Pregnancy Termination

First Trimester Abortion

History

• 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

Physical Exam

• Vitals

• Pelvic examination

  • Uterus size

    • 12w rises out of pelvis

    • 15-16w midpoint between symphysis pubis and umbilicus

    • 20w umbilicus

Investigations

• 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)

Treatment

• 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)

Follow-up at 7-14d

• 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

Missed/Incomplete Abortions

Treatment (all options reasonable)

• 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