Guideline sources The following summarized guidelines for the evaluation and management of pregnancy termination are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2021; 2020; 2013), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2016), and the Society of Family Planning (SFP 2014; 2013; 2012). 1 2 3 4 5 6 7 8 Guidelines 1. Diagnostic investigations Determination of gestational age: As per ACOG 2020 guidelines, confirm the pregnancy and determine gestational age before medication abortion. B As per SOGC 2016 guidelines: Use a reliable method to confirm that a pregnancy is at appropriate gestational age for effective and safe medical abortion. B https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 1/9 6/29/23, 11:25 PM Pregnancy termination Pathway Consider estimating gestational age with the last menstrual period, clinical history, and physical examination if the patient is certain of the date of her last menstrual period and ultrasound is not readily accessible. Obtain ultrasound when uncertainty remains. C As per SFP 2013 guidelines, confirm pregnancy before uterine aspiration. B Pre-abortion evaluation: As per ACOG 2020 guidelines, obtain Rh factor testing in patients with unknown Rh status before medication abortion. Ensure shared decision-making to allow patients to make an informed choice about their care in situations where Rh testing is not available or would significantly delay medication abortion. B Show 2 more As per SFP 2013 guidelines: Obtain preoperative Hgb or hematocrit in all females undergoing second-trimester abortion and anemic patients undergoing first-trimester medical abortion. B Consider obtaining a preoperative coagulation screen on an individualized basis since fetal demise with fetus retained for 4 weeks may be associated with an increased risk of DIC. C Evaluation for placenta accreta: evaluate for placenta accreta in patients with a uterine scar and placenta previa at 16 weeks of gestation. Obtain ultrasound as the first step for the evaluation of placenta accreta. Consider obtaining MRI if the diagnosis is uncertain. A 2. Diagnostic procedures Pathological examination: avoid obtaining routine pathological assessment of tissue aspirates as they add little diagnostic value in settings where gross or microscopic examination of pregnancy tissue is routinely carried out by well-trained and experienced staff members, and where local or regional laws mandating outside pathologic examination do not supervene. D 3. Medical management Medication abortion, setting: As per ACOG 2020 guidelines, consider providing medication abortion by any clinician with the skills to screen patients for eligibility for medication abortion and to provide appropriate follow-up. B Show 2 more As per SOGC 2016 guidelines, refer females promptly to another healthcare provider/facility or provide information on where they may be able to access abortion care if the healthcare provider is uncomfortable with abortion counseling or provision. B As per SFP 2013 guidelines, refer patients at high risk of hemorrhage to a hospital service or high-acuity center to decrease possible morbidity. B As per SFP 2012 guidelines: Manage females (for first-trimester abortion) with stable, controlled hypertension, diabetes, or asthma in an outpatient setting. B https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 2/9 6/29/23, 11:25 PM Pregnancy termination Pathway Manage patients (for first-trimester abortion) with any of the following conditions in a hospital setting: Situation Guidance Vascular-untreated aneurysm CNS Space occupying lesions Impaired renal function (serum creatinine > 2.5 mg/dL) Renal disease Uncontrolled blood rpessure (systolic BP > 160 mmHg or diastolic BP > 105 mmHg) Hypertension Uncontrolled hyperthyroidism Endocrine Uncontrolled diabetes Pheochromocytoma Congenital (cyanotic disease, right or LV dilation, uncontrolled tachyarrhythmia) Cardiac Coronary disease (history of myocardial infarction, treatment angina) Cardiomyopathy (dilated, hypertrophic, history of peripartum cardiomyopathy) Valvular disease (aortic stenosis peak gradient 60 mmHg, mitral stenosis valve area < 1.5 cm , MR or AR with LV dilation) Uncontrolled asthma Pulmonary Restrictive lung disease Pulmonary hypertension Lupus flare Rheumatological Lupus inhibitor requiring anticoagulation Hepatic disease elevated PT Gastrointestinal Esophageal varices