Abortion: Telemedicine and Self-Management

Today we’re joined by Dr. Sarah Gutman, who is an assistant professor of OB/GYN at the University of Pennsylvania, and a recent graduate of their fellowship in complex family planning. She’s joining us today to talk about some of the most important and interesting topics trending in the weeks after the Dobbs vs Jackson Women’s Health: self-managed abortion and telemedicine abortion.

What is telemedicine abortion?

• Provision of medication abortion care using telemedicine services, typically fully remote but can involve some degree of in-person contact for part of the process, under the supervision of a medical provider.

• Who are the appropriate candidates for telemedicine abortion?

  • Eligibility criteria for studies evaluating telemedicine abortion have typically included:

    • Pregnancy less than 10 weeks gestation,

    • No contraindications to mifepristone or misoprostol and

    • The ability to receive mife/miso by mail

• What are the steps of a typical telemedicine abortion visit?

  • Initial consult – confirmation of dating, review of medical history/risks factors, discussion of how medication should be used and expectations for abortion process.

  • Patients should be certain of their LMP within one week, and it should be <77days before anticipated start of mifepristone

  • Evaluate for symptoms or risk factors for ectopic pregnancy, including vaginal bleeding, pelvic pain, prior ectopic, current IUD use, prior tubal surgery

    • Interestingly, the rate of ectopic pregnancy among patients seeking abortion is lower than the general population – between 1.5 – 6 per 1,000 pregnancies compared to about 20 per 1,000 pregnancies in the general population

  • Ensure no contraindications for medication abortion

    • RH type and hemogloblin are not needed

  • Receipt of medications – due to restrictions in mifepristone accessibility, typically this has been through the mail

• Medication abortion has been covered by the podcast in the past, but as a reminder: the two medications used for medication abortion are mifepristone and misoprostol.

  • Mifepristone is a taken orally as a one-time 200mg dose

  • Misoprostol can be used vaginally, sublingually, or buccally, 800mcg are given initially with the option to repeat a dose if needed.

    • Patients are informed to take within 48h of mifepristone administration.

    • Consider a second dose if GA >63 days or no bleeding in 24 hours.

  • Analgesics, antiemetics – many providers give ibuprofen and Zofran

• When to seek help:

  • Heavy bleeding soaking >2 pads/hour for more than 2 hours,

  • Passing blood clots larger than a lemon, or

  • Symptoms of blood loss such as feeling dizzy/lightheaded.

• Follow up

  • Symptoms – can be assessed at 7-14 days through a text, secure messaging, telephone all, or video.

    • Patients are counseled to expect bleeding heavier than a period, and that they may pass blood clots and see some tan/pink tissue.

  • Urine pregnancy tests – given 4 to 6 weeks following the abortion

What is the evidence behind telemedicine abortion?

• Efficacy is very high – around 95% of abortions are completed without needing a procedure.

• Complications are exceedingly rare.

  • Around 6% of patients visit an ER or urgent care center related to the abortion

  • The rate of adverse events is less than 1%, with hospitalization <0.5%, transfusion 0.4%, infection <0.1%

What is self-managed abortion?

• Self-managed abortion has also been referred to as self-sourced medication abortion (SSMA)

• Society of Family Planning definition:

  • “It refers to any action taken to end a pregnancy outside of the formal healthcare system, and includes self-sourcing mifepristone and/or misoprostol, consuming herbs or botanicals, ingesting toxic substances, and using physical methods.”

• Historically, people fearing criminalization or unable to access abortion care often turned to unsafe or invasive methods of self-managing their abortion – think of the abortion scene in ‘Dirty Dancing’ and the use of a coat-hanger as a sign of an unsafe abortion.

  • However, increased access to the medications used for abortion, in particular misoprostol, had made self-managed abortion much safer and more effective.

  • Other reasons besides access that people may choose self-managed abortion, including privacy, discomfort with the available medical services, and person safety.

What are the components of SMA?

• Similar to telemedicine abortion, SMA includes assessment of eligibility, administration of abortion medications, management of the abortion process, and assessment of abortion completion.

  • These actions are all taken without the formal guidance of a healthcare provider.

