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  • Start Here

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    You may view parts of the course as a guest. If you wish to take the course, click on the enroll button above.

    Before you begin the course, you must complete two short tasks: (1) the Pre-Course Survey, and (2) the Pre-Course Test. Please DO NOT proceed with the course unless you have filled out both. These allow us to access various aspects of the course itself and are MANDATORY to receive your certificate upon completion of the course. Thank you very much; we hope you find the course useful. 

  • Course Home Page

    Female body reproductive system, stylized imageThis Medication Abortion course provides learners with the foundational knowledge required to provide medication abortion care in the first trimester of pregnancy. The course addresses the core competencies outlined in the World Health Organization (WHO) document “Sexual and reproductive health: Core competencies in primary care” and the tasks outlined in the WHO document “Health worker roles in providing safe abortion care and post-abortion contraception.” All components of this training (like all NextGenU.org trainings) are free, including registration, learning, testing, and a certificate of completion.

    This course is designed for healthcare providers with at least a foundational knowledge of physiology and pharmacology, clinical skills (history taking, physical exam), and basic ultrasound.  The course may be appropriate for advanced medical students, medical residents, or primary care-level providers, including advanced practice clinicians. Components of the course may also be suitable for auxiliary staff such as counselors, medical assistants, and nurses.

    There are six lessons to complete through online study and peer and mentored activities. These modules introduce counseling and informed consent; pre-abortion care: assessing eligibility for medication abortion; regimens for medication abortion; administering medication; follow-up; and logistics of providing medication abortion. At the end of this course, learners should have the knowledge needed to discuss abortion care options and informed consent; complete a pre-abortion evaluation and describe the eligibility criteria for medication abortion; identify medications used in medication abortion, along with their regimens; administer appropriate medications; and provide follow-up care to women seeking medication abortion.

    Practice quizzes are found in each module, and at the end of the course you’ll take a final exam and have a chance to assess this training. We will provide you with the results of your final exam, peer activities, and other assessments. We can report your testing information and share your work with anyone (school, employer, etc.) you request. We hope this is a wonderful learning experience for you and that your assessments will teach us how we can make it even better.

                                                Please start by taking the  Image of a piece of paper with a pencil to represent a surveypre-course survey

    Like all NextGenU.org courses, this course is competency-based, using competencies from the World Health Organization (WHO) and learning resources from world-class academic and governmental organizations such as the University of California, San Francisco, Bixby Center for Global Reproductive Health, and the World Health Organization.  The course developers include Sara Baird MD and Amelia Plant MPH, and the advisory committee includes Francine Coeytaux MPH, Marji Gold MD MPH, Gwewasang Martin, Wendy Norman MD MPH, and Linda Prine MD.  Our co-sponsoring organizations include the Clinical Training Center for Family Planning in Cameroon (CTC4FP), Plan C, the Reproductive Health Access Project (RHAP), TEACH, and The Center for Reproductive Health Education In Family Medicine (RHEDI). Some content from this course has been adapted from the Ipas courses "First Trimester Abortion with Mifepristone and Misoprostol" and/or "First Trimester Abortion with Misoprostol Only" (accessed December 2017). The original course material can be found at the IpasUniversity online learning platform at www.ipasu.org. For more information about Ipas, go to www.ipas.org.

  • About Abortion

    Concept of 'about', image of lightbulbs to indicate learning

    Please STOP. Before you begin the course, you must complete two short tasks: (1) the Pre-Course Survey, and (2) the Pre-Course Test. Please DO NOT proceed with the course unless you have filled out both.  These allow us to access various aspects of the course itself and are MANDATORY to receive your certificate upon completion of the course. Thank you very much.

    Abortion is common. Globally, about 25% of all pregnancies ended in abortion between 2010 and 2014. Preventing unplanned births by the use of contraceptives and safe abortion has benefits at the individual, family, and societal levels. Women who are able to choose when to have children are better able to chart the courses of their own lives. They are more likely to complete higher levels of education, be more active in the workforce, and contribute more to a country’s economy (Reher, 2011). Limiting family sizes decreases household poverty, as more resources are available to educate, clothe, house, and feed existing family members (UNFPA, 2010).

    At the country level, as the number of children per household falls, the number of people in the workforce rises.  This results in a favorable economic situation that allows countries to develop (Bloom, Canning, & Sevilla, 2003). Historically, no country has successfully developed without a corresponding drop in fertility.

    Providing access to contraceptives goes a long way, but unplanned pregnancies cannot be eliminated altogether. A woman may experience an unplanned pregnancy for a number of reasons, including a lapse in access, contraceptive failure, reproductive coercion or sexual assault, or diagnosis of abnormal pregnancy. Safe abortion is essential to women’s emotional and physical health, family-level economic opportunities, and societal development. 

    Although legal abortion is safe and effective, complications from unsafe abortion are common in regions where abortion is illegal or highly restricted and is a leading global cause of death for women aged 15–19 (Guttmacher Institute, 2017). Increasing access to abortion and reproductive health information has even been shown to lower abortion rates (UNFPA, 2010). But even in settings where abortion is legal, restrictions often limit women’s access to care. The training of providers is an essential step to destigmatizing abortion care and expanding geographic access to care.

     

  • Introduction to Medication Abortion

    Image of chemical model of Misoprostol

    The course contains the following lessons:

    1. Counseling and Informed Consent
    2. Pre-abortion Care: Assessing Eligibility for Medication Abortion
    3. Regimens for Medication Abortion
    4. Administering Medication
    5. Follow-up
    6. Logistics of Providing Medication Abortion

    Course learning objectives:

    At the end of this course, learners should have the knowledge needed to:

    • Discuss abortion care options and informed consent
    • Complete a pre-abortion evaluation and describe the eligibility criteria for medication abortion
    • Identify medications used in medication abortion, along with their regimens
    • Administer appropriate medications
    • Provide follow-up care to women seeking medication abortion

    In-person training:

    The content of this course is designed to prepare learners with the knowledge needed to provide clinical abortion care; however, completion of this course alone is not a confirmation of competency.

    In addition to this knowledge-based course, we recommend that all learners identify a local mentor in their area to obtain in-person, hands-on experience in conjunction with this course material. 

    Regional variation:

    In addition to the medical content provided in this course, you must familiarize yourself with local, regional, and national laws and restrictions that may apply to the provision of abortion care in your area. There will be regional variation in the standard of care, as well as legal/regulatory restrictions that may impact your practice. NextGenU.org is not responsible for maintaining up-to-date standards for all geographic and legal regions.

     

    • Abortion Providers and Values Clarification

      Image of pdf from the National Abortion Federation: A values clarification guideWho can provide abortions?

      Abortion providers may have a variety of background trainings. For more information about who can provide abortion services, read the documents listed below from the World Health Organization and the National Abortion Federation.


      Values Clarification

      Before beginning this course, take a moment to reflect on your own values as a provider. Many people have social, religious, cultural, and personal influences on their practice as an abortion provider.  These influences can consciously or subconsciously affect our patient interactions during counseling and care.

      Consider completing an individual values clarification workbook such as the one available through the U.S.-based National Abortion Federation, "A Values Clarification Guide for Health Care Professionals."

      It is also important to consider the values of your staff, colleagues, and patients before implementing abortion care. Resources for group values clarification workshops will be presented at the end of this course.

    • Lesson 1: Counseling and Informed Consent

      Learning Objectives IconLearning objectives:

      At the end of this lesson, learners will be able to:

      • Use patient-centered language to discuss early pregnancy options
      • Review early abortion options with patients
      • Describe steps of informed consent for women seeking medication abortion
      • Explain the overview of the medication abortion process to patients and provide aftercare instructions

      Empathetic communication is one of the most important roles of a healthcare provider. The language used throughout the visit, including counseling and during the pre-abortion evaluation, the abortion itself, and at the follow-up visit, will affect the woman’s experience and satisfaction with the abortion process. All staff and providers should be familiar with the basic tools of communication surrounding abortion care.  The patient’s experience begins when she calls to schedule the appointment; all staff, from the telephone call center and front desk to the support staff and providers, must be prepared to receive patients with accurate knowledge and with a kind and nonjudgmental tone. Similarly, even at clinics with designated counseling staff, providers are ultimately responsible for informed consent and must be familiar with the content of counseling and consent.

      This “Counseling and Informed Consent” lesson includes the following sections:

      1. Options counseling
      2. Abortion options
      3. Informed consent
      4. Overview of what patients should expect
      This lesson addresses the following competencies from the WHO Sexual and Reproductive Health Core Competencies for Primary Care.

      • Knowledge competencies:
        • Pregnancy options for women and couples, including those who are HIV positive
        • Barriers to safe, legal abortion and how to address them
        • How, when, and where to refer women
        • Abortion law and its applicability (legal protection available to women and providers)
      • Skills competencies:
        • Provide complete and easy-to-understand information about abortion and recurrent abortions
        • Refer the client to another provider in case of conscientious objection, or need for high-level care, or if abortion methods are not available
        • Ability to refer to antenatal care if the client decides to remain pregnant

      • Lesson 1.1: Options counseling

        Key Points 

        • Providers should focus on good communication throughout the visit, both verbally, non-verbally, and with clear written materials.

        Learning Objective IconLearning Objectives:

              • Describe terms and phrases that can be used to nurture a non-judgmental and patient-centered environment
              • Describe how non-verbal communication can be used during an abortion visit
              • Use patient-centered language to discuss early pregnancy options
              • Describe concepts of confidentiality and how they may apply to the patient

        We will first review overall tips for effective and empathetic communication with patients.  The readings below include examples of verbal and non-verbal communication that can be utilized throughout a woman’s abortion visit. 

        Communicating well

        Good communication is more than explaining things clearly. It involves active listening, positive body language, being non-judgmental, and encouraging the woman to ask questions.  Healthcare providers (physicians, midwives, nurses, counselors, and others) should ask their patients open-ended questions and listen carefully to the answers. Using some of the same words and phrases the woman uses may help ensure that she clearly understands her health situation, her options, and how to proceed once she has made a decision for medication abortion.

        To avoid confusion, anxiety, and unnecessary telephone calls or clinic visits, adequate counseling in clear language is crucial. As some women may not understand written materials or remember all verbal instructions, materials with visual images can help the patient know what to expect and aid in remembering key information and instructions at home.

         Confidentiality

        Based on the rules and regulations of confidentiality in your area, explain to the patient that the visit will be confidential, and describe any limits to confidentiality that may exist. Many regions have mandatory reporting – situations in which a provider/clinic is required to breach confidentiality and report information.  Specific conditions vary widely, but may include statutory rape and sexually transmitted infections.  A short discussion on confidentiality and the limits of confidentiality should occur at the start of the counseling session.

        Age of consent/caring for the pregnant adolescent

        Pregnancy options for teens are also dependent on regional laws and regulations about the age a teen can consent to an abortion.  Laws restricting minors can include:

        1. Parental notification – one or more parent must be notified that the minor is getting an abortion
        2. Parental consent – one or more parent must consent for the abortion
        3. No parental notification or consent – the minor can obtain an abortion without parental knowledge
        4. Judicial bypass – most regions with restrictions allow teens to obtain a judicial bypass to parental involvement


        1. Lesson 1.2: Abortion options

          Key Points 

          • Women should receive counseling about aspiration versus medication abortion based on their individual factors.
          • Many women who choose medication abortion prefer it because it may feel more ‘natural,’ does not require instrumentation of the uterus, and is a process that can take place in the privacy of one’s home.
          • Women are more likely to have a successful medication abortion experience when they are well prepared for the process.

          Learning Objective IconLearning Objective:

                • Explain to a patient or colleague the risks and benefits of medication abortion versus a manual vacuum aspiration

          There are two main types of abortion, medication abortion (also called "medical abortion" or "pill abortion") and aspiration abortion (most commonly, manual vacuum aspiration, also called "surgical abortion" or "in-clinic abortion").

          A woman may have many reasons for choosing one type of abortion over another.  These may include her prior experience, chronic medical conditions, and clinic availability. This lesson reviews some of the differences between medication and aspiration abortion and how to discuss these differences with patients to develop the right plan of care.

        2. Lesson 1.3: Informed consent

          Key Points 

          • During informed consent, the provider should explain risks and safety information with the patient, and confirm a patient’s understanding of the process of medication abortion.
          • Review any legal restrictions that may apply to your clinical practice about informed consent, such as required counseling content or mandatory forms.


          Target icon to represent the concept of Learning ObjectivesLearning Objectives:

              • Describe the importance of clear communication with patients
              • Review the key components of informed consent for medication abortion
              • Identify sample resources that can be utilized to develop your own informed consent document for clinical practice

          Once a patient has chosen to obtain a medication abortion, it must be clear that she understands the medication abortion process, what to expect during and after the abortion, and the benefits and risks of medication abortion. Although these are essential components of basic informed consent, counseling should focus on educating the woman beyond the minimum documentation requirements. Women are more likely to have an overall positive medication abortion experience when they are well prepared for the process.

          Unless a woman having a medication abortion chooses to have an abortion in a health facility, most of the abortion process will take place at home. This makes it important to discuss her plans about when to take the medicines, who will be with her at home to support her (or who will check on her), what to expect when she takes the medications, who can help her if there is an emergency, and how she will handle work or her family responsibilities (such as childcare or eldercare) after taking the pills.

          Women need to be well prepared and supported when choosing the medication abortion. Good communication between the healthcare team and the patient is essential. The next few sections give a very short overview of the key issues on communicating well so that women have the full and clear information they need.

           Prior to any abortion procedure, the provider or counselor needs to have a conversation with the woman to determine if she:

          • Is having the abortion because it is her choice and is not being coerced or threatened to have the abortion
          • Is aware of the choices available to her, including having a vacuum aspiration procedure
          • Has questions answered about the pregnancy or the abortion procedure
          • Is comfortable with her decision. If she seems highly conflicted or ambiguous, she may need additional support or counseling to discuss her life situation and decision
          • Understands how the process occurs, including how she will take the medications, the follow-up plan, and potential complications
          • Understands that there is a range of experience with medication abortion. The symptoms expected should be described to her in detail

        3. Lesson 1.4: Overview of what patients should expect

          Key Points

          • Before making a decision on the type of abortion, some women want more detail about what to expect from the medication abortion process.
          • Women who are informed and prepared report having a better experience with medication abortion.

          Learning Objectives Icon Learning Objectives:

              • Learn how to describe the medication abortion process to patients
              • Review aftercare instructions, including warning signs, with patients

          This lesson reviews what additional information should be shared with the patient before a medication abortion. The material discussed here may come up at different times during the counseling process.  Some women may ask for more details when choosing between aspiration and medication abortion.  Others will choose to have a medication abortion and only need more detail later during the informed consent process.

