutes to evaluate for improvement.
    • Hypovolemia symptoms (e.g., dizziness, syncope) warrant immediate evaluation (history, orthostatic vital signs, pelvic exam) and often urgent uterine aspiration.
    • Hemoglobin or hematocrit can guide the need for iron or blood transfusion.
    • Blood transfusion is rarely needed (<0.2% of cases).
    • No single method of treating post-medication bleeding is universally considered superior, but approaches have included repeat misoprostol, methylergonovine, NSAIDs, high dose oral contraceptives, and expectant management. Repeat misoprostol is frequently helpful, but data is lacking.Use of oral contraceptives showed decrease in total bleeding days (Che 2016), and NSAIDS for 3-5 days have been shown to be effective for other causes of heavy menstrual bleeding (Bofill Rodriguez 2019).

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  1. What will I see when the pregnancy passes?
    • At < 9 weeks LMP, blood and clots are usually visible, and a gestational sac may be seen (white frond-like material in clumps), but it is unlikely to identify an embryo.
    • At > 9 weeks LMP, a fetus may be identifiable; counsel people accordingly.
    • If asked, consider showing a drawing and counsel with information such as: “At the point you are in pregnancy, this is what the pregnancy / fetus looks like. Would you like more information?” If requested, you can share images on https://myanetwork.org/the-issue-of-tissue/ for 9 weeks and less, or https://www.ineedana.com/pills-after-12-weeks for more information. Pregnancy tissue < 14 weeks can be treated as other biological material (blood and pregnancy tissue can be flushed and soiled pads can be discarded).

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  1. My partner wants me to keep this pregnancy. Will they know that I had an abortion?
    • As a provider it is important to remember that partners have reported people to the police and people who have abusive partners are more at risk of being reported. You can tell them that symptoms of an abortion with pills and a miscarriage (early pregnancy loss) are identical. This happens in 15-20% of all pregnancies, so a partner will not know the difference. There is no current test to show that a person has used mifepristone and/or misoprostol to end their pregnancy, although when misoprostol is used vaginally, pill fragments may remain for multiple days. For information about avoiding digital footprints, see Digital Defense Fund guide to abortion privacy.

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  1. 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?

    • Discuss the individual circumstances, to help the person decide whether a medication or a procedural abortion might be preferable.
    • Explore options for a safe location where they might be able to use the medications and pass the pregnancy; e.g. a supportive relative’s home or a friend’s home. For information about avoiding digital footprints, see Digital Defense Fund guide to abortion privacy.

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  1. I took abortion medications that I ordered online from a website. Does my doctor have to report it?
    • Self-managed abortions by any method are criminalized in some states in the U.S. and people can face prosecution. Health care providers do not have to report it if you disclose it to them. Please refer to https://www.reprolegalhelpline.org/ for more details.
    • There is no blood test to find out if you took the abortion medications. However, patients in restrictive areas may want to avoid vaginal misoprostol, as fragments may be found on vaginal exam.

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  1. I have irregular periods, and had a positive pregnancy test – a surprise as I’m taking testosterone as a transgender male.
    1. What workup do I need before a medication abortion?
      • Irregular cycles (or even amenorrhea) associated with testosterone will not necessarily stop ovulation, and are not effective as contraception (SFP 2020). This person’s self-report of a positive pregnancy test is enough to confirm pregnancy, but given an unknown LMP this patient needs an US for dating. There are no other differences in medication abortion provision (see Ch. 2: Gender Identity and Pregnancy)
    2. How might I get an ultrasound in a state that bans abortion?
      • An US may be obtained from a community health center , family planning clinic, local Ob/Gyn with ultrasound.
      • Try ordering an OB/Gyn US via https://radiologyassist.com/, which advertises national scheduling with a mild discount, and payment plans. However, it creates a paper trail with the patient’s name and an out-of-state provider.
      • If insured and the above are unavailable, any clinician can order an US to an independent imaging center, or the person can try with a local Urgent Care or ED.
      • The patient does not need to share their plans/desire for abortion with any health care professional when obtaining an US
      • If none of the above are available, and only as a last resort, consider having them go to a Crisis Pregnancy Center (CPC). CPCs have been known to give intentionally misleading information, USs, and gestational measurements in an effort to encourage people to continue their pregnancies, but sometimes are the only affordable option. If they go, advise they:
        • Use an alias, and leave both phone and ID at home
        • If they must take a phone, turn off location services to avoid tracking.
        • Expect to be given information that is not evidence-based (misinformation about abortion causing cancer, infertility, etc.)
        • Stay alert – make sure the US image is your own (some centers give false images)
        • Request a copy of the US images, or take a photo of it, including identifiers and measurements.
        • Note: This is something our movement should address by increasing the number of abortion positive pregnancy centers.

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EXERCISE 4.2 (FOLLOW-UP TRIAGE BY TELEHEALTH OR IN-PERSON CARE)

  1. I vomited three hours after using the mifepristone, what should I do?
    • Nothing. There is no need to redose the mifepristone if ingested for >60 minutes.

