Low-sensitivity urine pregnancy testing to assess medical abortion outcome: A systematic review

Telemedicine for the provision of medication abortion to pregnant people at up to twelve weeks of pregnancy: a systematic literature review and meta-analysis

BACKGROUND

Telemedicine represents an important strategy to facilitate access to medication abortion (MAB) procedures, reduces distance barriers and expands coverage to underserved communities. The aim is evaluating the self-managed MAB (provided through telemedicine as the sole intervention or in comparison to in-person care) in pregnant people at up to 12 weeks of pregnancy.

METHODS

A literature search was conducted using electronic databases: MEDLINE, Embase, Cochrane (Central Register of Controlled Trials and Database of Systematic Reviews), LILACS, SciELO, and Google Scholar. The search was based on the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework, and was not restricted to any years of publication, and studies could be published in English or Spanish. Study screening and selection, risk of bias assessment, and data extraction were performed by peer reviewers. Risk of bias was evaluated with RoB 2.0 and ROBIS-I. A narrative and descriptive synthesis of the results was conducted. Meta-analyses with random-effects models were performed using Review Manager version 5.4 to calculate pooled risk differences, along with their individual 95% confidence intervals. The rate of evidence certainty was based on GRADE recommendations.

RESULTS

21 articles published between 2011 and 2022 met the inclusion criteria. Among them, 20 were observational studies, and 1 was a randomized clinical trial. Regarding the risk of bias, 5 studies had a serious risk, 15 had a moderate risk, and 1 had an undetermined risk. In terms of the type of intervention, 7 compared telemedicine to standard care. The meta-analysis of effectiveness revealed no statistically significant differences between the two modalities of care (RD = 0.01; 95%CI 0.00, 0.02). Our meta-analyses show that there were no significant differences in the occurrence of adverse events or in patient satisfaction when comparing the two methods of healthcare delivery.

CONCLUSION

Telemedicine is an effective and viable alternative for MAB, similar to standard care. The occurrence of complications was low in both forms of healthcare delivery. Telemedicine services are an opportunity to expand access to safe abortion services.

Telephone follow-up after early medical abortion using Australia's first low sensitivity urine pregnancy test

BACKGROUND

Follow-up after early medical abortion (EMA) in Australia often entails tracking serum human chorionic gonadotropin levels or performing ultrasonography in-clinic. In other countries, methods of follow-up such as using a low-sensitivity urine pregnancy test (LSUPT), telephone evaluation and a questionnaire have been demonstrated to be safe and acceptable.

AIMS

To evaluate the safety and efficacy of telephone follow-up after EMA using an LSUPT and questionnaire.

MATERIALS AND METHODS

A prospective observational cohort study of patients undergoing telephone follow-up after EMA using an LSUPT and questionnaire was conducted from March 26 to July 31, 2020. Outcomes of patients who returned to clinic because of a positive LSUPT were evaluated and adverse event rates were calculated. Routinely collected adverse event information was used to compare complication rates during the evaluation period with that prior to introduction of the LSUPT.

RESULTS

During the study period, 2223 patients underwent the new protocol. One hundred and ninety-seven patients had a positive LSUPT at their telephone follow-up. One hundred and thirty-two had an incomplete abortion, 11 had a continuing pregnancy, 53 had a complete abortion and one left the clinic before full assessment.

CONCLUSIONS

Introduction of telephone follow-up with an at-home LSUPT reduced the number of patients requiring unnecessary clinic appointments, with over 90% of patients completing their follow-up at home. Complication rates during the study period were found to be at least comparable with previously identified organisational adverse events.

Update on medication abortion follow-up options: many sizes to fit all

PURPOSE OF REVIEW

To assess the efficacy, benefits, and limitations of available and emerging follow-up options for medication abortion.

RECENT FINDINGS

Medication abortion follow-up does not have to be a 'one size fits all' protocol. From most to least invasive, follow-up options include facility-based ultrasound, laboratory-based repeat serum beta-human chorionic gonadotropin (hCG) testing, urine hCG testing (high sensitivity, low sensitivity, and multilevel pregnancy tests), self-assessment with symptom evaluation, and no intervention. Provider or facility-dependent follow-up, including ultrasound and serum testing are effective, but have several limitations, including needing to return to a facility and cost. Remote, client-led follow-up options, such as urine pregnancy testing and symptoms evaluation, are well tolerated and effective for ruling out the rare outcome of ongoing pregnancy after medication abortion and have several advantages. Advantages include being inexpensive and flexible. However, it is important to note that low-sensitivity and multilevel pregnancy tests are not available in all settings. In studies evaluating client-led follow-up with urine pregnancy tests, ongoing pregnancies were identified over half the time with symptoms alone.

SUMMARY

Guidelines from several professional organizations have aligned with the evidence and no longer recommend routine office-based follow-up. To ensure care is person-centered, providers should offer follow-up options that align with the comfort, logistical ability, and values of the client.

Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review

OBJECTIVE

To inform UK service development to support medical abortion at home, appropriate for person and context.

DESIGN

Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion.

INTERVENTIONS

Interventions and new models of abortion care relevant to the UK.

OUTCOME MEASURES

Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory.

RESULTS

We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception.

CONCLUSIONS

Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.

Termination of pregnancy services in Irish general practice from January 2019 to June 2019

OBJECTIVE

To describe how a general-practitioner-delivered community medical abortion service is provided in Ireland, including a description of the unique model of care delivered within the framework of new legislation. To investigate the characteristics and contraceptive choices of women attending in the first six months of the service.

STUDY DESIGN

Twenty-seven general practitioners conducted a retrospective chart review. We described the service and analyzed demographic characteristics, treatment outcomes, adverse events, and contraception use. We defined treatment success as complete abortion without surgical intervention.

RESULTS

Twenty-seven general practitioners from the Southern Task Group on Abortion and Reproductive Topics (START) group collected data from 475 women who had attended requesting medical abortion from January 1st 2019 to June 30th 2019. Out of these, 315 (66%) were more than 25 years old, and 261 (55%) had at least one child. The mean gestational age at initial presentation was 49 days. Five (1%) had a gestational age which exceeded 84 days. Four hundred and twenty (89%) proceeded with community medical abortion following an initial consultation. The process was completed without the need for surgical intervention in 412 (98%) cases. Six (1.4%) women had a mild post-treatment infection, and received community treatment with oral antibiotics. Thirty-three (7.9%) patients were referred to hospital for additional evaluation following treatment. Two hundred ninety (69%) adopted contraception post abortion; only 160 (34%) were using contraception prior to pregnancy.

CONCLUSION

The general-practitioner-delivered community medical abortion service described in the study is safe, effective, and accessible for the majority of, but not all women seeking abortion. The model of care used in Ireland provides an ideal opportunity to discuss contraceptive choice.

IMPLICATIONS STATEMENT

This review provides demographic, efficacy, and safety data for the general-practitioner-provided community medical abortion service in Ireland. An effective and largely accessible model of care is demonstrated. These findings can help inform legislative review, clinical guidelines, and generate hypotheses for future research.

"False positive" urine pregnancy test results after successful medication abortion

OBJECTIVE

To examine the proportion of high-sensitivity urine pregnancy test (HSPT) results that were positive by time after successful medication abortion.

STUDY DESIGN

We used data from an ongoing study that provides mifepristone and misoprostol for medication abortion by direct-to-patient telemedicine and mail. Providers evaluated abortion outcomes by patient interview and clinical tests per clinical judgment and participant preference. We identified all participants enrolled July 2016 to September, 2020 who had an HSPT result and no indication of viable pregnancy after treatment. We used logistic regression to examine the association between the timing of the initial post-treatment HSPT, gestational age, and the proportion of HSPTs that gave a positive result.

RESULTS

Of the 472 participants in our analysis, 88 (19%) had positive initial HSPTs. The proportions that were positive at ≤20 days, 21 to 27 days, 28 to 34 days, and ≥35 days after mifepristone ingestion was 14 of 29 (48%), 15 of 58 (26%), 49 of 258 (19%), and 10 of 127 (8%), respectively (p < 0.001). Gestational age at mifepristone ingestion was not significantly related to positive HSPT results (p = 0.28). Multivariable logistic regression confirmed both findings and did not identify a statistically significant interaction between these variables. In the 67 participants who relied solely on further HSPTs to confirm abortion outcome, the median interval between the initial positive test and first negative test was 14 days.

CONCLUSIONS

The proportion of participants with positive HSPTs declined with time after successful medication abortion. However, nearly one-fifth of participants with complete abortion had positive tests 4 weeks after treatment.

IMPLICATIONS

HSPTs provide an inexpensive, convenient option for confirming success of medication abortion at home. However, a substantial minority of patients without ongoing pregnancy have positive HSPT results. Development of a symptom-based strategy for medication abortion outcome assessment without any confirmatory tests should be a priority.

Comparison of two home pregnancy tests for self-confirmation of medication abortion status: A randomized trial

OBJECTIVES

To evaluate individuals' ability to perform and comprehend low-sensitivity and multilevel urine pregnancy tests during medication abortion follow-up.

STUDY DESIGN

We conducted a pilot study of individuals using mifepristone and misoprostol for medication abortion through 63-days gestation. We randomly assigned participants to use a 1000 mIU/mL low-sensitivity pregnancy test or a five-level multilevel pregnancy test. Seven days after mifepristone, participants performed their test and completed a questionnaire. One week later, participants performed another test if day 7 low-sensitivity test had been positive or day 7 multilevel test had not shown a one-level drop. We assessed comprehension of abortion status based on participants' final test interpretation, and defined correct comprehension when patient report of pregnancy status was consistent with pregnancy test result. We also assessed usability with a 100-mm Visual Analogue Scale (0 'very easy'; 100 'very difficult') and satisfaction.