          The information here is an overview. After completing the remaining lessons, please review this lesson and reconsider the informed consent process.

          What to expect during the clinic visit

          The specific flow of the clinic visit will vary from clinic to clinic. Patients should be informed of the overall steps and timeline to expect from the visit, which will usually include counseling, intake/medical history, dating (exam and/or ultrasound), and medication disbursement.

          How to describe the medication abortion process

          The detailed step-by-step process of how women should take the medications will be reviewed during Lesson 3, and a more detailed discussion of what women should expect is in Lesson 4. In the counseling session, however, it is important to briefly review the medications and what patients should expect in the days after taking the pills.

          Below is a common example of how this process can be described to patients, when using the common mifepristone/misoprostol regimen. Again, this should be tailored based on the protocol in your clinic or region, and this will be reviewed in the following lessons (for example, will she be taking the pills at home or in the clinic?):

          1. The medication abortion uses two different medicines.
          2. The first medicine is called mifepristone, and this stops the pregnancy from growing. This is a pill that you will swallow here in the clinic.  
          3. Sometimes women have a little bleeding after the first medicine, but it is still important to take the second medicine.
          4. The second medicine is called misoprostol, and this helps your uterus squeeze and push out the pregnancy and other tissue. This is a medicine that you will take at home tomorrow, by putting it in your cheeks for 30 minutes.
          5. Most women start bleeding a couple hours after the second medicine is taken.  The bleeding can get heavy and include passing clots.  Cramping and abdominal pain is also common. 
          6. The heavy bleeding should stop within 1–3 hours.  Most women know when the abortion is over.  The bleeding will then be more like a regular period.
          7. If you don’t have any bleeding, or only a little bleeding, call us or come back right away, because this may mean that the medication didn’t work.  We may need to give you more medication.
          8. Some women can have side effects from the medicine, like nausea, vomiting, diarrhea, and headache.  Most side effects are mild.  A mild fever and chills can also happen but should not last more than 24 hours.
          9. You will come back to the clinic in 1–2 weeks so we can confirm that the abortion process is complete. 

          Discuss pain with patients 

          The levels of pain women can experience with the medication abortion will vary, as everyone’s reaction to pain is different. The physical symptoms that women can expect with the medication abortion, as well as pain control, will be reviewed in detail in Lesson 4. Women should be informed of their pain management options and what medication/s the clinic will give them to take home.

          What to expect after the abortion

          Before administering the pills, review aftercare instructions and ensure that the patient understands the warning signs to re-contact the clinic and whether or not she needs to make a follow-up appointment. Typical aftercare instructions are included in the required readings. Follow-up and complications of abortion will be reviewed during Lesson 5.

          Signing consent forms

          Once a patient has all the necessary information, she can sign the consent forms. Sample consent forms have been included in the Resources folder.  Note that some regions have legal requirements for consent forms (and for the content of consent).  Consider your region to ensure that you perform the appropriate counseling and use the proper documentation for consent.

        4. Lesson 1: Case Study: Kim

        5. Lesson 1: Key Points

           Lesson 1.1

          • Providers should focus on good communication throughout the visit, both verbally, non-verbally, and with clear written materials.

           Lesson 1.2

          • Women should receive counseling about aspiration versus medication abortion based on their individual factors.
          • Many women who choose medication abortion prefer it because it may feel more ‘natural,’ does not require instrumentation of the uterus, and is a process that can take place in the privacy of one’s home.
          • Women are more likely to have a successful medication abortion experience when they are well prepared for the process.

           Lesson 1.3

          • During informed consent, the provider should explain risks and safety information with the patient, and confirm a patient’s understanding of the process of medication abortion.
          • Review any legal restrictions that may apply to your clinical practice about informed consent, such as required counseling content or mandatory forms. 

          Lesson 1.4

          • Before making a decision about which type of abortion she may want, some women want more detail about what to expect from the medication abortion process. 
          • Women who are informed and prepared report having a better experience with medication abortion.
          • Lesson 2: Pre-abortion Care – Assessing Eligibility for Medication Abortion

            Clipboard with paper, checkmarks to indicate checking of different criteria to indicate assessment factors in making decisions

            Learning Objectives icon  Learning Objectives:

            At the end of this lesson, learners will be able to:

            • Identify the general eligibility criteria for medication abortion, and be able to find the eligibility criteria for medication abortion in their country
            • Describe how to diagnose and date a pregnancy
            • Explain how to screen for ectopic pregnancy
            • Describe the contraindications to medication abortion
            • Identify the recommended laboratory testing prior to medication abortion

            This lesson provides information on assessing a woman’s eligibility to obtain a medication abortion. 

            This “Pre-abortion care – Assessing eligibility for medication abortion” lesson includes the following sections:

            1. Obtaining a pertinent history and physical
            2. Diagnosing and dating pregnancy
            3. Screening for ectopic pregnancy
            4. Ruling out contraindications
            5. Laboratory testing

            The information in this lesson is evidence-based. Please consult your regional and national laws and regulations for restrictions that may apply to your specific clinical practice.

            This lesson addresses the following competencies from the WHO Sexual and Reproductive Health Core Competencies in Primary Care.

            • Knowledge competencies:
              • Signs and symptoms of pregnancy
              • Gestational age and its calculation
              • Abortion management standards and guidelines
              • Medical eligibility for all available abortion methods
              • How, when, and where to refer women
              • Abortion law and its applicability
              • National norms, standards, and guidelines for abortion care, including rules for conscientious objection
              • Confirmation of pregnancy and determination of gestational age
            • Skills competencies:
              • Perform abdominal and vaginal examination to assess gestational age
              • Perform a bimanual uterine examination
              • Refer when needed
              • Provide complete and easy-to-understand information about abortion and recurrent abortions
              • Refer the client to another provider in case of conscientious objection, or need for high-level care, or if abortion methods are not available
              • Provide medical abortion according to national standards, including appropriate pain management

            This lesson also addresses the following task outlined in the WHO Health Worker Roles document, “Assessing eligibility for medical abortion (diagnosing and dating the pregnancy, ruling out medical contraindications, and screening for possible ectopic pregnancy).”

            • Lesson 2.1: Obtaining a pertinent history and physical

              Key Points

              • A history and physical should focus on obtaining information about gestational age, identifying contraindications and risk factors for complications.
              • Most laboratory tests are not a required part of evaluation before abortion.  Labs performed prior to medication abortion may include hemoglobin and Rh testing; these tests are considered mandatory in some settings (in the United States, for example) but may be considered optional depending on the clinical setting and patient factors.

               Learning Objective IconLearning Objective:

                  • Describe the components of a pertinent history and physical exam for patients seeking an abortion

              The first step to assessing a woman’s eligibility for the medication abortion is obtaining information about her medical history, focusing on information that may affect her eligibility.

            • Lesson 2.2: Diagnosing and dating pregnancy

              Key Points

              • Last menstrual period (LMP) in conjunction with a bimanual exam can reliably estimate gestational age in most patients.
              • When the bimanual exam findings do not correlate to the expected gestational age (by LMP) it is important to consider inaccurate dating, as well as alternative diagnoses.  Ultrasound should be considered in this setting.
              • In some settings where it is easily available, ultrasound is considered the standard of care.
              Learning objectives iconLearning Objectives:
                    • Describe different methods of diagnosing pregnancy
                    • Describe the benefits and limitations of using the last menstrual period (LMP), bimanual exam, or ultrasound for early pregnancy dating
                    • Assess gestational age and confirm pregnancy is in the first trimester
                    • Describe the expected human chorionic gonadotrophin (hCG) and ultrasound findings for normal intrauterine pregnancies at varying gestational ages

              Gestational dating is an important part of preparation for medication abortion.  The clinician should follow three steps when estimating gestational age:

              1. Confirm that the patient is pregnant
              2. Confirm that the pregnancy is intrauterine
              3. Estimate gestational age

              Medication regimens and gestational age limitations will be discussed in detail in Lesson 3. While reading these materials on gestational dating, however, you may wish to keep in mind that in many regions, women are eligible for medication abortion (the focus of this course) only up to 70 days gestation (or 10 weeks from the LMP)

              As described in the reading, protocols for diagnosing and dating pregnancy may also depend on your geographic area. Legal requirements may include, for example, asking the patient if she wants to see the ultrasound. Double-check your regional and national laws and regulations.


              Gestational dating

              Gestational dating is an important element in determining a woman's eligibility for medication abortion and the regimen that should be used.

              Providers commonly use three approaches to gestational dating: determining the date of the last menstrual period (LMP), uterine sizing using a bimanual exam, and uterine sizing with the use of ultrasound.

               

              Last menstrual period (LMP)

              Menstrual age dates the pregnancy frogestational dating image - drops of bloodm the first day of the last normal menstrual period. It may help the woman to recall this date through questions about what she was doing when her last period began.

              In one study in rural Pune, India, and urban Atlanta, United States, all but one of the 222 women in Atlanta and four of the 200 women in Pune, India were able to provide either the date of unprotected intercourse or the date of their LMP (Ellertson et al., 2000).

              Sometimes LMP estimations may be difficult. For example:

              • Some women experience bleeding during early pregnancy that is mistaken for a menstrual period.
              • Breastfeeding women may become pregnant without having regular menstrual periods.
              • Women using certain forms of contraception do not have regular periods, or ovulation may occur at unpredictable times relative to bleeding.
              • Adolescents or older women with irregular cycles may not experience established regular periods.

              Therefore, the date of a woman's LMP should not be the only factor in determining the gestational age of a pregnancy. Nevertheless, the use of LMP to estimate gestational age may be particularly accurate in countries where women rely heavily on fertility awareness methods.


              Bimanual exam 

              Before any uterine evacuation procedure, including medication abortion, the provider must perform a bimanual exam to assess the size, consistency, and position of the uterus and adnexa.

              bimanual examPrior to performing a pelvic exam, the clinician should encourage the woman to empty her bladder and should also let the woman know what to expect. This is especially important if this is the woman's first pelvic exam.

              To assess the uterus and adnexa, the clinician places two fingers into the vagina and then palpates the abdomen with the other hand. The size of the uterus is then assessed (illustration © Stephen C. Edgerton/Ipas).

              Assessing the uterus in early pregnancy can be challenging and requires a great deal of practice.

                                                                                                                                                                                                                     

               

              Situations that make it difficult to accurately assess uterine size include:

              • fibroids
              • retroverted position of the uterus
              • obesity
              • full bladder
              • multiple pregnancies (such as twins)
              • molar pregnancy
              • the woman’s contraction of her abdominal muscles (not relaxing her abdomen)

              If the uterus is smaller than expected, consider one of the following:

              • the woman is not pregnant
              • inaccurate menstrual dating
              • ectopic pregnancy (although, even if the pregnancy is ectopic, the uterus typically grows larger than non-pregnant size)
              • early pregnancy failure, including missed abortion (missed miscarriage)
              • normal variation between women at a given length of pregnancy


              If the uterus is larger than expected, consider one of the following:

              • inaccurate menstrual dating
              • multiple pregnancies
              • uterine anomalies such as fibroids or bicornuate uterus
              • gestational trophoblastic neoplasm/molar pregnancy (although the uterus can sometimes be smaller)
              • normal variation between women at a given length of pregnancy

              If uncertain about the size of the uterus, or if there is a clinically significant discrepancy between size and gestational age determined by LMP, it may be helpful to ask another clinician to check the uterine size by bimanual exam or to use an ultrasound, if available.


              Ultrasound

              Ultrasound is not a requirement for medication abortion. However, in many settings, especially in the United States, ultrasound is considered the standard of care. In clinics where it is easily accessible, ultrasound is a helpful tool to quickly confirm gestational age and will often be performed instead of a bimanual exam. Studies continue to be published demonstrating the safety of medication abortion without ultrasound, yet you should consider your local standard of care and personal comfort level with gestational dating by exam.

              In any setting, indications for receiving an ultrasound include:

              • estimated gestational age > 9 weeks
              • uncertain LMP (irregular menses, recent delivery or abortion, recent contraception use)
              • difficult sizing (i.e., obesity)
              • provider uncertainty with exam
              • adnexal mass or pain
              • size/dates discrepancy – including the examples above
              • cost of quantitative human chorionic gonadotrophin (hCG) level (in settings where sonogram may cost less)
              • symptoms suggestive of ectopic pregnancy

              When used, ultrasound can be done trans-abdominally or trans-vaginally, and should confirm gestational age as well as confirm that the pregnancy is intrauterine.


              Pregnancy of Unknown Location

              A Pregnancy of Unknown Location (PUL) is the term used to describe a pregnancy that has not been confirmed to be intrauterine. Two common PUL scenarios exist:

              1. When an ultrasound is not done as part of the assessment of gestational age, but the pregnancy is likely intrauterine
              2. When an ultrasound is performed, but there is no visible gestational sac

              In the first scenario, patients are still eligible for medication or aspiration abortion as long as there is reasonable dating based on LMP/exam and there is no sign of ectopic pregnancy or other contraindication (signs of ectopic and other contraindications are discussed elsewhere in this lesson).

              In the second scenario, the provider is faced with a dilemma of distinguishing between an early intrauterine pregnancy and an abnormal pregnancy. The discriminatory zone is the range of hCG above which an intrauterine pregnancy should be identifiable on ultrasound. For example, a woman with no gestational sac on ultrasound has a serum quantitative hCG level below the discriminatory zone; the provider can feel reassured that she is likely to have an early intrauterine pregnancy. However, if the patient hCG level is above the discriminatory zone, the provider must question why no gestational sac is visible and consider ectopic pregnancy.

              The specific hCG level of the discriminatory zone will vary based on provider and patient factors, as well as the quality of ultrasound equipment. Understanding the discriminatory zone is essential when evaluating women with Pregnancy of Unknown Location.

              Women with Pregnancy of Unknown Location are usually eligible for medication or surgical abortion if there are no symptoms of ectopic pregnancy. For women with PUL who are receiving aspiration abortion, follow-up is needed confirming that the abortion is completed.  This will be further discussed in the Follow-up lesson.


              Role of serum quantitative hCG testing

              Serum quantitative hCG tests do not have a role in gestational dating. The level of hCG is a poor correlate to gestational age; a wide range of expected values occurs in normal pregnancies.

              In some settings, hCG levels are drawn as part of the initial visit for medication abortion (on the same day that the first medication is taken). This level is not used for confirmation of gestational age, but rather as a baseline value to ensure completion of medication abortion at follow-up. Further discussion of abortion follow-up is discussed in the Follow-up lesson.


