CHAPTER 4 TEACHING POINTS: MEDICATION ABORTION

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

EXERCISE 4.1

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

• • Yes. Patients can have a MAB and have the medications delivered to them if allowed in that state.
  • Studies have demonstrated safety, effectiveness, efficiency, and acceptability of direct-to-patient telehealth provision without any in-person visits (Raymond 2019), though U.S. restrictions still prevent this from being implemented beyond the research setting.
  • The follow up appointment may be done via telemedicine (with or without follow up urine hCG or serial blood hCGs drawn at a location in close proximity to the patient).
  • Consider legality of telemedicine MAB depending on the state of practice (KFF 2022).

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

1. • MAB is >95% effective in most settings. Continuing pregnancy rate is rare (≤1% to 3%, as above) regardless of pregnancy dating when using the recommended mifepristone with misoprostol regimens. Redosing misoprostol alone (or mifepristone and misoprostol) is an option that can be discussed but has limited evidence. For >63 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 CPG 2022).
   • Uterine aspiration may be needed for excessive bleeding/cramping, or by patient request.
   • For persistent gestational sac without evidence of development, a 2nd dose misoprostol can be offered, or patient can be followed for several more weeks if stable.
   • For asymptomatic patient (minimal bleeding or cramping) with echogenic material and thickened endometrial stripe on US, no further treatment is necessary.

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

• • After misoprostol, bleeding usually starts within 1 to 10 hours (average 4 hours).
  • Bleeding can be heavier than a normal period and accompanied by cramps and/or clots. Bleeding usually slows substantially after passing the pregnancy.
  • If the bleeding soaks more than 2 maxi-pads per hour for greater than 2 consecutive hours, that is more than normal; have patient call if they are concerned.
  • Hypovolemia symptoms 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).
  • There is scant data regarding the optimal treatment for moderate bleeding. The efficacy of commonly used agents (such as a second dose of misoprostol, methylergonovine, or a tapered regimen of high-dose oral contraceptives) is unknown.

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4. What will I see when the pregnancy passes?

• • Below 63 days LMP, blood and clots are normally visible, and it is unlikely a patient would identify an embryo.
  • At > 63 days LMP, the fetus may be identifiable; counsel patients accordingly.
  • Consider showing a drawing and counsel with information such as: “At X weeks of pregnancy, this is what the pregnancy / fetus looks like. Would you like more information or do you want to go ahead with the medication abortion?” If they are not comfortable, they may prefer an aspiration abortion.

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

• • The symptoms of an abortion with pills and a miscarriage (spontaneous abortion) are identical. Miscarriage happens in 15-20% of all pregnancies

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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?
   

• • Discuss the individual circumstance with the patient, to help them decide whether a medication or an aspiration abortion might be preferable.
  • Explore options for a safe location where the young person might be able to use the misoprostol; e.g. a supportive relative’s house, a friend’s house.

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7. 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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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.
   

1. 1. Discuss the individual circumstance with the patient, to help them decide whether a medication or an aspiration abortion might be preferable.
      • No, due to unknown LMP and irregular spotting, we are unable to date the pregnancy or confirm intrauterine pregnancy. Additionally, provision via telemedicine must be allowed in your state (currently in 31 states; KFF 2022).
   2. What additional workup do I need?
      • The patient therefore needs an US prior to visit or in the office.
   3. I received the medications in-person after an ultrasound showed a 6 wk pregnancy. I get telemedicine follow up in 1 week. In addition to confirming abortion completion, what else will I need?
      • Even in amenorrheic patients, testosterone therapy does not necessarily stop ovulation, and is not effective as contraception (Bonnington 2019). Discuss birth control options during the initial appointment or during follow up if patient desires.

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EXERCISE 4.2

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?
   • 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. Have the patient recheck temperature again in 2-3 hours.

b) 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 office visit to evaluate for infection. Work-up should include:
    • Evaluation for other etiologies of symptoms
    • Questions about pelvic pain, bleeding pattern, or odorous discharge
    • Review of systems to rule out other sources of fever
    • Pelvic exam for tenderness, pus, GC/CT if not done prior
    • CBC to evaluate for leukocytosis.
    • Ultrasound to evaluate for retained tissue

• • Significant pelvic or cervical motion tenderness with fever suggests post-abortal endometritis, and appropriate antibiotics should be initiated. If US shows significant intrauterine material, uterine aspiration is also indicated.

