Algorithms for Medication Abortion: Making it Safe and Simple Linda Prine MD Dan Napolitano MD Erin Hendricks MD Beth Israel Residency in Urban Family Practice

Medication Abortion can be offered as a routine part of family medicine outpatient care  Women with unintended pregnancies are first given options counseling  If they choose medication abortion, gestational age under 9 weeks must be established  Bimanual exam and certain LMP dates are adequate for assessing gestational age  Consents signed, quant hCG drawn, Rh type determined, anticipatory guidance done, phone contact set up  Woman returns in 4-14 days to assess completion

Ultrasound Rarely Needed Prior to Medication Abortion  Indications for Ultrasound  Unsure LMP  Difficulty with sizing uterus (due to body habitus, patient discomfort w/exam, etc.)  Became pregnant while on contraceptive  Size not consistent with dates  Irregular menses  Note: additional history often helpful, for example: a negative pregnancy test two weeks ago, and yesterday a positive pregnancy test

Medication Abortion: when Ultrasound shows no IUP* Return visit one week, obtain Beta hCG, expect drop more than 50%*** < 2,000: Two options 2,000-15,000 Consider MTX for presumed ectopic vs. urgent referral to gyn >15,000 TO ER Obtain beta hCG Sac obtained, Usual “take home” post procedure instructions No sac obtained *Ultrasound is not routinely needed for a medication abortion. The indications are: unsure dates, unable to confirm dates by sizing, or size not consistent with dates. ** If quant >2000, recall for Mtx or ER, depending upon level *** If no drop, see ongoing pregnancy algorithm Certain LMP < 4.5 weeks or serial home preg test only turned neg to pos w/in past week Uncertain LMP, no additional hx Certain LMP > 4.5 weeks Patient agrees to aspiration? No Yes Rises <66% Rises >66%, give mife, miso Obtain beta hCG** Give mife, miso Repeat quant in 48 hrs

Phone Triage Call - Bleeding with Medication Abortion Patient calls, reports bleeding During first 24 hours after using misoprostol Spotting for 2-3 weeks following med ab Persistent bleeding (not spotting) one month following med ab Soaking more than 2 pads per hour x 2 consecutive hours? Bleeding has slowed, return for F/U one week Take 800mg Ibuprofen, Increase fluids, call back 1 hour Reassure: this is normal Bleeding persists heavy (very rare), Come into office Check Hct, check orthostatics, if normal, offer one week iron and watchful waiting, if abnormal (very rare): offer aspiration YesNo Asymptomatic, feels well Symptomatic (very rare) Come into office

Pregnancy without FH or with retained sac only: Offer EXPECTANT MANAGEMENT, REPEAT MISOPROSTOL **, or ASPIRATION Pregnancy with FH 9 weeks: Offer REPEAT MISOPROSTOL ** or ASPIRATION Pregnancy with FH > 9 weeks: Recommend ASPIRATION REPEAT MISOPROSTOL No POCs on sono or hCG drop >50%, process complete Aspiration completes abortion Options for Ongoing Pregnancy or Retained Gestational Sac on Ultrasound After Medication Abortion* (which occurs <1% of the time) *Ultrasound is not routinely needed for a medication abortion. An ultrasound is indicated if the follow-up Beta hCG does not drop more than 50% or if the history makes you suspicious that the pregnancy was not expelled. Thickened, heterogeneous endometrium is normal ultrasound finding post med ab. **Repeating misoprostol 800mcg is successful about 85% of the time. ≤ EXPECTANT MANAGEMENT Persistent POCs? NoYes ASPIRATION

Summary  Medication abortion is a safe and important alternative for women  It can be offered in a primary care setting where ultrasound is not available on-site  The complications and difficulties are all rare  Knowing where to find guidance for these difficult cases should give new providers additional confidence that they can offer this important care to their patients