            • Lesson 2.3: Screening for ectopic pregnancy

              Key Points

              • Patients should be screened for ectopic pregnancy by history and physical exam, and additional testing including ultrasound should be done if indicated.
              • Medication or aspiration abortion will NOT treat ectopic pregnancy.  All patients with suspected or confirmed ectopic pregnancy should be emergently referred to an experienced provider where appropriate evaluation and treatment can be performed.
              Learning Objectives iconLearning Objective:
                    • Describe the history and physical exam findings that suggest ectopic pregnancy

              As discussed in the previous lesson, ultrasound is not a requirement of medication abortion. Patients who do not get ultrasound (and some who do) are managed as a “pregnancy of unknown location.”  All patients should be screened for ectopic pregnancy by history and physical exam, and additional testing, including ultrasound, should be performed if indicated.

              Ectopic pregnancy, which occurs when a fertilized egg attaches outside the uterus (most often in a fallopian tube), can be challenging to identify or rule out. Vacuum aspiration or medical abortion cannot terminate an ectopic pregnancy, and may delay diagnosis.

              Ectopic Pregnancy

              Screening for ectopic pregnancy 

                1. Assess for risk factors

                  Although more than half of ectopic pregnancies occur in women who have no known risk factors, certain conditions place women at higher risk (Murray, 2005):

                  • Previous tubal or other pelvic surgery
                  • Previous ectopic pregnancy
                  • History of pelvic inflammatory disease
                  • Tubal abnormalities are strongly associated with an increased risk of ectopic pregnancy (Barnhart, 2009)
                  • Pregnancies with an IUD in place
                    • Although pregnancies with an IUD in place are rare, an estimated 25–50% of these are ectopic (Barnhart, 2009).  The IUD does NOT cause ectopic pregnancy; in fact, the overall risk of ectopic pregnancy is lower.  However, the IUD is more effective at preventing intrauterine pregnancies than it is at preventing ectopic pregnancies, so the percentage of pregnancies that are ectopic will be higher.


                    2. Assess for symptoms

                      A woman with an early ectopic pregnancy may be asymptomatic. If she has symptoms, they may include the following:

                      • Uterine size that is smaller than expected
                      • A palpable adnexal mass
                      • Sudden, intense, persistent lower abdominal pain/cramping (initially one-sided, then generalized)
                      • Possible vaginal bleeding, which may be irregular (spotting)
                      • No products of conception after a vacuum aspiration procedure
                      • Fainting, shoulder pain (diaphragm irritation due to internal bleeding), tachycardia (rapid heart rate), or dizziness of more than a few seconds, any of which may indicate internal bleeding; internal bleeding can occur even if vaginal bleeding is not present


                      An ectopic pregnancy may be asymptomatic until shortly before rupture.

                        3. When needed, confirm the presence of intrauterine pregnancy with ultrasound

                          Suspicious findings from either patient history or physical may be addressed by performing ultrasound, which helps confirm intrauterine pregnancy. If present, an intrauterine pregnancy effectively rules out ectopic pregnancy (however, see "Heterotopic pregnancy" below).

                          Ultrasound may not be able to visualize ectopic pregnancy. Most ultrasounds will NOT show an ectopic pregnancy, even if one is present. 

                          The ultrasound may exhibit signs of ectopic pregnancy.  These can include the following:

                          • Pseudosac
                          • Free fluid in the cul-de-sac
                          • Absence of intrauterine pregnancy despite hCG above the discriminatory zone
                          • Absence of intrauterine pregnancy despite expected gestational age of > 35 days by LMP

                          Examples of normal and abnormal ultrasound findings in early pregnancy are summarized in the next assigned readings.

                            4. When ectopic pregnancy is suspected or diagnosed

                              • Medication abortion should NOT be performed
                              • Immediately refer to a provider experienced in the diagnosis and management of ectopic pregnancy

                              Early diagnosis and treatment saves women's lives and helps preserve future fertility. It is important to identify and treat ectopic pregnancy immediately, as delay in treatment can be fatal.

                               

                              5.  When ectopic pregnancy is unlikely but cannot be ruled out (for example, pregnancy of unknown location)

                              Medication abortion can successfully be performed on early gestations before confirmation of intrauterine pregnancy.  Follow hCG levels closely to confirm an appropriate drop.

                              Aspiration can be considered as a diagnostic tool; either tissue exam or serial quantitative hCG levels should confirm that the abortion is complete. Inadequate drops in hCG level, and/or no tissue on exam, will raise the suspicion for ectopic pregnancy. For women at medium risk, this may be a preferred option, since the time to diagnosis is often faster, and side effects of medication abortion may mimic symptoms of ectopic pregnancy (e.g., bleeding, cramping, lightheadedness).


                              Heterotopic pregnancy

                              One in 20,000 pregnancies are heterotopic—i.e., one pregnancy inside the uterus and one ectopic pregnancy simultaneously. Do not disregard a high suspicion of ectopic pregnancy even if an intrauterine pregnancy is present.


                               

                            1. Lesson 2.4: Ruling out contraindications

                              Key Points

                              • There are few absolute contraindications to medication abortion.
                              • Special consideration should be given to patients with certain conditions, such as severe anemia.  The decision to proceed with the medication abortion will depend on the clinical setting and available resources.
                              Learning Objectives iconLearning Objective:
                                  • Describe the relative and absolute contraindications for medication abortion

                              In this lesson, you will review some of the medical conditions important to ensuring safety for women seeking medication abortion.

                              Most contraindications to medication abortion are related to medication interactions. The two medications most commonly used for medication abortion are mifepristone and misoprostol.  These medications will be reviewed in detail in Lesson 3, but are discussed here in the context of contraindications.

                              Few absolute contraindications exist with respect to medication abortion. Screening for the following conditions should be a routine part of the patient’s history and physical. When absolute or relative contraindications are present, women should be informed of the relative risk/s, and counseling about the risks and benefits of surgical versus medication abortion must take these conditions into account.

                              Absolute contraindications include the following:

                              • Allergy to any of the medications (mifepristone, misoprostol, or methotrexate)
                              • Inherited porphyria
                                • Mifepristone may also cause a dangerous accumulation of protoporphyrin.
                              • Known or suspected ectopic pregnancy
                              • IUD in place
                                • IUD must be removed prior to medication abortion; this can occur immediately before the medication abortion.
                              • Adrenal insufficiency or adrenal failure
                                • This is a contraindication to the use of mifepristone, which has an antiglucocorticoid effect that can trigger adrenal crisis in at-risk individuals.
                              • Severe uncontrolled asthma
                                • Women with severe uncontrolled asthma are at risk of fatal asthma exacerbation due to the antiglucocorticoid effect of mifepristone.

                               
                              Relative contraindications include the following:

                              • Long-term intermittent systemic corticosteroid use
                                • Women with long-term corticosteroid use may be candidates for medication abortion. Providers must use clinical judgment and can consider increasing steroid use for three to four days with close patient monitoring.
                                • Conditions such as poorly controlled asthma may be worsened by mifepristone, and caution should be taken.
                              • Anticoagulant use, or hemorrhagic disorder/coagulopathy
                                • These conditions are labeled as contraindications on some product labeling but not others.
                                • No evidence exists on the use of medication abortion in women with hemorrhagic disorder or coagulopathy. Women with these conditions are at higher risk of excessive bleeding during the medication abortion process, however. Eligibility must be considered on a case-by-case basis.
                              • Severe anemia
                                • No absolute cutoff exists regarding eligibility for medication abortion in women with anemia; however, they are at higher risk of requiring a transfusion if hemorrhage were to occur.
                              • No access to follow-up
                                • This is considered a contraindication to at-home medication abortion. Women who will not have access to follow-up can choose to have an in-clinic medication abortion, where they may be monitored until the heavy bleeding is over and they are no longer pregnant.
                              • Pre-existing heart disease or cardiovascular risk factor, or other chronic medical conditions
                                • Whether to provide medication abortion to women with these conditions depends on the available options for safe abortion care, referrals, and clinical judgment. If medication abortion is provided, it should be given under close observation.


                              Medication abortion is SAFE in women with these conditions:

                              • HIV/AIDS
                                • The presence of HIV infection does not affect the medication abortion regimen.
                                • There are no medical interactions between the medicines used for medication abortion and antiretrovirals.
                              • Previous or current sexually transmitted infection (STI)
                                • Prior STI does not affect the medication abortion regimen. Women should be re-screened for STI at the time of abortion.
                                • Women with symptomatic or asymptomatic STI can be treated concurrently with medication abortion.
                              • Breastfeeding women
                                • Women who are breastfeeding may take mifepristone and misoprostol for medication abortion. Low levels of misoprostol have been detected in breast milk 30 minutes after oral dosing, with a peak concentration at one hour. Although no harmful effects have been found in infants after maternal misoprostol ingestion, women who are concerned may nurse immediately before taking medications or wait four to five hours after their last dose of medication (Abdel-Aleem, 2003; Sääv et al., 2010; Vogel, 2004).
                              • Adolescents
                                • Most aspects of providing abortion care for young women are the same as for adult women, but some special considerations exist.
                                • Although women of all ages need pain management, the perception of pain and use of analgesia has been found to be higher on average in younger women than in older women.
                                • This is likely a young woman’s first pelvic exam, and she may be nervous or afraid. Therefore, providers should take special care to
                                  • ensure at least visual, and preferably auditory, privacy.
                                  • explain what you are doing at each step.
                                  • perform the examination as gently and smoothly as possible. If a range of specula sizes are available, use the size appropriate to the woman and conducive to the exam or procedure.
                              • Women with asthma
                                • Women using asthma inhalers, including inhaled corticosteroids, may have medication abortion because the medications in asthma inhalers are not systemically absorbed. Although some prostaglandins are vasoconstrictors, misoprostol is a type of prostaglandin that promotes bronchodilation, decreases inflammation and increases oxygen flow (Bernstein & Kandinov, 2004).
                                • In the case of severe or poorly controlled asthma for women on systemic steroids, the risks of mifepristone may be greater than the benefits (i.e., a severe asthma attack can lead to death). The clinician should carefully weigh the woman's clinical condition, current and recent history of asthma severity, and available options for abortion.
                              • Women with prior cesarean section (C-section)
                                • Women with prior cesarean sections (C-sections) are eligible for medication abortion in the first trimester.
                              • Multiple gestations
                                • A woman who is pregnant with twins (or other multiple gestations) may take mifepristone and misoprostol using the standard dosages of medications. The success rate for women with multiple gestations is comparable to those with singleton pregnancies (Hayes et al., 2011).
                              • Obesity
                                • There is no difference in efficacy with mifepristone and misoprostol among obese women compared to non-obese women (Strafford et al., 2009). Thus, no dose adjustment for mifepristone or misoprostol is required.  

                            2. Lesson 2.5: Laboratory testing

                              Key Point

                              • While there are no absolute lab requirements prior to abortion, many providers perform Rh testing (when Rh immunoglobulin is available) and a hemoglobin test, along with offering screening for sexually transmitted infection (e.g., chlamydia, gonorrhea, HIV).
                              Learning Objectives IconLearning Objective:
                                  • Describe the recommended laboratory testing prior to medication abortion

                              Recommendations for laboratory testing may vary by geographical standard of care. Medically speaking, no lab tests are absolutely required prior to abortion (medication or aspiration). Nonetheless, lab tests are frequently performed, primarily focusing on public health (screening for sexually transmitted infection) and/or screening for contraindications (e.g., hemoglobin). Abortions should not be delayed beyond the same day while waiting for screening lab results. This does not apply to labs that are done for diagnostic purposes and, as always, is at the discretion of the provider.

                            3. Lesson 2: Case Study: Themba

                            4. Lesson 2: Key Points

                              Lesson 2.1

                              • A history and physical should focus on obtaining information about gestational age, identifying contraindications and risk factors for complications.
                              • Most laboratory tests are not a required part of evaluation before abortion.  Labs performed prior to medication abortion may include hemoglobin and Rh testing; these tests are considered mandatory in some settings (in the United States, for example) but may be considered optional depending on the clinical setting and patient factors.

                               
                              Lesson 2.2

                              • Last menstrual period (LMP) in conjunction with a bimanual exam can reliably estimate gestational age in most patients.
                              • When the bimanual exam findings do not correlate to the expected gestational age (by LMP) it is important to consider inaccurate dating, as well as alternative diagnoses.  Ultrasound should be considered in this setting.
                              • In some settings where it is easily available, ultrasound is considered the standard of care.

                               
                              Lesson 2.3

                              • Patients should be screened for ectopic pregnancy by history and physical exam, and additional testing including ultrasound should be done if indicated.
                              • Medication or aspiration abortion will NOT treat ectopic pregnancy.  All patients with suspected or confirmed ectopic pregnancy should be emergently referred to an experienced provider where appropriate evaluation and treatment can be performed.

                               
                              Lesson 2.4

                              • There are few absolute contraindications to medication abortion.
                              • Special consideration should be given to patients with certain conditions, such as severe anemia.  The decision to proceed with the medication abortion will depend on the clinical setting and available resources.

                               
                              Lesson 2.5

                              • While there are no absolute lab requirements prior to abortion, many providers perform Rh testing (when Rh immunoglobulin is available) and a hemoglobin test, along with offering screening for sexually transmitted infection (e.g., chlamydia, gonorrhea, HIV).
                              • Lesson 3: Regimens for Medication Abortion

                                Learning Objectives IconLearning Objective:

                                At the end of this lesson, learners will be able to:

                                • Describe in detail the steps required to provide a medication abortion using mifepristone and misoprostol
                                • Describe indications and methods for medication abortion using misoprostol alone
                                • Describe indications and methods for medication abortion using methotrexate

                                Overview

                                This lesson provides basic information about different regimens that can be used for medication abortion.

                                The training in this course focuses on medication abortion <70 days gestation from LMP. Some of the required readings discuss medication abortion beyond this gestational age. Although medication abortion beyond 70 days gestation is safe, effective, and used in certain settings, this practice is not considered the standard of care and/or is restricted by law in some countries.

                                The “Regimens for Medication Abortion” lesson covers the following sections:

                                1. Medication abortion using mifepristone and misoprostol
                                2. Medication abortion using misoprostol alone
                                3. Medication abortion using methotrexate
                                This lesson addresses the following competencies from the WHO Sexual and Reproductive Health Core Competencies for Primary Care.

