What is the recommended regimen for medical termination of pregnancy in a 7-week gestation patient with no known medical history of bleeding disorders, adrenal insufficiency, or medication allergies?

Medical Termination of Pregnancy at 7 Weeks Gestation

The recommended regimen is mifepristone 200 mg orally followed by misoprostol 800 mcg (buccal or vaginal) administered 24-48 hours later, which achieves a 92% success rate at this gestational age. 1, 2, 3

Recommended Protocol

Medication Regimen

• Administer mifepristone 200 mg orally as the initial dose 1, 2
• Follow with misoprostol 800 mcg administered 24-48 hours later (buccal or vaginal route) 1, 2, 4
• The 36-48 hour interval is superior to same-day administration, with success rates of 96% versus 89% respectively 4
• At 7 weeks (49 days or less), this regimen achieves complete abortion in 92% of cases 3

Setting and Monitoring

• Perform the procedure in a hospital setting with close monitoring for this patient population 1
• Observe the patient for 4 hours after misoprostol administration 3
• Schedule follow-up assessment at day 15 to confirm complete abortion 3

Expected Effects and Management

Normal Expected Effects

• Cramping and bleeding are expected, with bleeding lasting an average of 9-16 days 2
• Termination typically occurs within 4 hours after misoprostol in 49% of women and within 24 hours in 75% 3
• Gastrointestinal symptoms (nausea, vomiting, diarrhea) and low-grade fever are common 2, 3

Pain and Symptom Management

• Manage adverse effects with NSAIDs or antiemetics as needed 2
• Abdominal pain increases with advancing gestational age but is manageable at 7 weeks 3

Essential Post-Procedure Care

Prophylaxis Requirements

• Administer prophylactic antibiotics to prevent post-abortal endometritis, which occurs in 5-20% of women without prophylaxis versus 1.3% with prophylaxis 1, 5
• Provide anti-D immunoglobulin to Rh-negative women to prevent alloimmunization 1, 5

Follow-Up Confirmation

• Confirm complete abortion using clinical history combined with:
  • Serial quantitative beta-hCG levels, OR
  • Urine pregnancy testing, OR
  • Ultrasonography 2
• Pelvic ultrasound within 7 days is recommended to assess for retained products 4

Failure Rates and Complications

Success Rates by Gestational Age

• At ≤49 days (7 weeks): 92% complete abortion rate 3
• At 50-56 days: 83% success rate 3
• At 57-63 days: 77% success rate 3

Rare Complications to Monitor

• Ongoing pregnancy occurs in only 1% at ≤49 days gestation 3
• Infection, hemorrhage, and undiagnosed ectopic pregnancy are rare 2
• Need for unplanned surgical intervention: approximately 2% at this gestational age 3
• Hospitalization rate: 2% in the ≤49 days group 3

Critical Pitfalls to Avoid

Timing Errors

• Do not administer misoprostol at 6 hours - this reduces efficacy from 96% to 89% and increases ongoing pregnancy risk from 1% to 2% 4
• Do not delay beyond 48 hours unnecessarily, as this may reduce patient compliance 6

Contraindications to Screen For

• Severe cardiovascular disease, especially pulmonary arterial hypertension, is an absolute contraindication to medical termination 5
• Severe liver or kidney disease may alter drug metabolism and requires careful consideration 5
• Confirm gestational age and rule out ectopic pregnancy using ultrasonography when clinical dating is uncertain or risk factors exist 2

Alternative Approach

• Dilation and evacuation (D&E) remains the safest procedure with lower complication rates (hemorrhage 9.1% vs 28.3%, infection 1.3% vs 23.9% compared to medical methods) and should be considered if medical contraindications exist 1, 5