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NASHVILLE, TENN. – Medical management of abortion and early pregnancy loss is best achieved with both mifepristone and misoprostol, according to Sarah W. Prager, MD.
First-trimester procedures account for about 90% of elective abortions, with about two-thirds of those occurring before 8 weeks of gestation and 80% occurring in the first 10 weeks – and therefore considered eligible for medical management, Dr. Prager, director of the Family Planning Division and Family Planning Fellowship at the University of Washington, Seattle, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
“We estimate that it’s approximately 31% of all abortions that are done using medication, but it’s about 45% of those eligible by gestational age,” she noted.
The alternative is uterine aspiration, and in the absence of a clear contraindication, patient preference should determine management choice, she said.
The same is true for early pregnancy loss (spontaneous abortion), which is the most common complication of early pregnancy, occurring in about 20% of clinically recognized pregnancies.
“That means that there are about 1 million spontaneous abortions happening annually in the United States, and about 80% of those are in the first trimester,” Dr. Prager said.
Expectant management is an additional option for managing early pregnancy loss, she noted.
Candidates
Medical management is appropriate for patients who are undergoing elective abortion at up to about 70 days of gestation or with pregnancy loss in the first trimester.
“They should have stable vital signs, no evidence of infection, no allergies to the medications being used, no serious social or medical problems,” Dr. Prager said, explaining that “a shared decision making process” is important for patients with extreme anxiety or homelessness/lack of stable housing, for example, in order to make sure that medical management is a good option.
“While she definitely gets to have the final say, unless there is a real medical contraindication, it definitely should be part of that decision making,” Dr. Prager said, adding that adequate counseling and acceptance by the patient of the risks and side effects also are imperative.
Protocol
The most effective evidence-based treatment protocol for elective abortion through day 70 of gestation includes a 200-mg oral dose of mifepristone, followed 24-72 hours later with at-home buccal or vaginal administration of an 800-mcg dose of misoprostol, with follow up within 1-2 weeks, Dr. Prager said, citing a 2010 Cochrane review.
The Food and Drug Administration–approved protocol, which was updated in April 2016, adheres closely to those findings, except that it calls for misoprostol within 48 hours of mifepristone dosing. Optional repeat dosing of misoprostol is allowed, as well, she noted.
Buccal or vaginal administration of misoprostol is preferable to oral and sublingual administration because while the latter approaches provide more rapid onset, the former approaches provide significantly better sustained action over a 5-hour period of time.
“And by not having that big peak at the beginning, it actually decreases the side effects that women experience with the misoprostol medication,” she said.
Misoprostol can also be given alone for early pregnancy loss management – also at a dose of 800 mcg buccally or vaginally – with repeat dosing at 12-24 hours for incomplete abortion. However, new data suggest that, before about 63 days of gestation, giving two doses 3 hours apart is slightly more effective. That approach can also be repeated if necessary, Dr. Prager said.
Pain management is an important part of treatment, as both miscarriage and medication abortion can range from uncomfortable to extremely painful, depending on the patient, her prior obstetric experience, and her life experiences.
“I recommend talking to all your patients about pain management. For most people, just using some type of NSAID is probably going to be sufficient,” she said, noting that some women will require a narcotic.
Antiemetic medication may also be necessary, as some women will experience nausea and vomiting.
Complications and intervention
Major complications are rare with medical management of first-trimester abortion and early pregnancy loss, but can include ongoing pregnancy, which is infrequent but possible; incomplete abortion, which is easily managed; and allergic reactions, which are “extremely rare,” Dr. Prager said.
Hemorrhage can occur, but isn’t common and usually is at a level that doesn’t require blood transfusion. “But it does require somebody to come in, potentially needing uterine aspiration or sometimes just a second dose of misoprostol,” she said.
Serious infections are “extraordinarily uncommon,” with an actual risk of infectious death of 0.5 per 100,000, and therefore antibiotic prophylaxis is not recommended.
