Special Episode: Abortion Rights in the USA

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In light of this week’s events, Fei and Nick sit down to talk through abortion rights in the US and evaluate the place of abortion as healthcare in the US.

The Current State of Abortion in the USA

  • Earlier this week: leaked Supreme Court document to overturn Roe v. Wade 

    • If you have not: https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473

    • Just so we are clear, this does not mean that Roe V. Wade is overturned 

      • Per Politico: “Deliberations on controversial cases have in the past been fluid. Justices can and sometimes do change their votes as draft opinions circulate and major decisions can be subject to multiple drafts and vote-trading, sometimes until just days before a decision is unveiled. The court’s holding will not be final until it is published, likely in the next two months.” 

  • Roe V Wade has not yet been overturned, so in the US, technically abortion is still legal 

Where Things Stand if Roe is Overturned

  • There are multiple states that have restrictions in some way or other. So for example, only 6 states have no restrictions on abortion: 

    • Oregon, Colorado, New Mexico, New Jersey, Vermont and New Hampshire 

    • Most states have limitations at viability, and certain states have limitations at 24-25 weeks

      • 24-25 week limitation: Nevada, PA, FL, Massachusetts, and Virginia 

      • Still others state “viability” but individual institutions limit the gestational ages, effectively making the limitation less than viability (AHEM RI, Women and Infants ← don’t have to actually call them out)  

    •  Some states have 22 week limits (North Dakota, South Dakota, Nebraska, Kansas, Oklahoma, Iowa, Wisconsin, Indiana, Ohio, West Virginia, Georgia, South Carolina, Alabama, Louisiana, Arkansas 

    • Others have limitation at 15 or 20 weeks (Mississipi, Kentucky) 

    • Most restrictive: Texas, at 6 weeks 

  • And still more restrictions exist beyond gestational age:

    • In the setting of minors, parental consent or inform laws exist for all but 7 states 

    • There is also a mandatory waiting period for 24 hours or more in 24 states 

    • State constitutional protection of abortion exist in only 14 states 

    • No government funding for abortion (US government insurance will not fund it) 

      • First trimester abortions can cost $500-$1000 out of pocket 

  • Currently, should Roe v. Wade get overturned, legislatures in 22 states said they would move to ban or further restrict abortion laws 

US Case Law Regarding Abortion Rights

  • Roe V. Wade (1973)

    • Court case involving Norma McCorvey (Jane Roe) who became pregnant in 1969 with her third child 

    • She could not have an abortion as she wanted because in Texas it was illegal 

    • Her attorneys filed a lawsuit on her behalf in the US federal court, alleging that the Texas abortion laws were unconstitutional

    • The US District Court ruled in her favor and the state appealed to the Supreme Court 

    • In 1973, the Supreme Court Ruled in a 7-2 decision that per the Due Process Clause of the Fourteenth Amendment, this provides a “right to privacy” that protects a woman’s right to choose 

    • However, there were clauses: 

      • Right is not absolute and must be balanced against governments’ interests in protecting women’s health and prenatal life 

      • Tied state regulation to the three trimesters of pregnancy: during first trimester, government could not prohibit abortion at all; second trimester, government could require reasonable health regulations; during third trimester, abortion could be prohibited entirely so long as the laws contained exceptions for cases when they were necessary to save the life or health of the mother 

    • What this means: yes, abortion was now legal, but it left a lot up for interpretation 

      • States could still enact other provisions that would make it difficult to get an abortion (ie. long waiting periods, informed consent laws, spousal or parental consent) 

  • Planned Parenthood vs. Casey (1992) 

    • Another landmark trial where the Court upheld the right to have an abortion that was established in Roe v. Wade 

    • The case arose from a challenge to 5 provisions of the Pennsylvania Abortion Control Act of 1982

      • The provisions included (not limited to) requirements for waiting period unless there was a “medical emergency,” spousal notice, and parental consent for minors (other two were informed consent and reporting requirements or record keeping for abortion service facilities) 

    • The court upheld Roe and also overturned the original trimester framework in favor a viability analysis  

      • While this is typically seen at 24 weeks, but since Casey, states have enacted laws to restrict abortion, including abortions earlier than the general standard of 24 weeks 

