Care for Women Choosing Medication Abortion

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

Bleeding is an expected part of the abortion process. Although rare, it is important for the provider to recognize when bleeding is excessive and indicative of a potentially serious complication. Of the estimated 80,000 women who had a mifepristone abortion in the first year after approval, 13 had bleeding serious enough to require transfusion, and 50 underwent uterine aspiration for bleeding (almost all on a nonemergent basis).3 Ectopic pregnancy must always be considered as well.

In its training course Early Options: A Provider's Guide to Medical Abortion, the National Abortion Federation suggests some questions to ask patients who report heavy bleeding, including:

* Which stage of the abortion process are you in? Which medications have you taken? When?

* How much bleeding has occurred? [Find out the type and the size of sanitary pads used, how saturated the pads became, and the size and number of clots passed in a given period of time.]

* Is the bleeding episodic or continuous?

* How much activity can you do before getting tired?

* Are you having other symptoms, such as dizziness, light-headedness, weakness, or fatigue?

* Have you taken any other medications, or used drugs or alcohol today?

* How far do you live from an emergency medical center?

* Do you have access to a telephone and to transportation?

In this case, the patient's rate of bleeding is below the commonly used threshold of two or more maxipads per hour for 2 consecutive hours. The bleeding coincides with a time when the pregnancy is likely terminating (6 hours after misoprostol administration). The patient denies symptoms of hypovolemia. If she is otherwise healthy with a normal hematocrit at baseline, it is appropriate to reassure the patient, provide the patient with indications that suggest the need to seek further care, and develop a detailed plan for close follow-up by phone.

* Case 5: Confirming Abortion Completion

Two weeks after initiating medication abortion to terminate a pregnancy of 50 days gestation, a patient presents for routine follow-up. Two days after taking mifepristone, she administered misoprostol vaginally at home, as instructed. After misoprostol administration, she experienced mild cramping and bleeding. She currently has no symptoms, other than some continuing spotting. You perform a vaginal ultrasound, which shows a gestational sac without signs of continued growth or embryonic cardiac activity. What happened? How would you manage this patient?

Protocols for medication abortion include a clinical follow-up at 1 to 2 weeks after mifepristone to ensure abortion completion. In this case, the patient has a persistent gestational sac. Women with a persistent gestational sac can present with heavy or prolonged bleeding, although some are asymptomatic. If the patient is clinically stable, she can be managed expectantly, take a repeat dose of misoprostol, or undergo uterine aspiration, depending on her and her clinician's preferences.

In early clinical trials of mifepristone, between 2% and 8% of patients underwent an aspiration intervention for bleeding, incomplete abortion, or continuing pregnancy.11,12,22 The rate of aspiration interventions decreases as providers become experienced with medication abortion, possibly because they are more familiar with bleeding patterns and more comfortable with expectant management.23 The FDA requires that mifepristone prescribers have a plan in place for emergency treatment, including surgical backup, whether in their own clinic or in another medical facility.