                                • Knowledge competencies:
                                  • Abortion management standards and guidelines
                                  • Abortion law and its applicability (legal protection available to women and providers)
                                  • National norms, standards, and guidelines for abortion care, including rules for conscientious objection
                                • Skills competencies:
                                  • Provide medical abortion according to national standards, including appropriate pain management


                                This lesson also addresses the following task outlined in the WHO Health Worker Roles document: “Administering the medications and managing the process and common side-effects independently.”

                                • Lesson 3.1: Medication abortion using mifepristone and misoprostol

                                  Key Points
                                  • Mifepristone and misoprostol together represent a safe and effective method for medication abortion—the preferred method when these medications are available.
                                  • In most countries, the mifepristone/misoprostol regimen is available for use up to 70 days gestation.
                                  • The recommended dosing for maximum efficacy is 200 mg mifepristone orally, followed in 24–48 hours by 800 mcg misoprostol via buccal, sublingual, or vaginal route.
                                  • Evidence also supports an alternative protocol of 200 mg mifepristone, followed in 6–72 hours by 800 mcg misoprostol vaginally.
                                  Learning Objectives IconLearning Objectives:
                                      • Identify different regimens involving the use of both mifepristone and misoprostol for medication abortion
                                      • Describe in detail the current evidence-based regimen options to provide a medication abortion using mifepristone and misoprostol
                                      • Identify what regional regulations of mifepristone and misoprostol will apply to your clinical practice, and identify the local standard of care

                                  When legal and available, the use of mifepristone and misoprostol in a combined regimen is recommended for medication abortion. Different regimens for medication abortion using mifepristone and misoprostol are used around the world. The required readings below are based on data supported by clinical trials and evidence-based practice. Note that the majority of evidence supports the use of mifepristone and misoprostol under 70 days gestation. There is some evidence for medication abortion in higher gestational ages, although this is not legally available in all regions, including the United States and Canada. The final reading, from the World Health Organization, examines regimens for gestational ages > 70 days, which may be used in some settings. Always consult your regional laws and restrictions, which may affect what regimen is available in your practice area.

                                  First-Trimester Abortion with Mifepristone and Misoprostol

                                  First-trimester abortion regimens: Mifepristone with misoprostol

                                  Different regimens using mifepristone and misoprostol for medication abortion are used around the world. The following instructions are based on the most effective regimens used in clinical trials and evidence-based practice.

                                  This document covers the recommended regimen for pregnancies up to 10 weeks gestation, and for pregnancies between 10 and 13 weeks.

                                   

                                  Did you know?

                                  Having a medication abortion does not make subsequent medication abortions less effective.

                                   

                                  About mifepristone

                                  Mifepristone, developed in France and originally known as RU-486, was first approved for clinical use in 1988.   

                                  Mifepristone is always taken orally (by swallowing it) and has several different actions. Its principal role is to block receptors of progesterone, a naturally produced hormone that prepares the lining of the uterus for a fertilized egg and helps maintain pregnancy.

                                  Without the action of progesterone, the lining of the uterus does not support the growing pregnancy and the pregnancy may detach from the lining of the uterus.  Bleeding may or may not begin after mifepristone is used.

                                  Mifepristone also causes the cervix to soften and makes the uterus more receptive to the actions of misoprostol.

                                   
                                   

                                  About misoprostol

                                  Prostaglandins are naturally occurring hormones that cause contractions of the uterus. Misoprostol, a synthetic prostaglandin, was developed to prevent gastric ulcers and is widely marketed under various trade names (Fernandez et al., 2008).

                                  Misoprostol stimulates cervical ripening (softening) and uterine contractions. Misoprostol can be relatively inexpensive, is stable at room temperature (15–30 degrees C or 59–86 degrees F) with appropriate packaging and storage, and is available in many countries. For more information about other gynecologic and obstetric uses of misoprostol, see www.misoprostol.org.

                                  Misoprostol can be administered vaginally or by mouth – sublingually (under the tongue) or buccally (in the cheek).

                                   

                                  Combined mechanism of action

                                  combined mechanism of action

                                  The combination of mifepristone plus misoprostol is more effective in achieving complete abortion than misoprostol alone (Kulier, 2011).

                                  Once the mifepristone (progesterone blockade) begins, a series of changes occur. The lining of the uterus thins (decidual necrosis), making it less able to support the growing pregnancy. Uterine contractions begin, and the cervix becomes softer. Then, when misoprostol is taken, contractions become stronger, bleeding occurs, and the pregnancy expels from the uterus







                                  Medication administration
                                  Administration of mifepristone
                                   

                                  For women up to 13 weeks since LMP, the provider should administer 200 mg mifepristone orally. Usually, mifepristone is given in the clinic. A recent study showed that women can safely take mifepristone at home, if they choose, with no change in safety or effectiveness.

                                  Whether women take mifepristone in the clinic or at home, they should be instructed to take misoprostol 24 to 48 hours later.


                                  Administration of misoprostol

                                  There are a range of options for the route, dosage, and timing of misoprostol administration. Buccal, sublingual, or vaginal are all recommended routes during the first trimester. More information about each of these methods of administration is below. Oral misoprostol is not recommended, due to decreased efficacy and increased side effects.

                                  For women under 10 weeks, misoprostol may be taken at home or in a clinic, according to her preference. For medication abortion between 10 and 13 weeks, women should return to the health facility to take misoprostol and stay there until the abortion is complete.

                                  Institutional or national policy may determine how mifepristone and misoprostol must be taken.
                                   

                                   

                                  Recommended regimens: Up to 10 weeks

                                  Mifepristone dosage is 200 mg orally (swallowed), followed by misoprostol 800 mcg, 24–48 hours after mifepristone. See table below for misoprostol route options. Misoprostol may be taken at home or in the clinic for women under 10 weeks.

                                  Gestational Age

                                  Mifepristone Dose

                                  Misoprostol Dose, Route, and Timing

                                  Up to 10 weeks (Kulier, 2011)

                                  200 mg orally

                                  After 24–48 hours, 800 mcg buccally, sublingually, or vaginally, for one dose

                                  Alternative regimen*

                                  200 mg orally

                                  After 6–72 hours, 800 mcg vaginally, for one dose

                                  * For gestations < 35 days or > 56 days, waiting 24 hours prior to misoprostol administration is most effective.


                                  Regimens and efficacy: 10–13 weeks

                                  • Medication abortion has been shown to be safe and effective between 10 and 13 weeks, although this is based on fewer studies compared to earlier in pregnancy. Recommendations for 11–13 weeks are based on even smaller numbers of women.
                                  • For medication abortion with mifepristone and misoprostol between 10 and 13 weeks, women should return to the health facility to take misoprostol and stay there until the abortion is complete.  This may mean staying in the facility overnight.

                                  10–13 weeks (Hamoda, 2005a; Hamoda, 2005b)

                                  200 mg orally

                                  After 36–48 hours, 800 mcg vaginally, followed by 400 mcg vaginally or sublingually every 3 hours, for a maximum of 5 doses of misoprostol

                                   

                                  Buccal use of misoprostol (in the cheek)

                                  buccal use of misoprostol (in the cheek)
                                  © Stephen C. Edgerton/Ipas

                                  Follow specific regimen for gestational age, route, dose, and timing.

                                  Instructions for buccal use of misoprostol:

                                  • Pills are tucked between the cheek (two pills each side, four pills total) and the gum.
                                  • The pills may dissolve in about 10 minutes.
                                  • If they don’t fully dissolve, swallow whatever is left of the pills in 30 minutes.

                                  Some brands of misoprostol may dissolve well before 30 minutes. As long as the pills stay in the cheek for 30 minutes or dissolve, the medicine has absorbed.

                                  This illustration shows two pills in each cheek, for a total of four pills.
                                                                                                                                                                                      
                                  Sublingual use of misoprostol
                                    © Stephen C. Edgerton/Ipas

                                   



                                  Sublingual use of misoprostol (under the tongue)

                                  Follow specific regimen for gestational age, route, dose, and timing.

                                  Instructions for sublingual use of misoprostol:

                                  • Place four pills under the tongue.
                                  • The pills may dissolve in about 10 minutes.
                                  • If they don’t fully dissolve, swallow whatever is left of the pills in 30 minutes.


                                  This illustration shows four pills under the tongue.

                                                                                                                                                                                                                                                                                                                                                                                                             
                                                                                                                                                                                                                       

                                   

                                  Vaginal use of misoprostol
                                  vaginal use of misoprostol
                                  © Stephen C. Edgerton/Ipas

                                  • If the woman is inserting the pills, she should wash her hands.
                                  • The woman empties her bladder and lies down.
                                  • If a provider is inserting pills, the provider washes hands and puts on clean exam gloves.
                                  • All the misoprostol pills are inserted.
                                  • The pills need to be pushed as far as possible into the vagina; they do not need to be in any special place in the vagina.
                                  • Often the pills will not dissolve, but the medication is still absorbed.
                                  • Fragments of the pills may remain visible for many hours.
                                  • After lying down for 30 minutes, if pills fall out when a woman stands up or goes to the bathroom, the pills do not need to be reinserted; the active medicine has absorbed by that time.   
                                                                                                                                                                                                     

                                     

                                   

                                   

                                • Lesson 3.2: Medication abortion using misoprostol alone

                                  Key Points

                                  • Misoprostol-only abortion is a safe and effective alternative in settings where mifepristone is not available, but it is less effective than the mifepristone/misoprostol combined regimen.
                                  • In most countries, the misoprostol regimen is available.
                                  • The misoprostol regimen is most effective before 63 days gestation but can be used at higher gestational ages when permitted.
                                  • In the first trimester, the recommended dosing for misoprostol-only abortion is 800 mcg by vaginal, buccal or sublingual route, repeated every 3 to 12 hours, for up to 3 doses.
                                  Learning Objectives iconLearning Objectives:
                                      • Identify indications for use of a misoprostol-only regimen for medication abortion
                                      • Identify the relative effectiveness of a misoprostol-only regimen versus combined mifepristone/misoprostol for first-trimester abortion
                                      • Describe the recommended regimens to provide a medication abortion using misoprostol alone
                                      • Identify what regional regulations of misoprostol will apply to your clinical practice, and identify the local standard of care



                                  Although misoprostol-only regimens are not as effective in completing abortion than mifepristone-misoprostol combined regimens, it is a good option for medication abortion in settings where mifepristone is not available.  There are legal and political barriers worldwide that limit the availability of mifepristone, while misoprostol is more widely available (given its other uses), is inexpensive and does not require refrigeration.


                                  The reading below will go over, in more detail, the history and recommended protocol for providing a medication abortion using misoprostol only


                                  One of the recommended dosing protocols for misoprostol-only medication abortion is 800 mcg by vaginal, buccal, or sublingual route, repeated every 3-12 hours for up to 3 doses or until the passage of POC. There are other protocols which can be used, and are reviewed further in the reading.


                                  Because misoprostol-only medication abortion is not as effective as the combined regimen, all patients should have follow up to confirm abortion completion.  

                                • Lesson 3.3: Medication abortion using methotrexate

                                  Key Points

                                  • Methotrexate can be used for medication abortion, but has more side effects than other regimens.
                                  • The use of methotrexate has been limited since the introduction of mifepristone.
                                  Learning Objectives iconLearning Objectives:
                                      • Describe indications and methods for medication abortion using methotrexate
                                      • Identify what regional regulations of methotrexate will apply to your clinical practice, and identify the local standard of care


                                  Methotrexate is now an infrequently used method for medication abortion, although it was more heavily utilized prior to the introduction of mifepristone.

                                  Currently, the main clinical application of methotrexate is for management of ectopic pregnancy. Methotrexate for medication abortion is sometimes also used in the management of pregnancies of unknown location for women with an undesired pregnancy.  The current lesson is designed as a general overview of methotrexate.

                                • Lesson 3: Case Study: Soledad

                                • Lesson 3: Key Points

                                  Lesson 3.1

                                  • Mifepristone and misoprostol together represent a safe and effective method for medication abortion—the preferred method when these medications are available.
                                  • In most countries, the mifepristone/misoprostol regimen is available for use up to 70 days gestation.
                                  • The recommended dosing for maximum efficacy is 200 mg mifepristone orally, followed in 24–48 hours by 800 mcg misoprostol via buccal, sublingual, or vaginal route.
                                  • Evidence also supports an alternative protocol of 200 mg mifepristone, followed in 6–72 hours by 800 mcg misoprostol vaginally

                                   
                                  Lesson 3.2

                                  • Misoprostol-only abortion is a safe and effective alternative in settings where mifepristone is not available, but it is less effective than the mifepristone/misoprostol combined regimen.
                                  • In most countries, the misoprostol regimen is available.
                                  • The misoprostol regimen is most effective before 63 days gestation but can be used at higher gestational ages when permitted.
                                  • In the first trimester, the recommended dosing for misoprostol-only abortion is 800 mcg by vaginal or sublingual route, repeated every 3 to 12 hours, for up to 3 doses.

                                   
                                  Lesson 3.3

                                  • Methotrexate can be used for medication abortion, but has more side effects than other regimens.
                                  • The use of methotrexate has been limited since the introduction of mifepristone.
                                    • Lesson 4: Administering Medication

                                      Learning objective iconLearning objectives:

                                      At the end of this lesson, learners will be able to:

                                      • Explain to a patient what to expect from the medication abortion process, including what to expect in the clinic, at home, and during follow-up
                                      • Explain to a patient the range of potential side effects, and what warning signs to look for to return to the clinic for evaluation
                                      • Describe pharmacologic and non-pharmacologic methods for pain control
                                      • Describe the evidence for antibiotic prophylaxis during medication abortion
                                      • Describe the evidence for anti-D immunoglobulin use
                                      • Counsel women on contraceptive options after medication abortion
                                      • List all appropriate regimens for medication abortion, including for in-clinic and at-home use

                                      Overview

                                      In the last three lessons we have reviewed the informed consent process, the pre-abortion evaluation procedure, and medication regimens that can be used.  This lesson reviews the step-by-step process of administering the pills needed for medication abortion.

                                      The “Administering Medications” lesson includes the following sections:

                                      1. What patients should expect
                                      2. Managing pain
                                      3. The role of antibiotics in medication abortion
                                      4. The role of Rh testing and anti-D immunoglobulin in medication abortion
                                      5. Contraception
                                      6. Administering medication – Summary

                                      This lesson addresses the following competencies from the WHO Sexual and Reproductive Health Core Competencies for Primary Care.