      • Also replaced the strict scrutiny standard of review required by Roe with the “undue burden” standard, under which abortion restrictions would be unconstitutional when they were enacted for “the purpose or effect of placing a substancial obstacle in the path of a woman seeking an abortion of a nonviable fetus” 

      • The court upheld 4 provisions of the PA law, but invalidated the requirement of the spousal notification 

  • Dobbs v. Jackson Women’s Health Organization (2022)

    • Pending US supreme court case dealing with the constitutionality of the 2018 Mississippi state law that bans abortions after 15 weeks 

    • In March 2018, Mississippi passed the Gestational Age Act 

    • Within a day, the remaining abortion clinic in MS (Jackson Women’s Health Organization) sued the state challenging the constitutionality of the bill 

    • In the district court for southern MS, the judge ruled for the clinic and placed an injunction on the state enjoining them from enforcing the Act 

    • State appealed to the Fifth Circuit → upheld the judge’s ruling

    • The state then petitioned their act to the Supreme Court in June 2020 - case was heard on December 2021

    • Which then leads us to our leaked Politico draft that appears to overturn Roe v. Wade on May 2, 2022! 

What about other countries / guidelines?

  • WHO guidelines - recently updated on 3/9/2022: https://srhr.org/abortioncare/

    • It’s very long, but some important points as below: 

      • WHO recommends against mandatory waiting periods

      • Recommend that abortion be available on request of the woman/pregnant person without authorization of any other individual, body, or institution 

      • Recommend against laws and other regulations that prohibit abortion based on gestational age limits 

      • Recommend the full decriminalization of abortion

      • Recommend against the use of ultrasound scanning as a prerequisite for providing abortion services 

  • Other countries

    • Canada - no laws or restrictions regulating abortion

    • In most countries (other than the US and Australia) - right to abortion has been legalized by respective parliament/government instead of by state 

    • Legal in all European nations, though some gestational age limits apply 

      • Usually up to 16 weeks

Why is abortion healthcare? 

  • Abortion History in the US 

    •  1973 - Roe V. Wade; abortion is a constitutional right 

      • Three years later: Hyde Amendment; block federal funds from being used to pay for abortion outside of narrow scope of rape, incest, or life endangerment 

    • Prior to this: 

      • Until the early 1800s, abortion was legal until “quickening” 

      • Shift toward banning abortion was born from racism, misogyny, and desire to control pregnant people’s bodies

        • In mid 1800s: US shifted toward criminalizing abortion 

        • Black midwives and healers were condemned for performing abortions and care of pregnant people 

        • Motivated potentially by declining birthrates of white Protestant American women in the 1800s and increased migration 

Safe Abortion Care and Why It is Needed

  • It will occur whether or not it is prohibited

    • The Guttmacher Institute reports that in 2017 the abortion rate in countries that prohibit or limit abortion was 37/1000 people and the abortion rate was 34/1000 people in countries that broadly allow for abortion 

    • Unsafe abortion leads to 4.7-13.2% of maternal deaths  

  • Most abortions occur early on and is safe when there is good healthcare

    • According to the CDC, in 2016, 65.5% of abortions occurred at 8 weeks or less 

    • 91% occured before 13 weeks  

    • Only 1.2% of abortions are performed at 21 weeks or later 

  • For ways that abortions are done: look at our previous abortion episodes

  • Abortions are safer than pregnancy

    • Risk of death from abortion is <1/100,000; risk of dying in childbirth is 14xgreater than risk of dying from an early abortion 

    • Complications from medication abortion is <1% of patients 

    • Rate of complication in surgical abortion is 0.5-4% 

    • It does not increase your risk of future cancer and does not decrease your fertility

  • Who gets abortions?

    • Guttmacher Institute in 2014: 

      • 39% white, 28% black, 25% LatinX 6% Asian/PI, 3% other  

      • So the demographic is everyone 

    •  In addition:

      • 62% identified as religiously affiliated

      • 59% were people that had children 

      • 60% were people in their 20s  

    • Reasons for abortions

      • 74% state that having a child would interfere with education, work, or ability to care for dependents (so abortions decrease the risk that someone becomes unable to work, relies on the state for welfare – this is what conservatives want right??  ← don’t have to say this … it’s just my rage) 

      • 73% could not afford a baby (again, that person is being fiscally smart!) 

