This protocol provides basic requirements for implementing medication abortion services at a family medicine teaching site. This interactive version also includes additional relevant research and practice tips via pop-up linksPop-ups can be used to enhance teaching and self-study by providing additional context for sexual and reproductive health care provision.(hover or click on dotted underlines to access). A print-ready word/PDF version of the protocol is also available.
Medication Abortion ProtocolDesigned for states with fewer restrictions on abortion care. This protocol should be modified to reflect individual state restrictions as needed.
Patients requesting appointments for abortion should be scheduled within 7 days of appointment request. If no appointments are available, the provider should be consulted. Especially during the COVID-19 pandemic, consider the feasibility of telemedicine/minimal contact care.
- For pregnancy termination up to 11 weeks (77 days)The FDA protocol includes pregnancies up to 70 days from LMP and many states require providers to adhere to this limit. However current literature supports medication abortion being safe and effective up to 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. from last menstrual period (LMP)
- Allergy to mifepristone or misoprostol or other prostaglandins
- Concurrent long term systemic steroid use
- Chronic adrenal failure
- Has coagulopathy, hemorrhagic disorders, or is taking an anticoagulant
- Has inherited porphyria
- Has an IUD in placeIUD must be removed prior to medication abortion.
- Ectopic pregnancy*
*Medication abortion is not effective at ending an ectopic pregnancy but it will not hasten a rupture or further complicate an ectopic pregnancySee: Shannon C, et al. Ectopic pregnancy and medical abortion. Obstet Gynecol. 2004 Jul;104(1):161-7. DOI: 10.1097/01.AOG.0000130839.61098.12. Women with ectopic pregnancies should be offered a more effective treatment.
On the day of the abortion:
- Obtain and document the best way to contact the patient (ie. Cell phone, etc)
- Confirm eligibility (rule out contraindications)
- Estimate Gestational Age (GA)
- Document 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. and bimanual exam if neededThere is a trend to move away from bimanual exams and replace them with abdominal exams (to rule out pregnancies greater than 13 weeks). See: Raymond EG, et al. Simplified medical abortion screening: a demonstration project. Contraception. 2018 Apr;97(4):292-296. doi: 10.1016/j.contraception.2017.11.005. Epub 2017 Nov 21.
- Ultrasound only if indicated (see Ultrasound-as-Needed Protocol)
- Evaluate need for Rh testing.Some clinic protocols require Rh to be documented prior to initiating the medication abortion. Others allow the Rh to be drawn on the day of provision with recall for patients who need RhoGAM®. If a patient’s EGA is <56 days, Rh type is likely not needed.New clinical evidence related to the low volume of fetal blood cells in maternal circulation after early abortion and epidemiologic evidence related to the low risk of sensitization in women from countries who do not get anti-D immune globulin in early pregnancy has led NAF to change its recommendations. No testing or treatment is needed for all abortions below 56 days. For more, see: Mark, Alice et al. Foregoing Rh testing and anti-D immunoglobulin for women presenting for early abortion: a recommendation from the National Abortion Federation’s Clinical Policies Committee. Contraception, Volume 99, Issue 5, 265-266. Hollenbach, S.J., M. Cochran, and A. Harrington. “Provoked” feto-maternal hemorrhage may represent insensible cell exchange in pregnancies from 6 to 22 weeks gestational age. Contraception. 2019 Aug;100(2):142-146. doi: 10.1016/j.contraception.2019.03.051. Epub 2019 Apr 11.
- Consider drawing initial serum HCG level (to have as a baseline in case the patient returns and there is uncertainty regarding the abortion being complete)
- Complete Patient agreement
- Dispense Mifepristone 200mg and confirm day and time patient will take
- Dispense Misoprostol 800mcg (x2 doses) and confirm day and time patient will take
- Patient will take 1st dose (800mcg) at the agreed upon time
- Patients who are >63 daysMedication abortion later in pregnancy has increased efficacy rates when repeat doses of misoprostol are given. From 64-70 days, a second dose of misoprostol 800 mcg four hours after the first dose may be used. From 71 to 77 days, a second dose of misoprostol 800 mcg four hours after the first dose should be given.
See: NAF CPG 2020should be advised to take the 2nd dose of misoprostol 4 hours after the first
- Patients who are <63 days may be instructed to hold onto the 2nd dose and use only after discussion with their provider
- Prescribe pain medications (ibuprofen 400mg and Vicodin 5/325mg)
- Review Information for Patients after Medication Abortion
- Confirm that patient knows how to reach the medical team if needed
- Discuss a follow-up planTraditionally an in-person clinic visit, there is increasing data to support following-up by phone or secure health messaging. See: Perriera LK, et al. Feasibility of telephone follow-up after medical abortion. Contraception. 2010 Feb;81(2):143-9. doi: 10.1016/j.contraception.2009.08.008. Epub 2009 Sep 30. with the patient
- Offer opportunity to discuss future or same-day contraceptionIf patient desires, provide her with Rx for pill, patch, or ring. Or offer her a follow-up office visit for depo/IUD initiation. If patient desires progestin implant, consider insertion same day as abortion. For more on this topic, see: Hognert H, et al. Immediate versus delayed insertion of an etonogestrel releasing implant at medical abortion-a randomized controlled equivalence trial. Hum Reprod. 2016 Nov;31(11):2484-2490. Epub 2016 Sep 22.
- Complete Mandated reporting form as per city or state protocol
At follow up:
- Either in person or by phone/secure health message, confirm with patient history of bleeding and cramping consistent with passage of pregnancy and that she no longer feels pregnant
- Order follow up serum HCG level or urine pregnancy test
- In-clinic: Serum HCG should decrease by 60% in 3 days or 90% in 7 days
- Out-of-office: Urine pregnancy test should be done around 3-4 weeks after mifepristone. Confirm with patient that result is negative by phone/secure health message.