Care for Women Choosing Medication Abortion

Nurse Practitioner, Oct 2004 by Taylor, Diana, Hwang, Ann C, Stewart, Felicia H

Women choosing medication abortion should be informed that if the procedure is unsuccessful or if they experience excessive bleeding, they may require an aspiration intervention to complete the abortion. In early clinical trials, between 2% and 8% of patients underwent aspiration.11,12,22 These rates decrease as providers become more experienced with medication abortion.23 Some of the key features of medication and aspiration abortion are compared in the table titled, "Comparison of Medication Abortion with Aspiration Abortion."3,9,12,22,24,25

Contraindications to mifepristone-misoprostol include: ectopic pregnancy (because mifepristone does not treat ectopic pregnancy); an IUD in place (the IUD must be removed before the medication abortion); adrenal failure; current long-term systemic corticosteroid therapy; a history of allergy to mifepristone, misoprostol, or prostaglandins; a bleeding disorder or treatment with anticoagulation drugs; an uncontrolled seizure disorder; inherited porphyrias; and inflammatory bowel disease. Providers should use caution with patients who suffer from severe anemia. It is unknown whether mifepristone or the misoprostol metabolite is excreted in breastmilk, so breastfeeding mothers might consider discarding breastmilk around the time of the medication abortion.

* Case 2: Clinical Diagnosis of Early Pregnancy

A 25-year-old patient, Gravida 1 Para 0 (GIPO) presents for medication abortion. Her LMP was 45 days ago, and she had unprotected intercourse approximately 3 weeks ago. She used a home pregnancy test yesterday, which was positive. She has not noted any breast tenderness or nausea. How do you confirm and date the pregnancy?

This patient's history of missed menses and a positive home pregnancy test is suggestive of pregnancy. Because current medication abortion regimens are only recommended through 49 or 63 days gestation (depending on the regimen used), accurate gestational dating is an important component of providing medication abortion care. Clinically, pregnancy is dated from the first day of the last menstrual period, a system based on an "ideal" 28-day cycle with fertilization presumed to occur on day 14. However, only a minority of women of reproductive age have the "ideal" cycle length. Moreover, fertilization can occur from 6 days before to 3 days after the presumed date of ovulation, contributing another source of inaccuracy. The clinician must also be able to recognize abnormal pregnancy, such as ectopic pregnancy, early pregnancy failure, and molar pregnancy.

Clinical evaluation to establish the diagnosis and dating of pregnancy includes a pertinent history and physical examination (with attention to the signs and symptoms of early pregnancy), pregnancy testing, and possibly ultrasonographic imaging. Urine pregnancy tests are highly sensitive, testing positive in 98% of women by 7 days after implantation (around the time of missed menses). With home pregnancy tests, inaccurate readings can occur if the test is not correctly used or if the results are misinterpreted. While medication abortion researchers in the U.S. have routinely used ultrasound for gestational dating, experienced medication abortion providers in other countries have reported high rates of safety and efficacy using clinical findings such as bimanual examination for dating. Quantitative β-HCG testing can also be helpful for dating pregnancy and monitoring the abortion.26,27 Clinicians must always be mindful of the possibility of ectopic pregnancy, even if the initial ultrasound is reassuring.