  • It is hard to get access to abortion care already, even in “liberal” states 

    • Among women seeking care for abortion in California, 11.9% traveled 50 miles or more 

    • Especially those who seek second trimester abortions or who live in rural areas 

    • One study of 6022 telemed requests: 76% of requests were from states with hostile restrictions

      • However, 60% reported a combination of barriers to clinic access and preference for self-management for privacy and convenience 

    • Why is this important to know? 

      • There are inevitably those that cannot travel 50 miles or more (and this is Cailfornia!) 

      • There are those who do not have $500-$1000 lying around for abortion 

      • What this means is that right now, safe, legal abortion is effectively unattainable for those people who are poor or do not have resources 

      • By further restricting abortion laws, we are going to inevitably make things worse for those who do not have resources (people with money and resources will always be able to get abortions) 

Call to Action: Based off the ACOG CO 815 Increasing Access to Abortion

  • The Hyde amendment and any law that restrict public or private insurance coverage of abortion should be eliminated 

  • There should not be undue barriers that restrict access to abortion including but not limited to: 

    • Bans by gestational age 

    • Requirements that only a physician or an Ob/Gyn give abortion care 

    • Telemedicine bans 

    • Restrictions on medication abortions (including mailing medication through the USPS) 

    • Requirement for mandatory counseling

    • Waiting periods before abortion 

    • Ultrasound requirements 

    • Mandatory parental consent/informing of parents 

    • Mandatory spousal consent or informing of spouse 

    • Faciliy and staffing requirements as outlined in the Targeted REgulations of Abortion Providers (TRAP) laws 

  • Ob/Gyn and family medicine practices will have opt-out abortion training for medical student, resident, and advanced-practice clinicians, and government funding will be ensured for these programs 

  • Obtaining an abortion or aiding another to obtain an abortion, or providing an abortion should not be considered criminal activities

  • Institutions should see abortion as healthcare and support it as such 

  • Any decision for abortion and method of abortion should be between the patient and her healthcare provider, and not be dictated by the government, healthcare facility, or ability to pay for abortion  

What can you do to help?

  • VOTE! 

  • Talk to your institutions – see if they will make a commitment to keeping abortion care as part of their practice 

  • Call your representatives

    • We know that you are all from different places, but we are especially talking to folks from the United States 

    • Find your senators here: https://www.senate.gov/senators/senators-contact.htm

    • Find your representatives here: https://www.house.gov/representatives

    • Let them know you are a constituent 

    • Here is a brief script from the ACLU that you can use. Know that there are Democratic Senators that are now working on protecting abortion rights, but there is nothing written/official as of yet 

      • Hi, my name is [SAY YOUR NAME] and my zip code is [SAY YOUR ZIP CODE]. [If you’d like, you can say that you are a physician, medical student, PA, healthcare provider of any type, etc.] I’m a constituent of [SAY SENATORS’ NAME] and I’m calling to urge the senator/representative to work with others to help codify abortion rights into law. 

  • Donate or volunteer for your local Planned Parenthood

  • Donate to the ACLU and join their mailing list: 

  • Familiarize yourself further with your state (and neighboring states’) laws and regulations for abortion via the Guttmacher institute 

  • Other things 

  • As a provider 

    • If you march, make sure to protect yourselves 

      • How to protest/attend a rally/march successfully 

        • Research what others are saying about the event/rally - is it safe to go? Will there likely be counterprotesters? Could things end with violence? 

        • Try not to go alone (esp if you are female, trans, BIPOC) - it’s safer to go in a group 

        • Wear a mask

        • Bring a pack and have with you water and snacks, medications, phone, phone charger and other essentials you may need (ie. pads, tampons, bandaids) 

        • Make sure your phone is only unlockable by password (police cannot force you to unlock, but they can unlock it with your face or fingerprint against your will) 

          • Consider turning it onto airplane mode while protesting 

        • Wear comfortable, close-toed shoes 

        • Write emergency contact information or emergency legal counsel numbers on your arm in permanent marker 

        • Stay vigilant. If arrested, demand legal representation before speaking to the police 

    • If you want to be seen in your white coats, that is ok, but make sure you are safe and go in a group 

      • If you don’t want to be recognized, make sure to wear your mask/goggles, cover tattoos that are recognizable.  