“This is not to say that there can’t be serious infectious problems with medication abortion, and actually also with spontaneous abortion ... but it’s extremely rare,” Dr. Prager said, adding that “there are also consequences to giving everybody antibiotics if they are not necessary. I, personally, am way more afraid of antibiotic resistance these days than I am about preventing an infection from an medication abortion.”
Intervention is necessary in certain situations, including when the gestational sac remains and when the patient continues to have clinical symptoms or has developed clinical symptoms, she said.
“Does she now show signs of infection? Is she bleeding very heavily or [is she] extremely uncomfortable with cramping? Those are all really great reasons to intervene,” she said.
Sometimes patients just prefer to switch to an alternative method of management, particularly in cases of early pregnancy loss when medical management has “not been successful after some period of time,” Dr. Prager added.
Outcomes
Studies have shown that the success rates with a single dose of 400-800 mcg of misoprostol range from 25% to 88%, and with repeat dosing for incomplete abortion at 24 hours, the success rate improves to between 80% and 88%. The success rate with placebo is 16%-60%; this indicates that “some miscarriages just happen expectantly,” Dr. Prager explained.
“We already knew that ... and that’s why expectant management is an option with early pregnancy loss,” she said, adding that expectant management works about 50% of the time – “if you wait long enough.”
However, success rates with medical management depend on the type of miscarriage; the rate is close to 100% with incomplete abortion, but for other types, such as anembryonic pregnancy or fetal demise, it is slightly less effective at about 87%, Dr. Prager noted.
When mifepristone and misoprostol are both used, success rates for early pregnancy loss range from 52% to 84% in observational trials and using nonstandard doses, and between 90% and 93% with standard dosing.
Other recent data, which led to a 2016 “reaffirmation” of an ACOG practice bulletin on medical management of first-trimester abortion, show an 83% success rate with the combination therapy in anembryonic pregnancies, and a 25% reduction in the need for further intervention (N Engl J Med. 2018;378:2161-70).
“So it really was significantly more effective to be using that addition of the mifepristone,” she said. “My take-home message about this is that, if mifepristone is something that you have easily available to you at your clinical site, absolutely use it, because it creates better outcomes for your patients. However, if it’s not available to you ... it is still perfectly reasonable for patients to choose medication management of their early pregnancy loss and use misoprostol only.
“It is effective enough, and that is just part of your informed consent.”
Postabortion care
Postmiscarriage care is important and involves several components, Dr. Prager said.
- RhoGAM treatment. The use of RhoGAM to prevent Rh immunization has been routine, but data increasingly suggest this is not necessary, and in some countries it is not given at all, particularly at 8 or fewer weeks of gestation and sometimes even during the whole first trimester for early pregnancy loss. “That is not common practice yet in the United States; I’m not recommending at this time that everybody change their practice ... but I will say that there are some really interesting studies going on right now in the United States that are looking specifically at this, and I think we may, within the next 10 years or so, change this practice of giving RhoGAM at all gestational ages,” she said.
- Counseling about bleeding. Light to moderate bleeding after abortion is common for about 2 weeks after abortion, with normal menses returning between 4 and 8 weeks, and typically around 6 weeks. “I usually ask patients to come back and see me if they have not had what seems to be a normal period to them 8 weeks following their completed process,” Dr. Prager said.
- Counseling about human chorionic gonadotropin levels. It is also helpful to inform patients that human chorionic gonadotropin may remain present for about 2-4 weeks after completed abortion, resulting in a positive pregnancy test during that time. A positive test at 4 weeks may still be normal, but warrants evaluation to determine why the patient is testing positive.
- Counseling about conception timing. Data do not support delaying repeat pregnancy after abortion. Studies show no difference in the ability to conceive or in pregnancy outcomes among women who conceive without delay after early pregnancy loss and in those who wait at least 3 months. “So what I now tell women is ‘when you’re emotionally ready to start trying to get pregnant again, it’s perfectly medically acceptable to do so. There’s no biologic reason why you have to wait,’ ” she said.
- Contraception initiation. Contraception, including IUDs, can be initiated right away after elective or spontaneous abortion. However, for IUD insertion after medical abortion, it is important to first use ultrasound to confirm complete abortion, Dr. Prager said.
