What is the step‑by‑step management of a patient presenting to the office requesting a medical abortion?

Step-by-Step Management of Medical Abortion Request

Provide same-day assessment and initiate medical abortion within one week, using mifepristone 200 mg orally followed by misoprostol 800 mcg buccally 24-48 hours later for pregnancies up to 63 days (9 weeks) from last menstrual period. 1, 2

Initial Assessment (Ideally Within 1 Week of Request)

Confirm Pregnancy and Gestational Age

• Obtain last menstrual period (LMP) and calculate gestational age from first day of LMP 3, 4
• Perform transvaginal or abdominal ultrasound to confirm intrauterine pregnancy and gestational age 3, 5
• If gestational sac not visible on ultrasound with LMP ≤42 days: Consider pregnancy of unknown location—you can either initiate same-day medication abortion while simultaneously ruling out ectopic with serial hCG testing, or delay treatment until diagnosis is established with repeat ultrasound 6
• If gestational age 64-70 days: Medical abortion remains highly effective (92.3% success rate) 7
• If gestational age 71-77 days: Efficacy drops to 86.7% with significantly higher ongoing pregnancy rates (8.7%); surgical abortion may be preferable, though medical abortion can still be offered if strongly preferred 7

Eligibility Screening

• Confirm patient desires abortion and is making an informed, voluntary decision 3
• Rule out ectopic pregnancy via ultrasound or serial hCG if pregnancy of unknown location 6
• Assess for contraindications to mifepristone/misoprostol (chronic adrenal failure, hemorrhagic disorders, anticoagulation therapy, inherited porphyrias) 3
• Do not require mandatory counseling or mandatory waiting periods—these create barriers without improving safety 1

Counseling on What to Expect

• Explain the regimen: mifepristone in office, then misoprostol at home 24-48 hours later 2
• Discuss expected bleeding and cramping—heavier than normal menses with passage of tissue 4
• Explain efficacy: 97.7% overall success, highest at 29-42 days (98.8%), lowest at 57-63 days (95.5%) 2
• Discuss rare complications: infection requiring hospitalization (0.01%), transfusion (0.03%) 2
• Provide pain management plan: NSAIDs as first-line, with opioid analgesics if needed 4

Treatment Initiation (Within 1 Week of Assessment)

Medication Administration

• Administer mifepristone 200 mg orally in office 2
• Provide misoprostol 800 mcg for buccal administration at home 24-48 hours later 2
• Instruct patient to place 4 tablets (200 mcg each) between cheek and gum for 30 minutes, then swallow remaining fragments 2

Consider Alternative Service Delivery

• Offer assessment by phone or video call if patient prefers 1
• Allow self-referral without requiring GP referral 1
• Maximize role of nurses and midwives in providing care 1

Follow-Up (1 Week After Misoprostol)

Confirm Abortion Success

• Offer patient choice of follow-up method: in-clinic ultrasound, remote assessment with serum hCG, or self-assessment with urine pregnancy test 8
• Remote/self-assessment is equally effective and safe as in-clinic follow-up, with higher patient satisfaction 8
• If using urine pregnancy test remotely, multilevel tests result in fewer unscheduled visits than high-sensitivity tests 8
• Serum hCG measurement is acceptable when ultrasound unavailable, though ultrasound remains gold standard 4

Management of Incomplete Abortion

• If ongoing pregnancy detected: Offer uterine aspiration or repeat misoprostol dose 3
• Aspiration needed in 2.3% overall, increasing with gestational age 2
• Ongoing pregnancy rates: 3.6% at 64-70 days, 8.7% at 71-77 days 7

Critical Pitfalls to Avoid

• Do not delay care with unnecessary barriers: Multiple visits, mandatory waiting periods, and compulsory counseling increase complications without improving safety 1
• Do not restrict to FDA-approved regimen: The evidence-based regimen (200 mg mifepristone + 800 mcg buccal misoprostol) is safer and more effective than the outdated FDA protocol 2
• Do not allow personal beliefs to delay referral: If unwilling to provide abortion care, immediately refer to appropriate provider 1, 9
• Do not require in-person follow-up: Remote assessment is equally safe and preferred by most patients 8
• Ensure timely referral if beyond your gestational age capacity: Some services cannot provide abortion at later gestational ages; avoid making patients repeat assessments 1