A repeat dose of misoprostol 800 mcg following mifepristone for outpatient medical abortion at 64-70 and 71-77 days of gestation: A retrospective chart review

Success of medication abortion with mifepristone followed by two doses of misoprostol in very early pregnancy

OBJECTIVES

To compare medication abortion (MAB) success in very early pregnancy (VEP) with mifepristone followed by either one or two doses of misoprostol.

STUDY DESIGN

We performed a retrospective cohort analysis of VEP MABs from July 1, 2021 to May 31, 2022 treated with mifepristone 200 mg oral followed by a single dose of misoprostol 800 mcg buccal 24 to 48 hours later and MABs from June 21, 2022 to October 31, 2022 treated with mifepristone 200 mg oral followed by two doses of misoprostol 800 mcg buccal spaced 4 hours apart, with first dose taken 24 to 48 hours after mifepristone. Serum BhCG was collected at the time of mifepristone treatment with additional BhCG collected 48 to 72 hours after misoprostol treatment in both groups. Success was defined as a BhCG decline of ≥50%. MAB failure was defined as ongoing, viable pregnancy determined by follow-up ultrasound or procedural intervention with aspiration.

RESULTS

There were 423 patients in the single-dose misoprostol group and 262 patients in the two-dose misoprostol group. There were no significant differences between the two groups in baseline characteristics. In the single-dose group, 372 (87.9%) were treated successfully; in the two-dose group, 224 (85.5%) were treated successfully. There was no significant difference in MAB success between the groups (p = 0.73).

CONCLUSIONS

The addition of a second dose of misoprostol does not improve the success of MAB in VEP.

IMPLICATIONS

Additional research is needed to identify interventions to improve the success of MAB in VEP.

A Proof-of-Concept Study of Ulipristal Acetate for Early Medication Abortion

BACKGROUND

The current regimen for early medication abortion in many countries is mifepristone and misoprostol, but mifepristone is relatively expensive and limited in many regions. Ulipristal acetate, with a similar chemical profile, might be an alternative. This proof-of-concept study evaluated ulipristal acetate and misoprostol for medication abortion through 63 days of gestation.

METHODS

We conducted a two-stage clinical study to choose an effective and acceptable ulipristal-misoprostol regimen. First, we undertook a dose-finding study. Sixty-six participants were randomly assigned to either 60 mg or 90 mg of oral ulipristal, followed by 800 μg of buccal misoprostol. Because the two groups had similar efficacy and safety profiles, we opted for the 60-mg ulipristal dose for an open-label study with 100 additional participants, resulting in a total of 133 participants using the same regimen. To evaluate acceptability, we applied a structured questionnaire at the end of the follow-up visit.

RESULTS

Pregnancy termination occurred with the combination of oral ulipristal 60 mg and buccal misoprostol 800 μg in 129 out of 133, or 97.0%, (95% confidence interval [CI], 94.1 to 99.9%), of participants. Among those for whom this regimen did not result in pregnancy termination, one participant had a completion with sharp curettage, two received manual vacuum aspiration, and one underwent a repeat medication abortion with misoprostol alone. Side effects included chills (77.4%; 95% CI, 70.3 to 84.5%), diarrhea (66.9%; 95% CI, 59.0 to 74.8%), and nausea (48.1%; 95% CI, 39.7 to 56.5%). No serious adverse events were reported. The regimen was deemed "acceptable" or "highly acceptable" by 97.7% (95% CI, 95.2 to 100.0%) of participants.

CONCLUSIONS

This study suggests that ulipristal acetate followed by misoprostol is an effective and acceptable medication abortion regimen with no reported serious adverse events. (This project is supported by the OPTions Initiative. The study registered as ISRCTN35625202.).

Efficacy of medication abortion with concurrent initiation of progestin contraceptives: A retrospective cohort study

OBJECTIVES

To evaluate medication abortion (MAB) outcomes for participants receiving intramuscular depot medroxyprogesterone acetate (DMPA) injections or subdermal etonogestrel implants concurrently with mifepristone compared to those who did not in a real-world setting.

STUDY DESIGN

This retrospective cohort study included MAB patients from one Planned Parenthood health center in St. Paul, MN, between 2017 and 2019. We abstracted electronic health records and compared sociodemographic variables, clinical information, and treatment failure rates (primary outcome) between study groups with logistic regression (generating odds ratios [OR] and 95% confidence intervals [CI]).

RESULTS

Among 7296 MAB participants, 224 (3.1%) received DMPA injections and 309 (4.2%) received etonogestrel implants concurrently with mifepristone; 141 (62.9%) and 200 (64.7%) completed follow-up respectively. From a random sample of 1000, 990 comparison participants met inclusion criteria; 704 (71.1%) completed follow-up. Fourteen (9.9%) DMPA participants (aOR 4.26, 95% CI 1.87-9.68, p < 0.001) and 6 (3.0%) etonogestrel implant participants (aOR 1.38, 95% CI 0.48-3.55, p = 0.522) required additional treatment to empty the uterus and/or had an ongoing pregnancy, each contrasted with 15 (2.1%) comparison patients (models adjusted for gestational duration, patient age, parity, and race).