- Grief counseling. This may be appropriate in cases of early pregnancy loss and for elective abortions. “Both groups of people may need some counseling, may be experiencing grief around this process – and they may not be,” she said. “I think we just need to be sensitive about asking our patients what their needs might be around this.”
Future directions
The future of medical management for first trimester abortion may involve “demedicalization,” Dr. Prager said.
“There are many papers coming out now about clinic versus home use of mifepristone,” she said, explaining that home use would require removing the FDA’s Risk Evaluation and Mitigation Strategy restriction that requires that the drug be dispensed in a clinic by a physician or physician extender.
Studies are also looking at prescriptions, pharmacist provision of mifepristone, and mailing of medications to women in rural areas.
Another area of research beyond these “really creative ways of using these medications” is whether medical management is effective beyond 10 weeks. A study that will soon be published is looking at mifepristone and two doses of misoprostol at 11 weeks, she noted.
“I think from pregnancy diagnosis through at least week 10 – soon we will see potentially week 11 – medical abortion techniques are safe, they’re effective, and they’re extremely well accepted by patients,” she said. “Also ... a diverse group of clinicians can be trained to offer medical abortion and provide back-up so that access can be improved.”
Dr. Prager reported having no financial disclosures.
NASHVILLE, TENN. – Medical management of abortion and early pregnancy loss is best achieved with both mifepristone and misoprostol, according to Sarah W. Prager, MD.
First-trimester procedures account for about 90% of elective abortions, with about two-thirds of those occurring before 8 weeks of gestation and 80% occurring in the first 10 weeks – and therefore considered eligible for medical management, Dr. Prager, director of the Family Planning Division and Family Planning Fellowship at the University of Washington, Seattle, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
“We estimate that it’s approximately 31% of all abortions that are done using medication, but it’s about 45% of those eligible by gestational age,” she noted.
The alternative is uterine aspiration, and in the absence of a clear contraindication, patient preference should determine management choice, she said.
The same is true for early pregnancy loss (spontaneous abortion), which is the most common complication of early pregnancy, occurring in about 20% of clinically recognized pregnancies.
“That means that there are about 1 million spontaneous abortions happening annually in the United States, and about 80% of those are in the first trimester,” Dr. Prager said.
Expectant management is an additional option for managing early pregnancy loss, she noted.
Candidates
Medical management is appropriate for patients who are undergoing elective abortion at up to about 70 days of gestation or with pregnancy loss in the first trimester.
“They should have stable vital signs, no evidence of infection, no allergies to the medications being used, no serious social or medical problems,” Dr. Prager said, explaining that “a shared decision making process” is important for patients with extreme anxiety or homelessness/lack of stable housing, for example, in order to make sure that medical management is a good option.
“While she definitely gets to have the final say, unless there is a real medical contraindication, it definitely should be part of that decision making,” Dr. Prager said, adding that adequate counseling and acceptance by the patient of the risks and side effects also are imperative.
Protocol
The most effective evidence-based treatment protocol for elective abortion through day 70 of gestation includes a 200-mg oral dose of mifepristone, followed 24-72 hours later with at-home buccal or vaginal administration of an 800-mcg dose of misoprostol, with follow up within 1-2 weeks, Dr. Prager said, citing a 2010 Cochrane review.
The Food and Drug Administration–approved protocol, which was updated in April 2016, adheres closely to those findings, except that it calls for misoprostol within 48 hours of mifepristone dosing. Optional repeat dosing of misoprostol is allowed, as well, she noted.
Buccal or vaginal administration of misoprostol is preferable to oral and sublingual administration because while the latter approaches provide more rapid onset, the former approaches provide significantly better sustained action over a 5-hour period of time.
“And by not having that big peak at the beginning, it actually decreases the side effects that women experience with the misoprostol medication,” she said.
