Tips on providing medication abortion

It’s been five years since Mifegymiso was approved for use in Canada for medication abortion. The procedure itself is simple: Patients take an initial 200 mg mifepristone orally, followed by 800 micrograms of misoprostol taken buccally or vaginally 24 to 48 hours later, at home. Yet, as with any procedure, there’s more to it than just administering pharmaceuticals. Guidance comes from the Society of Obstetricians and Gynaecologists of Canada (SOGC) 2016 guidelines and the National Abortion Federation’s clinical policy guidelines for abortion care. There’s also advice from the growing number of physicians providing medication abortions. This includes Dr. Bruce Allan, an obstetrician and gynecologist and medical director of the Kensington Clinic in Calgary, who gave a presentation on medication abortion at the SOGC annual clinical and scientific conference held in Ottawa in June. It also includes Dr. Sarah Warden, a family physician and lead in the mifepristone program at the Bay Centre for Birth Control and Women’s College Hospital in Toronto, who spoke to the Medical Post about the procedure. Here’s what they said. Determining eligibility There are clinical parameters for eligibility of a medication abortion, the most obvious being that the gestation age is not beyond 70 days and the patient has no underlying contraindications. Other conditions are outlined in guidelines, and include making sure patients aren’t anemic. Health Canada changed Mifegymiso’s prescribing information in 2019 to no longer require an ultrasound, although an ultrasound is still recommended when gestational age is uncertain or an ectopic pregnancy is likely. At the Kensington Clinic, everyone seeking a medication abortion gets a transvaginal or abdominal ultrasound to determine the location of the pregnancy, gestational age and if there are twins, Dr. Allan said. But if a timely ultrasound isn’t easy to access, a patient’s last menstrual period can be used to determine the gestational age. This allows for a no-touch protocol for certain patients who don’t have risk for ectopic pregnancy or concerning health conditions. “We listen to the patients and determine clinically whether it works or not,” Dr. Warden explained. “The vast majority of those patients don’t have to enter a health facility at all.” Being able to offer no-touch abortion at the Bay Centre for Birth Control has improved access for certain patients, especially during COVID-19, she said. Without an ultrasound, there’s no confirmation that the pregnancy is in the uterus, and no clarification if it’s an ectopic pregnancy or not. Although, for many patients, even with an ultrasound it’s a “pregnancy of unknown location” because patients often present when it’s too early to determine the pregnancy location in an ultrasound. “We still give a medication abortion to those patients, we just watch them a little more closely,” Dr. Warden said. This practice is in keeping with National Abortion Federation Guidelines, which recommend giving patients with pregnancy of unknown location medication abortion. A drop in beta human chorionic gonadotropin (bHCG) levels on a blood test following medication abortion confirms the pregnancy was intrauterine. “The rate of ectopic pregnancy is so low, in general it’s less than 1% in our population,” Dr. Warden said. All patients are assessed for risk factors for an ectopic pregnancy, and patients at high risk may be managed differently. Patients may also need to get bloodwork to determine if they are Rh negative or Rh positive. The National Abortion Federation guidelines note it is reasonable to forego Rh testing when gestational age is younger than eight weeks. The SOGC recommends Rh immunoglobulin for Rh negative patients who have a medication abortion after 49 days gestation period. Rh immunoglobulin could be offered before 49 days, although there’s no evidence to support or refute giving it during this early part of pregnancy, the SOGC says. If the request for a medication abortion is not from the person who is pregnant or if the patient isn’t able to give consent due to significant ambivalence, they should also be considered ineligible for medication abortion, Dr. Allan said. Counselling Counselling is key with medication abortion. Patients need to comprehend the nature of the procedure. “I think it’s really important that patients understand how much cramping and how much bleeding they will have,” Dr. Warden said. “We still sometimes have patients coming in and saying, ‘This is what I want because I can just take a pill and go to sleep and then my pregnancy is over.’” At the Bay Centre for Birth Control in Toronto, they give patients two different pain medications and make sure