Integrating abortion into primary care reduces barriers and increases access. Medication abortion (MAB) using mifepristone and misoprostol, or misoprostol alone, is safe and effective. MAB can be initiated with a clinician, in person, or via telehealth, as well as self-managed. Follow-up should be offered but can also be self-directed. Procedural abortion (PAB) should be trauma-informed and include options for pain control. PAB does not require follow-up. Medication and procedural abortion care is part of full-spectrum reproductive health care and within the scope of the primary care clinician.
Key points
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Medication and procedural abortion care is within the scope of most primary care clinicians including advanced practice clinicans; primary care integration increases access and promotes Reproductive Justice.
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Medication abortion via telemedicine, using a no-touch protocol, is safe and effective for most patients.
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Primary care clinicians should understand common follow-up concerns for patients undergoing clinician-led and self-managed abortion.
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Procedural abortion care should be trauma-informed and include options for pain control.
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Medication and procedural abortion are the same as evidenced-based treatment for early pregnancy loss.
Introduction
In the United States, 1 in 4 women a
a Not only cis women have abortions, though most data collection is from this population. For this article, the authors will use gender-neutral language to include all people with the capacity for pregnancy except when referring to respective studied populations.
will have 1 or more abortions by age 45 , and one-fifth of pregnancies end in abortion. Most abortions occur in the first trimester. First-trimester medication and procedural abortions are safe, effective, and within the scope of the primary care clinician, yet only 1% of abortions occur outside of a specialty clinic such as a primary care office. Expanding abortion provision beyond obstetrics and gynecology to other specialties and advanced practice clinicians is fundamental to safeguarding and improving access, especially in rural communities. Primary care integration promotes continuity of care, reduces the need for extra appointments, fees, and travel, reduces the odds of interactions with protestors, and allows patients to receive their abortion care in a place they know. It also reduces the burden on specialty abortion clinics and allows for increased access for those who need to travel or have abortions beyond the first trimester.Assuring access to abortion care is rooted in Reproductive Justice (RJ). RJ is built from a Human Rights framework and combines reproductive rights and social justice. While the ideology has existed and been practiced within many communities for generations, the term was formalized by a group of Black women in 1994. It posits that everyone has the right to bodily autonomy, and to have children, not have children, and parent in safe and sustainable communities. States with the least supportive parenting resources and the highest maternal mortality rates are also the states with the most restrictive abortion policies. Twentieth-century public health messaging around abortion rights is centered around “choice.” We cannot achieve RJ without shifting the narrative to access.
Excellent and equitable primary care for people with the capacity for pregnancy includes not only contraception, fertility, and perinatal services but also the ability to manage a miscarriage and provide early abortion care. This article aims to serve as an overview and jumping-off point for clinicians initiating or expanding their primary care-based abortion services.
Options counseling
Some patients may present with a positive home pregnancy test while others have a test included in routine care. Clinicians should avoid assumptions and foster a trauma-informed space by providing silence, asking open-ended questions, and using neutral language. For example, “your pregnancy test is positive which means you are pregnant, how do you feel about that?” Every patient should be provided with the option of abortion or continuing the pregnancy with the option to parent or make an adoption plan. While some may chose adoption, it is not an alterative to abortion.
Terms and phrases such as “termination,” “putting up for adoption,” and “keeping the baby” should be avoided.
Options counseling may include assistance in deciding what type of abortion the patient would like. Table 1 delineates key differences between medication and procedural abortion.
| Medical Abortion (<77–84 d) | Procedural Abortion |
|---|---|
|
|
Pregnancy dating
There are multiple modalities for determining gestational age. Ultrasound, while commonly used, is not a requirement for medication or procedural abortion.
Use of last menstrual period (LMP) is an accurate means of establishing dating. Obtaining a patient’s history including irregular periods, hormone use, risk factors for ectopic pregnancy, and symptoms of ectopic pregnancy can help determine if the LMP is accurate or if further evaluation is indicated. If an ultrasound is needed, a patient can be referred if it is unavailable in the office.
Use of LMP for dating expands access to abortion care when ultrasound is not readily available. Patients report high confidence in protocols that allow for no or minimal testing.
