Module 2: Early Medical Abortion
5. Aftercare and management of complications
Verification of completion of abortion
New Zealand Aotearoa Abortion Clinical Guideline 2021, recommendation 2.2.5 states: “For medical abortion up to 10+0 weeks’ gestation, offer follow-up assessment either in person or by telehealth. Confirm the abortion is complete and exclude ongoing pregnancy by:
- serum β-hCG testing: Completion may be confirmed by a drop in serum β-hCG level of 80% or more from day of mifepristone to 7–14 days after mifepristone. If less than 80% drop, investigate further and manage as appropriate
- urine β-hCG testing: A negative low-sensitivity urine pregnancy test at 3 or 4 weeks after treatment will exclude an ongoing pregnancy. If positive, investigate further and manage as appropriate
- ultrasound scan.”
It is especially important to confirm abortion is complete if ultrasound has not been performed before early medical abortion, to exclude ectopic pregnancy”.
Continuing pregnancy after EMA is uncommon (1–3%) but important not to miss. Clinical signs of continuing pregnancy include: 1) having only scant bleeding after taking the medicines; 2) patients who despite significant bleeding are still experiencing ongoing pregnancy related symptoms such as nausea, tiredness, frequent urination and breast tenderness; and 3) people who do not have a return of menses at 4–6 weeks (taking into account any possible changes due to the method of contraception used post abortion).
It is important to verify completion of abortion by one of the following methods:
- Serum βhCG drop of >80% 7 to 14 days after administration of mifepristone (check baseline serum βhCG on day of mifepristone)
- Negative low sensitivity urine pregnancy test 2 to 4 weeks after abortion
- Absence of gestational sac on ultrasound scan which was present before
- Clinical history and examination, e.g. self-reported: the gestational sac was seen to pass, bleeding is settling, pregnancy symptoms have gone, and the uterus is involuted on vaginal examination
- It is the expectation of the Midwifery Council that midwives offer in person follow up post abortion
If the pregnancy is found to be ongoing following an EMA the patient must be advised of their options; these include to repeat the EMA procedure if they are under 10 weeks, to undergo a surgical abortion or if they choose to continue the pregnancy, they must be referred for ongoing pregnancy care and advised of the risks to the pregnancy including miscarriage and the need for a detailed early scan for limb malformations.
Additional follow-up
New Zealand Aotearoa Abortion Clinical Guideline 2021, recommendation 5.4.1 states: “Consider selective follow-up with their health practitioner for people who:
- Are at risk of (or develop) complications
- Still need contraception
- May need ongoing mental health support
- Are living with complexities
- Are young, or
- Request follow-up”
Reporting
To comply with the Contraception, Sterilisation, and Abortion Act 1977 abortion service providers must submit a notification to the Ministry of Health within one month of an abortion. The Ministry of Health collates the national data on abortions and uses this to report on issues such as timely and equitable access to abortion services.
There is a guide provided on the Ministry of Health Abortion Reporting webpage to completing and submitting the notification report, via an online form. A PDF version of the form is also available on request.
For further information, see the module 1 section on legal reporting requirements.
Signs and management of complications
All abortion providers should have a plan in place for referring a pregnant person to a hospital for emergency assessment and admission if required. Patients should be provided with sufficient information about the EMA procedure to allow another health practitioner elsewhere to manage complications in an emergency situation.
Retained products of conception (RPOC) is the most common complication after EMA. Problematic cramping, pain and/or bleeding in the first week is common (2–9%) but may continue to occur for 2–5 weeks after the medicines. This extended duration of bleeding may result from retained pregnancy tissue (i.e. RPOC). A slow to drop serum βhCG may also suggest RPOC.
- Check how much bleeding is occurring (how long has it been going on, how often are they changing pads, are the pads completely soaked through? Are they faint and dizzy when they stand up?)
- Check pulse and blood pressure
- Do a vaginal speculum examination to look for RPOC at the cervical os and assess amount of bleeding
If the patient feels unwell or is haemodynamically unstable provide immediate emergency care as appropriate and refer urgently to secondary care.
If the patient feels well and is haemodynamically stable offer a choice of treatments:
- Explain, reassure and manage conservatively (wait to pass spontaneously)
- Give another dose of misoprostol (400 micrograms buccally or sublingually, not vaginally)
- Refer to secondary care for further assessment and management
A previously undiagnosed ectopic pregnancy is a rare but important not to miss life-threatening condition. Be alert to this possibility when a person without a confirmed intrauterine pregnancy has an EMA. Ectopic pregnancy may be asymptomatic, and an ectopic pregnancy may only be detected when the follow-up βhCG is not falling as expected. Patients may present with symptoms of pelvic pain, vaginal spotting/bleeding or with tachycardia, hypotension and shock. Refer all patients with these findings urgently to the nearest hospital.
Endometritis/ pelvic inflammatory disease after EMA is uncommon but important not to miss. Patients may present with fever, abdominal pain and/or a malodourous vaginal discharge and have uterine or adnexal tenderness on bimanual examination. In cases of suspected endometritis/pelvic inflammatory disease urgent treatment as per guidelines is recommended.