Misoprostol can also be given alone for early pregnancy loss management – also at a dose of 800 mcg buccally or vaginally – with repeat dosing at 12-24 hours for incomplete abortion. However, new data suggest that, before about 63 days of gestation, giving two doses 3 hours apart is slightly more effective. That approach can also be repeated if necessary, Dr. Prager said.
Pain management is an important part of treatment, as both miscarriage and medication abortion can range from uncomfortable to extremely painful, depending on the patient, her prior obstetric experience, and her life experiences.
“I recommend talking to all your patients about pain management. For most people, just using some type of NSAID is probably going to be sufficient,” she said, noting that some women will require a narcotic.
Antiemetic medication may also be necessary, as some women will experience nausea and vomiting.
Complications and intervention
Major complications are rare with medical management of first-trimester abortion and early pregnancy loss, but can include ongoing pregnancy, which is infrequent but possible; incomplete abortion, which is easily managed; and allergic reactions, which are “extremely rare,” Dr. Prager said.
Hemorrhage can occur, but isn’t common and usually is at a level that doesn’t require blood transfusion. “But it does require somebody to come in, potentially needing uterine aspiration or sometimes just a second dose of misoprostol,” she said.
Serious infections are “extraordinarily uncommon,” with an actual risk of infectious death of 0.5 per 100,000, and therefore antibiotic prophylaxis is not recommended.
“This is not to say that there can’t be serious infectious problems with medication abortion, and actually also with spontaneous abortion ... but it’s extremely rare,” Dr. Prager said, adding that “there are also consequences to giving everybody antibiotics if they are not necessary. I, personally, am way more afraid of antibiotic resistance these days than I am about preventing an infection from an medication abortion.”
Intervention is necessary in certain situations, including when the gestational sac remains and when the patient continues to have clinical symptoms or has developed clinical symptoms, she said.
“Does she now show signs of infection? Is she bleeding very heavily or [is she] extremely uncomfortable with cramping? Those are all really great reasons to intervene,” she said.
Sometimes patients just prefer to switch to an alternative method of management, particularly in cases of early pregnancy loss when medical management has “not been successful after some period of time,” Dr. Prager added.
Outcomes
Studies have shown that the success rates with a single dose of 400-800 mcg of misoprostol range from 25% to 88%, and with repeat dosing for incomplete abortion at 24 hours, the success rate improves to between 80% and 88%. The success rate with placebo is 16%-60%; this indicates that “some miscarriages just happen expectantly,” Dr. Prager explained.
“We already knew that ... and that’s why expectant management is an option with early pregnancy loss,” she said, adding that expectant management works about 50% of the time – “if you wait long enough.”
However, success rates with medical management depend on the type of miscarriage; the rate is close to 100% with incomplete abortion, but for other types, such as anembryonic pregnancy or fetal demise, it is slightly less effective at about 87%, Dr. Prager noted.
When mifepristone and misoprostol are both used, success rates for early pregnancy loss range from 52% to 84% in observational trials and using nonstandard doses, and between 90% and 93% with standard dosing.
Other recent data, which led to a 2016 “reaffirmation” of an ACOG practice bulletin on medical management of first-trimester abortion, show an 83% success rate with the combination therapy in anembryonic pregnancies, and a 25% reduction in the need for further intervention (N Engl J Med. 2018;378:2161-70).
“So it really was significantly more effective to be using that addition of the mifepristone,” she said. “My take-home message about this is that, if mifepristone is something that you have easily available to you at your clinical site, absolutely use it, because it creates better outcomes for your patients. However, if it’s not available to you ... it is still perfectly reasonable for patients to choose medication management of their early pregnancy loss and use misoprostol only.
“It is effective enough, and that is just part of your informed consent.”
Postabortion care
Postmiscarriage care is important and involves several components, Dr. Prager said.
- RhoGAM treatment. The use of RhoGAM to prevent Rh immunization has been routine, but data increasingly suggest this is not necessary, and in some countries it is not given at all, particularly at 8 or fewer weeks of gestation and sometimes even during the whole first trimester for early pregnancy loss. “That is not common practice yet in the United States; I’m not recommending at this time that everybody change their practice ... but I will say that there are some really interesting studies going on right now in the United States that are looking specifically at this, and I think we may, within the next 10 years or so, change this practice of giving RhoGAM at all gestational ages,” she said.
