• Nathan Riley, MD

Obgyno Wino Podcast Episode 55 - Medical Abortion up to 70 Days of Gestation

“If we do not believe within ourselves this deeply rooted feeling that there is something higher than ourselves, we shall never find the strength to evolve into something higher.” - Rudolf Steiner

2017 Willamette Valley Pinot Noir from Chemistry Wine

PB#225 - Published October 2020

Five Pearls

1. Medication abortion is safe and effective (just slightly less effective than uterine evacuation).

2. The standard regimen is mifepristone 200 mg PO followed by misoprostol 800 mcg per vagina 24-48 hrs later

3. Patients who reliably report menstruation within 56 days of presentation for medication abortion do not require ultrasound confirmation.

4. Patients at high risk for ectopic pregnancy based your clinical assessment should not be offered medication abortion.

5. Medication abortion has no adverse effect on future fertility or future pregnancy outcomes.

Stats on abortion in the U.S.

- 25% of women will have an abortion during their lifetime

- 60% occur at ≤ 10 wga

- 40% of abortions are performed by medication

- medication abortion is attributed with the shift in recent years of abortion to earlier gestational ages

What are the options for abortion?

- counseling should include risks and benefit of both procedural (i.e. uterine aspiration) and medical management

- medication abortion takes longer to completion, requires more active patient participation

- uterine aspiration requires one visit, is slightly more effective, and allows for direct assessment of pregnancy tissue by the clinician (in medication abortion, the tissue will be passed at home and generally discarded)

- if medication abortion doesn't work, uterine aspiration may still be necessary (0.2% chance within 24 hrs of medication administration)

How does medication abortion work?

- mifepristone + prostaglandin E1 (misoprostol); the former blocks progesterone receptors while the latter causes cervical ripening and uterine contractions

- if mifepristone is unavailable, then misoprostol alone will suffice

- mifepristone's activity leads to decidual necrosis, cervical softening, and increased sensitivity to prostaglandins (e.g. misoprostol)

- mifepristone is sometimes hard to get because of the FDA's risk evaluation and mitigation strategy (REMS) program, which permits the drug to be dispensed by only certain healthcare settings under a certified prescriber

- patient can expect cramping and bleeding (both much heavier than menses)

- adverse effects usually occur after misoprostol versus mifepristone (nausea 43-66% , vomiting 23-40%, diarrhea 23-35%, headache 13-40%, dizziness 28-39%, and thermoregulatory effects like hot flushes or chills 32-69%) --> GI issues are common but less so with vaginal routes!

Note: enteral misoprostol is not mentioned because it's less effective!

- counsel your patient that they should seek medical attention if their bleeding exceeds 2 heavy pads per hour for 2 consecutive hours

Eligibility and contraindications to medication abortion

- gestational age must be 70 days or less

- may be preferable to uterine aspiration in the presence of uterine fibroids that distort the cervical canal or uterine cavity, presence of congenital uterine anomalies, or introital scarring resulting from infibulation

- twin pregnancy also not a contraindication, same regimen will work

Note: infibulation is a practice of some northeastern African cultures consisting of clitoral excision and approximation of the vulva to prevent intercourse or clitoral stimulation; it's also referred to as female genital mutilation

- contraindications: ectopic pregnancy, if patient is on long-term systemic steroid therapy, patients with chronic adrenal failure, known coagulopathy or on anticoagulation, patients with inherited porphyria, or a known intolerance or allergy to mifepristone or misoprostol

- remove an IUD before medication abortion

- anemia should also prompt consideration given transfusion rate after medication abortion is higher than uterine evacuation (albeit both have low absolute risk: 0.1% versus 0.01%, respectively)

- don't offer medication abortion to a patient for whom you have concerns about their ability to follow-up

When should I recommend uterine aspiration if I suspect medication abortion has failed or is incomplete?

- totally a clinical decision

- depends on how the patient is feeling and whether bleeding is slowing

- check baseline H/H and vital signs

Is there a risk for teratogenicity if the medication route fails?

- no evidence of teratogenic effect from mifepristone

- misoprostol is associated with limb defects +/- Möbius' syndrome (type of facial paralysis) when used in the 1st trimester

- this should be included in counseling (although the vast majority of patients go through with uterine aspiration after medication abortion failure)

What if a patient takes mifepristone then changes their mind before they takes the misoprostol, Will taking high dose progesterone increase the likelihood of pregnancy continuing unaffected?

- ACOG says no. But only this was paper was cited, and it suggests that studies to support this theory were poorly contrived

- Side note: mifepristone administration without misoprostol carries increased risk of excessive bleeding

What needs to happen in the clinic before medication abortion?

- counseling and careful history and review of systems

- estimation of gestational age by menstrual cycle history or by ultrasound (goes transabdominal if possible!)

- if LMP was reliably within 56 days of medication abortion, no ultrasound is required beforehand to confirm dating

- if there's any suspicion for ectopic pregnancy (or strong history), do your full workup (medication abortion is probably not recommended)

- check Rh status if unknown (Rho(D) immune globulin should be administered if indicated per ACOG) --> though this remains up for debate helpful at <10 wga

- H/H may be indicated but only if you suspect anemia based on clinical findings or patient's history

- telemedicine can be used safely and effectively for the diagnosis and management of medication abortion!

Recall: risk factors of ectopic pregnancy include prior tubal surgery, history of PID, pregnancy in setting of progestin-only contraception or IUD)

Are prophylactic antibiotics recommended?

- No. Risk of serious infection is <1%

How can I best manage a patient's pain after medication abortion?

- pain usually abates within 24 hrs

- NSAIDs are the mainstay; don't prescribe opioids! (if pain is that bad, you probably should recommend they come in for evaluation!)

- my go-to: ibuprofen 400-600 mg every 4-6 hrs PRN (not to exceed 2400 mg in 24 hrs)

Should my patient follow-up in the clinic?

- unlikely that this will be desired by your patient or clinically helpful in any way

- not necessary but reasonable to offer it to the patient

- if a patient thinks they passed pregnancy tissue, they are right >95% of the time; if there's any doubt, you can trend serial hCG (a drop in hCG of 80% collected 6 days after medication abortion indicates success)

- post-abortion ultrasound is also not super helpful; measuring the EEC tells you nearly nothing; if you do an US, look for GS. Only 6% of patients require uterine aspiration if no GS is noted

- if GS is present, it will likely be expelled without intervention (even if GS noted 2 weeks out)

- if patient has bothersome symptoms, you can repeat dose of misoprostol 800 mcg per vagina (uterine evacuation is always on the table; same goes for a total medication failure)

- make sure they have adequate social support at home! and have some support group or counselor information on-hand

How should I counsel my patient on contraception after their medication abortion?

- apart from IUD or permanent sterilization, all methods are available on day 1 (when they take mifepristone)

- 1 week after the mifepristone, all methods are available, including IUD

- placement of an IUD within 6 weeks of medication abortion carries higher risk for expulsion (still overall low risk, ~2%)

Fun fact: patients who opt for depot medroxyprogesterone acetate on day 1 may increase the risk of ongoing pregnancy (the progesterone may counter the mifepristone, but AOCG mentions previously in this PB that the likelihood is low)

Will medication abortion affect my fertility?

- No. Studies consistently show that medication abortion has no adverse effect on future fertility or on pregnancy outcomes

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