Medication Abortion Protocol

This protocol provides basic requirements for implementing medication abortion services at a family medicine teaching site. This interactive version allows you to click or taptooltip text for citations and practice tips. A print-ready/PDF version of the protocol is also available.

Scheduling

Patients requesting a medication abortion ideally should be scheduled within 7 days of contacting your office; consider the feasibility of telemedicine / minimal contact care to provide care sooner.

Patient eligibility

Up to 12 weeks (84 days) from first day of last menstrual period (LMP)
Positive pregnancy test

Contraindications

Allergy to mifepristone or misoprostol or other prostaglandins
Concurrent long term systemic steroid use
Chronic adrenal failure
Coagulopathy, hemorrhagic disorders, or on an anticoagulant
Inherited porphyria
IUD in place (remove first)
Ectopic pregnancy

	Current evidence-based protocol (2022)	FDA protocol (label last updated in 2016)
Gestational age limit	84 days/12 weeks from LMP		70 days/10 weeks from LMP
Mifepristone	200mg orally Dispensed, mailed or prescribed	200mg orally Dispensed
Misoprostol	800mcg buccally 24‒48 hours after mifepristone OR 800mcg vaginally 6‒72 hours after mifepristone A second 800mcg dose may be used 4 hours after the first for patients 64‒70d, and is recommended for those 71‒84 days. Second dose may be given as backup to all patients. Dispensed, mailed, or prescribed	800mcg buccally, 24‒48 hours after mifepristone Dispensed or prescribed
Follow up (optional)	Per patient preference, can be offered in person or remotely and scheduled for 4‒14 days after mifepristone. Also per patient preference, clinicians can offer a follow up 4‒6 weeks after initial dose of mifepristone to discuss UPT result and confirm abortion completion.		7‒14 days after mifepristone, in person or remote (not specified)
Who can provide	Provided by or under the supervision of a clinician		Provided by or under the supervision of a clinician

Current Evidence-Based Protocol Abortion (2022)
FDA Protocol (Updated 2016)

Gestational age limit

84 days/ 12 weeks from LMP

Mifepristone

200 mg orally

Dispensed, mailed or prescribed

Misopristone

800mcg buccally 24–48 hours after mifepristone OR800mcg vaginally 6–72 hours after mifepristoneA second 800mcg dose of misoprostol may be used 4 hours after the first for patients 64‒70d, and is recommended for those 71‒84 days for those 71‒84 days. Second dose may be given as backup to all patients.Dispensed, mailed, or prescribed

Follow-up (optional)

Per patient preference, can be offered in person or remotely and scheduled for 4‒14 days after mifepristone. Also per patient preference, clinicians can offer a follow up 4‒6 weeks after initial dose of mifepristone to discuss UPT result and confirm abortion completion.

Who Can Provide

Provided by or under the supervision of a clinician

Gestational age limit

70 days/10 weeks from LMP

Mifepristone

200mg orally

Dispensed

Misopristone

800mcg buccally, 24‒48 hours after mifepristone Dispensed or prescribed

Follow-up (optional)

7‒14 days after mifepristone, in person or remote (not specified)

Who Can Provide

Provided by or under the supervision of a clinician

Before the abortion

Document patient’s preferred contact info and method (i.e., phone, email, portal, etc.)
Determine eligibility (confirm pregnancy and rule out contraindications)
Determine gestational age (GA)≤ 84 daysusing:
- LMP
- Bimanual exam only if indicated
- Ultrasound only if indicated or required by law (also see Ultrasound-as-Needed Protocol)
Rh testing and RhIg administration (for Rh negative patients) not needed for patients <70 days and may be waived before 84 days
Complete Mifepristone Patient Agreement and any other consents specific to the practice facility.
Dispense or prescribe mifepristone 200mg for oral use and discuss day and time patient will take (including that same day in the office if the patient chooses)
Dispense or prescribe misoprostol 800mcg (x2 doses depending on GA and other circumstances ) and discuss day and time patient will take it
- Patient will take 1^st dose (800mcg) at the agreed upon time
- Patients who are >63 days may be advised to take the 2^nd dose of misoprostol 4 hours after the first
- Patients who are ≤63 days may be instructed to hold onto the 2^nd dose and use only after discussion with their provider
Prescribe pain medications (ibuprofen 800mg 30 minutes before misoprostol, then 400‒800mg q6hrs as needed). Also as needed, offer acetaminophen with narcotic (e.g., 5/325mg) and anti-emetic (e.g., ondansetron ODT 4mg SL q4hrs prn or promethazine 25mg po prn q6hrs)
Review Information for Patients after Medication Abortion
Confirm that patient knows how to reach the medical team if needed, including after office hours if available
Discuss a remote or in-person follow-up plan with the patient.
- If the patient wants a follow-up visit, they can make an appointment for 4‒14 days after taking the mifepristone
- If patient chooses UPT follow-up, provide test or advise patient they can take one on their own 5‒6 weeks after using mifepristone. Also offer the patient in-person or telemedicine follow up at this time if desired.
- If patient chooses serum HCG follow up, draw/order initial serum level and schedule appointment for follow-up blood test.
Ask the patient if they want to discuss contraception the same day or in the future or not at all.
Complete mandated reporting form as per city or state protocol.

At follow up:

Whether in-person or remote, confirm with patient (at 4‒14 days):
- history of bleeding and cramping consistent with passage of pregnancy
- they no longer feel pregnant
If patient chose beta-HCG follow-up, second serum HCG level can be drawn as early as 3 days after taking mifepristone (Serum HCG should decrease 50% by 3 days, 60% by 4−5 days, and 80% by 7 days).
Consider a sonogram if patient still feels pregnant, uncertain history, or inconclusive HCG drop.
If patient chose UPT follow-up, test should be done 5‒6 weeks after mifepristone is taken. If patient decides to do the test on their own, advise them to contact the office if result is positive.