Care for Women Choosing Medication Abortion

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

* Case 3: Patient Preparation: Expected Side Effects

With the patient in Case 2, your physical examination and sonographic dating diagnose an intrauterine pregnancy at approximately 42 days gestation. The patient has no contraindications to mifepristone-misoprostol. Before giving her mifepristone and instructions for self-administration of misoprostol, you counsel her carefully about side effects. What side effects can she expect to experience? What symptoms and signs should prompt her to seek clinical advice or care?

Careful counseling and preparation of the patient are important components of women's satisfaction with their abortion care. Women should be told that vaginal bleeding is expected with the abortion process, and that the amount of bleeding considered normal for medication abortion is greater than it would be for a menstrual period and may include blood clots. The heaviest bleeding usually coincides with the expulsion of the pregnancy (which for most women occurs within 24 hours of misoprostol administration), with a lighter flow continuing for 1 to 2 weeks, although some women report spotting for several weeks afterward.22

Abdominal pain and cramping are also expected with medication abortion, and are usually associated with misoprostol administration. Using a hot water bottle or heating pad can help, as can nonsteroidal anti-inflammatory medications, such as ibuprofen, or if needed, narcotic analgesic medications. (Nonsteroidal anti-inflammatory drugs do not decrease the efficacy of the medication abortion regimen).28 In a large U.S. trial of mifepristone medication abortion, 68% of women received at least one pain medication (usually acetaminophen), while 29% also received opiates.22

Aside from bleeding and pain, the most common side effects reported in three large trials using the FDA-approved regimen were gastrointestinal in nature-nausea, vomiting, and diarrhea.29 Temporary fever is also common immediately following misoprostol administration. The side effects associated with a normal medication abortion are generally minor and self-limited, and some of the symptoms women experience during medication abortion may be related to pregnancy.

Qualitative studies of women's experiences of medication abortion found that women tended to experience the most discomfort and fatigue on the day they took misoprostol, and needed to spend the day at home resting.30 Help patients prepare for the possibility that they will feel tired, and advise them to prepare comfort measures (such as a hot water bottle, maxipads, and analgesic medications). Patients should have written instructions and a number to call if they have questions or concerns. Common indications for when to call the clinic include: severe pain not relieved with oral analgesics; heavy vaginal bleeding (soaking through at least two maxipads per hour for 2 consecutive hours); and documented fever beginning 6 hours or more after use of misoprostol.

* Case 4: Managing Complications

You are covering the clinic over the weekend when the answering service forwards you a call from a patient. She is a healthy 28-year-old G2P1, at 45 days LMP, undergoing medication abortion. She took mifepristone at the clinic 2 days ago, and inserted 800 mcg of vaginal misoprostol 6 hours ago. She is experiencing mild cramping and abdominal pain relieved with ibuprofen, but is concerned about her heavy vaginal bleeding. For the past 2 hours, she has soaked through a maxipad each hour and has passed some thick clots. She does not feel dizzy or faint. What questions should you ask patients who call to report heavy bleeding? How might you manage this patient?