  • People who self-manage their medication abortions should be able to estimate their gestational age using their last menstrual period and be aware of their cycle regularity and any contraception use.

• There are many clinical resources available online, including through the Reproductive Health Access Project, Doctors without Borders, and Aid Access.

• The WHO recommends mifepristone followed by misoprostol.

  • However, if mifepristone is not accessible, misoprostol can be used alone, typically 800 mcg used vaginally, sublingually, or buccally repeated every 3 hours or up to 3 doses until expulsion occurs.

• How common is SMA?

  • Recent cross-sectional data suggests 7% of individuals in the US attempt SMA at some point in their lifetime, and this is likely growing due to increased restrictions on abortion access.

• What is the safety and efficacy of SMA?

  • Data is limited: it’s difficult to study something that is outside the healthcare system.

  • However, from the data we have available and by extrapolating data from the telemedicine abortion models with lowest amount of supervision, self-managed abortion using mifepristone and misoprostol appears to be as safe and effective as medication abortion within a clinical setting.

  • A meta-analysis of misoprostol alone regimens used <91 days gestation found a 6.8% ongoing pregnancy rate

    • Serious adverse events occur <1% of the time.

• How can providers support patients who have chosen self-managed abortion?

  • When people are criminalized for abortion, it is often due to a healthcare provider reporting them to the police.

  • Currently, there are no mandated reporting laws for healthcare providers.

  • There is legal help available for patients concerned about their options and criminalization, such as If/When/How

    • People of color and low-income individuals are most likely to be targeted and disproportionately criminalized.

Summary

• Telemedicine abortion is the provision of medication abortion through telehealth under a healthcare providers supervision. Self-managed abortion is actions taken outside the formal healthcare setting to end a pregnancy.

• Both telemedicine abortion and self-managed abortion using mifepristone and misoprostol are remarkably safe and effective.

• While protocols vary, typically patients receiving telemedicine abortion should be at or below 10 weeks gestation, should not have any risk factors or symptoms concerning for ectopic pregnancy, and should not have any contraindications to taking mifepristone or misoprostol. After taking their medications, they should be able to monitor their vaginal bleeding and cramping and take a home urine pregnancy test in 4-6 weeks to confirm completion of the abortion.

• Importantly, there are no laws mandating that healthcare providers report patients for suspected self-managed abortion. If patients are concerned about criminalization there are legal resources available such as If/When/How.

Additional Resources

• Society of Family Planning interim clinical recommendations: Self-managed abortion (https://www.societyfp.org/society-of-family-planning-interim-clinical-recommendations-self-managed-abortion/)

• Raymond et al. TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States. Contraception 2019 (https://doi.org/10.1016/j.contraception.2019.05.013)

• Baldwin et al. Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic. Contraception 2021 (DOI: 10.1016/j.contraception.2021.03.019)

Medication Abortion

Epidemiology of Abortion

In 2017:

• 60% of abortions occured prior to 10 weeks gestation;

• Medication abortion comprised 39% of all abortions.

Medication abortion may be more attractive than procedural abortion because it can be done safely, effectively, and discretely, at the patient’s preference. 

Who is eligible for medication abortion?

Most patients at 70 days gestation or less are eligible for medical abortions. Patients with distorting fibroids, uterine anomalies, or scarring of the introitus due to FGM may benefit (versus aspiration). Multiple gestation is not a contraindication, and can use the same regimen as singleton gestations. 

Gestational age should be confirmed prior to initiating a medication abortion, by certain LMP within the past 56 days in patients with regular cycles and no symptoms or signs of ectopic pregnancy. Clinical or sonographic exam are not required before medication abortion.

Rh status should be verified, with RhoGam administered if indicated for Rh negative patients. Research here is continuing, but RhoGam is recommended by ACOG for all Rh negative patients. Some situations may call for shared decision-making on this front, and some institutions and professional groups do not recommend RhoGam prior to 10 weeks gestation. 

Additional laboratories, counseling, or evaluation may be required by local or state laws prior to proceeding with medication abortion.

Finally, medication abortion may not be an appropriate choice for patients: 

• with suspected or confirmed ectopic pregnancies, 

• patients with an IUD that remains in situ, 

• patients with chronic medical conditions: 

  • long-term steroid use, 

  • coagulopathy or anticoagulation use, 

  • adrenal insufficiency.