    • Educate your patients and hear what they have to say 

    • Prescribe refills on birth control pills, patches, contraceptive rings, etc. 

    • Place LARCs as desired by your patients 

    • Prescribe emergency contraception and tell patients to pick them up and keep it with them 

    • Compile a list of providers/places that provide abortion services and make them readily accessible to patient if they desire them 

Postpartum IUD Placement, with Dr. Sarah Prager

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This week we are joined by Dr. Sarah Prager, a professor at the University of Washington in OB/GYN and Complex Family Planning. She shares with us some particular expertise in an ever-more common procedure - the postpartum IUD placement. There’s definitely a few pearls in the podcast that are worth listening for!

Definitions: 

  • Immediate postplacental insertion: within 10 minutes of placental extraction

  • Immediate postpartum insertion: 10 minutes to 48 hours after delivery

  • Delayed postpartum insertion: 48 hours to 6-8 weeks after delivery

  • Interval placement: IUD placement not related to recent delivery

  • Trans-cesarean insertion: IUD placed through the hysterotomy at the time of cesarean delivery

Exclusion criteria:

  • Chorioamnionitis/uterine infection

  • Prolonged rupture of membranes (18-24 hours)

  • Excessive postpartum bleeding that is unresolved

  • Extensive genital trauma that would be negatively impacted by IUD placement

Expulsion rates: 

  • 10% if placed in the first 10 minutes

  • Up to 25-30% if placed after 48 hours

  • Limited data on 10 minutes to 48 hours

    • Pilot study in Zambia showed 4% expulsion with “morning after delivery” IUD placement

  • Provider experience matters!

    • Study from 1985 showed providers cut their expulsion rates almost in half comparing the beginning to the end of the study

  • Take home message: don’t get discouraged! Your expulsion rate will decrease with experience!

Copper vs. LNG-IUD

  • Most older data is with various copper IUDs (primarily the Copper T 380A – ParaGard)

  • Some limited data with specifically Mirena brand LNG-IUD.

  • Recent data often pooled LNG-IUD, without separating different IUDs

  • Limited comparative data

    • Possibly higher expulsion rates with LNG-IUD than Copper IUD

    • Could be due to method used for insertion – inserter vs. no inserter

    • LNG-IUD inserters are long enough to reach the fundus of a PP uterus, ParaGard IUD inserters are not

    • There is a dedicated PP inserter for Copper IUD (longer, stiffer, but not available in USA at this time); unclear if it changes outcomes

  • Recent study out of Kaiser showed slightly lower expulsion rates for breastfeeding vs. non-breastfeeding people.

    • Largest study to date with mostly LNG-IUD

    • Expulsion rates:

      • 10.7% expulsion by 5 years with placement 0-3 days

      • 3.9% for 3 days to 6 weeks

      • 3.2%for 6-14 weeks postpartum

      • 4.9% for interval placement

Medical Eligibility Criteria:

  • CDC: category 1 or 2 at any time, regardless of type of IUD or breastfeeding status.

    • Of course, category 4 if uterus is infected

  • WHO: category more nuanced depending on type of IUD and timing of placement

Method of placement:

  • With the inserter

    • Need a long enough inserter

    • Often can use the LNG-IUD inserters

    • Also need the inserter to be stiff enough – sometimes doesn’t work with LNG-IUD inserters

    • Dedicated copper IUD inserter both longer and stiffer

  • With an instrument

    • Can use a ring forceps

    • Can use a Kelly placenta forceps (longer)

  • With your hand

    • No difference in expulsion seen compared with instrument

    • Personal bias – WAY more painful! No-one likes a hand in their uterus

      • Not reported in the early studies that compared this to using a ring

Clinical tips and tricks for successful insertion with an instrument:

  • Place a ring on the anterior lip of the cervix

  • Hold the IUD gently in a ring forceps (don’t click down if LNG-IUD – don’t want to disrupt the LNG delivery system!)