- Counseling about bleeding. Light to moderate bleeding after abortion is common for about 2 weeks after abortion, with normal menses returning between 4 and 8 weeks, and typically around 6 weeks. “I usually ask patients to come back and see me if they have not had what seems to be a normal period to them 8 weeks following their completed process,” Dr. Prager said.
- Counseling about human chorionic gonadotropin levels. It is also helpful to inform patients that human chorionic gonadotropin may remain present for about 2-4 weeks after completed abortion, resulting in a positive pregnancy test during that time. A positive test at 4 weeks may still be normal, but warrants evaluation to determine why the patient is testing positive.
- Counseling about conception timing. Data do not support delaying repeat pregnancy after abortion. Studies show no difference in the ability to conceive or in pregnancy outcomes among women who conceive without delay after early pregnancy loss and in those who wait at least 3 months. “So what I now tell women is ‘when you’re emotionally ready to start trying to get pregnant again, it’s perfectly medically acceptable to do so. There’s no biologic reason why you have to wait,’ ” she said.
- Contraception initiation. Contraception, including IUDs, can be initiated right away after elective or spontaneous abortion. However, for IUD insertion after medical abortion, it is important to first use ultrasound to confirm complete abortion, Dr. Prager said.
- Grief counseling. This may be appropriate in cases of early pregnancy loss and for elective abortions. “Both groups of people may need some counseling, may be experiencing grief around this process – and they may not be,” she said. “I think we just need to be sensitive about asking our patients what their needs might be around this.”
Future directions
The future of medical management for first trimester abortion may involve “demedicalization,” Dr. Prager said.
“There are many papers coming out now about clinic versus home use of mifepristone,” she said, explaining that home use would require removing the FDA’s Risk Evaluation and Mitigation Strategy restriction that requires that the drug be dispensed in a clinic by a physician or physician extender.
Studies are also looking at prescriptions, pharmacist provision of mifepristone, and mailing of medications to women in rural areas.
Another area of research beyond these “really creative ways of using these medications” is whether medical management is effective beyond 10 weeks. A study that will soon be published is looking at mifepristone and two doses of misoprostol at 11 weeks, she noted.
“I think from pregnancy diagnosis through at least week 10 – soon we will see potentially week 11 – medical abortion techniques are safe, they’re effective, and they’re extremely well accepted by patients,” she said. “Also ... a diverse group of clinicians can be trained to offer medical abortion and provide back-up so that access can be improved.”
Dr. Prager reported having no financial disclosures.
NASHVILLE, TENN. – Medical management of abortion and early pregnancy loss is best achieved with both mifepristone and misoprostol, according to Sarah W. Prager, MD.
First-trimester procedures account for about 90% of elective abortions, with about two-thirds of those occurring before 8 weeks of gestation and 80% occurring in the first 10 weeks – and therefore considered eligible for medical management, Dr. Prager, director of the Family Planning Division and Family Planning Fellowship at the University of Washington, Seattle, said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
“We estimate that it’s approximately 31% of all abortions that are done using medication, but it’s about 45% of those eligible by gestational age,” she noted.
The alternative is uterine aspiration, and in the absence of a clear contraindication, patient preference should determine management choice, she said.
The same is true for early pregnancy loss (spontaneous abortion), which is the most common complication of early pregnancy, occurring in about 20% of clinically recognized pregnancies.
“That means that there are about 1 million spontaneous abortions happening annually in the United States, and about 80% of those are in the first trimester,” Dr. Prager said.
Expectant management is an additional option for managing early pregnancy loss, she noted.
Candidates
Medical management is appropriate for patients who are undergoing elective abortion at up to about 70 days of gestation or with pregnancy loss in the first trimester.
“They should have stable vital signs, no evidence of infection, no allergies to the medications being used, no serious social or medical problems,” Dr. Prager said, explaining that “a shared decision making process” is important for patients with extreme anxiety or homelessness/lack of stable housing, for example, in order to make sure that medical management is a good option.