                                      • Knowledge competencies:
                                        • Abortion management standards and guidelines
                                        • Fertility return after abortion
                                        • National norms, standards, and guidelines for abortion care, including rules for conscientious objection to provision of induced abortion
                                        • Signs, symptoms, and management of spontaneous abortion, missed abortion, and induced abortion, along with related complications
                                        • Medical eligibility for all available abortion methods
                                        • Pain management, including verbal reassurance
                                        • Medical eligibility requirements for contraceptive methods
                                        • Post-abortion family planning methods
                                        • Return to fertility post-abortion and safe time to get pregnant again
                                        • How and where to obtain contraceptives
                                      • Skills competencies:
                                        • Provide complete and easy-to-understand information about abortion and recurrent abortions
                                        • Ability to discuss sexual and reproductive healthcare (SRH) following abortion – i.e., contraception, STI screening
                                        • Provide medical abortion according to national standards, including appropriate pain management
                                        • Provide contraceptive methods, including insertion of IUDs and implants, injectables, and emergency contraception immediately after abortion or post-abortion services have been performed


                                      This module also addresses the following task outlined in the WHO Health Worker Roles document: “Administering the medications and managing the process and common side-effects independently.”

                                      • Lesson 4.1: What patients should expect

                                        Key Points

                                        • The expected effects of medication abortion may include bleeding with clots, cramping, diarrhea, headache, and vomiting.
                                        • A woman should call the clinic immediately if she experiences excessive bleeding, fever > 24 hours after taking misoprostol, bad-smelling discharge, severe abdominal pain, or if she otherwise is feeling very ill.
                                        Learning Objective IconLearning Objectives:
                                            • Explain to a patient what to expect from the medication abortion process, including what to expect in clinic, at home, and during follow-up
                                            • Explain to a patient what side effects she may experience and what warning signs to look for to return to clinic for evaluation

                                        Many of the instructions about what to expect from a medication abortion are given during the informed consent process itself. Medication abortion should be considered irreversible – misoprostol is considered a teratogen (the teratogenicity of mifepristone is unknown), and mifepristone alone can terminate a pregnancy. As such, all patient questions should be answered before administering any medication.

                                        When a patient has confirmed her decision to proceed with medication abortion, the provider must review detailed instructions on how to take the medications, what to expect, when the patient should contact the office with problems, and what follow-up she needs.  These instructions were briefly mentioned in the Informed Consent lesson but will be reviewed in more detail here.

                                        Patient education is key for a woman to know what to expect from the process at home. Although some of the information presented here may have been discussed as part of the consent process (for example, when discussing the aspiration versus medication abortion options), these points should be reviewed and the patient’s understanding should be confirmed prior to taking any medication.

                                        What the woman needs to know:

                                        How and when to take the medicines

                                        To assess that the woman understands when and how to take the misoprostol (assuming she will self-administer it at home), ask, "When will you take these medicines?" "Please tell me how you're going to take the pills and how many pills you're going to take." 

                                        image of symptoms over time
                                        • Cramping
                                        • Diarrhea
                                        • Headache
                                        • Initial Bleeding
                                        • Vomiting

                                        Vaginal bleeding

                                        After taking mifepristone, most women feel no change. Approximately 8-25 percent of women will have some spotting or bleeding after mifepristone, prior to taking misoprostol (Schaff 2001, Schaff 2002). It is important to administer the misoprostol even if bleeding has already started.

                                        Bleeding most often starts 2-4 hours after taking misoprostol. As the uterus contracts and its contents are expelled through the cervix, women generally feel the peak of cramping and an increase in bleeding; after this point the bleeding begins to diminish. This process with the heaviest bleeding will typically last about 1-3 hours, and during this time the bleeding is often accompanied by passage of clots.

                                        Women should be advised to call the clinic if they do not experience bleeding and cramping within 24 hours of taking the misoprostol – this is usually a sign of failed medication abortion and women should be evaluated (see Lesson 5 for additional information about follow up).

                                        Once the pregnancy has been expelled, bleeding and cramping improve. In the next few days, women will usually experience bleeding typical of a period. The bleeding will usually last longer than a period, but will decrease over time.  The average duration of bleeding is about two weeks but some women will bleed or spot for over a month.

                                         

                                        Cramping

                                        Most women will experience lower abdominal pain and cramping, which may be stronger than during a menstrual period and is usually associated with times of heavier bleeding. In general, severity of the bleeding and cramping will wax and wane together. Women’s experience of pain is highly individual, which makes it impossible to predict how much pain a particular woman will experience during and after the expulsion of the pregnancy.

                                        Most women find pain from medication abortion to be manageable, especially if they are prepared for the range of pain they might experience and take pain medicines as advised. Women should be provided with pain medication or a prescription at their first clinic visit – this is reviewed in more detail in Lesson 4.2.

                                         

                                        Other potential side effects

                                        Over half of women in clinical trials of mifepristone and misoprostol or misoprostol only experience gastrointestinal side effects, including nausea, vomiting and diarrhea. Fever and chills are also commonly seen with misoprostol but they are usually short lived and should resolve with antipyretics. Headache, weakness and dizziness are also common though should be mild. Most of these side effects are mild and self-limited and can be treated at home. However, women who complain of prolonged or severe side effects that continue to occur 24 hours after the last dose of medications should be evaluated.

                                        Some of these symptoms are similar to symptoms that may be caused by pregnancy itself. Pregnancy-related symptoms should precede the abortion, and will improve after abortion completion. Nausea, which is usually associated with high hCG levels, will usually improve rapidly, within the first 1-3 days. Other symptoms associated with increased estrogen levels, just as breast tenderness, may take several weeks to completely resolve.

                                        First-trimester medication abortion with mifepristone and misoprostol is safe, and most women will not experience complications. However, all women should know what warning signs require prompt medical attention, and where to seek care if needed. Complications and management of complications will be discussed in more detail in Lesson 5. The warning signs below are important to review with women at the time of their initial appointment.

                                         

                                        Warning signs that warrant immediate evaluation:

                                        Women with the following symptoms should be evaluated in the same day as she contacts the clinic.  If possible, this may be done in the provider’s clinic, but providers should use clinical judgement, and consider referring women directly to an emergency room setting.

                                        • Excessive bleeding:  Soaking more than two sanitary pads per hour for more than two consecutive hours, especially if accompanied by prolonged dizziness, lightheadedness and increasing fatigue
                                        • Unusual or bad-smelling vaginal discharge, especially if accompanied by severe cramps or abdominal pain
                                        • Severe abdominal pain that occurs any day after the day misoprostol is taken.
                                        • Fever that occurs any day after the day misoprostol is taken.
                                        • Persistent severe nausea or vomiting that occurs any day after the day misoprostol is taken.
                                        • Feeling very sick, with or without fever, especially any day after the first day misoprostol is taken.
                                        • Signs of allergic reaction including hives or shortness of breath


                                        Is should be clear now that the medications used for abortion, particularly misoprostol, can cause some uncomfortable symptoms which mimic infection. As outlined above, these medication-related symptoms should resolve within 24 hours and persistent symptoms warrant clinic evaluation.

                                         

                                        Warning signs that warrant non-emergent evaluation

                                         If any of the following are present when the patient calls, women should be advised to follow up as soon as possible, or within 1-2 days:

                                        • If bleeding is like a heavy menstrual period for a week or longer and is not gradually getting lighter
                                        • If the woman experiences intermittent gushing bleeding

                                         

                                        The following may indicate that the medicines didn’t work to end the pregnancy. They may also be a sign of ectopic pregnancy. She should return as soon as possible for evaluation. 

                                        • If the woman has no bleeding or only minimal bleeding after taking misoprostol
                                        • If the woman feels she is still pregnant

                                         

                                      • Lesson 4.2: Managing pain

                                        Key Points

                                        • Pain control is an important part of counseling a woman for medication abortion so that she maintains appropriate expectations and knows how to manage her symptoms.
                                        • Most women take one dose of at least ibuprofen for pain during the heaviest bleeding after misoprostol. Some women will also take an oral opiate analgesic if available. Anxiolytics may also be considered.
                                        • Non-pharmacologic pain control options include heating pads, support persons, and a supportive environment (acceptable child care, safe housing, and available bathrooms and sanitary supplies).
                                        Learning Objectives iconLearning Objective:
                                            • Describe pharmacologic and non-pharmacologic methods for pain control during medication abortion

                                         

                                        Pain is one of the most common side effects of medication abortion. Women’s experiences vary widely, and it is impossible to predict an individual’s experience.  Variables associated with increased reported pain include nulliparity, younger age, higher anxiety score, lack of choice regarding the method of abortion (for example, if contraindications are present), and lack of information about the level of pain associated with the procedure.  These variables should be considered when evaluating and counseling a woman about what to expect from the medication abortion, in order to best prepare her

                                        In addition to non-pharmacologic methods, which should be discussed with all patients, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are considered the standard of care for primary management of medication-abortion related pain.  When not available or not appropriate (for example, allergies or medical contraindication to NSAIDs), acetaminophen may also be used, although acetaminophen is typically less effective. 

                                        Some providers also prescribe an opiate pain medication for breakthrough pain – this is at the discretion of the provider. Studies suggest that almost all women will utilize ibuprofen for pain control, and much fewer use opiates, even when they are available. Many providers are steering away from routine prescription of controlled substances, instead considering them on a case-by-case basis.

                                        Typical pain medication prescriptions include:
                                        Ibuprofen 600–800 mg every 6–8 hours, as needed (max 2,400 mg per day)
                                        Naproxen 225–550 mg every 8–12 hours, as needed (max 1,250 mg per day)
                                        Acetaminophen/paracetamol 325–625 mg every 4–6 hours, as needed (max 2,000 mg per day)

                                        Opiates (if prescribed, usually for 2–4 tablets):
                                        Acetaminophen/codeine (325 mg / 30 mg) 1–2 tablets every 4–6 hours, as needed
                                        Acetaminophen/hydrocodone (325 mg / 5 mg) 1–2 tablets every 4–6 hours, as needed
                                        Acetaminophen/oxycodone (325 mg / 5 mg) 1–2 tablets every 4–6 hours, as needed

                                        Anxiolytics (if prescribed, usually for 1–2 tablets):
                                        Diazepam 5 mg, one-time dose


                                        Non-pharmacologic pain control methods include:

                                        • Supportive environment – this can vary woman-to-woman, but consider:
                                          • Basic personal safety – access to shelter, clean water, food
                                          • Support person(s)
                                          • If the woman already has children, childcare
                                          • Music
                                        • Heating pad on the lower abdomen or lower back, which can include:
                                          • Commercial electric heating pads
                                          • Warm water in bottle
                                          • Dry rice in a cloth container (i.e., sock) – can be gently warmed in a microwave or oven (take precaution not to overheat / risk of burn)

                                      • Lesson 4.3: The role of antibiotics in medication abortion

                                        Key Points

                                        • Insufficient data exist to recommend the routine use of prophylactic antibiotics during medication abortion.
                                        • Although rare, serious infections do occur, antibiotics are unlikely to play a prophylactic role; providers and patients should be informed about this risk, and any symptoms of infection should be managed aggressively.
                                        • Some clinics or regions will direct the use of antibiotic prophylaxis as protocol or the standard of care. As always, be aware of your regional requirements.

                                        Learning Objective IconLearning objectives:

                                            • Describe the evidence for antibiotic prophylaxis during medication abortion, and how to prescribe when indicated
                                            • Identify the local regulations and standard of care regarding use of antibiotics in your practice area

                                         

                                        Insufficient data exist to recommend prophylactic antibiotics in medication abortion; however, your local standard of care or institutional protocol may direct the use of antibiotics.


                                        Remember, a suspected infection should always be appropriately treated.


                                        When used for prophylaxis, antibiotic regimens may include one of the following:

                                        Azithromycin 500 mg x 1 dose

                                        Metronidazole 500 mg x 1 dose

                                        Doxycycline 200 mg x 1 dose



                                      • Lesson 4.4: The role of Rh testing and anti-D immunoglobulin in medication abortion

                                        Key Points

                                        • No data indicate that Rh alloimmunization occurs during first-trimester abortion or miscarriage.
                                        • Rh testing is routinely done and is the standard of care in many settings where anti-D immunoglobulin is readily available for patients.
                                        • Rh testing and anti-D (rh) immunoglobulin are not requirements for medication abortion and are not administered in many settings, especially where anti-D immunoglobulin is not readily available.
                                        Learning Objectives IconLearning objectives:
                                            • Describe the evidence for anti-D immunoglobulin use during medication abortion, and how to prescribe when indicated
                                            • Identify the local regulations and standard of care regarding use of Rh testing and anti-D immunoglobulin in your practice area


                                        Is Rh testing needed prior to medication abortion?  Do Rh-negative women require immunization with anti-D (rh) immunoglobulin during a medication abortion?

                                        Rh-negative women who become exposed to Rh-positive blood may become “alloimmunized,” or develop anti-Rh antibodies. Women with Rh alloimmunization may have complications in future pregnancies, including hemolytic disease of the newborn. Anti-D immunoglobulin (also known as rh immunoglobulin or Rho (D) immunoglobulin, in the United States marketed as RhoGAM and containing 300 mcg) was developed to prevent the maternal formation of anti-Rh antibodies, and is routinely given to women during their third trimester of pregnancy.

                                        In theory, a bleeding episode at any point in pregnancy puts women at risk for exposure to and immunization against Rh proteins. However, the need for anti-D immunoglobulin during the first trimester is unclear, as overall blood volumes are low; minimal data support its use.

                                        Many providers administer a smaller dose of immunoglobulin (In the United States, marketed as MICRhoGAM and containing 50 mcg) to women who experience bleeding episodes in the first trimester. This includes women with threatened miscarriage, those with confirmed miscarriage, or those who are undergoing first-trimester aspiration or medication abortion. Despite the lack of evidence in its support, administration of anti-D immunoglobulin (RhoGAM or MICRhoGAM) is safe, with no reported adverse effects.

                                        In many settings, however, including in most low-resource areas, women are not routinely treated with anti-D immunoglobulin; no known adverse effects have occurred in these populations.

                                        For women with a gestational age > 13 weeks, Rh testing and administration of anti-D immunoglobulin may play a more meaningful role, yet data are still lacking.

                                        The big picture:

                                        Despite at least 40 years of research and debate, controversy continues over the use of anti-D (rh) immunoglobulin during first-trimester abortion (aspiration or medication) or miscarriage. The standard of care in your community, along with the cost, should be considered. Despite the lack of medical evidence to its benefit, anti-D immunoglobulin confers minimal risk. Rh status (whether negative or unknown) should not interfere with a woman’s ability to receive an abortion.

                                         

                                        Note: Content from this page was adapted from information provided by the Reproductive Health Access Project (RHAP).  More information can be found at www.reproductiveaccess.org.