  • Anemia or hemoglobinopathy: 

    • Transfusion rates are higher with medication abortion versus aspiration (0.1 to 0.01%); patients in this category may benefit from aspiration or closer monitoring but are likely reasonable candidates. 

• Finally, patients should be willing to follow up completely and have good contact information, understand that medication abortion may take some time for completion, and be able to understand instructions to ensure success. 

Counseling:

Clear instructions on what to expect should be provided to patients who undergo medication abortion:

• Bleeding and cramping, with bleeding much heavier than menses.

  • Bleeding heavier than two maxi pads per hour for 2 hours should prompt patients to contact their clinician.

  • Patients should be counselled that additional intervention may be needed in the event of excess bleeding or suspected failure; however this is rare (less than 1%, and transfusion rates less than 0.1%). 

• Rate of ongoing pregnancy is low, and the risk increases at later gestational ages.

  • The risk of ongoing pregnancy at 64-70 days gestation is around 3%.

  • Teratogenicity is associated with the use of both mifepristone and misoprostol, so patients should be counseled about this in the event of medication failure, or if patients attempt to use high-dose progestins for unsanctioned “abortion reversal.”

  • There is no regimen that has been demonstrated to reverse abortion after administration of medications, and this has been shown in small studies to increase risk of complications.

• Side effects of misoprostol use are commonly GI upset, hot flushes, fever or chills. Mifepristone is generally well tolerated with few side effects.

• Risk of infection is overall very low, so there is no indication for antibiotic prophylaxis.

What medications are used for medication abortion?

There are a number of approved regimens, but the most successful and preferred is a combination of mifepristone and misoprostol.

• Mifepristone is a selective progesterone receptor modulator.

  • Binds progesterone receptor with greater affinity than progesterone, but does not activate it, thus acting as an antiprogestin.

  • The provision of mifepristone in the USA is dependent on a “risk evaluation and mitigation strategy,” or REMS program, facilitated by the FDA. ACOG and other professional organizations oppose the ongoing use of the REMS program as it does not make care safer and creates a barrier to the most effective form of medication abortion. 

• Misoprostol is a prostaglandin E1 analog.

  • Causes cervical softening and uterine contractions. 

The FDA approved combination is mifepristone 200mg orally, followed 24-48hrs later by 800 mcg of buccal misoprostol.

The WHO suggests misoprostol can be administered vaginally, buccally, or sublingually at the same dose and interval. 

Success rates range from 93% to 98% (lower success rate at more advanced gestational age). The rate of ongoing pregnancy in the highest gestational age range (64-70 days) was small at 3.1%. 

Misoprostol alone may also be used at 800 mcg vaginally, sublingually, or buccally, every 3 hours for up to 3 doses. However, mife-miso is a much more effective method and should be used if available. 

What clinical follow up is recommended after medication abortion?

Follow up can be performed clinically or remotely via telemedicine. Clinicians are able to successfully determine if pregnancy expulsion has occurred with 96-99% accuracy based on symptomatology alone. The use of pregnancy tests can also be a helpful adjunct to confirm expulsion, but are not absolutely necessary.

Sonography can be used as well, but may also predispose patients to additional unnecessary procedures. The measurement of endometrial thickness does not predict need for subsequent aspiration or complications. 

If abortion is suspected to be incomplete, the patient can be counseled about aspiration versus a repeat dose of misoprostol or expectant management. Surprisingly, studies have shown that even with a gestational sac is retained at 2 weeks after initial medication use, expulsion will usually occur spontaneously in the coming weeks! Ongoing symptoms such as irregular bleeding can persist in this case though, so many patients opt for intervention. 

What about contraception after medication abortion?

Most contraceptive methods are safe to start immediately or soon after abortion. Complete abortion should be ensured before placement of an IUD; usually a week after medication administration. 

Progestin-based contraceptives have a theoretical risk of interfering with mifepristone efficacy; this has been demonstrated with DMPA use on day 1 of the medication abortion, and thus patients should be counseled that risk of ongoing pregnancy may be greater in this scenario. This has not been observed with etonogestrel implants.