  • Know the orientation of the IUD with respect to the orientation of the ring handles to make sure you place IUD with the proper orientation in the uterus!!!

  • Once the IUD is in the lower uterine segment, gently let go of the ring on the cervix and place the non-dominant hand on the uterine fundus

  • Drop your wrist! Drop your shoulder! Aim for the fundal hand

    • Angle different from interval insertions – basically aim for the umiblicus

    • Will not go wrong if you aim for the fundus! Feel it with your fundal hand!

  • Let go of the IUD and gently remove the ring without pulling on the IUD or strings

  • If strings are visible, cut at the os

    • Can also pre-cut the strings of LNG-IUDs so they are about 10 cm

    • Cutting strings can sometimes pull the IUD lower or out

  • Can use ultrasound if you want!

If using an inserter: 

  • Pre-deploy the IUD – you do not need the narrow profile with an open cervix!

  • Personal bias – don’t use the inserter

If using your hand:

  • Change your gloves

  • Precut the strings

  • Hold between the index and middle fingers with the strings laying across your palm

  • Make sure you don’t pull it out when you remove your hand!

If trans-cesarean placement:

  • Close 1/3 – ½ the hysterotomy then place

  • Precut the strings shorter before directing down into the cervix

  • Personal bias again toward instrument placement, but usually hand and inserter also work fine

Follow-up care:

  • See patients at 1-2 weeks postpartum and trim strings as needed.

    • May need to do this again at 6-week visit

  • If strings not visible at follow-up, do an ultrasound to verify presence of IUD in the uterus

    • If IUD there, NO NEED FOR ROUTINE ULTRASOUND TO CHECK CONTINUED PRESENCE OF THE IUD

    • Counsel patient that efficacy unchanged, but removal may be more complicated if strings don’t emerge from the cervix

      • This should have been a counseling point during consent!

Permanent Sterilization with Dr. Aparna Sridhar

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Here’s the RoshReview Question of the Week:

​​A 38-year-old woman presents to your office seeking counseling. She has four children, and she would like to have a tubal sterilization procedure. You explain to your patient the risks and benefits of bilateral salpingectomy compared to tubal ligation. Which of the following is this patient at risk for if she undergoes this procedure?

Check out the correct answer by following the links above!

Today we welcome back Dr. Aparna Sridhar, associate professor at UCLA Health, to talk about permanent sterilization counseling. You may remember her from our previous episode about combined hormonal contraceptives.

Dr. Sridhar gives us an awesome overview of all forms of permanent sterilization, including male permanent sterilization (vasectomy).

Second Trimester Abortion

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Second Trimester Abortion: Legal Issues

  • In the US, 1.2 million abortions occured in 2008.

    • Of these, approximately 10% took place after 13 weeks, with more than half occurring between 13 and 15 weeks. 

    • Only 1.3% of abortions are performed at or after 21 weeks gestation.

  • There are varying state-level statutes that may limit the gestational age for obtaining an abortion, or the type of abortion treatment that can be offered.

  • The Guttmacher Institute maintains an overview of abortion laws by state. Some highlights from them:

    • 43 states have gestational age limits on when abortion can be performed. These range from 20 weeks to viability, with some statutes currently being challenged in court that could restrict access as early as 6-15 weeks.

    • 21 states prohibit “partial-birth” abortions, which is a misnomer that we will explain momentarily.

      • 2 states have standing bans on standard dilation and evacuation (Mississippi and West Virginia), with an additional 9 having some enjoinment on enforcement of a ban on D&E. 

    • 26 states require waiting periods between counseling and a procedure. 18 states require specific counseling which may include false or misleading information on:

      • Link between breast cancer and abortion (5 states).

      • The ability of a fetus to feel pain (13 states).

      • Long-term mental health consequences of abortion (8 states).

Methods of 2nd Trimester Abortion

Dilation and Evacuation

  • Use of medication or mechanical techniques to dilate the cervix, followed by the use of grasping forceps to remove the fetus.