                                        • Lesson 4.5: Contraception

                                          Key Points

                                          • Contraception should be offered to women at the time the medication abortion is initiated (at the time of mifepristone), as ovulation may occur soon after the abortion is complete.
                                          • Combined contraceptives, the progestin-only implant, and medroxyprogesterone injections are all safe methods to give at the time of mifepristone, and do not appear to decrease the efficacy of the medication abortion.
                                          • Progestin or copper intrauterine devices should be inserted at follow-up as soon as ongoing pregnancy has been reliably excluded.
                                          Learning Objectives IconLearning Objectives:
                                              • Describe the contraceptive methods available after medication abortion
                                              • Describe when to initiate each contraceptive method after medication abortion

                                           

                                          Because ovulation can occur almost immediately after a uterine evacuation, contraception should be provided immediately to women who want to prevent or delay pregnancy. Many contraceptive methods can be offered to women at the time of the first medication abortion. Many contraceptives do not significantly impact the efficacy of medication abortion, and starting the method before the follow-up visit allows for earlier onset of contraceptive effects.

                                          Combined contraceptives – do not interfere with medication abortion, and can be initiated at the time of mifepristone.

                                          Medroxyprogesterone and the progestin implant – do not interfere with efficacy, and can be initiated at the time of mifepristone (less data than with combined methods, but studies are reassuring).

                                          IUD (progestin or copper) – can be initiated at the follow-up visit as soon as it is reasonably certain the woman is no longer pregnant.  Delay of IUD insertion beyond the first follow-up visit does not decrease expulsion rates.

                                          Natural family planning/fertility awareness is not a reliable method until the woman has experienced at least one post-abortion menses, and only if she had regular menstrual periods before the abortion.

                                        • Lesson 4.6: Administering medication – Summary

                                          Learning Objectives IconLearning Objectives:

                                                • List all appropriate medicines for medication abortion, including for in-clinic and at-home use
                                                • Make a “to-do” checklist for pre-abortion and abortion care that is pertinent to your practice area
                                        • Lesson 4: Case Study: Agata

                                        • Lesson 4: Key Points

                                          Lesson 4.1

                                          • The expected effects of medication abortion may include bleeding with clots, cramping, diarrhea, headache, and vomiting.
                                          • A woman should call the clinic immediately if she experiences excessive bleeding, fever > 24 hours after taking misoprostol, bad-smelling discharge, severe abdominal pain, or if she otherwise is feeling very ill.

                                           
                                          Lesson 4.2

                                          • Pain control is an important part of counseling a woman for medication abortion so that she maintains appropriate expectations and knows how to manage her symptoms.
                                          • Most women take one dose of at least ibuprofen for pain during the heaviest bleeding after misoprostol. Some women will also take an oral opiate analgesic if available. Anxiolytics may also be considered.
                                          • Non-pharmacologic pain control options include heating pads, support persons, and a supportive environment (acceptable child care, safe housing, and available bathrooms and sanitary supplies).

                                           
                                          Lesson 4.3

                                          • Insufficient data exist to recommend the routine use of prophylactic antibiotics during medication abortion.
                                          • Although rare, serious infections do occur, antibiotics are unlikely to play a prophylactic role; providers and patients should be informed about this risk, and any symptoms of infection should be managed aggressively.
                                          • Some clinics or regions will direct the use of antibiotic prophylaxis as protocol or the standard of care. As always, be aware of your regional requirements.


                                          Lesson 4.4

                                          • No data indicate that Rh alloimmunization occurs during first-trimester abortion or miscarriage.
                                          • Rh testing is routinely done and is the standard of care in many settings where anti-D immunoglobulin is readily available for patients.
                                          • Rh testing and anti-D (rh) immunoglobulin are not requirements for medication abortion and are not administered in many settings, especially where anti-D immunoglobulin is not readily available.


                                          Lesson 4.5

                                          • Contraception should be offered to women at the time the medication abortion is initiated (at the time of mifepristone), as ovulation may occur soon after the abortion is complete.
                                          • Combined contraceptives, the progestin-only implant, and medroxyprogesterone injections are all safe methods to give at the time of mifepristone, and do not appear to decrease the efficacy of the medication abortion.
                                          • Progestin or copper intrauterine devices should be inserted at follow-up as soon as ongoing pregnancy has been reliably excluded.
                                            • Lesson 5: Follow-up

                                              Learning Objective IconLearning objectives:

                                              At the end of this lesson, learners will be able to:

                                              • Identify steps needed to confirm completion of medication abortion
                                              • Describe the most common outcomes of medication abortion
                                              • Describe the most common complications of medication abortion
                                              • Describe management of complications after medication abortion
                                              • Discuss myths about abortion care complications and describe where to find data to help counteract those myths

                                              Overview

                                              The previous lessons reviewed the medication abortion process through the administration of medications and discharge home. This lesson reviews the steps for follow-up of medication abortion, potential complications, and common complication myths.

                                              The “Follow-up” lesson includes the following sections:

                                              1. Assessing completion of medication abortion
                                              2. Common outcomes and complications after medication abortion
                                              3. Abortion myths

                                              This lesson addresses the following competencies from the WHO Sexual and Reproductive Health Core Competencies for Primary Care.

                                              • Knowledge competencies:
                                                • Abortion management standards and guidelines
                                                • Referral management for repeat spontaneous abortion and complications that are not treatable in loco
                                                • Symptoms and signs of abortion complications
                                                • How, when, and where to refer women
                                                • National norms, standards, and guidelines for abortion care
                                                • Abortion law and its applicability (legal protection available to women and providers)
                                              • Skills competencies:
                                                • Recognize complications of abortion
                                                • Treat abortion complications
                                                • Refer when needed
                                                • Provide medical abortion according to national standards, including appropriate pain management
                                                • Manage abortion-related complications
                                                • Provide complete and easy-to-understand information about abortion and recurrent abortions
                                                • Refer the client to another provider in case of conscientious objection, or need for high-level care, or if abortion methods are not available

                                              This lesson also addresses the following task outlined in the WHO Health Worker Roles document: “Assessing completion of the procedure and the need for further clinic-based follow-up.”

                                              • Lesson 5.1: Assessing completion of medication abortion

                                                Key Points

                                                • Follow-up requirements will vary by geographic region – but in any setting, each woman should be offered a follow-up visit if she prefers.
                                                • During the follow-up visit, providers can confirm that the abortion is complete, manage any side effects or complications, answer any questions, and address contraception.
                                                • Assessing abortion completion can be done either by trending bhCG, repeating an ultrasound, or repeating the bimanual exam. The medication abortion process and symptoms of ongoing pregnancy should be assessed in all patients.
                                                • A follow-up ultrasound should not show any residual gestational sac or products of conception (POC). A thin endometrial stripe or a thickened heterogeneous lining may be present. Neither finding warrants intervention unless the patient is having symptoms. Any finding of retained POC or sac warrants intervention.
                                                • Quantitative serum hCG levels should drop by 50% within 48 hours of bleeding, or by 80% within 7 days of bleeding.
                                                • On bimanual exam, if the woman has had a pregnancy up to 7 weeks, the uterus should feel non-pregnant within 2 weeks of bleeding. If gestation was 8 weeks or more, the uterus should feel smaller within 2 weeks of bleeding.

                                                Learning Objectives IconLearning Objective:

                                                      • Identify the steps needed to confirm successful medication abortion

                                                 

                                                Follow-up requirements

                                                Do all women need a follow-up appointment?doctor talking to patient during follow-up

                                                Because of the high success rate and low complication rate, the 2012 WHO guidelines do not require routine follow-up after an uncomplicated medication abortion using mifepristone and misoprostol (WHO, 2012) when a woman feels confident that the abortion was successful.

                                                Women are good at assessing when a medication abortion is complete – in multiple studies after taking mifepristone/misoprostol, women who believed that they had experienced a successful abortion were correct over 99% of the time (Cameron, 2012; Jackson, 2012; Perriera, 2010; Rossi, 2004).

                                                Women are less accurate in assessing whether they have had an ongoing pregnancy. In one study of women treated with mifepristone/misoprostol for first-trimester abortion, two-thirds of the women with ongoing pregnancy recognized that they were still pregnant from their symptoms alone; the remaining third did not (Jackson, 2012).


                                                In all settings, indications for making a follow-up appointment include the following:

                                                1. The woman is not sure if the abortion was complete.
                                                2. The misoprostol-only regimen was used (due to this regimen’s higher ongoing pregnancy rates).
                                                3. The woman prefers to have a follow-up appointment to confirm she is no longer pregnant.
                                                4. Any symptoms warranting follow-up should result in a follow-up appointment (anticipatory guidance must be given to the patient, as explained in Lesson 4).

                                                 
                                                What are the follow-up requirements in my region?

                                                Routine follow-up may be a requirement according to your local regulations and/or standards of care.  In the United States and Canada, following up 7–14 days after any medication abortion is considered a requirement. Women who are unable to follow-up are usually considered ineligible for medication abortion.

                                                 

                                                Follow-up visit
                                                The follow-up visit has the following objectives:

                                                1. Confirm completion of the medication abortion.
                                                2. Diagnose and treat any “failed” medication abortion (ongoing pregnancy or retained products of conception).
                                                3. Address any questions or concerns.
                                                4. Address contraception.
                                                 
                                                Confirming a successful medication abortion
                                                Steps to assess success of the abortiondoctor talking to patient during follow-up

                                                1. Review how the patient took each medication. For example, say “Tell me how and when you took each pill.

                                                2. Review symptoms:

                                                a. Ask the woman whether she felt like she expelled the pregnancy. Did she have heavy bleeding and cramping after she took misoprostol? Did she pass tissue or clots?

                                                b. Ask the woman if she ever felt pregnant, and if she still feels pregnant now. Review what pregnancy symptoms she experienced prior to and after the abortion. For example, if the woman had morning sickness and breast tenderness beforehand, has that resolved?

                                                3. Obtain objective evidence of abortion completion.

                                                IF AN ULTRASOUND WAS PERFORMED AT THE FIRST VISIT

                                                A normal follow-up ultrasound may show a range of findings, including an empty uterus or a thickened heterogeneous endometrium.  In the absence of symptoms (see below), these ultrasound findings DO NOT need intervention.  In general, the rule of thumb is to “treat the symptoms, not the ultrasound.”

                                                The ultrasound may demonstrate a retained gestational sac (see photos in the next required reading), other retained products of conception, or ongoing pregnancy (yolk sac, fetal pole with or without cardiac activity). These findings DO require intervention. Intervention options are reviewed in Lesson 5.2.

                                                 

                                                IF QUANTITATIVE HCG WAS OBTAINED AT THE FIRST VISIT

                                                Quantitative hCG can also be used to confirm abortion completion.

                                                Quantitative hCG levels should drop by 50% within 48 hours of bleeding, or drop by 80% within 7 days of bleeding.

                                                A decrease in hCG by less than the amount above should raise suspicion for incomplete abortion; however, ectopic pregnancy must also be considered if intrauterine pregnancy has not already been confirmed (for example, in a pregnancy of unknown location).  Ultrasound can be a helpful diagnostic tool to identify ongoing pregnancy. Women with a pregnancy of unknown location and insufficient drop in hCG levels should be referred to a facility equipped to diagnose and manage ectopic pregnancy. 

                                                Semi-quantitative hCG tools are now being used in some settings to help women and providers assess medication abortion completion. Early studies have shown this to be an effective tool for a woman’s at-home use in conjunction with telephone follow-up – women in the studies were able to accurately read and interpret the semi-quantitative urine hCG result.

                                                IF BIMANUAL EXAM WAS PERFORMED AT THE FIRST VISIT

                                                Perform a pelvic exam. Compare it to the exam documented prior to the medication abortion.

                                                If the woman had a pregnancy of up to 7 weeks gestation at the clinical assessment, the uterus should feel non-pregnant 2 weeks after taking the medications.

                                                If the woman had a pregnancy of 8 weeks gestation or more, the uterus should be smaller 2 weeks after taking the medications.

                                                Clinical indications that the abortion is most likely complete are as follows:

                                                • Pregnancy symptoms have stopped.
                                                • Bleeding pattern is normal.
                                                • Uterine size is non-pregnant, or smaller than before.

                                                If there is any doubt, the provider can do the following:

                                                • Have another or more experienced clinician perform an exam to check.
                                                • Ask the woman to return in 1 week and re-check her (provided she would still be within gestational eligibility to receive vacuum aspiration if needed).
                                                • Conduct or refer for an ultrasound to look for a gestational sac or an ongoing pregnancy.

                                                 

                                                Alternatives to clinic-based follow-up

                                                If a woman and her provider agree, the provider may offer to follow up by telephone to provide information and support and help the woman assess the success of the medication abortion, as needed. Sites that offer this option should establish a protocol for telephone follow-up and provide women with a telephone number for the facility or provider.

                                                Health facilities can also utilize outreach professionals, such as community health nurses, to whom women can turn for support during medication abortion and with contraceptive and other reproductive health needs.

                                                Any contact by telephone initiated by a provider or by outreach workers should only be made if a woman gives her consent beforehand, and the contact must be carried out very carefully to maintain the woman’s privacy.

                                                 

                                                Steps for telephone follow-up
                                                Steps to assess completion by telephone or by outreach workers:

                                                1. Assess the amount and timing of vaginal bleeding and cramping.
                                                2. Ask the woman if she had ever felt pregnant before medication abortion and, if so, whether she still feels pregnant now. Review what pregnancy symptoms she experienced prior to and after the abortion. For example, if the woman had morning sickness and breast tenderness beforehand, have they resolved?
                                                3. Review adherence to the protocol. For example, ask, “Tell me how you took the misoprostol pills.”
                                                4. The woman should be assessed in person if either or both of the following occur:
                                                  • Symptom review or protocol adherence suggests problems.
                                                  • The clinician, the outreach worker, or the woman is in doubt regarding ongoing pregnancy.

                                                 

                                                Contraceptive use after medication abortion

                                                After medication abortion, a woman may have sex when she feels comfortable doing so. Because ovulation can occur almost immediately after a uterine evacuation, contraception should be provided immediately to women who want to prevent or delay pregnancy. If a woman desires long-acting contraception or sterilization but it cannot be provided, an interim method should be given and referral made to the appropriate facility. In general, all modern contraceptive methods can be used immediately following first-trimester medication abortion, provided no contraindications exist.

                                                Modern hormonal methods such as oral contraceptives, implants, injectables, the vaginal ring, and the skin patch may be provided with the first pill of a medication abortion (WHO, 2012); oral contraception has no effect on bleeding (Davis, 2000).

