9.1 Medical Abortion Patient Assessment

How to confirm gestational age

• pregnancy test + last menstrual period

• Clinical physical exam

How to rule out ectopic pregnancy

• Risk factors for ectopic pregnancy, clinical symptoms (abdominal pain, vaginal bleeding)

• Ultrasound required if suspect ectopic pregnancy

Risk factors for ectopic pregnancy

• Previous ectopic pregnancy

• Tubal surgery

• Pregnancy through assisted reproduction techniques

• IUD in place

• History PID or salpingitis

Mifegymiso Absolute CIs

• Ambivalence about abortion

• Ectopic pregnancy

• Uncontrolled asthma

• Chronic adrenal failure

• Inherited porphyria

• Allergy to mifepristone or misoprostol

Mifegymiso Relative CIs

• Unconfirmed gestational age

• IUD inserted* (IUD should be removed before administration)

• Long term corticosteroid use

• Hemorrhagic disorder or anticoagulant therapy

• Anemia

Follow up protocol for medication medical abortion

Confirm able to follow-up within 7 – 14 days after administration

MIFE/MISO: Patient Counseling Checklist

• Directions for use – need to take as directed and in the right order

• Efficacy – highly effective, ends 98% of pregnancies if taken within 70 days (10 weeks)

• What to expect after taking MIFE/MISO

• Adverse effects and how to manage

• Considerations for start date

• Considered irreversible

• Suggestions for supportive care

• Reinforce the importance of adherence - MIFE/MISO is embryotoxic if pregnancy not terminated

• Review follow-up in 7 – 14 days with primary care provider/prescriber

Look at online tools for counselling IRL

Cramping counselling 

• Typically begins 2-4 hours after the misoprostol dose

• Cramping is worse than with menstrual period

• May take an analgesic for cramping/pain (NSAID)

• Some cramping may continue up to a day or so

Vaginal bleeding counselling

• Starts 1 – 48 hours after misoprostol dose

• Heavy bleeding may last 2 – 4 hours (lighter bleeding/spotting may continue until next period)

• Bleeding is heavier than normal and may contain lemon sized blood clots

• Be prepared with sanitary pads

When will the pregnancy pass once after taking the medication?

within 2 to 24 hours of taking the misoprostol.

How to manage fever, headache AE

May see fever within a few hours of MISO dose

Can take NSAID or acetaminophen to help

How to manage N/V AE

Can take dimenhydrinate

How to manage diarrhea AE

Can take loperamide to help

When to seek urgent care for bleeding after taking MIFE/MISO

• Soaking 2 maxipads per hour for more than 2 hours

• Clots larger than lemon size (2 or more hours)

When to seek urgent care for cramping/pain after taking MIFE/MISO

No improvement even with pain medications 

When to seek urgent care for other symptoms (N/V, fever, diarrhea after taking MIFE/MISO

Occurs more than 24 hours after taking misoprostol

What to do if patient vomits 1 hour after taking mifepristone

If vomiting less than one hour after taking mifepristone, the dose should be repeated (and anti-nausea med provided)

What to do if patient vomits during buccal absorption of misoprostol

if during buccal absorption then will need a new misoprostol prescription

What to do if patient vomits after swallowing fragments of misoprostol (after 30 minutes buccal)

then no action required as it has been absorbed

When can COC/POP be started after medical abortion?

Start soon after the misoprostol dose

When can IUD be inserted after medical abortion?

wait until abortion confirmed

Off label medications for abortion

• Methotrexate + misoprostol

• misoprostol monotherapy

Methotrexate + misoprostol dosing in abortion

Methotrexate 50 mg po or im

Followed by misoprostol 4 x 200 mcg in vagina days 4, 5 or 6

How far into pregnancy can you take Methotrexate + misoprostol and time to completion of abortion?

• Up to 63 days gestation

• Time to completion of medical abortion about 7 days (vs 3 days with MIFE/MISO)

Misoprostol monotherapy in abortion dosing regimen

• Misoprostol 4 x 200 mcg in vagina, if no response in 24 hours repeat dose

• Not as effective as with combination, often needs repeat doses