with a history of bleeding Uncontrolled IBD Severe anemia Hematological Sickle cell disease with a history of crisis Idiopathic thrombocytopenic purpura with active thrombocytopenia Thrombophilia requiring anticoagulation Counseling regarding treatment options and timing of abortion Oncology https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 3/9 6/29/23, 11:25 PM Pregnancy termination Pathway Gynecologic cancers restricting access to the uterus Significantly impaired renal function (creatinine > 2.5 mg/dL) Transplant History of recent rejection Poorly functioning transplanted organ Inability to obtain informed consent Psychiatric Inability to tolerate an outpatient procedure History of suicide attempt. B Medication abortion, regimens: As per ACOG 2020 guidelines, administer combined mifepristone-misoprostol regimens over misoprostol-only regimens as the preferred therapy for medication abortion. Initiate a misoprostol-only regimen as an alternative if a combined mifepristone-misoprostol regimen is not available. A As per SOGC 2016 guidelines: Use only evidence-based regimens to perform medical abortion. A Administer the combination of mifepristone (200 mg PO, for one dose) and misoprostol (800 g buccal/vaginal/sublingual, for one dose) as the regimen of choice for medical abortion within 70 days of the last menstrual period, among eligible females. A As per SFP 2012 guidelines: Increase the dose of mifepristone > 200 mg for first-trimester medical abortion in patients receiving CYP450 inducers. B Increase the dose of corticosteroids in patients with corticosteroid-dependent conditions receiving mifepristone because of mifepristone's anti-corticosteroid properties. B Medication abortion (contraindications): Do not perform medication abortion in patients with any of the following: confirmed or suspected ectopic pregnancy intrauterine device in place (the intrauterine device can be removed before medication abortion) current long-term systemic corticosteroid therapy chronic adrenal failure known coagulopathy or anticoagulant therapy inherited porphyria intolerance or allergy to mifepristone or misoprostol. D Pain management: As per ACOG 2020 guidelines, administer NSAIDs for pain management in patients undergoing medication abortion. A As per SOGC 2016 guidelines, recognize that prophylactic ibuprofen administration does not provide superior pain control compared with as-needed dosing in females undergoing https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 4/9 6/29/23, 11:25 PM Pregnancy termination Pathway medical abortion. A Anti-D immunoglobulin: As per ACOG 2020 guidelines, administer RhD immunoglobulin if indicated. Ensure shared decision-making to allow patients to make an informed choice about their care in situations where RhD IgAdministration is not available or would significantly delay medication abortion. B As per SOGC 2016 guidelines: Administer Rh immunoglobulin to Rh-negative females undergoing medical abortion beyond 49 days from last menstrual period. B Consider offering Rh IgAdministration in females undergoing medical abortion at earlier stages of pregnancy ( 49 days from last menstrual period). C Antibiotic prophylaxis: As per ACOG 2020 guidelines, do not use routine prophylactic antibiotics for medication abortion. D As per SOGC 2016 guidelines, insufficient evidence to recommend routine antibiotic prophylaxis in females undergoing first-trimester medical abortion. I As per SFP 2012 guidelines, do not administer additional antibiotics for the prevention of infective endocarditis in patients with high-risk cardiac conditions undergoing first-trimester medical abortion. D Methylergonovine maleate prophylaxis: insufficient evidence regarding the prophylactic use of methylergonovine maleate before first-trimester abortion in reducing the need for re- aspiration. I 4. Surgical interventions Surgical abortion, indications: As per SFP 2013 guidelines: Recognize that surgical abortion can be performed successfully and safely as early as 3 weeks from the last menstrual period if a protocol exists including sensitive pregnancy testing, immediate and meticulous examination of the aspirate, and follow-up of questionable specimens to rule out an ectopic pregnancy or continuing gestation. B Recognize that early surgical abortion carries lower morbidity and mortality than procedures performed later in gestation, and