New Zealand College of Sexual & Reproductive Health

Abortion Training

Module 2: Early Medical Abortion

7. Review of key learning points

1. Support patients through the EMA process

  • A focused medical history needs to be taken to identify any contraindications or precautions to EMA
    • Absolute contraindications
      • Allergy to mifepristone or misoprostol
      • Adrenal failure
      • Poorly controlled severe asthma
      • Steroid dependency
      • Hereditary porphyria
      • Greater than 70 days of pregnancy
      • IUC in situ – it is okay to proceed if removed
      • Suspected ectopic pregnancy
    • Relative contradictions: a) severe anaemia, b) serious or unstable health conditions such as ischaemic heart disease or c) taking anticoagulants or having a bleeding disorder
    • Precautions to EMA: a) inability to follow care instructions, b) inability to access emergency help – e.g. no telephone access, no transport or no adult companion at home, c) limited ability to communicate with health professionals in an emergency
  • It is very important that practitioners ensure that:
    • a safe method of communication chosen by the person for ongoing communication is recorded
    • the patient has access to 24-hour support during the EMA process
    • the patient has access to transport/telephone/emergency health services
    • the patient has someone at home with them who is aware of the EMA
  • The process of EMA involves taking a 200 mg dose of mifepristone orally, followed 24 to 48 hours later by 800 micrograms misoprostol vaginally, sublingually or buccally.
    • If the abortion has not occurred after 6 hours, a further dose of misoprostol 400 micrograms can be administered – providers should consider providing a prescription or extra tablets to save them having to return to the clinic
    • If a patient feels nauseated or has experienced hyperemesis prior to the abortion, offer an anti-emetic prior to taking the mifepristone. If a patient vomits within an hour of taking mifepristone, offer them another dose
  • Pain management
    • Non-steroidal anti-inflammatory medicines should be the first-line agents for pain management (for example ibuprofen, naproxen or diclofenac)
    • For more severe pain, consider tramadol or codeine
    • For nausea, offer anti-emetics (for example oral ondansetron)
  • Routine use of prophylactic antibiotics prior to EMA is not recommended
  • Do not routinely offer anti-D prophylaxis to people having an EMA

2. Address the range of what to expect during the EMA with the patient

  • A pregnant person should be aware that counselling is freely available, but not required, at all stages of the abortion experience. This should be readily available on request to ensure that there is no unnecessary delay to their abortion
  • Information about the EMA process:
    • Patients should be advised that bleeding and cramping can start very quickly after misoprostol administration, and the abortion will usually be completed within 4 to 6 hours
    • It takes about 20 minutes for the tablets to dissolve when taken sublingually and 30 minutes if taken buccally. Any tablet remnants can be swallowed after these times.
    • Advise the patient that they will likely experience menstrual-like cramps, pain and bleeding, and that the pain experienced may be more like a miscarriage than menses - the cramping can be severe
    • Patients should have clear instructions as to what pain relief is available and this should be provided by the health practitioner (practitioner supply order (PSO) or prescription). Non-pharmacologic pain management such as heat packs, natural remedies, and emotional support from an adult companion should be encouraged
  • Patients should be informed of the potential side effects, risks and complications of EMA:
    • Side effects include fever, chills, nausea, vomiting, diarrhoea, weakness, headache, dizziness
    • Risks include ongoing pregnancy, requiring surgical intervention (less than 5%) and blood transfusion (less than 1%)
  • Inform the patient how and when to access further support and/or emergency care:
    • If bleeding is excessive, soaking through 2 maxi pads an hour for 2 or more consecutive hours
    • When they may need additional medicine – if they do not bleed within 24 hours of taking misoprostol, or if they fail to take the misoprostol as instructed
    • If their symptoms are suggestive of continuing pregnancy – e.g. less than 4 days bleeding, if they still ‘feel’ pregnant, if their next period doesn’t arrive when expected

3. Assess for completion of EMA

  • Completion of abortion may be verified by:
    • Serum βhCG drop of > 80% 7-14 days after administration of mifepristone
    • Negative urine pregnancy test 2-4 weeks after abortion
    • Absence of gestational sac on ultrasound
    • Clinical history and examination (e.g. the person says they saw the gestational sac pass, bleeding is settling, pregnancy symptoms have gone and uterus is involuted on vaginal examination)
  • Notify the Ministry of Health of the EMA via the online abortion notification report form.

4. Identify and manage common complications of EMA

  • If the abortion has not occurred within 6 hours of the misoprostol dose, a second dose of misoprostol 400 micrograms may be given
  • 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 given sufficient information (electronically or on paper) about the procedure to pass on to another practitioner elsewhere to manage complications

Made with by the bpacnz team

Partner links