• • 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 (abdominal or pelvic pain, nausea, diarrhea, malaise) along with dramatic leukocytosis and hemoconcentration (Fjerstad 2011, Meites 2010) In patients with this presentation, a high index of suspicion is needed for Clostridium-mediated toxic shock syndrome as it may progress rapidly to fulminant sepsis and death. If atypical infection is suspected, refer for inpatient sepsis management with infection disease consultation.

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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, sublingual, oral misoprostol). What should I do?
   
   • If the misoprostol pills are vomited (or fall out if taken vaginally) less than 30 minutes after placed, the patient may need a second misoprostol dose. 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. Discuss taking antiemetics prior to redosing misoprostol if the patient vomited.

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3. I took 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?

• • Mifepristone alone may cause bleeding but is often inadequate for successful abortion; misoprostol significantly increases efficacy – and therefore the safety of the regimen.
  • Advise the patient to take misoprostol now.

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

• • Nothing. There is no need to redose the mifepristone if ingested for >30 minutes.

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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?

• • Assess the amount of bleeding, symptoms of hypovolemia to ensure no hemorrhage.
  • Review records for confirmation of MAB completion (symptom check with negative home urine pregnancy test, adequately down-trending serum hCG, or US).
  • If there has been little to no interim symptoms of prolonged bleeding and cramping, this new onset heavy bleeding may represent onset of menses.
  • If prolonged bleeding and cramping have been ongoing, consider evaluation and management with uterine aspiration as appropriate.

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EXERCISE 4.3

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.

• • This patient’s rapidly rising hCG level suggests continuing viable pregnancy, despite a history of bleeding after misoprostol. Ectopic pregnancy should also be excluded.
  • Consider US, if available and the patient is able to follow up in the office.
  • If ectopic can be firmly ruled out with an US, treatment options include aspiration, repeat misoprostol alone (second dose is about 30% effective), or repeat mifepristone with misoprostol (may be a patient-centered option, but no evidence base for efficacy).
  • If no intrauterine pregnancy is identified despite rising hCG, the patient must be evaluated and treated for presumed ectopic pregnancy.

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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 in 2 weeks, there is a moderate amount of heterogeneous debris in the endometrial cavity.

1. 1. What management would you suggest for heterogeneous uterine material?
      • If US is performed at the follow-up visit, the sole purpose is to determine if the patient is still pregnant (SFP 2014).
      • 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 2022).
      • Providers can monitor such patients based on symptoms (SFP 2014).
   2. How would you manage this patient differently if they were symptomatic with ongoing moderate vaginal bleeding and/or cramping?
      • An aspiration may be warranted for hemodynamic instability or for patient preference (SFP Clinical Guidelines 2014).
      • Clinicians providing MAB may wish to be trained in uterine evacuation procedures; alternatively, they may establish referral relationships with other providers trained in aspiration.

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3. A 19 year-old G4P0 patient 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?
      • Hemodynamic status (orthostasis or orthostatic vital signs)
      • Exam to assess active bleeding and uterine bogginess
   2. What diagnostic work-up may be of assistance?
      • Hemoglobin/hematocrit
      • Ultrasound (if available)
   3. What management options would you offer this patient?
      • Urgent uterine aspiration is indicated
      • Intravenous access is likely indicated
      • Uterotonics may be indicated
      • Initiate iron supplementation as needed
      • Blood transfusion is rarely needed but may be necessary.
   4. What are indications for a uterine aspiration after medication abortion?
      • Bleeding in hemodynamically unstable patient (emergent)
      • Continuing pregnancy: Persistent growth, cardiac activity, or persistent increase in hCG. Can offer:
        • Uterine aspiration
        • Asecond dose of misoprostol (completes expulsion in 35% patients with ongoing pregnancy <63 days; Reeves 2008), or
        • Repeat misoprostol and mifepristone (patient-centered but not evidence based approach, lacking data on efficacy), or
      • Symptomatic problematic bleeding / cramping unresponsive to medical treatment
      • Patient preference if declines repeat misoprostol and has retained pregnancy or tissue