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JOGC

Medical Abortion

Published:April 22, 2016DOI:https://doi.org/10.1016/j.jogc.2016.01.002

      Abstract

      Objective

      This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

      Intended Users

      Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

      Target Population

      Women with an unintended first trimester pregnancy.

      Evidence

      Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

      Values

      The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

      Benefits, Harms and/or Costs

      Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

      Summary Statements

      Introduction
      • 1.
        In countries where mifepristone is approved, women have improved access to medical abortion; however, abortion rates do not increase. (Level II-3)
      • 2.
        Women who can choose their method of abortion have higher satisfaction rates. (Level II-1)
      Pre-procedure care
      • 3.
        In the absence of readily accessible ultrasound, gestational age can be estimated using last menstrual period (LMP), clinical history, and physical examination, in women who are certain of the date of their LMP. Ultrasound is needed when uncertainty remains. (Level II-2)
      • 4.
        The probability of ectopic pregnancy among women requesting abortion is consistently lower than in the general population. (Level II-3)
      Medical abortion regimens
      • 5.
        There is limited evidence regarding teratogenicity of mifepristone, but overall the risk appears to be low. (Level III)
      • 6.
        Misoprostol is a known teratogen when used in the first trimester of a pregnancy. (Level II-2)
      • 7.
        The risk of teratogenicity is high with the use of methotrexate. (Level II-3)
      • 8.
        Oral mifepristone 200 mg and buccal misoprostol 800 μg is 95% to 98% effective up to 49 days after last menstrual period. The risk of ongoing pregnancy is less than 1%. (Level I)
      • 9.
        Oral mifepristone 200 mg and buccal, vaginal, or sublingual misoprostol 800 μg is 87% to 98% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is less than 3.5%. (Level I)
      • 10.
        Intramuscular/oral methotrexate and vaginal/buccal misoprostol is 84% to 97% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is 0.4% to 4.3%. (Level I)
      Providing medical abortion
      • 11.
        There is no evidence to support or refute the routine administration of Rh immunoglobulin to Rh negative women who undergo medical abortion before 49 days last menstrual period. (Level III)
      • 12.
        There is no strong evidence supporting routine antibiotic prophylaxis for medical abortion. (Level II-2)
      • 13.
        Medical abortion is associated with bleeding, which is often heavier than a menstrual period, and with potentially severe cramping. (Level III)
      • 14.
        Prophylactic ibuprofen administration does not provide superior pain control compared with as-needed dosing in women undergoing medical abortion. (Level I)
      Post-abortion care
      • 15.
        Follow-up rates are similar for both remote and in-clinic visits. (Level II-2)
      • 16.
        When both women and their clinician believe successful expulsion has taken place, based on history alone, complete abortion is likely. (Level II-2)
      • 17.
        Either ultrasound and/or serial bhCG measurements provide definitive evidence of pregnancy termination. (Level I)
      • 18.
        A fall of beta human chorionic gonadotropin levels of 80% or more from pre-treatment to first follow-up at 7 to 14 days is indicative of a completed medical abortion. (Level II-2)
      • 19.
        If ultrasound is used to assess completion of a medical abortion, endometrial thickness alone is not predictive of the need for subsequent surgical intervention. (Level II-2)
      • 20.
        Retained products of conception requiring aspiration are more common in medical compared with surgical abortion. (Level II-2)
      • 21.
        A second dose of misoprostol may lead to completion of a medical abortion when there is a retained gestational sac or an ongoing pregnancy. (Level III)
      • 22.
        Severe complications following medical abortion are rare. (Level II-2)
      • 23.
        Ovulation may occur as soon as 8 days after starting the medical abortion procedure. (Level III)
      • 24.
        Insertion of intrauterine device at the follow-up visit after medical abortion is associated with higher insertion rates and equivalent expulsion rates compared with delayed insertion. (Level I)