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  1. My pills fell in the toilet (after vaginal use; or vomited after buccal or sublingual use). What should I do?

    • If the misoprostol pills fell in the toilet (or were vomited if taken buccally or sublingually) less than 30 minutes after being placed, a second misoprostol dose may be needed. Discuss taking antiemetics prior to redosing misoprostol if the patient vomited, or use a vaginal route. If >30 minutes has elapsed, there is no need to redose as the active ingredient will have had adequate time to be absorbed, even if the pill appears undissolved. They may choose to wait to see if appropriate bleeding begins, and re-dose if no bleeding occurs within 4 hours.

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  1. 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?
    • No. Common side effects of misoprostol are temperature elevation, and flu-like symptoms. These are usually self-limited, and the body temperature should return to normal within a few hours. They can recheck a temperature and call you if still having these symptoms or higher fever, especially if symptoms occur/persist >24 hours after the misoprostol dose.

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  1. I took pills but had no bleeding?
    1. Mifepristone alone can cause bleeding (in 10%), but is usually inadequate for successful abortion; misoprostol should be taken if not yet taken.
    2. Determine how long ago the person took the pills and whether it was mifepristone or misoprostol (with route taken) or both.
    3. Advise the person to take misoprostol depending on what pills were previously taken, the route they were taken, and when.
    4. Ask the brand of UPT used (Clear Blue, Early Response and digital tests have many false positives, as they’re extremely sensitive, so consider a different brand)
    5. Recheck dating and confirm the number of weeks pregnant.
    6. The recommendations for taking misoprostol for < 9 weeks are 4 tabs once; whereas at > 9 weeks 4 tabs followed by another 4 tabs four hours later.
    7. They can repeat misoprostol four hours after the last dose (rather than waiting a full 24 hours), as multiple doses of misoprostol are more effective in the first 24 hours.

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  1. One week after misoprostol pills, I still have ongoing pregnancy symptoms.
    1. Consider the type of pregnancy symptoms they are reporting. Persistent nausea and vomiting are more sensitive than continued bloating or fatigue.
    2. Recheck dating
    3. Ask when they took mifepristone, and when they took misoprostol dose(s), considering if it was 4 tabs if < 9 weeks, whereas at > 9 weeks 4 tabs followed by another 4 tabs 4 hours later.
    4. Have them recheck UPT to ensure it is still positive: using an inexpensive, two-line test.
    5. Differentiate their symptoms from another illness (e.g. URI with cough, sneeze, aches, sore throat).
    6. Consider repeating the entire MAB regimen or offering procedural abortion.
    7. Consider serum hCG testing or an US to understand pregnancy status.

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  1. I have ongoing positive urine pregnancy test at 5 weeks
    1. Generally, wait until 5 weeks to recheck UPT, as it remains positive until hCG reaches 5-25. They can consider checking it again in one week.
    2. Ask if UPT was taken with first morning urination (when urine is diluted)).
    3. Ask what brand of UPT was used (Clear Blue, Early Response and digital tests have many false positives, as they are extremely sensitive, so might try a different brand). Did they read the result at the time indicated on the package? (This can look falsely positive due to evaporation).
    4. Ask if they had bleeding as expected after taking the pills?
    5. How many weeks pregnant at the time they took the pills?
    6. Ask if they have ongoing pregnancy symptoms?
    7. Ask if they had sex since the MAB. Could it be a new pregnancy?
    8. Consider US to check pregnancy status and determine dating.
    9. If it seems to be an ongoing or new pregnancy, consider repeating the entire MAB regimen or having them obtain a procedural abortion. If ongoing pregnancy is suspected, ensure MAB dose adjustment, as needed, based on gestation of ongoing pregnancy.

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  1. If followed with serial hCGs, and the initial level is 782 IU/L and rises to 5530 IU/L on Day 4 after mifepristone and misoprostol.
    1. The rapidly rising hCG level suggests ongoing pregnancy or ectopic pregnancy.
    2. Obtain US as soon as possible.
    3. If ectopic is ruled out, treatment options include repeating the entire MAB regimen or offer/refer for procedural abortion.
    4. If they are now > 12 weeks, M&A Hotline can assist with a referral.
    5. If no intrauterine pregnancy is identified despite rising hCG, the patient must be evaluated and treated for presumed ectopic pregnancy.

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  1. If being followed up after MAB with ultrasound:
    1. How do you counsel and manage someone with asymptomatic uterine debris on ultrasound?
      • Follow-up US is to determine if still pregnant.
      • Endometrial thickness should not be used to guide management after MAB. The post-abortion uterus will normally contain sonographically hyperechoic tissue that consists of blood, blood clots, and decidua (Reeves 2009 / 2008). In the absence of heavy bleeding or cramping, avoid unnecessary intervention for US findings (NAF CPG 2024). Clinicians can monitor such individuals based on symptoms (ACOG 2020).
    2. How would you counsel and manage this person differently if they were symptomatic with ongoing moderate vaginal bleeding and/or cramping?
      • An aspiration may be warranted for a person’s preference with ongoing symptoms, or for hemodynamic instability (ACOG 2020)
      • Uterine aspiration procedures can be provided by you, your clinic, or alternatively, via a referral relationship with another trained clinician.

