Circumstances of pregnancy
Symptoms of pregnancy/complications (vaginal bleeding)
Menstrual history
Obstetrical history
Gynecologic history (LMP, contraception, STI, partner)
Determine gestational age
PMH (disease), medications, allergies
Social history
Vitals
Pelvic examination
Uterus size
12w rises out of pelvis
15-16w midpoint between symphysis pubis and umbilicus
20w umbilicus
Pelvic ultrasound (gestational age, r/o ectopic)
Quantitative serum bhCG the day Mifepristone is taken, expect 80% or more decrease in 7d
Consider Hemoglobin, hematocrit
Consider Rh(D) status
Consider STI screening (Gono/Chlam, HIV, Syphilis, Hep B/C)
Abortion method (medical vs. surgical)
Explain experience (pain, bleeding) as well as potential complications (infections, bleeding, hospitalization, surgery)
Ensure has access to (or can phone) emergency medical care if soaking two full heavy pads per hour for 2 consecutive hours, Fever with T>38C or >24h after Misoprostol, severe pain, nausea, etc...
Mifepristone 200mg PO then followed 24-48h later by Misoprostol 800mcg vaginal or buccal (between cheeks and gums and swallowed after 30mins) up to 10w gestation (or 70d post LMP )
May consider prophylactic antibiotics (doxycycline 100mg PO BID x7d starting with mifepristone), but NNT >5000 to prevent a serious infection
Contraindicated in ectopic pregnancy, IUD in place, chronic adrenal failure, longterm corticosteroid therapy, bleeding disorder, lack of access to emergent care
Expect 3 days of heavy vaginal bleeding and 2 weeks of bleeding in total (may have spotting up to one month)
Rh Ig controversial in first trimester abortion due to lack of evidence, cost and availability
Consider in Rh neg patients (especially if gestation >8-10w)
Surgical dilation and curettage up to 14w gestation
Contraception should be considered after abortion (ovulation may occur 8d post abortion)
On the day of Mifepristone: Depo-Provera
On the day of Misoprostol: OCP, patch, etc...
On day #7: IUD or Nuvaring
Analgesia (Acetaminophen, Ibuprofen, +/- Opioids PRN)
Confirm history (cramps decreased after tissues passed)
If abnormal bleeding/cramping (light or excessive/prolonged) consider ongoing pregnancy or ectopic
Pelvic examination (decreased and firm uterus)
Repeat ultrasound examination
Serial bhCG (decrease >80%) at 7-14d suggests completed medical abortion
May consider repeat Misoprostol dose or surgical evacuation at first follow-up visit
If >2-3w post medical abortion, offer surgical uterine evacuation
Expectant - 56% success
May wait up to 2-8 weeks unless excessive bleeding
Medical - 81% success
Misoprostol 800mcg orally or vaginally with repeat dose up to 7d later if no response
Consider Mifepristone 200mg PO 24h prior to misoprostol
Surgical management - 96% success
Consider surgical management for women who do not want to wait, or avoid the experience of pain/bleeding
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