“While she definitely gets to have the final say, unless there is a real medical contraindication, it definitely should be part of that decision making,” Dr. Prager said, adding that adequate counseling and acceptance by the patient of the risks and side effects also are imperative.
Protocol
The most effective evidence-based treatment protocol for elective abortion through day 70 of gestation includes a 200-mg oral dose of mifepristone, followed 24-72 hours later with at-home buccal or vaginal administration of an 800-mcg dose of misoprostol, with follow up within 1-2 weeks, Dr. Prager said, citing a 2010 Cochrane review.
The Food and Drug Administration–approved protocol, which was updated in April 2016, adheres closely to those findings, except that it calls for misoprostol within 48 hours of mifepristone dosing. Optional repeat dosing of misoprostol is allowed, as well, she noted.
Buccal or vaginal administration of misoprostol is preferable to oral and sublingual administration because while the latter approaches provide more rapid onset, the former approaches provide significantly better sustained action over a 5-hour period of time.
“And by not having that big peak at the beginning, it actually decreases the side effects that women experience with the misoprostol medication,” she said.
Misoprostol can also be given alone for early pregnancy loss management – also at a dose of 800 mcg buccally or vaginally – with repeat dosing at 12-24 hours for incomplete abortion. However, new data suggest that, before about 63 days of gestation, giving two doses 3 hours apart is slightly more effective. That approach can also be repeated if necessary, Dr. Prager said.
Pain management is an important part of treatment, as both miscarriage and medication abortion can range from uncomfortable to extremely painful, depending on the patient, her prior obstetric experience, and her life experiences.
“I recommend talking to all your patients about pain management. For most people, just using some type of NSAID is probably going to be sufficient,” she said, noting that some women will require a narcotic.
Antiemetic medication may also be necessary, as some women will experience nausea and vomiting.
Complications and intervention
Major complications are rare with medical management of first-trimester abortion and early pregnancy loss, but can include ongoing pregnancy, which is infrequent but possible; incomplete abortion, which is easily managed; and allergic reactions, which are “extremely rare,” Dr. Prager said.
Hemorrhage can occur, but isn’t common and usually is at a level that doesn’t require blood transfusion. “But it does require somebody to come in, potentially needing uterine aspiration or sometimes just a second dose of misoprostol,” she said.
Serious infections are “extraordinarily uncommon,” with an actual risk of infectious death of 0.5 per 100,000, and therefore antibiotic prophylaxis is not recommended.
“This is not to say that there can’t be serious infectious problems with medication abortion, and actually also with spontaneous abortion ... but it’s extremely rare,” Dr. Prager said, adding that “there are also consequences to giving everybody antibiotics if they are not necessary. I, personally, am way more afraid of antibiotic resistance these days than I am about preventing an infection from an medication abortion.”
Intervention is necessary in certain situations, including when the gestational sac remains and when the patient continues to have clinical symptoms or has developed clinical symptoms, she said.
“Does she now show signs of infection? Is she bleeding very heavily or [is she] extremely uncomfortable with cramping? Those are all really great reasons to intervene,” she said.
Sometimes patients just prefer to switch to an alternative method of management, particularly in cases of early pregnancy loss when medical management has “not been successful after some period of time,” Dr. Prager added.
Outcomes
Studies have shown that the success rates with a single dose of 400-800 mcg of misoprostol range from 25% to 88%, and with repeat dosing for incomplete abortion at 24 hours, the success rate improves to between 80% and 88%. The success rate with placebo is 16%-60%; this indicates that “some miscarriages just happen expectantly,” Dr. Prager explained.
“We already knew that ... and that’s why expectant management is an option with early pregnancy loss,” she said, adding that expectant management works about 50% of the time – “if you wait long enough.”
However, success rates with medical management depend on the type of miscarriage; the rate is close to 100% with incomplete abortion, but for other types, such as anembryonic pregnancy or fetal demise, it is slightly less effective at about 87%, Dr. Prager noted.