early aspiration may expedite the diagnosis of ectopic pregnancy, resulting in less invasive treatment. A As per SFP 2012 guidelines, prefer surgical abortion for first-trimester abortion in patients with a bleeding disorder or being anticoagulated in the first trimester. B Surgical abortion (cervical preparation): ensure cervical preparation before dilation and evacuation (for second-trimester abortion) to decrease the risk of cervical trauma. A Show 8 more Surgical abortion, procedures: as per SFP 2013 guidelines, perform either manual or electric vacuum aspiration for first-trimester abortion given their comparably high efficacy, safety, and patient acceptability. A https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 5/9 6/29/23, 11:25 PM Pregnancy termination Pathway Show 2 more Surgical abortion, paracervical vasopressin: as per SFP 2013 guidelines, consider administering vasopressin during the paracervical block to decrease blood loss from dilation and evacuation. C Surgical abortion (intraoperative ultrasound): consider obtaining routine intraoperative ultrasound in training settings to decrease the risk of incomplete abortion with first-trimester surgical abortion and perforation with standard dilatation and evacuation. C Surgical abortion, outcomes: as per SFP 2013 guidelines, recognize that: clinical outcomes are indistinguishable in comparable, suitably equipped inpatient and outpatient abortion settings with well-trained staff A cost depends largely on the prevailing wage differential between advanced practice clinicians who often staff medical abortion programs and the providers who perform surgical abortions B complication rates are higher for clinicians with less experience in surgical abortion provision. B licensed or accredited, trained midlevel providers perform first-trimester surgical abortion procedures with outcomes comparable to those of their physician counterparts. A 5. Specific circumstances Patients with pregnancy of unknown location: provide abortion care without delay in females with a pregnancy of unknown location and requesting medical abortion, provided that they have no clinical symptoms of ectopic pregnancy. B Show 4 more 6. Patient education Pre-abortion counseling: As per ACOG 2020 guidelines, counsel patients that medication abortion failure rates, especially continuing pregnancy rates, increase as gestational age approaches 10 weeks. A Show 4 more As per SOGC 2016 guidelines, ensure that females seeking an abortion have the capacity to provide voluntary informed consent. Counsel females on the proposed intervention and alternatives, outcomes, and risks. B Show 4 more As per SFP 2013 guidelines, counsel females regarding surgical and medical methods of abortion addressing the risk of bleeding informing them that bleeding is likely to be greater with medical abortion than with surgical abortion, although the rates of hemorrhage remain low. A 7. Follow-up and surveillance https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 6/9 6/29/23, 11:25 PM Pregnancy termination Pathway Follow-up assessment: As per ACOG 2020 guidelines: Do not obtain routine in-person follow-up after uncomplicated medication abortion. Offer the choice of self-assessment or clinical follow-up evaluation to assess medication abortion success. Consider obtaining follow-up evaluation by medical history, clinical examination, serum hCG testing, or ultrasound when medically indicated or preferred by the patient. D Determine whether the gestational sac is present as the sole purpose if an ultrasound is obtained at follow-up after medication abortion. Recognize that the measurements of endometrial thickness or other findings do not predict the need for subsequent uterine aspiration. A As per SOGC 2016 guidelines, obtain a follow-up assessment in all females undergoing medical abortion, in order to confirm completion of the abortion. B Show 2 more Management of post-abortion bleeding: As per SOGC 2016 guidelines, recognize that medical abortion is associated with bleeding, which is often heavier than a menstrual period, and with potentially severe cramping. B As per SFP 2013 guidelines, administer uterotonic medications to control hemorrhage from uterine atony. Administer methylergonovine maleate, misoprostol and vasopressin as first- line agents, with methylergonovine maleate and vasopressin showing the most rapid response, in