National Abortion Federation Best Practices for Medical Abortion
The evidence-based regimen for medication abortion up to 70 days (10 weeks) gestation consists of mifepristone 200 mg orally followed by misoprostol 800 mcg administered buccally or vaginally 24-48 hours later, with home administration of misoprostol being safe and effective. 1, 2, 3
Medication Regimen
Standard Protocol
- Administer mifepristone 200 mg orally on day 1 2, 3
- Follow with misoprostol 800 mcg buccally or vaginally 24-48 hours after mifepristone 2, 3
- Misoprostol can be self-administered at home safely 2
- This evidence-based regimen is more effective and uses lower doses than the original FDA-approved protocol (which required 600 mg mifepristone and 400 mcg oral misoprostol) 2
Alternative Timing Option
- Simultaneous administration (mifepristone and vaginal misoprostol given together) achieves similar efficacy (95.1% complete abortion rate) compared to the 24-hour interval regimen (96.9%), though it causes more immediate side effects like nausea, diarrhea, and chills 4
Efficacy by Gestational Age
The regimen demonstrates excellent efficacy across the gestational age spectrum up to 63 days 2:
- 29-35 days: 98.8% success rate 2
- 36-42 days: 98.8% success rate 2
- 57-63 days: 95.5% success rate 2
- Overall efficacy through 63 days: 97.7% 2
- Efficacy remains high through 70 days gestation 1, 3
Pre-Treatment Requirements
Gestational Age Confirmation
- Determine gestational age using ultrasonography or reliable menstrual history 3
- Ultrasonography is mandatory when menstrual dating cannot be confirmed clinically or when risk factors for ectopic pregnancy exist 3
Provider Capabilities
- Must be capable of diagnosing ectopic pregnancies 5
- Must arrange for surgical abortion backup in case of failure or medical emergencies 5
Expected Effects and Side Effect Management
Normal Expected Effects
- Cramping and bleeding are expected therapeutic effects 3
- Bleeding lasts an average of 9-16 days 3
- Half of patients pass the pregnancy within the first few hours after misoprostol administration 5
Managing Misoprostol Side Effects
- Low-grade fever and gastrointestinal symptoms can be managed with NSAIDs or antiemetics 3
- Nausea, diarrhea, and warmth/chills are more common with simultaneous administration 4
Follow-Up and Confirmation of Completion
Confirmation Methods
- Use clinical history combined with one of the following 3:
- Serial quantitative beta-hCG levels
- Urine pregnancy testing
- Transvaginal ultrasonography
- Schedule follow-up evaluation 7±1 days after initiating treatment 4
Management of Incomplete Abortion
- Offer a second dose of misoprostol to women who have not aborted at first follow-up 4
- Arrange additional evaluation approximately 1 week after second dose 4
- Attempt phone contact approximately 5 weeks after treatment 4
Complications and Safety Profile
Rare Complications
- Infection requiring hospitalization: 0.01% 2
- Transfusion rate: 0.03% 2
- Ongoing viable pregnancy is rare 5
- Undiagnosed ectopic pregnancy 3
- Hemorrhage requiring surgical intervention: 2-10% of patients require aspiration 5
Critical Distinction
- Expected bleeding (14 days average) must be differentiated from hemorrhage, which requires surgical intervention 5
Contraception Initiation Post-Abortion
- Contraception can be initiated immediately if pregnancy is not desired 6
- Combined hormonal contraceptives can start within 7 days post-abortion without backup contraception needed 6
- Progestin-only pills require only 2 days of backup contraception 6
- IUDs can be inserted within 7 days, including immediately after completion 6
- Fertility returns immediately after abortion, so unprotected intercourse can result in pregnancy right away 6