Medical abortion care

A medical abortion is the use of medicines to end a pregnancy. Medical care for a medical abortion is different than medical care for a surgical abortion. This is because a medical abortion is like a miscarriage (in this case, caused by medicines) that takes place at home over 1 to 2 days and does not require your health professional to be present. After a couple of weeks of bleeding, you then see your health professional for a follow-up examination.

Care before a medical abortion

Before a medical abortion, your health professional will:

• Evaluate your medical history, including any medicines you are taking.
• Do a physical examination, including a pelvic examination, to evaluate your health, how long you have been pregnant, and location of the embryo or fetus.
• Perform an ultrasound to confirm how far along and where the pregnancy is. Not all health professionals choose to do this step.
• Discuss your decision to have an abortion and your feelings about the decision.
• Discuss your plans for future pregnancies and birth control use.
• Explain how the medicines will work, possible side effects (nausea, vomiting, and diarrhea are common), and when to call your health professional. It is important for your health professional to know whether you:¹
  • Have access to a telephone, to call if you have problems.
  • Have transportation to a health care facility if you need to be evaluated.
  • Will be able to return for a follow-up appointment.
  • Are prepared for the cramping pain and bleeding that will occur as the uterine contents are passed.
  • Understand that a surgical abortion will be necessary if a medical abortion fails to complete the process.

In addition to the medicines used to cause an abortion, your health professional will give you medicines to minimize side effects, with specific instructions for their use. These medicines are used:

• For cramping pain caused by uterine contractions.
• To prevent nausea or vomiting.
• To prevent infection.

All women who have Rh-negative blood type will be given Rh immune globulin to prevent Rh sensitization after an abortion.

If you need to call your health professional about your symptoms during a medical abortion, be prepared to provide information about:¹

• How heavy the bleeding is compared with your normal menstrual bleeding. The heaviest bleeding should stop 1 to 2 hours after passing the pregnancy tissue.
• The number and types of pads used in 1 hour and the total number of soaked pads used.
• The presence and size of blood clots.
• Whether any pregnancy tissue has been passed.
• The severity of your cramping or pain.

Care after a medical abortion

Carefully follow all of your health professional's instructions and review what-to-expect information after a medical abortion. Follow these instructions:

• Most women can return to normal activities in 1 to 2 days after the uterus has cleared. Avoid strenuous exercise for 1 to 2 weeks.
• Do not have sexual intercourse for 1 to 2 weeks or as advised by your health professional.
• Be sure to use birth control when you start having sex again, and use condoms to prevent infection. For immediately effective birth control, you can use a barrier method (such as a diaphragm, cervical cap, or condom). An intrauterine device (IUD) is effective immediately after it is placed in the uterus. If you start hormone birth control pills, patches, or injections right after the procedure, be sure to use a backup method until the hormone medicine becomes effective. For more information, see the topic Birth Control.
• Do not rinse the vagina with fluids (douche). This could increase your risk of infections that can lead to pelvic inflammatory disease.

Normal symptoms that most women will experience after a medical abortion include:

• Bleeding or spotting for up to 14 days. Bleeding may last longer for pregnancies of more than 7 weeks.
• Cramping for the first 2 weeks. Some women may have menstrual-like cramping for as long as 6 weeks.
• Emotional reactions for 2 to 3 weeks, often influenced by changes in pregnancy hormones. It's normal to feel one or more emotions such as relief, guilt, sadness, and grief.

Less than 1% of all women who have an abortion have serious problems afterward.²

Call your health professional immediately if you have any of these symptoms after an abortion:

• Severe bleeding. Both medical and surgical abortions usually cause bleeding that is different from a normal menstrual period. Severe bleeding can mean:
  • Passing clots that are bigger than a golf ball, lasting 2 or more hours.
  • Soaking more than 2 large sanitary pads in an hour, for 2 hours in a row.
  • Bleeding heavily for 12 hours in a row.
• Signs of infection in your whole body, such as headache, muscle aches, dizziness, or a general feeling of illness. Severe infection is possible without fever.
• Severe pain in the abdomen that is not relieved by pain medicine, rest, or heat
• Hot flushes or a fever of 100.4F or higher that lasts longer than 4 hours
• Vomiting lasting more than 4 to 6 hours
• Sudden abdominal swelling or rapid heart rate
• Vaginal discharge that has increased in amount or smells bad
• Pain, swelling, or redness in the genital area

Call your health professional for an appointment if you have had any of these symptoms after a recent abortion:

• No bleeding. If bleeding does not occur, then the medicines may not be working. A second dose of misoprostol may be needed. Methotrexate and misoprostol may take up to 3 weeks to be effective.
• Bleeding (not spotting) for longer than 2 weeks
• New, unexplained symptoms that may be caused by medicines used in your treatment
• No menstrual period within 6 weeks after the procedure
• Signs and symptoms of depression. Hormonal changes after a pregnancy can cause postpartum depression that requires treatment.

Complications that can occur include: ³

• Tissue remaining in the uterus (retained products of conception). Cramping abdominal pain and bleeding will recur within a week of the procedure.
• Infection. Symptoms of fever of 100.4F or higher, pain, and abdominal tenderness will usually start within 2 to 3 days of the procedure. But you can have a serious infection without fever.
• Blood clots blocking the cervix (hematometra). If the uterus doesn't contract to pass all of the tissue, the cervical opening can become blocked, preventing blood from leaving the uterus. The uterus will become enlarged and tender. Abdominal pain, cramping, and nausea may be present.
• Moderate to severe bleeding (hemorrhage). Bleeding may be more than normal if:
  • Products of conception are retained in the uterus.
  • The uterus has not contracted toward its prepregnancy size (atony).
  • Uterine muscle rupture has occurred. In rare cases, an upper uterine incision scar tears open when a medicine is used to induce contractions. (The lower uterus, where most cesarean scars are, is thicker and not at risk for rupture.)

When a medical abortion fails (2% of the time among women 9 weeks pregnant or less^{1, 4}), a surgical abortion must be done as follow-up to prevent complications or development of a fetus with abnormalities.

Follow-up examination after a medical abortion

A follow-up examination is done 2 to 3 weeks after a medical abortion. The examination may include:³

• A physical examination, to check the cervix and uterus.
• A lab test to check for a low human chorionic gonadotropin (hCG) level, which shows the pregnancy has ended.
• A blood test, to check for anemia.
• An ultrasound, to confirm the uterus is empty.
• A discussion of birth control use. If birth control measures were started immediately after the abortion procedure, the proper use of the method can be discussed again. You can choose to have an intrauterine device (IUD) inserted at this time.

Citations

1. Trupin SR, Moreno C (2002). Medical abortion: Overview and management. Medscape General Medicine, 4(1). Also available online: http://www.medscape.com/viewarticle/429755_1.

2. Facts on induced abortion in the United States (2006). In Brief. New York: Alan Guttmacher Institute. Also available online: http://www.guttmacher.org/pubs/fb_induced_abortion.html.

3. Paul M, et al. (1999). A Clinician's Guide to Medical and Surgical Abortion. New York: Churchill Livingstone.

4. Trupin SR (2003). Induced abortion. In JR Scott et al., eds., Danforth's Obstetrics and Gynecology, 9th ed., pp. 561–580. Philadelphia: Lippincott Williams and Wilkins.