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.

 

Scheduling:

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.

Patient Eligibilty:

Contraindications:

  • 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.

Evidence-based protocol
FDA protocol (2016)On the mifepristone labeling, but providers and patients may sometimes choose variations.
Gestational Age Limit
77 days/11weeks from LMP
70 days/10 weeks from LMP
MifepristoneMifepristone is only available through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS).  Prescribers must complete a Prescriber Agreement Form. Patients must sign a Patient Agreement Form. Though FDA regulations state Mifepristone must be dispensed directly to patients in a health care setting, a federal injunction prevents the FDA from enforcing this regulation during the COVID-19 pandemic.
200mg orally, Dispensed to patientPatients can choose whether to take the mifepristone in the office right away or wait to take it at a different location.
200mg orally, Dispensed in officePatients can choose whether to take the mifepristone in the office right away or wait to take it at a different location.
Misoprostol
800mcg buccallyThe FDA label recommends buccal administration: However, some sites still offer vaginal administration. or vaginally, Dispensed or prescribed, 12-72 hours after mifepristone. A second 800mcg dose of misoprostol is used 4 hours after the first for patients with EGA>63 days.
800mcg buccallyThe FDA label recommends buccal administration: However, some sites still offer vaginal administration., Dispensed or prescribed, 24-48 hoursCurrent data shows 24-48h administration to be slightly more effective than <24h administration. See: Chen MJ and Creinin MD. Mifepristone With Buccal Misoprostol for Medical Abortion: A Systematic Review. Obstet Gynecol. 2015 Jul;126(1):12-21. doi: 10.1097/AOG.0000000000000897. after mifepristone.
Follow Up
7-14 days after mifepristone, in person or remotely
7-14 days after mifepristone, follow up location not specifiedThis allows the patient to choose either an in-office follow-up visit or an alternative follow-up plan.
Who can provide
provided by or under the supervision of a health care provider
provided by or under the supervision of a health care provider

 

On the day of the abortion:

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.