Medication Abortion Up to 70 Days of Gestation
Publication Date: October 1, 2020
Last Updated: March 14, 2022
Recommendations
Combined mifepristone–misoprostol regimens are recommended as the preferred therapy for medication abortion because they are significantly more effective than misoprostol-only regimens. If a combined mifepristone–misoprostol regimen is not available, a misoprostol-only regimen is the recommended alternative. (A)
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Clinicians should counsel patients that medication abortion failure rates, especially continuing pregnancy rates, increase as gestational age approaches 10 weeks. (A)
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Any clinician with the skills to screen patients for eligibility for medication abortion and to provide appropriate follow-up can provide medication abortion. (A)
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Patients can safely and effectively use mifepristone at home for medication abortion. (A)
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Patients can safely and effectively self-administer misoprostol at home for medication abortion. (A)
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Nonsteroidal anti-inflammatory drugs are recommended for pain management in patients who undergo a medication abortion. (A)
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Routine in-person follow-up is not necessary after uncomplicated medication abortion. Clinicians should offer patients the choice of self-assessment or clinical follow-up evaluation to assess medication abortion success. If medically indicated or preferred by the patient, follow-up evaluation can be performed by medical history, clinical examination, serum human chorionic gonadotropin (hCG) testing, or ultrasonography. (A)
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If an ultrasound examination is performed at follow-up after medication abortion, the 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. (A)
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Medication abortion is not recommended for patients with any of the following: confirmed or suspected ectopic pregnancy, intrauterine device (IUD) in place (the IUD can be removed before medication abortion), current long-term systemic corticosteroid therapy, chronic adrenal failure, known coagulopathy or anticoagulant therapy, inherited porphyria, or intolerance or allergy to mifepristone or misoprostol. (B)
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Before undergoing medication abortion, patients should be counseled regarding the teratogenicity of misoprostol in the event of an unsuccessful medication abortion. (B)
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Before medication abortion is performed, the clinician should confirm pregnancy and estimate gestational age. For patients with regular menstrual cycles, a certain last menstrual period within the prior 56 days, and no signs, symptoms, or risk factors for ectopic pregnancy, a clinical examination or ultrasound examination is not necessary before medication abortion. (B)
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Most patients with clinical indications for an ultrasound examination before medication abortion can be initially screened with transabdominal ultrasonography, reserving transvaginal ultrasonography for situations in which further clarification is required. (B)
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Medication abortion can be provided safely and effectively by telemedicine with a high level of patient satisfaction. (B)
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The routine use of prophylactic antibiotics is not recommended for medication abortion. (B)
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An incomplete medication abortion can be treated with a repeat dose of misoprostol, uterine aspiration, or expectant management, depending on the clinical circumstances and patient preference. (B)
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Ongoing pregnancy after medication abortion can be treated with a repeat dose of misoprostol or uterine aspiration, depending on the clinical circumstances and patient preference. (B)
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Patients undergoing medication abortion who desire contraception should be counseled that
- almost all contraceptive methods, except IUDs and permanent contraception, can be safely initiated immediately on day 1 (mifepristone intake) of medication abortion.
- all contraceptive methods can be safely initiated after successful medication abortion.
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Patients who select depot medroxyprogesterone acetate (DMPA) for contraception should be counseled that administration of DMPA on day 1 of the medication abortion regimen may increase the risk of ongoing pregnancy. (B)
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Patients can be counseled that medication abortion does not have an adverse effect on future fertility or future pregnancy outcomes. (B)
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Patients who choose abortion should be counseled about all methods available as well as the risks, advantages, disadvantages, and the different features of these options. (C)
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Most patients at 70 days of gestation or less who desire abortion are eligible for a medication abortion. (C)
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Patient counseling before medication abortion should include discussion of when patients should contact their clinician in the case of heavy bleeding (soaking more than two maxi pads per hour for 2 consecutive hours) and when to access urgent intervention. (C)
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All patients with a continuing pregnancy after using mifepristone and misoprostol should be provided with all pregnancy options and a thorough discussion of the risks and benefits of each. (C)
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In the very rare case that patients change their mind about having an abortion after taking mifepristone and want to continue the pregnancy, they should be monitored expectantly. (C)
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Rh testing is recommended in patients with unknown Rh status before medication abortion, and Rh D immunoglobulin should be administered if indicated. In situations where Rh testing and Rh D immunoglobulin administration are not available or would significantly delay medication abortion, shared decision making is recommended so that patients can make an informed choice about their care. (C)
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Clinicians who wish to provide medication abortion services should be trained to perform uterine evacuation procedures or should be able to refer to a clinician who has this training. (C)
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Recommendation Grading
Overview
Title
Medication Abortion Up to 70 Days of Gestation
Authoring Organization
American College of Obstetricians and Gynecologists
Publication Month/Year
October 1, 2020
Last Updated Month/Year
February 6, 2024
Supplemental Implementation Tools
Document Type
Consensus
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Adolescent, Adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Physician, nurse nurse midwife, nurse certified nurse midwife, nurse, nurse practitioner, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D000028 - Abortion, Induced
Keywords
abortion, medication abortion, medical abortion
Methodology
Number of Source Documents
128
Literature Search Start Date
January 1, 2000
Literature Search End Date
February 1, 2020