Pregnancy of Unknown Location
Patients often seek abortion care early in pregnancy. For patients with a positive pregnancy test and no pregnancy visualized on ultrasound, the differential includes a false positive test, early intrauterine pregnancy, early pregnancy loss, or ectopic pregnancy. For patients at low risk of ectopic pregnancy, medication and procedural abortion can be initiated while determining the location of the pregnancy.
Medication abortion (MAB) protocols for pregnancy of unknown location utilize beta human chorionic gonadotropin (hCG) trending. Expect a 50% decrease at 48 hours from misoprostol use. In most cases, trending to zero is not indicated. Patients should be given ectopic precautions while awaiting results. Procedural abortion (PAB) expedites care by allowing for direct visualization of products of conception (POCs). If no POCs are visualized, or decrease is <50%, referral should be made for suspected ectopic.
Serum hCG trending can also be used when patients prefer to identify pregnancy location prior to initiating care.
Laboratory evaluation
There is no required laboratory testing before first-trimester medical or procedural abortion. Many restrictive states require certain tests, so it is important to review your local laws.
Routine testing of hemoglobin for first-trimester abortion has not been shown to improve clinical outcomes. However, clinicians should screen patients for symptoms of anemia and/or increased risk of postabortion hemorrhage and check hemoglobin/hematocrit as indicated.
Extensive data demonstrate that Rh testing and administration of Rh immunoglobulin (RhIg) to Rh-negative patients before abortion or miscarriage up to 12 weeks is not necessary.
Medication abortion
MAB, also known as medical abortion or abortion with pills, is the most common form of abortion care in the United States. The Food and Drug Adminsitration (FDA)-approved regimen consists of mifepristone taken orally, followed by misoprostol which can be administered sublingually, buccally, or vaginally. MAB is safe via telemedicine using a no-test protocol as described earlier. The use of abortion pills is FDA approved up to 70 days gestation. Clinical practice guidelines support use through 77 days and World Health Organization guidelines supports MAB through 84 days. The recommended evidence-based regimens are summarized in Table 2 . Of note, simultaneous use of mifepristone and vaginal misoprostol has also been shown to be noninferior to 24-hour interval dosing up to 63 days gestation. Vaginal dosing helps to reduce side effects. Side effects of misoprostol can include low-grade fever, chills, sore throat, nausea, vomiting, and diarrhea.
Eligibility
There are few absolute contraindications to medical abortion with mifepristone and misoprostol which are summarized in Table 3 . Breastfeeding, inhaled corticosteroid use, hypertension, sickle cell disease, and having no reliable contact information are not contraindications. If a patient has an intrauterine device (IUD) in place, it should be removed before taking medications. In these cases, ultrasound should be performed given the higher risk of ectopic pregnancy.
| Medical Condition | Potential Concern | Comments |
|---|---|---|
| Long-term oral steroid use/chronic adrenal failure | Adrenal crisis | Mifepristone can block cortisol receptors precipitating adrenal crisis. Can consider misoprostol-only regimens. |
| Inherited porphyria | Porphyria storm | Mifepristone is a cytochrome P-350 inducer |
| Hemorrhagic disorder or blood thinner use (except Aspirin) | Hemorrhage | Procedural abortion is generally preferred in this scenario |
| IUD in situ | Uterine damage/perforation, infection, retained products of conception | If IUD can be removed, can proceed with medication abortion |
| Known ectopic pregnancy | Ongoing ectopic pregnancy | Mifepristone and misoprostol are not effective for treatment of ectopic pregnancy. |
If a patient is beyond the gestational limit for MAB, they should be offered or referred for procedural care.
Counseling and Informed Consent
All patients should undergo an informed consent process to confirm they understand the risks, benefits, and alternatives and are making a voluntary decision without coercion.
MAB is extremely safe. Risks include heavy bleeding, infection, continuing pregnancy, and the possible need for a follow-up procedure.
Patients should be counseled on how to take the pills and signs/symptoms necessitating return to care ( Table 4 ) and who to contact after hours. If there is no 24-hour option for contact, patients should be given explicit instructions on when to seek emergency care.
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