patients realize there may be “blood clots the size of a lemon,” or they might see pregnancy tissue. “We definitely don’t sugarcoat what that is going to be like, because then patients might go to the emergency or call us more on call,” she said. Patients also need to understand that medication abortion cannot be reversed, despite posts on social media suggesting otherwise, Dr. Allan said. Counselling can also help to make sure patients are proceeding with a medical abortion for appropriate reasons. Dr. Allan said that some people seek an abortion because they believe they’ve damaged the pregnancy with their behaviour, such as drinking. Dr. Allan said these patients can be referred to a maternal-fetal medicine specialist. Dr. Warden said they see this in their clinic as well, and their nurse counsellors try to make sure patients have accurate information about risk so they can make the most informed decision they can. For example, one patient believed she couldn’t financially support a baby and wouldn’t have access to healthcare, but when the clinic staff informed her about all the resources available to her, she changed her decision. “We don’t ask people why they are terminating their pregnancy. We just ask if they have any questions or if there are any other factors going into it. It’s a very open-ended, holistic process,” Dr. Warden explained. The nature of the pregnancy may also affect counselling, Dr. Allan said. For example, a person’s decision may be affected if they’re carrying twins or if the pregnancy is not viable. It’s worth noting that the experience of medication abortion for multiples is no different than for other pregnancies. “The data hasn’t shown that it makes it more difficult or makes it take longer,” Dr. Warden said. Access Ensure that the patient’s pharmacy will be able to order in Mifegymiso. All provinces and territories cover the cost, but the pharmacy needs to know how to properly bill the healthcare plan. Dr. Warden said that with the prescription, she often includes a tip sheet for the pharmacist on how to bill for the medication. She makes sure patients know they won’t have to pay for it. Followup The recommended followup is seven to 14 days. “We do all of our follow-ups remotely,” Dr. Warden said. Patients get bloodwork done seven days after taking the medication and have a pre-booked phone appointment one to two weeks later. A fall of bHCG levels by 80% indicates the successful termination of a pregnancy, the SOGC guidelines state. At the Calgary clinic, patients are asked to call in 10 days, and also if a pregnancy test comes back positive after six weeks. Before the followup, there needs to be a way for patients to contact a healthcare professional with questions or concerns after the procedure. The Kensington Clinic has a 24-hour call line staffed by a nurse. “A lot of the calls are reassurance calls,” Dr. Allan said. Most can be handled over the phone. At the Bay Centre for Birth Control, the phone calls are handled with an on-call rotation between providers. “That’s one of the biggest challenges doing this as an individual primary care practitioner out in the community—if you don’t have a group of you that can answer the phone calls with these patients,” Dr. Warden said. Some sole providers have patients call provincial health phone lines, and others carry a mobile phone. Patients in remote areas need to have a support person in case they have complications and need to be taken to the emergency department, Dr. Warden said. Further procedures Studies suggest medication abortion is 95% to 98% effective. “That’s exactly what we see in our clinic,” Dr. Warden said. In most cases, where medication abortion isn’t effective, products of conception remain that need to be removed by aspiration. In 0.5% of cases, the patient remains pregnant, and a second dose or an aspiration abortion may be required, since Mifegymiso has teratogenic effects. What Dr. Allan calls the scariest potential complication is a group A streptococcal clostridial infection. “You might go through your entire career without seeing that, but it might be the second one you do,” he said. He has yet to see one, but advises others to watch for signs of infection. Providing medication abortion Providing medication abortions is within primary care’s scope of practice, Dr. Warden said. In fact, it may be best provided by the patient’s family doctor, said Dr. Sheila Dunn, a family physician at the Women’s College Family Practice Health Centre. Sometimes patients are lost to followup, but “They wouldn’t get lost if they were with their family physician,” she told the Medical Post at the SOGC meeting.

Tips on providing medication abortion

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