patients with active bleeding. B Show 3 more Management of ongoing pregnancy: As per ACOG 2020 guidelines, consider administering a repeat dose of misoprostol, performing uterine aspiration, or offering expectant management, depending on the clinical circumstances and patient preferences, in patients with an incomplete medication abortion. C Show 2 more As per SOGC 2016 guidelines, administer repeat misoprostol or perform surgical evacuation in females with an ongoing pregnancy at first follow-up after attempted medical abortion with mifepristone/misoprostol. B Show 2 more Post-abortion contraception: As per ACOG 2021 guidelines, ensure that contraceptive counseling and methods are available to all females after induced abortion, and respect their right to decline or postpone this care. E Show 3 more As per ACOG 2020 guidelines: Counsel regarding the following in patients undergoing medication abortion desiring contraception: almost all contraceptive methods except intrauterine devices and permanent contraception can be safely initiated immediately on day 1 (mifepristone intake) of medication abortion all contraceptive methods can be safely initiated after successful medication abortion. B https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 7/9 6/29/23, 11:25 PM Pregnancy termination Pathway Counsel patients choosing depot medroxyprogesterone acetate for contraception that administration of depot medroxyprogesterone acetate on day 1 of the medication abortion regimen may increase the risk of ongoing pregnancy. B As per SOGC 2016 guidelines: Initiate hormonal contraception, if desired by the patient, as soon as possible after taking misoprostol. B Delay insertion of intrauterine devices, if desired by the patient, until the follow-up visit after medical abortion, once completion of the abortion is confirmed. B 8. Quality improvement Health professional training: as per ACOG 2020 guidelines, train clinicians wishing to provide medication abortion services in performing uterine evacuation procedures or to ensure they are able to refer patients to a clinician having this training. B Clinical findings Symptoms Abdominal cramps Abdominal discomfort Abdominal pain Fever Foul-smelling vaginal discharge Infection Low back pain Studies 2014 CHOICE Teenage girls and women who were provided contraception at no cost and educated about reversible contraception and the benefits of long-acting, reversible contraceptive (LARC) methods had rates of pregnancy, birth, and abortion that were much lower than the national rates for sexually experienced teens (34.0, 19.4, and 9.7 per 1,000 teens vs. 158.5, 94.0, and 41.5 per 1,000 teens, respectively). Secura GM et al. N Engl J Med. 2014 Oct 2. References 1. Dustin Costescu, Edith Guilbert, Jeanne Bernardin et al. Medical Abortion. J Obstet Gynaecol Can. 2016 Apr;38 4 366 89. Open 2. Kerns J, Steinauer J. Management of postabortion hemorrhage: SFP guideline. Contraception. 2013 Mar;87 3 331 42. Open https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 8/9 6/29/23, 11:25 PM Pregnancy termination Pathway 3. f Jody Steinauer, MD, Andrea Jackson et al. ACOG Practice Bulletin No. 135 Second-trimester abortion. Obstet Gynecol. 2013 Jun;121 6 1394 1406. Open 4. Lichtenberg ES, Paul M, . Surgical abortion prior to 7 weeks of gestation. Contraception. 2013 Jul;88 1 7 17. Open 5. American College of Obstetricians and Gynecologists Committee on Practice Bulletins Gynecology, Society of Family Planning. Medication Abortion Up to 70 Days of Gestation: ACOG Practice Bulletin, Number 225. Obstet Gynecol. 2020 Oct;136 4):e31-e47. Open 6. M Guiahi, A Davis, Society of Family Planning. First-trimester abortion in women with medical conditions: release date October 2012 SFP guideline #20122. Contraception. 2012 Dec;86 6 622 30. Open 7. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, and the Contraceptive Equity Expert Work Group. Access to Postabortion Contraception: ACOG Committee Opinion, Number 833. Obstet Gynecol. 2021 Aug 1;138 2):e91-e95. Open 8. Michelle C Fox, Colleen M Krajewski. Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013 4. Contraception. 2014 Feb;89 2 75 84. Open 9. Mitchell D. Creinin, MD and Daniel A. Grossman, MD. Practice bulletin no. 143 medical management of first-trimester abortion. Obstet Gynecol. 2014 Mar;123 3 676 692. Open https://web.pathway.md/diseases/recnHJEA7ftTF5EDI 9/9