  • Most commonly achieved with osmotic dilators in combination with misoprostol for cervical ripening.

    • The success of cervical preparation at 18 weeks gestation and above may be improved with the use of mifepristone the night prior to the procedure in combination with osmotic dilators.

      • However mifepristone may also increase risk of pregnancy expulsion prior to the procedure, particularly if misoprostol is subsequently used for further dilation.

  • A variant of this technique is known by a variety of names such as “dilation and extraction” or “intact D&E,” in which further dilation is achieved which allows for removal of an intact fetus except for possible calvarial decompression. 

    • This has been labeled in some publications as partial-birth abortion and may be restricted to some degree in a number of jurisdictions. 

    • In order to avoid consequences associated with these laws, some experts advise preoperative feticidal injection with KCl or digoxin. 

Medical or Induction Abortion

  • Induction may also be used to achieve abortion, however this is less-cost effective, takes more time, and is more associated with complications.

  • Generally, this is achieved through similar techniques for cervical ripening to labor induction -- mechanical dilators or balloon catheters, misoprostol, and oxytocin. 

    • The most efficacious medical management is mifepristone administered 24-48 hours prior to misoprostol initiation, based on RCT evidence.

    • Osmotic dilators do not necessarily add benefit to misoprostol in this setting. 

  • Preoperative feticidal injection does not shorten the duration of induction, but may be used if preferable to the woman or provider to avoid transient fetal survival after expulsion. 

  • ACOG lists three primary techniques for medication abortion in the second trimester; ACOG and SFP note that the mife-miso regimen is the most efficacious for 2nd trimester induction abortion:

Hysterotomy or Hysterectomy

  • Abdominal surgery is rarely indicated for second-trimester abortion, but is occasionally indicated in the event other procedures fail or are contraindicated. 

  • A prior cesarean or uterine scar is not an indication for hysterotomy for abortion, or for the avoidance of misoprostol, at least up until about 28 weeks gestation.

    • Retrospective cohort studies have demonstrated an insignificantly increased risk of uterine rupture for women with one prior cesarean delivery around 0.28%, versus rupture risk for unscarred uteri around 0.04%.

      • There is insufficient data to guide management on women with 2+ CDs. 

    • However, this remains well below the established acceptable risk threshold with trial of labor after cesarean at term without misoprostol use (rupture risk for 1 prior CD at 0.5-0.7%). 

      • The risk of rupture is suspected to increase with misoprostol use at or after 28 weeks, based on TOLAC data.

Complications and Other Situations

  • Mortality is 0.6 / 100k legal, induced abortions, with that rate being tied to gestational age at the time of abortion.

    • At 21 weeks gestation or greater, the rate of mortality rises to 8.9 / 100k procedures.

    • Maternal mortality for live birth is 17.6 / 100k live births in USA (or double that for 21+wk abortion, by comparison).

  • Postabortion hemorrhage is defined as “blood loss > 500cc and/or bleeding requiring a clinical response such as transfusion or hospital admission.”

    • Rates of transfusion range from 0.1 - 0.7%, with higher rates seen for medical 2nd trimester abortion. 

    • Management is similar to hemorrhage after term vaginal delivery, ruling out retained products and uterine atony as primary causes.

      • Cervical laceration, uterine rupture, and abnormal placentation are also rarer but important concerns, particularly in more advanced gestational age and in women with prior cesarean delivery. 

  • Postabortion infection is uncommon, occurring in 0.1-4% of 2nd trimester abortions.

    • Antibiotic prophylaxis is indicated prior to dilation and evacuation.

      • SFP recommends 200mg doxycycline preoperatively.

      • The ACOG PB recommends use of 100mg doxycycline preoperatively and 200mg postoperatively

      • RCT methodologies on antibiotic use support solely preoperative antibiotic use as sufficient. 

  • Postabortion contraception placement in the form of IUDs additionally does not increase infection risk, but expulsion rates may be higher after abortion than with interval placement.

  • Reversible contraception of almost any kind (no diaphragms or cervical caps) can be initiated immediately post-abortion, and ovulation can resume as soon as 21 days post-procedure.

Medication Abortion

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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.