This protocol provides guidance on performing medication abortion without sonography. A print-ready word/PDF version of the protocol is also available.
                           

Ultrasound-as-NeededData support safety of medication abortion without ultrasound. See:
                           
Raymond EG, Bracken H. Early medical abortion without prior ultrasound. Contraception. 2015 Sep;92(3):212-4. doi: 10.1016/j.contraception.2015.04.008. Epub 2015 Apr 24.
                           
Kaneshiro B, et al. Expanding medical abortion: can medical abortion be effectively provided without the routine use of ultrasound? Contraception. 2011 Mar;83(3):194-201. doi: 10.1016/j.contraception.2010.07.023. Epub 2010 Sep 17.
Protocol for Medication Abortion

NAF guidelines state:

“The use of ultrasound is not a requirement for the provision of first trimester abortion care. Proper use of ultrasound may inform clinical decision-making in abortion care.”

“Gestational age must be verified to be within the limits of the facility medical abortion protocol.”

                 -NAF, Clinical Policy Guidelines for Abortion Care, 2020

Medication abortion can be performed without routine use of ultrasound. Ultrasound is a tool that, in consideration of patient history, exam findings, and personal preferencesPatients and providers may decide to obtain an ultrasound in abortion contexts such as a history of miscarriage, a history of multiple gestation, or menorrhagia–but in such cases ultrasound is not required for the patient to proceed with the medication abortion., can sometimes be useful in caring for patients who seek abortion care. Although most patients do not need an ultrasound prior to medication abortion, many practices have routinized ultrasonography for a variety of reasonsThese include, for example, resident training needs and clinic policies based on state laws mandating ultrasound examination and viewing. (There is no evidence that ultrasound improves care under these mandates.). However, requiring routine sonography before medication abortion can limit access due to:
  • Financial cost to medical office of purchasing/maintaining an ultrasound machine
  • Difficulty obtaining necessary training on limited use ultrasound and/or cost of paying technician
  • Financial cost to patients obtaining these sonograms (especially if paying out of pocket)
  • Delays in care
  • Provider discomfort offering medication abortion WITHOUT ultrasound if training was only with ultrasound

When is ultrasound indicated in abortion care?

    To determine gestational age

    The gestational age can usually be estimated using a combination of patient history, LMPData supports reliability of LMP to calculate gestational age. See:
                               
    Constant D, et al. Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study. Reprod Health. 2017 Aug 22;14(1):100. doi: 10.1186/s12978-017-0365-7.
                               
    Schonberg D, et al. The accuracy of using last menstrual period to determine gestational age for first trimester medication abortion: a systematic review. Contraception. 2014 Nov;90(5):480-7. doi: 10.1016/j.contraception.2014.07.004. Epub 2014 Jul 18.
                               
    Bracken H, et al. Alternatives to routine ultrasound for eligibility assessment prior to early termination of pregnancy with mifepristone-misoprostol. BJOG. 2011 Jan;118(1):17-23. doi: 10.1111/j.1471-0528.2010.02753.x. Epub 2010 Nov 23.
    , and exam. But ultrasound may be needed when:

  1. Gestational age is determined to be > 77 daysThe FDA protocol specifies a GA limit of 70 days from LMP and many states require providers to adhere to this limit. However current literature supports medication abortion being safe and effective through 77 days from LMP. See:
                               
    Dzuba I, et al. A Non-Inferiority Study of Outpatient Mifepristone-Misoprostol Medical Abortion at 64-70 Days and 71-77 Days of Gestation. Contraception. 2020 101(5):302‐308.
                               
    Kapp N, et al. Medical Abortion in the Late First Trimester: A Systematic Review. . Contraception. 2019 99(2):77-86.
    by patient LMP.
    1. If ultrasound is available on-site: if LMP >77 days ago, consider peforming sonography FIRST to determine GA
    2. If ultrasound is off-site: if LMP>77 days, consider performing bimanual exam FIRST and if exam is consistent with <11 weeks, proceed with MAB. If exam suggests pregnancy >11 weeks, refer out for sono/abortion
  2. Patient had no menses and it has been more than 77 days since delivery or abortion
  3. Pregnancy occurs while amenorrheic from using long-acting progestin contraceptive (i.e., Depo, implant)
  4. Provider uncertainty with bimanual exam

To assess for ectopic riskMedication abortion is not effective at ending an ectopic pregnancy but it will not hasten a rupture or further complicate an ectopic pregnancy. Women with ectopic pregnancies should be offered a more effective treatment. See:
                           
Shannon C, et al. Ectopic pregnancy and medical abortion. Obstet Gynecol. 2004 Jul;104(1):161-7.

Most patients do not need an ultrasound to rule out ectopic pregnancy. Certain risk factors can be assessed through history that would indicate a greater need for ultrasound evaluation, including:

  1. History of previous ectopic pregnancy
  2. Becoming pregnant with an IUD in place
  3. Vaginal bleeding
  4. Unilateral pelvic pain
  5. Adnexal mass on exam
    1. If low-suspicion of ectopic, discuss ease, comfort, and cost of sono vs. initiating medication abortion with close (3 day) follow up
    2. If high-suspicion of ectopic, refer for definitive care as appropriate
To confirm that abortion is complete

The abortion can usually be determined to be complete using a combination of patient history and urine or serum HCG. However, ultrasound my be indicated when:

  1. History not consistent with successful medication (no bleeding or cramping)
  2. Patient reports still feeling pregnant
  3. Serum HCG has not declined by 60% in 2-3 days or by 90% in 1 week
  4. No initial HCG was drawn and urine HCG is still positive more than 3 weeks later