When mifepristone and misoprostol are both used, success rates for early pregnancy loss range from 52% to 84% in observational trials and using nonstandard doses, and between 90% and 93% with standard dosing.
Other recent data, which led to a 2016 “reaffirmation” of an ACOG practice bulletin on medical management of first-trimester abortion, show an 83% success rate with the combination therapy in anembryonic pregnancies, and a 25% reduction in the need for further intervention (N Engl J Med. 2018;378:2161-70).
“So it really was significantly more effective to be using that addition of the mifepristone,” she said. “My take-home message about this is that, if mifepristone is something that you have easily available to you at your clinical site, absolutely use it, because it creates better outcomes for your patients. However, if it’s not available to you ... it is still perfectly reasonable for patients to choose medication management of their early pregnancy loss and use misoprostol only.
“It is effective enough, and that is just part of your informed consent.”
Postabortion care
Postmiscarriage care is important and involves several components, Dr. Prager said.
- RhoGAM treatment. The use of RhoGAM to prevent Rh immunization has been routine, but data increasingly suggest this is not necessary, and in some countries it is not given at all, particularly at 8 or fewer weeks of gestation and sometimes even during the whole first trimester for early pregnancy loss. “That is not common practice yet in the United States; I’m not recommending at this time that everybody change their practice ... but I will say that there are some really interesting studies going on right now in the United States that are looking specifically at this, and I think we may, within the next 10 years or so, change this practice of giving RhoGAM at all gestational ages,” she said.
- Counseling about bleeding. Light to moderate bleeding after abortion is common for about 2 weeks after abortion, with normal menses returning between 4 and 8 weeks, and typically around 6 weeks. “I usually ask patients to come back and see me if they have not had what seems to be a normal period to them 8 weeks following their completed process,” Dr. Prager said.
- Counseling about human chorionic gonadotropin levels. It is also helpful to inform patients that human chorionic gonadotropin may remain present for about 2-4 weeks after completed abortion, resulting in a positive pregnancy test during that time. A positive test at 4 weeks may still be normal, but warrants evaluation to determine why the patient is testing positive.
- Counseling about conception timing. Data do not support delaying repeat pregnancy after abortion. Studies show no difference in the ability to conceive or in pregnancy outcomes among women who conceive without delay after early pregnancy loss and in those who wait at least 3 months. “So what I now tell women is ‘when you’re emotionally ready to start trying to get pregnant again, it’s perfectly medically acceptable to do so. There’s no biologic reason why you have to wait,’ ” she said.
- Contraception initiation. Contraception, including IUDs, can be initiated right away after elective or spontaneous abortion. However, for IUD insertion after medical abortion, it is important to first use ultrasound to confirm complete abortion, Dr. Prager said.
- Grief counseling. This may be appropriate in cases of early pregnancy loss and for elective abortions. “Both groups of people may need some counseling, may be experiencing grief around this process – and they may not be,” she said. “I think we just need to be sensitive about asking our patients what their needs might be around this.”
Future directions
The future of medical management for first trimester abortion may involve “demedicalization,” Dr. Prager said.
“There are many papers coming out now about clinic versus home use of mifepristone,” she said, explaining that home use would require removing the FDA’s Risk Evaluation and Mitigation Strategy restriction that requires that the drug be dispensed in a clinic by a physician or physician extender.
Studies are also looking at prescriptions, pharmacist provision of mifepristone, and mailing of medications to women in rural areas.
Another area of research beyond these “really creative ways of using these medications” is whether medical management is effective beyond 10 weeks. A study that will soon be published is looking at mifepristone and two doses of misoprostol at 11 weeks, she noted.
“I think from pregnancy diagnosis through at least week 10 – soon we will see potentially week 11 – medical abortion techniques are safe, they’re effective, and they’re extremely well accepted by patients,” she said. “Also ... a diverse group of clinicians can be trained to offer medical abortion and provide back-up so that access can be improved.”
Dr. Prager reported having no financial disclosures.
EXPERT ANALYSIS FROM ACOG 2019