RESULTS

We enrolled and randomized 88 participants to low-sensitivity (n = 43) and multilevel (n = 45) test groups. Comprehension was correct in 38/39 (97%) and 41/45 (91%) of low-sensitivity and multilevel test users, respectively (p = 0.37). When the test indicated a possible ongoing pregnancy, all three low-sensitivity test users and two of three multilevel test users accurately comprehended their results. Participants rated ease of use as 7.5 (range 0-68) for low-sensitivity and 9.0 (range 0-52) for multilevel (p = 0.24) tests. Most participants were likely or very likely to recommend use of their test (32/36 [89%] low-sensitivity and 42/44 [95%] multilevel test users, p = 0.66).

CONCLUSIONS

Patients could comprehend and use low-sensitivity and multilevel tests during medication abortion follow-up with similar satisfaction.

IMPLICATIONS

Individuals are able to independently use both the low-sensitivity and multilevel tests for medication abortion follow-up. Both are acceptable for medication abortion follow-up without in-person contact, but future, larger studies to compare comprehension of both tests may be necessary.

Changes to medication abortion clinical practices in response to the COVID-19 pandemic

OBJECTIVES

To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic.

STUDY DESIGN

Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations.

RESULTS

Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits.

CONCLUSIONS

Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research.

IMPLICATIONS STATEMENT

Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

Medication Abortion Up to 70 Days of Gestation

Medication abortion, also referred to as medical abortion, is a safe and effective method of providing abortion. Medication abortion involves the use of medicines rather than uterine aspiration to induce an abortion. The U.S. Food and Drug Administration (FDA)-approved medication abortion regimen includes mifepristone and misoprostol. The purpose of this document is to provide updated evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation. Information about medication abortion after 70 days of gestation is provided in other ACOG publications [1].

Follow-up strategies to confirm the success of medical abortion of pregnancies up to 10 weeks' gestation: a systematic review with meta-analyses

OBJECTIVE

To compare the effectiveness, safety, and acceptability of in-clinic and remote/self-assessment, as well as different remote/self-assessments, for confirming the success of medical abortion at ≤10⁺⁰ weeks' gestation.

DATA SOURCES

Ovid Embase Classic and Embase; Ovid MEDLINE(R) and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations and Daily; and the Cochrane Library. We also consulted experts in this field for any ongoing or missed trials.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials published in English from 2000 onward, comparing in-clinic assessment with ultrasound to remote or self-assessment or comparing different remote or self-assessment strategies to confirm the success of medical abortion of pregnancies up to and including 10⁺⁰ weeks gestation, reporting any of the following outcomes: "missed ongoing pregnancy," "correct implementation of the follow-up strategy," patient satisfaction/preference, "adherence to follow-up strategy," "unscheduled visits/telephone calls to the abortion service," and surgical intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for randomized controlled trials. All outcomes were analyzed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel-Haenszel statistical method and a fixed effect model. The overall quality of the evidence was assessed using GRADE.

RESULTS

Four randomized controlled trials (n = 5761) compared in-clinic to remote self-assessment and found no clinically significant differences apart from higher preference rates for remote follow-up, especially in the remote follow-up groups. The quality of this evidence was compromised by attrition, no blinding, inconsistency, indirectness, and low event rates. Two randomized controlled trials (n = 1125) compared different remote assessment strategies (using urine pregnancy tests) and also found no clinically significant differences apart from a clinically significantly lower rate of unscheduled visits to the abortion service in the remote follow-up group using a multilevel urine pregnancy test compared to remote follow-up using a high-sensitivity urine pregnancy test. The quality of this evidence was compromised by small event rates, lack of blinding, indirectness and high attrition rates.

CONCLUSION

The published data support offering women who have had a medical abortion up to and including 10⁺⁰ weeks' gestation the choice of self-assessment, remote assessment, or clinic follow-up.

Abortion through telemedicine

PURPOSE OF REVIEW

Medical abortion offers a well tolerated and effective method to terminate early pregnancy, but remains underutilized in the United States. Over the last decade, 'telemedicine' has been studied as an option for medical abortion to improve access when patients and providers are not together. A number of studies have explored various practice models and their feasibility as an alternative to in-person service provision.

RECENT FINDINGS

A direct-to-clinic model of telemedicine medical abortion has similar efficacy with no increased risk of significant adverse events when compared with in-person abortion. A direct-to-consumer model is currently being studied in the United States. International models of direct-to-consumer medical abortion have shown promising results.

SUMMARY

The introduction of telemedicine into abortion care has been met with early success. Currently, there are limitations to the reach of telemedicine because of specific restrictions on mifepristone in the United States as well as laws that specifically prohibit telemedicine for abortion. If these barriers are removed, telemedicine can potentially increase abortion access.