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EXERCISE 4.3 (COMPLICATIONS)

Purpose: To practice management of complications after medication abortion, how would you manage the following situations?

  1. I took the misoprostol 30 hours ago and passed the pregnancy 24 hours ago, but now my temperature is 101.5 ° F.

Persistent elevated temperature (>100.4° F) for several hours or > 24 hours after misoprostol warrants an immediate evaluation for infection. The patient should be seen or referred for evaluation immediately. Evaluation should include:

  1. Questions about pelvic pain, bleeding pattern, odorous discharge, fever, malaise
  2. Review of systems to rule out other sources of fever
  3. Pelvic exam for tenderness, pus, GC/CT. Significant pelvic or cervical motion tenderness with fever suggests post-abortion endometritis, and appropriate antibiotics should be initiated.
  4. CBC to evaluate for leukocytosis
  5. US to evaluate for retained tissue. If the US shows significant intrauterine material, uterine aspiration is also indicated.
  6. If additional concerns arise for atypical infection, further evaluation may be warranted. In very rare cases, patients have presented with low-grade fever and nonspecific complaints (pelvic pain, nausea, diarrhea, malaise) along with dramatic leukocytosis and hemoconcentration (Fjerstad 2011, Meites 2010). With this presentation, a high index of suspicion is needed for Clostridium-mediated toxic shock syndrome, with immediate inpatient sepsis management and infection disease consultation.

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  1. I’m in a lot of pain (after misoprostol).
    1. What questions to ask; what differential diagnosis?
      • Important questions to ask:
        • Pain rating? Worse with jiggling / jumping? It is useful to mirror their language, not minimizing pain as “discomfort”.
        • Is pain one-sided or any shoulder pain? Any ectopics risk factors?
        • Any fever / chills / malaise (and when in relation to misoprostol)?
        • Any dizziness, weakness, orthostatic symptoms?
        • When was last NSAID, other medications?
        • What non-pharmacologic measures were tried (heat is amazing)
        • How much bleeding? Clots?
      • Differential diagnosis includes MAB pain, hematometra (retained clots), infection (needs more urgent procedure), ectopic pregnancy.
    2. What can I do, and must I go to the emergency department?
      • In addition to trying pain management above, have them take misoprostol 400 mg (if not having an emergent level of bleeding), to gently dilate the cervix and help squeeze out clots to stop bleeding.
      • If they are still in pain, evaluate them yourself or refer to the safest possible referral site or ED. To help avoid criminalization, caution them to focus on symptoms, without mentioning MAB medications used.
    3. What if the pain is mostly on one side?
      • For one-sided pain or any shoulder pain, review ectopic risk factors and obtain an US. If no intrauterine pregnancy is identified, the patient must be evaluated and treated for presumed ectopic pregnancy (possible methotrexate). For sample protocol for diagnosis and management and Ch. 3: Pregnancy of Unknown Location.
      • If ectopic is ruled out, treatment options include repeating the entire MAB regimen or offer/refer for procedural abortion. If they are now > 12 weeks and you do not provide services > 12 weeks, INeedAnA.com or the M&A Hotline can assist with a referral.

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  1. I took misoprostol a few hours ago, but have soaked 5 maxi-pads in 3 hours.
    1. Should I take the misoprostol I have at home, before I go to the emergency department?
      • This patient is having heavy bleeding of concern for hemorrhaging. Have them take misoprostol 400-800 mcg (sublingual, buccal or rectal so the vaginal bleeding doesn’t interfere with absorption). Proceed to the ED if bleeding doesn’t slow within 20-30 minutes (or take misoprostol on the way to the ED, and return home if the misoprostol works).
    2. What would you evaluate (exam and / or labs)?
      • Check for orthostatic symptoms and vital signs, obtain hemoglobin or hematocrit, and US if available.
    3. What management would you offer?
      • Consider management with repeat misoprostol or uterine aspiration as appropriate.
    4. What are indications for a uterine aspiration after MAB?
      • Emergent indications include
        • Excessive active bleeding with orthostatic hypotension or significant drop in hemoglobin/hematocrit
        • Signs or symptoms of endometritis with US showing intrauterine debris
      • Non-emergent indications:
        • Continuing pregnancy
        • Symptomatic problematic bleeding/cramping unresponsive to medication management
        • Patient preference if bothersome ongoing light/moderate bleeding

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  1. A person is at 7 weeks by LMP with 3 prior cesareans, is following up after medication abortion and experienced no bleeding. What would you do next?
    • This history raises concern for cesarean section ectopic pregnancy (CSEP), with pregnancy implantation in cesarean scar. Ultrasound should be performed, and compared to pre-medication ultrasound, if available. If CSEP is not identified, may consider repeat medication or aspiration, depending on patient preferences.
    • If there is concern for CSEP, ultrasound-guided uterine aspiration or operative resection is preferred and additional intragestational methotrexate may be considered (SMFM 2022). Depending on practice setting, may require transfer or higher level of care.

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