                                                An IUD can be inserted as soon as it is reasonably certain the woman is no longer pregnant. If the woman or her partner wish to schedule sterilization, an effective method of contraception should be provided until the sterilization takes place.


                                                • Lesson 5.2: Common outcomes and complications after medication abortion

                                                  Key Points

                                                  • The most common outcome after medication abortion is that the woman is no longer pregnant and has no abnormal symptoms.
                                                  • The most common abnormal findings at follow-up are problematic bleeding, ongoing pregnancy, and persistent pain.
                                                  • Problematic bleeding (not hemorrhage) can be treated with watchful waiting, repeating a dose of misoprostol, or aspiration.
                                                  • Vacuum aspiration is recommended for ongoing pregnancy after mifepristone/misoprostol. Repeat misoprostol or vacuum aspiration are options for women with retained POC, such as a non-viable pregnancy or a retained sac.
                                                  • Women with ongoing pain after medication abortion should be worked up for etiology, which may include infection, ectopic pregnancy, or trapped tissue in the cervix.
                                                  • Infection is rare. Endometritis should be treated as PID, per local guidelines. Severe infection is rare, but may be caused by Clostridium sordellii bacteria and can be fatal; symptoms should be treated rapidly and aggressively.

                                                  Learning Objectives IconLearning Objectives:
                                                        • Describe the most common outcomes of medication abortion
                                                        • Describe common situations that may warrant additional intervention, and describe the treatment options available
                                                        • Describe the potential, more serious complications of medication abortion
                                                        • Describe the general management of each complication
                                                    Outcomes after medication abortion

                                                    This section summarizes the most common outcomes a clinician will encounter after medication abortion. 

                                                     

                                                    Normal outcome

                                                    If a woman has taken the medicines as instructed, a normal outcome is the most common outcome; 95% of women who use mifepristone and misoprostol have a successful abortion. 

                                                    Generally, the day after the woman takes misoprostol, she will start to feel better and, by the time of the follow-up visit (if scheduled), she will no longer feel pregnant. Many women have bleeding much heavier than a normal menstrual period (although some have bleeding lighter than a menstrual period) on the day they take misoprostol. After the day of misoprostol, bleeding should be lighter. Some women have intense cramps on the day they take misoprostol, but after the pregnancy expels, the cramps diminish in intensity. Mild, intermittent cramps may persist for several days. By the time of a follow-up visit, the woman should feel well, and cramping is usually gone.

                                                    Approximately 60% of women who have had medication abortion still experience light bleeding or spotting at a two-week follow-up (Davis, 2000).

                                                     

                                                    Problematic bleeding

                                                    Some women report problematic bleeding at a follow-up visit, despite the fact that the pregnancy is not continuing, pregnancy symptoms have resolved, and the uterus is smaller in size.  Various patterns of problematic bleeding are described below.

                                                    blood drops
                                                            © Stephen C. Edgerton/Ipas

                                                     

                                                    Persistent, heavy, or erratic bleeding

                                                    This term applies when the woman bleeds as much as a heavy menstrual period continuously since taking misoprostol. If the woman has clinical symptoms of low blood volume due to bleeding (fatigue, weakness especially upon standing, racing pulse, feeling faint), and/or if hemoglobin or hematocrit (if testing is available) has dropped significantly from the initial value, vacuum aspiration should be performed.

                                                                                                                                                              

                                                                                                                                 

                                                    If her bleeding is currently not heavy but is somewhat prolonged or erratic and she is clinically stable and feels well, a repeat dose of misoprostol (for example, 400–800 mcg by vaginal or buccal route) may be offered as long as the woman is willing to return in one to three days for assessment. Providing a second dose of misoprostol to enhance uterine contractions is a common practice, although it is not clear from evidence whether the repeat misoprostol actually decreases bleeding. Fluid intake (oral hydration) and iron-rich foods or iron supplements should also be strongly encouraged.

                                                    Some women have days of very little or no bleeding followed irregularly by heavy, gushing bleeding. This can rarely happen even after several weeks. If the woman is symptomatic of anemia, the provider should perform vacuum aspiration. If she is not symptomatic of anemia and otherwise feels well, vacuum aspiration can still be offered in order to improve symptoms. A repeat dose of misoprostol may be offered as long as the woman is willing to return in one to three days for assessment. A repeat fluid intake (oral hydration) and iron-rich foods or iron supplements should be strongly encouraged.


                                                    IN SUM:

                                                    If the woman is experiencing problematic (but not severe) bleeding, discuss treatment options with her, including the following:

                                                    1. Waiting and watching, for up to several weeks
                                                    2. Repeating the dose of misoprostol to encourage uterine contractions
                                                    3. Uterine aspiration (for example, manual vacuum aspiration)
                                                      1. Note that sometimes a woman is tired of persistent bleeding and requests uterine aspiration even though it may not be clinically necessary; this option should be made available to her if possible. 

                                                     
                                                    All women with problematic bleeding should be encouraged to return if bleeding does not slow down despite the treatment, whether the treatment is watchful waiting, repeat misoprostol, or vacuum aspiration.

                                                     

                                                    Hemorrhage

                                                    Although approximately 75% of women will experience bleeding that exceeds blood loss from menstruation, it is uncommon for this bleeding to be clinically significant or to cause a significant drop in hemoglobin levels. However, remember that medication abortion is contraindicated in settings of severe anemia and, if a patient has severe anemia or is at risk of excess bleeding (i.e., coagulopathy), she should be counseled and urged to choose aspiration abortion.

                                                    Hemorrhage is always an emergency. Any woman experiencing hemorrhage needs emergency vacuum aspiration and, if available and indicated, fluid replacement and possibly blood transfusion.

                                                    Studies estimate that, after medication abortion, approximately 0.5–2.6% of women will require suction aspiration to control bleeding of any type, and 0.2% of women will require a blood transfusion.

                                                    Indications that bleeding (of any amount) requires immediate attention include:

                                                    • abundant gushing bleeding
                                                    • bleeding similar to a heavy period that persists for weeks, leading to anemia and hypovolemia
                                                    • pale appearance accompanied by weakness, agitation, or disorientation
                                                    • blood pressure drop or feeling faint upon standing
                                                    • rapid pulse, especially when associated with low blood pressure
                                                    • paleness around the conjunctiva or inner eyelids, and/or around the mouth, palms, or fingertips (may appear blue- or gray-tinged)
                                                    • dizziness and fainting
                                                    • decreased urine output

                                                     

                                                    Continuing pregnancy

                                                    A continuing pregnancy occurs in fewer than 1% of women who take mifepristone and misoprostol and approximately 4% to 6% of women who use misoprostol only (for gestations up to nine weeks).continuing pregnancy

                                                    A continuing pregnancy is suggested by a lack of vaginal bleeding, persistent pregnancy symptoms, and/or increasing uterine size. Ultrasound will show progression of pregnancy from the initial visit (if ultrasound was done). Vacuum aspiration is recommended if pregnancy continues after taking mifepristone and misoprostol.

                                                    If ultrasound demonstrates a non-viable pregnancy or retained gestational sac, repeat dosing of misoprostol is also an option. Patients may choose to have aspiration procedure right away or may choose to try the misoprostol again first. If a repeat dose of misoprostol is insufficient, vacuum aspiration is recommended.                                      
                                                                                                                                                                      
                                                                                                                                                                                                                
                                                    © Stephen C. Edgerton/Ipas

                                                     

                                                    Persistent pain

                                                    The range of pain women experience after taking misoprostol varies from mild to intense. Even if a woman experiences intense pain on the day she takes misoprostol, by the following day and the days thereafter, strong pain is abnormal and should be investigated. If a woman has intense pain that persists for longer than 4–6 hours after taking misoprostol, or if she reports intense pain unrelieved with ibuprofen and mild narcotics, consider the possibilities of:

                                                    • pregnancy tissue trapped in the os. If this is the case, it can sometimes be grasped with an instrument such as ring forceps and gently removed
                                                    • ectopic pregnancy
                                                    • upper reproductive tract infection
                                                    • poor pain tolerance

                                                     

                                                    A woman who has intense or ongoing pain warrants further examination to ensure that she does not have one of the above conditions. A careful history should be taken, along with a complete physical and bimanual exam, followed by management or referral as necessary.

                                                    The following steps can also be considered for women with ongoing pain, who may seek an emergency room or urgent care setting:

                                                    • additional PO, IM, or IV analgesics such as opiates
                                                    • additional medications for other side effects (for example, symptomatic treatment of nausea or diarrhea)
                                                    • uterine aspiration
                                                    • anxiolytics

                                                     

                                                    Infection

                                                    Fewer than 1% of women will experience infection (usually endometritis) after medication abortion.  Infection is usually polymicrobial and may be the result of ascending lower genital infection.

                                                    Symptoms of infection include:

                                                    • persistent or atypically severe abdominal/pelvic pain
                                                    • fever
                                                    • prolonged bleeding or spotting
                                                    • cervical motion tenderness, uterine tenderness, or adnexal tenderness
                                                    • elevated white blood count (WBC)


                                                    Treat any suspected infection with broad-spectrum antibiotics, as you would for pelvic inflammatory disease (PID).  Follow your regional recommendations for antibiotic selection. Mild infection can be treated as outpatient, with oral antibiotics. Consider aspiration if concurrent retained tissue is suspected.

                                                    Very rarely, women have experienced a fatal toxic shock syndrome from infection with Clostridia bacteria. This infection does not present like a typical pelvic infection and can cause symptoms including low-grade (or no) fever, malaise, flu-like symptoms, weakness, vomiting, tachycardia, hypotension, elevated hemoglobin and WBC count, and mild to moderate abdominal pain. This infection has been fatal in fewer than 10 women in the United States, out of more than 1 million women who have had medication abortions. Treatment is aggressive and must be initiated as quickly as possible. This serious infection is not exclusive to medication abortion – death from Clostridia infections has also been reported after miscarriage and other gynecologic procedures.

                                                     

                                                    Additional information on infection can be found at the following websites:

                                                    https://www.prochoice.org/online_cme/m2complications.asp#3

                                                    https://www.prochoice.org/online_cme/m2expected2.asp#2

                                                     

                                                     Complication myths

                                                    It is important to debunk certain myths surrounding medication abortion. The following facts are necessary for women to know regarding their future health and fertility.

                                                     Infertility – Women who obtain medication abortion do not experience infertility in the future.

                                                     Future abortion – Having a medication abortion does not make medication abortions less effective in the future. Women can safely have multiple medication abortions.

                                                     Future pregnancy – Medication abortion does not increase the risk of pregnancy complications, including preterm birth, low birthweight, birth defects, ectopic pregnancy, or miscarriage.

                                                     

                                                  • Lesson 5.3: Abortion myths

                                                    Learning Objective IconLearning Objective:

                                                          • Identify several of the common myths about abortion and abortion complications

                                                    As you approach the end of this course, consider again the patients whose lives are affected by abortion and by restricted abortion access. In the introduction, some of these stories were revealed; you also read about several abortion myths. Keeping in mind the material you have learned since then, we revisit some of these myths to present a fuller picture of the factors impacting women’s ability to access abortion.

                                                  • Lesson 5: Case Study: Sunita

                                                  • Lesson 5: Case Study: Nadia

                                                  • Lesson 5: Key Points

                                                    Lesson 5.1

                                                    • Follow-up requirements will vary by geographic region – but in any setting, each woman should be offered a follow-up visit if she prefers.
                                                    • During the follow-up visit, providers can confirm that the abortion is complete, manage any side effects or complications, answer any questions, and address contraception.
                                                    • Assessing abortion completion can be done either by trending bhCG, repeating an ultrasound, or repeating the bimanual exam. The medication abortion process and symptoms of ongoing pregnancy should be assessed in all patients.
                                                    • A follow-up ultrasound should not show any residual gestational sac or products of conception (POC). A thin endometrial stripe or a thickened heterogeneous lining may be present. Neither finding warrants intervention unless the patient is having symptoms. Any finding of retained POC or sac warrants intervention.
                                                    • Quantitative serum hCG levels should drop by 50% within 48 hours of bleeding, or by 80% within 7 days of bleeding.
                                                    • On bimanual exam, if the woman has had a pregnancy up to 7 weeks, the uterus should feel non-pregnant within 2 weeks of bleeding. If gestation was 8 weeks or more, the uterus should feel smaller within 2 weeks of bleeding.

                                                     
                                                    Lesson 5.2

                                                    • The most common outcome after medication abortion is that the woman is no longer pregnant and has no abnormal symptoms.
                                                    • The most common abnormal findings at follow-up are problematic bleeding, ongoing pregnancy, and persistent pain.
                                                    • Problematic bleeding (not hemorrhage) can be treated with watchful waiting, repeating a dose of misoprostol, or aspiration.
                                                    • Vacuum aspiration is recommended for ongoing pregnancy after mifepristone/misoprostol. Repeat misoprostol or vacuum aspiration are options for women with retained POC, such as a non-viable pregnancy or a retained sac.
                                                    • Women with ongoing pain after medication abortion should be worked up for etiology, which may include infection, ectopic pregnancy, or trapped tissue in the cervix.
                                                    • Infection is rare. Endometritis should be treated as PID, per local guidelines. Severe infection is rare, but may be caused by Clostridium sordellii bacteria and can be fatal; symptoms should be treated rapidly and aggressively.
                                                      • Lesson 6: Logistics of Providing Medication Abortion

                                                        Learning Objective IconLearning objectives:

                                                        At the end of this lesson, learners will be able to:

                                                        • List many common barriers to providing medication abortion services
                                                        • Describe resources and support organizations to help mitigate these barriers
                                                        • Describe alternative methods of abortion provision, including telemedicine or self-administered medication abortion
                                                        • Identify sources of logistical support to facilitate initiation of medication abortion services

                                                        In the first five lessons, as a foundation to start providing medication abortion services, you reviewed the information on medication. 

                                                        The next step is to discuss how to initiate medication abortion services in your practice. 

                                                        “Logistics of Providing Medication Abortion” includes the following sections:

                                                        1. Barriers to providing medication abortion (and potential solutions)
                                                        2. Resources
                                                        3. Medication abortion outside the clinic

                                                        • Lesson 6.1: Barriers to providing medication abortion (and potential solutions)

                                                          It is important to recognize the potential barriers to providing abortion care.  This list is not comprehensive - many barriers are geographically-dependent, and you need to consider your own practice area’s limitations.

                                                          In general, barriers can be:

                                                          1. Provider barriers
                                                          2. Patient barriers
                                                          3. Clinic barriers
                                                          4. Legal barriers (which can be related to any of the first 3 categories)


                                                          The goal of this lesson is to provide an overview of barriers to consider.  Solutions are offered where indicated. Many online resources can be found in the Resources document. 

