Policy Statement: Medical
induction is an effective method for early abortion. Adequate counseling and
follow-up care will enhance its and acceptability.
Standard 1: Patient history must be obtained and documented.
Standerd2: Intrauterine pregnancy must be Confirmed and
sonogram picture taken.
Standard 3: The patient must be informed about the about
the efficacy , side effects, and risks, especially excessive bleeding and
The patient must be informed of the need to ensure that she is no longer
pregnant and of the teratogenicity associated with the medications to be used.
Patient instructions must include written and oral information about use of
medications at home and symptoms of abortion complications.
Standard 6: The patient must be informed that a surgical
abortion will be recommended if medical abortion fails and this must be
Standard 7: The facility must provide an emergency
contact service on a 24-hour basis and must offer or assure referral for
uterine aspiration if indicated.
Standard 8: Gestational age must be verified and
Recommendation 8.1: Ultrasonography,
using a consistent and published table of fetal measurements, should be used to
confirm and document gestational age when physical exam and LMP are substantially
Option 8.01. Ultrasonography may be used routinely and
In case of strong urine pregnancy test and If intrauterine gestation has not
been confirmed by ultrasound, ectopic pregnancy must be considered. At a
minimum, evaluation will include history and physical exam and may also require
serology, sonography, and examination of uterine aspirate, as well ad documented
follow-up through either clinical resolution or transfer of care.
Standard 10 : Combination regimens are more
effective ingestationsless than 6 weeks than
prostaglandin alone. In less than 6
weeks of gestation where waiting is not a choice and mifepristone is available,
an evidence-based mifepristone/misoprostol regimen must be used.
Recommendation 10.1: When mifepristone
and vaginal, buccal, or sublingual misoprostol are used, the regimen is
recommended for gestations up to 70
Recommendation 10.2: When mifepristone and oral misoprostol are
used, the regimen is recommended for gestations up to 56 days.
Recommendation 10.3: Where mifepristone is not available and
methotrexate and misoprostol are used, a regimen using vaginal, buccal, or
sublingual misoprostol is recommended for gestations up to 63 days.
Recommendation 10.4: Where neither mifepristone or
methotrexate are available and
misoprostol alone is used, a regimen using vaginal, buccal, or sublingual misoprostol
is recommended for gestations up to 77 days.
Patient comfort level during the
abortion procedure must be considered.
Option 11.01: Analgesia or other comfort measures may
be used as needed unless there are contraindications.
Standard 12: Complication of the abortion must be
documented by ultrasonography, Hcg TESTING, OR BY CLINICAL MEANS. If the
patient has failed to follow-up as planned, clinical staff must document
attempts to reach the patient to ensure the abortion is complete. All attempts
to contact the patient ( phone calls and letters) must be documented in patient’s
12.1: Ultrasonography should be used to
evaluate complication of the abortion when expected bleeding does not occur
Ultrasonography may be used routinely.
Standard 13: Rh immune globulin must be offered in
accordance with Rh Guidelines.
Standard 14: Clinical
Policy Guidelines Standards 6, 7, 8 for
post-procedure Care must be followed
01: Either hematocrit or
hemoglobin screening should be obtained in women with history of significant
anemia or specific indication.
02. A complete blood count (CBC)
should be considered for women receiving methotrexate.
03: Vital signs (e.g. , blood
pressure, pulse, and temperature) and physical exan may be done as indicated by
medical history and patient symptoms.
patients prefer Pharmacological methods of terminating early pregnancies rather
than suction curettage. Medical abortion has several advantages for patients.
It avoids surgery and anesthesia and offers woman more active participation and
control over the abortion process. Medical
abortions are little (less than 1%) less effective than
surgical abortion but carries no risks associated with surgical abortions. less
complications than surgical abortions. It can take same office visits or in
some cases few more office visits to confirm the completion of procedure.
research has established the safety and efficacy of medical abortions for early
pregnancy termination. Methotrexate and
misoprostol have also been found to be effective and are used in some services
where mifepristone is not available. While misoprostol alone is inferior to
combined methods for termination of pregnancy, in areas where mifepristone or
methotrexate are not available, it may be an acceptable alternative.
is administered orally: Original trials involved a 600 md dose, but an
abundance of research indicated that 200 md provided comparable efficacy. The
best studied methotrexate regimen involved 50 mg/m2 (body surface area) given
intramuscularly, the same dose used in treating early unruptured ectopic
pregnancy. Research also indicated acceptable efficacy when methotrexate is
administered orally in dose of 25-50 mg.
Information has also evolved on the types, doses, and
routines of administration of the prostaglandin agents used in medical abortion
regimens. Currently, misoprostol is the
favored agent because it is efficacious, inexpensive, stable without
refrigeration, and already FDA-approved for other indications.
administration of misoprostol has a similar physiological effect on the uterus
as vaginal administration and is similarly highly effective for medical
abortions. Sublingual administration of misoprostol is also highly effective for
medical abortion with mifepristone, but is associated with a higher frequency
of chills. One large retrospective study suggests that a change of routine from
vaginal to buccal administration of misoprostol after mifepristone was
associated with a reduced incidence of serious infection, although absolute
risk is extremely low. The effectiveness of medical abortion declines very
gradually with advancing gestational age. This decline is more evident with
oral administration of misoprostol.
mentioned guidelines are by NAF (National Abortion Federation 2013) but at
Women’s Choice LI, De Joel Cooper a board certified OB/GYN has seen success of
medical abortion following his own protocol:
a) Patient detailed medical history.
b) Patient prior pregnancy history.
c) Patient Rh blood type ( positive or
d) Patient hemoglobin screening ( must
be over 10)
e) Patient vaginal or abdominal sonogram
to confirm IUP/Age.
f) Discussion of the findings by
Clinical staff with Dr. Cooper.
g) Counseling about procedure and
choices available. Risks and benefits of medical abortions.
h) Starting the procedure upon approval of
the clinician as follows:
1) Gestation under 6 weeks, recommendation
to wait till age 6+ or use of combination of Mifepristone/Misoprostol.
2) Gestation of 42day to 77 days, recommendation
to start the medical abortion procedure using , 400 mcg of Misoprostol by mouth
and 600 mcg of misoprostol vaginally. Waiting in the office on stretcher for 20
to 25 minutes and then discharged.
3) Discussion about post procedure
guidelines and setting up a post procedure date to return for medical examination
to confirm the pregnancy has ended.