      Recommendations

      Introduction
      • 1.
        Women who are eligible for medical abortion should be counselled on the availability of both medical and surgical options. (Level II-2A)
      Pre-procedure care
      • 2.
        When communicating with a woman who has an unintended pregnancy, health care providers should use appropriate nonjudgemental and nondirective language, preferably with additional written or online material, and should ensure a confidential environment. (Level III-A)
      • 3.
        Health care providers uncomfortable with abortion counselling or provision must promptly refer the woman to another health care provider/facility or provide information on where she may be able to access abortion care. (Level III-A)
      • 4.
        Women seeking an abortion should have the capacity to provide voluntary informed consent. Health care providers should counsel women on the proposed intervention and alternatives, outcomes, and risks. (Level III-A)
      • 5.
        Providers should use a reliable method to confirm that a pregnancy is at appropriate gestational age for effective and safe medical abortion. (Level II-2A)
      • 6.
        Women should be informed that medical abortion carries a small increased risk of additional intervention compared with surgical abortion. (Level II-2B)
      Medical abortion regimens
      • 7.
        Only evidence-based regimens should be used to perform medical abortion. (Level I-A)
      • 8.
        Mifepristone 200 mg oral and misoprostol 800 μg buccal/vaginal/sublingual is the regimen of choice for medical abortion up to 70 days among eligible women. (Level I-A)
      Providing medical abortion
      • 9.
        Rh immunoglobulin is recommended to Rh negative women undergoing medical abortion beyond 49 days from last menstrual period and may be offered before 49 days. (Level III-C)
      • 10.
        Women who have risk factors for ectopic pregnancy and/or clinical symptoms, such as abdominal pain and vaginal bleeding, should have an ultrasound and be adequately followed. (Level III-A)
      • 11.
        Women who have a pregnancy of unknown location and request medical abortion should receive abortion care without delay provided that they have no clinical symptoms of ectopic pregnancy (EP). If the transvaginal ultrasound demonstrates an empty uterus and the bhCG is > 2000 IU/L, the woman should be evaluated for an EP and appropriate counselling, investigations, and follow-up should be arranged. (Level III-B)
      • 12.
        All women with a pregnancy of unknown location, and women who have not had a pre-abortion ultrasound, must have serial bhCG levels until ectopic pregnancy has been excluded and/or the abortion is complete. (Level III-A)
      Post-abortion care
      • 13.
        All women undergoing medical abortion should have a follow-up assessment to confirm completion of the abortion. (Level II-2A)
      • 14.
        A reliable method of follow-up should be used. This can be done in clinic or remotely using ultrasound and/or serial bhCG measurements combined with clinical history. (Level II-2A)
      • 15.
        A fall of bhCG levels of less than 80% from pre-treatment to the first follow-up at 7 to 14 days requires further investigation/management/follow-up/referral. (Level II-2A)
      • 16.
        Providers should inform women about symptoms and signs of complications and give them clear information on emergency care. (Level III-A)
      • 17.
        Women with ongoing pregnancy at first follow-up after the start of a medical abortion with mifepristone/misoprostol should be offered repeat misoprostol or surgical evacuation. (Level III-A)
      • 18.
        Women with ongoing pregnancy 14 to 21 days after the start of a medical abortion with mifepristone/misoprostol should be offered surgical evacuation. (Level III-A)
      • 19.
        Surgical abortion is recommended for women with ongoing pregnancy after methotrexate/misoprostol for attempted medical abortion. (Level III-A)
      • 20.
        If a woman wishes to start a hormonal method of contraception, it should be started as soon as possible after taking misoprostol. (Level III-B)
      • 21.
        If a woman wishes to start using an intrauterine device, it should be inserted at the follow-up visit after medical abortion, once completion of the abortion is confirmed. (Level I-B)

      Key Words

      Abbreviations:

      ACOG (American College of Obstetrics and Gynecology), βhCG (beta human chorionic gonadotropin), COC (combined oral contraceptives), DMPA (depot medroxyprogesterone acetate), EP (ectopic pregnancy), GA (gestational age), IPV (intimate partner violence), IUD (intrauterine device), IUP (intrauterine pregnancy), LMP (last menstrual period), MA (medical abortion), MIFE (mifepristone), MIFE200/MISO800 (combination mifepristone and misoprostol, taken as directed in the product monograph), MISO (misoprostol), MTX (methotrexate), NAF (National Abortion Federation), NSAIDs (non-steroidal anti-inflammatory drugs), POP (progestin-only pill), PPFA (Planned Parenthood Federation of America), PUL (pregnancy of unknown location), RPOC (retained products of conception), SA (surgical abortion), SFP (Society of Family Planning), WHO (World Health Organization)
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        Journal of Obstetrics and Gynaecology Canada Vol. 39Issue 1
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          Costescu, D., E. Guilbert, J. Bernardin, A. Black, S. Dunn, B. Fitzsimmons et coll. Groupe de travail sur les directives cliniques en matière d'avortement provoqué de la Société des obstétriciens et gynécologues du Canada. « Avortement médical », Directive clinique de la SOGC, no 332, avril 2016. Dans Journal d'obstétrique et gynécologie du Canada, vol. 38, no 4, 2016, p. 390-420.
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