                                                          Provider barriers

                                                          Obtaining provider training to provide medication and aspiration abortion is a barrier that many physicians face. Training to provide medication abortion includes knowledge-based training (which this course is intended to provide), as well as in-person hands-on experience. In the next lesson, we will provide a list of resources that can be used for ongoing knowledge-based training or to be used as a reference for providers.  Many of the partner organizations of this course offer hands-on training and experience. If you are having trouble finding a mentor, or if you would like to become a mentor, please contact NextGenU.org.

                                                          Depending on the geographic location of the provider, malpractice insurance coverage may be a consideration. Be sure to check with your malpractice insurance provider to ensure that abortion services are covered. Supplemental (sometimes called “wrap around”) insurance policies can be obtained to cover care not included in a primary insurance policy. If malpractice insurance is an issue for you, please contact NextGenU.org and we will try help with malpractice-related resources.

                                                          Finally, some providers may find contract issues to be a barrier. This can be true when trying to provide care in a primary or secondary clinic site. For example, some providers may find their administration and/or direct supervisors to oppose their abortion-related work (this will be addressed in more detail below under “clinic barriers”). Some providers, by contract, are unable to work outside their primary clinic settings. Others may be able to do outside work, but only if the work is approved by of their supervisor, who may be anti-choice. Contracts have been used to as a tool to discourage providers from doing abortions. We encourage everyone to pay careful attention to any contract prior to signing, and look for abortion-related limitations.

                                                          Patient barriers

                                                          Patients may face barriers in accessing care. This may include transportation to the clinic, childcare, and financial barriers. It is important to consider and try to mitigate these barriers for your patients. Local or regional resources may be an option depending on your geographic location.  In the next lesson we provide the names of some organizations that may be able to help women access care.  For example, some organizations provide funding to women who would otherwise be unable to afford an abortion.

                                                          Clinic barriers

                                                          Getting staff support and administrative support is an important step to having abortion services in clinic.  Staff typically has a large share of the patient interaction, starting with whoever answers the phone when the patient calls to schedule an appointment.  Values clarification workshops can be a helpful step to getting staff on-board. Sample values clarification guides are located in the References list  Depending on the geographic location of the clinic, administrators will need to coordinate billing and insurance for abortion services. Guide sheets for billing and coding are also located in the References list.

                                                          Staff training is another clinic-based barrier.  For example, staff may be responsible for patient intake, basic labs, and providing counseling or aftercare instructions. In addition to this course, some online trainings are made specifically for non-providers / support staff. 

                                                          Organization and training of on-call and backup providers: this encompasses two categories of provider - those who will be on-call for patient questions (for example, overnight), as well as specialist care who will be available for complications (for example, if a patient has complications, requires a procedure in a higher level of care, or has a suspected ectopic pregnancy). 

                                                          For the on-call provider, having adequate training and clear telephone protocols (an example can be found in the next lesson) is essential.  Some providers may choose to be on-call for their own abortion patients, especially if their on-call partners are unable or unwilling to field calls related to abortion care.  Though we encourage providers to work with their colleagues, we realize this is not always an option and there will be a range of support. 

                                                          Similarly, the back-up provider is a group or individual who will provide the back-up support.  Though complications are rare, every abortion provider must have clear, written protocols about how to refer patients to a higher level of care. For medication abortion, this must include uterine aspiration / manual vacuum aspiration if this cannot done in the same clinic as the medication abortion.  Local mentors and colleagues may be able to help identify a back-up provider in your area.

                                                          Finally, the clinic must be able to obtain the equipment required to provide medication abortion. This minimal requirement will vary but may include Hb and Rh testing materials, and medications.  In some settings, obtaining medications used for medication abortion can be difficult.  For example, in the United States there are several restrictions on the ordering and administration of mifepristone.

                                                          Legal barriers

                                                          National, regional, and local legal restrictions may apply.  In the “resources” lesson, we provide a list of organizations that compile legal information. Be familiar with applicable restrictions in your area.

                                                          Legal restrictions can include, but are not limited to: gestational age restrictions, indication restrictions (for example, if abortion is only legal in cases of rape, incest, or danger to health), treatment of minors/parental consent, restrictions of telemedicine, and consent laws (for example, defining who is allowed to do the consent, or defining what information must be included).

                                                          Laws can also affect clinical practice. Examples include: whether a patient needs an ultrasound, whether an in-person follow-up is required, what specific regimen is used (for example, until recently only the 600 mg dose of mifepristone was approved by the FDA, the regulatory agency of the United States), or how medication must be dispensed (for example, if medication must be dispensed by a physician)

                                                        • Lesson 6.2: Medication abortion outside the clinic

                                                          Learning Objective IconLearning Objective:

                                                              • Describe how telemedicine can be an effective method to expand access to medication abortion
                                                              • Describe how self-managed abortion can be a safe effective method to expand access to medication abortion


                                                          Medication abortion using telemedicine

                                                          Although complications are rare, medication abortion is safest when done under the supervision of medical professionals, though this can often be done remotely. Telemedicine offers a way for women to access care even in areas where they cannot easily reach a physical clinic, although in-person access must be available to manage complications. For example, women should be within an hour of urgent care or emergency services in the unlikely case that complications occur. We support efforts to increase women’s access to safe abortion services, and in the current digital age, telemedicine will likely plan an increasingly important role in expanding access to care.

                                                          The only component of abortion evaluation that cannot be done remotely is objective confirmation of gestational age. Women may already have evaluation of gestational age by another provider. Some telemedicine programs rely on experienced clinicians (i.e. nurses, midwives, nurse practitioners) to do an exam or ultrasound, and report the results to the provider. Some research is being done on whether a telemedicine medication abortion can be done by relying only on a woman’s LMP for gestational dating. Experienced staff can also do most follow-up visits, and current research is evaluating the use of follow up by phone for eligible patients.

                                                          For example, in some abortion clinic networks, women can come to satellite clinics (which may be closer to their home) and receive their initial evaluation by staff (history, labwork, and ultrasound), followed by a “consultation” with a physician by video conference.  In a model being studied currently (Gynuity, 2018), patients can receive screening exams locally, then receive medication by mail, then have a follow up appointment locally - the local provider does not need to be able or willing to prescribe the medication themselves.

                                                          Despite its documented safety, anti-choice groups have targeted the use of telemedicine as a way of limiting access to care, and there is legislation against the use of telemedicine for abortion care in some areas, including several states in the U.S.

                                                          Self-managed abortion

                                                          Especially in settings with strict legal restrictions, women may use medication to induce abortion without seeking medical advice. This is often referred to as “self-managed abortion.”

                                                          Medication, usually misoprostol only, can be obtained online or across borders, and information about how to take medications can be found online.

                                                          In an effort to ensure access to quality medications, a variety of online organizations have worked to provide testing, information, and direct access to medications to women.

                                                          The following organizations provide information:

                                                          1. www.MedAb.org - run by the International Planned Parenthood Federation, is a database of where misoprostol, mifepristone, and combination packs are available, by nation.
                                                          2. The Plan C report card provides information about cost, shipping time, product quality, and medical oversight.Note that the link is https://static1.squarespace.com/static/55411f70e4b033b0c2b7dc0d/t/5bfe006a4d7a9cce9bbe6336/1543372907208/PlanCReportCardNEW.pdf


                                                          The following sites offer abortion pills through different types of online services:

                                                          1. www.womenonweb.org, www.womenhelp.org,  www.aidaccess.org, which offer lower pricing (including a sliding scale for those who can’t afford the pills), excellent information, and email/chat support services
                                                          2. Commercial online pharmacies may also offer the medications, but often have higher pricing and lack patient-centered information.


                                                          Research to date indicates that self-use is safe and effective, and the World Health Organization (WHO) supports self-managed abortion where clinical services are not available, including parts of the United States. Those who have self-managed abortion report favorably on the experience, citing the benefits of convenience, privacy, lower cost, and control over the experience.  In some countries such as India, the majority of abortions are self-managed. Some of the readings below offer data supporting self-managed abortion and discuss the experience further.

                                                          Some patients may ask providers for support as they self-manage abortion. Some considerations for providers include:

                                                          • Complications after self-managed abortion can be treated as a miscarriage
                                                          • There is no medical need for the treating provider to know whether a person has taken pills to self-induce an abortion. It may be prudent to not ask for any information about this from patients, particularly in places where patients who self-manage abortion may be criminalized.  Several women in the United States have been incarcerated after self-managed abortion.
                                                          • Medical privacy laws in some countries (including the US) prohibit providers from sharing confidential patient information (including whether they have self-managed an abortion) with legal authorities.
                                                          • SIA Legal has some resources for providers, which are available here:
                                                            https://docs.wixstatic.com/ugd/8f83e4_7ccf6d3c974d4a85a9f1bbb00c35b30e.pdf

                                                            https://docs.wixstatic.com/ugd/8f83e4_a537892c61524dd78c8e548c4cf3512a.pdf


                                                        • Lesson 6.3: Resources

                                                          There is no required reading for this section.  Instead, this lesson is to provide you with a list of resources that you may choose to use in entirety or to adapt to your specific clinical needs.  This list is not exhaustive, and many additional resources exist. If there is a resource you think should be included, let us know at NextGenU.org.

                                                          There are four categories of resources that you may need to access to help implement or continue medication abortion services in your clinic:


                                                          1.  Provider tools

                                                          a. Clinical guidelines
                                                          b. Hands-on training
                                                          c. Additional online training
                                                          d. Clinical competencies and skills evaluations

                                                          2. Patient tools

                                                          a. Options counseling
                                                          b. Abortion care support
                                                          c. Organizations that may help patients (US)

                                                          3. Clinic tools

                                                          a. Staff training
                                                          i. Values clarification
                                                          ii. Staff training
                                                          b. Forms
                                                          i. Consent forms
                                                          ii. Aftercare instructions
                                                          iii. Equipment checklists
                                                          iv. Note templates
                                                          c. Equipment
                                                          i. Obtaining medication
                                                          ii. Registering as a mifepristone provider

                                                          4. Legal resources

                                                        • Bibliography

                                                          1. Achilles SL, Reeves MF. Society for Family Planning guidelines: Prevention of infection after induced abortion. Contraception. 2011;83(4):295-309. doi:10.1016/j.contraception.2010.11.006.
                                                          2. Guiahi M, Davis A. Society for Family Planning guidelines: First-trimester abortion in women with medical conditions. Contraception. 2012;86(6):622-630. doi:10.1016/j.contraception.2012.09.001.
                                                          3. Kerns J, Steinauer J. Management of postabortion hemorrhage. Contraception. 2013;87(3):331-342. doi:10.1016/j.contraception.2012.10.024.
                                                          4. Fox MC, Krajewski CM. Society for Family Planning guidelines: Cervical preparation for second-trimester surgical abortion prior to 20 weeks’ gestation. Contraception. 2014;89(2):75-84. doi:10.1016/j.contraception.2013.11.001.
                                                          5. Allen RH, Goldberg AB. Society for Family Planning guidelines: Cervical dilation before first-trimester surgical abortion (<14 weeks’ gestation). Contraception. 2007;76(2):139-156. doi:10.1016/j.contraception.2007.05.001.
                                                          6. Bracken H, Clark W, Lichtenberg E, et al. Alternatives to routine ultrasound for eligibility assessment prior to early termination of pregnancy with mifepristone-misoprostol. BJOG An Int J Obstet Gynaecol. 2011;118(1):17-23. doi:10.1111/j.1471-0528.2010.02753.x.
                                                          7. World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems - 2nd Ed.; 2012. www.who.int/reproductivehealth. Accessed May 25, 2018.
                                                          8. World Health Organization. Clinical Practice Handbook for Safe Abortion.; 2014. http://apps.who.int/iris/bitstream/handle/10665/97415/9789241548717_eng.pdf?sequence=1. Accessed May 25, 2018.
                                                          9. Asif K, Etherington-Smith C, Friedman J, et al. From Choice, a World of Possibilities Introduction: Providing High Quality, Client-Centred Services.; 2008. https://www.ippf.org/sites/default/files/abortion_guidelines_and_protocol_english.pdf. Accessed May 25, 2018.
                                                          10. Ipas. Clinical Updates in Reproductive Health.; 2018. http://www.ipas.org/en/Resources/Ipas Publications/Clinical-Updates-in-Reproductive-Health.aspx. Accessed May 25, 2018.
                                                          11. Hayes JL, Achilles SL, Creinin MD, Reeves MF. Outcomes of medical abortion through 63 days in women with twin gestations. Contraception. 2011;84(5):505-507. doi:10.1016/j.contraception.2011.02.015.
                                                          12. Misoprostol.org: Safe usage guide for Obstetrics and Gynaecology. http://www.misoprostol.org/. Accessed May 25, 2018.
                                                          13. The Medication Abortion Website. http://www.medicationabortions.com/. Accessed May 25, 2018.
                                                          14. Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana A. Medical methods for first trimester abortion. Cochrane Database Syst Rev. 2011;(11):CD002855. doi:10.1002/14651858.CD002855.pub4.
                                                          15. Borgatta L, Kapp N. Society for Family Planning guidelines: Labor induction abortion in the second trimester. Contraception. 2011;84(1):4-18. doi:10.1016/j.contraception.2011.02.005.
                                                          16. Gynuity Health Projects: Map of Mifepristone Approvals. http://gynuity.org/resources/single/map-of-mifepristone-approvals/. Published 2017. Accessed May 25, 2018.
                                                          17. Paul M. Management of Unintended and Abnormal Pregnancy : Comprehensive Abortion Care. Wiley-Blackwell; 2009. https://www.wiley.com/en-us/Management+of+Unintended+and+Abnormal+Pregnancy%3A+Comprehensive+Abortion+Care+-p-9781405176965. Accessed May 25, 2018.
                                                          18. White K, Carroll E, Grossman D. Complications from first-trimester aspiration abortion: a systematic review of the literature. Contraception. 2015;92(5):422-438. doi:10.1016/j.contraception.2015.07.013.
                                                          19. Pazol K, Creanga AA, Burley KD, Jamieson DJ. Abortion surveillance - United States, 2011. MMWR Surveill Summ. 2014;63(11):1-41. http://www.ncbi.nlm.nih.gov/pubmed/25426741. Accessed May 25, 2018.
                                                          20. Miller E, Decker MR, McCauley HL, et al. Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception. 2010;81(4):316-322. doi:10.1016/j.contraception.2009.12.004.
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