CONCLUSION

Although our study is limited by high rates of loss to follow-up, our analysis suggests that concurrent administration of DMPA with mifepristone may decrease MAB efficacy, while etonogestrel implant placement does not appear to alter MAB outcomes. These findings are overall consistent with prior literature and inform post-MAB contraception counseling.

IMPLICATIONS

This retrospective cohort study reinforces prior randomized controlled trial findings that concurrent depot medroxyprogesterone acetate injection with mifepristone administration may decrease medication abortion efficacy. Conversely, concurrent etonogestrel contraceptive implant placement with mifepristone administration does not appear to decrease medication abortion efficacy. These findings inform post-abortion contraception counseling.

Understanding medication abortion ineligibility due to gestational age among a cohort of patients in Southern California

OBJECTIVE

Medication abortion (MAB) is safe and effective up to 77 days gestation. Limited data are available on how often patients are ineligible for MAB due to advanced gestational age and how many of those ineligible go on to receive procedural abortion.

STUDY DESIGN

Retrospective analysis of electronic health records from Planned Parenthood of the Pacific Southwest (PPPSW) from January - December 2021. PPPSW has four procedural abortion sites and 15 MAB-only clinics that offered appointments only if last menstrual period-based GA was ≤70 days or unknown. Patients >70 days gestation by intake ultrasound at a MAB-only clinic were referred to a procedural center.

RESULTS

Of 11,684 patients presenting for MAB at MAB-only sites 2224 (19%) did not receive a MAB; 3.8% (N = 444) presented past 70 days gestation and were thus ineligible due to gestational age limits. Of those ineligible (N = 444), 234 (53%) measured between 71-77 days of gestation. Three quarters (75.7%) of those ineligible went on to receive a procedural abortion at PPPSW after a mean wait time of 10 days. In multivariable analysis, no demographic factors were associated with higher odds of receiving a procedural abortion.

CONCLUSIONS

Presenting for MAB past a gestational age limit was uncommon, supporting safety of no-test MAB protocols. A quarter of people ineligible for MAB due to gestational age did not receive a procedural abortion at PPPSW. If MAB were offered up to 77 days, half of patients who were denied MAB due to gestational age could have received MAB, expanding patient access.

IMPLICATIONS

Being ineligible for MAB due to advanced gestational age was uncommon. Increasing MAB gestational age limits from 70 days to 77 days could further improve abortion access.

Telemedicine Abortion

Telemedicine has become a substantial part of abortion care in recent years. In this review, we discuss the history and regulatory landscape of telemedicine for medication abortion in the United States, different models of care for telemedicine, and the safety and effectiveness of medication abortion via telemedicine, including using history-based screening protocols for medication abortion without ultrasound. We also explore the acceptability of telemedicine for patients and their perspectives on its benefits, as well as the use of telemedicine for other parts of abortion care. Telemedicine has expanded access to abortion for many, although there remain limitations to its implementation.

Medication Abortion: A Comprehensive Review

This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.

Abortion Care in the United States - Current Evidence and Future Directions

Abortion Care in the United StatesAbortion services are a vital component of reproductive health care. Jung and colleagues review medication abortion and procedural abortion as well as implications of increasing restrictions on access in the United States.

Effects of the COVID-19 pandemic on family planning services

PURPOSE OF REVIEW

The COVID-19 pandemic has highlighted existing healthcare disparities worldwide and has challenged access to family planning (FP) services.

RECENT FINDINGS

Research has identified ways in which government regulations and healthcare programs have inhibited or increased access to FP services, as well as how the pandemic has changed individuals' sexual and reproductive health behaviors and intentions.

SUMMARY

The pandemic has had both positive and negative effects on access to FP services. Innovations in various delivery services, extended use of contraception, telehealth for medication abortion, and a no-test medication abortion protocol have decreased the need for in-person visits and improved access to FP services.

Mail-order pharmacy dispensing of mifepristone for medication abortion after in-person clinical assessment

OBJECTIVE(S)

To estimate the effectiveness, acceptability, and feasibility of medication abortion with mifepristone dispensed by a mail-order pharmacy after in-person clinical assessment.

STUDY DESIGN

This is an interim analysis of an ongoing prospective cohort study conducted at five sites. Clinicians assessed patients in clinic and, if they were eligible for medication abortion and ≤ 63 days' gestation, electronically sent prescriptions for mifepristone 200 mg orally and misoprostol 800 mcg buccally to a mail-order pharmacy, which shipped medications for next-day delivery. Participants completed surveys three and 14 days after enrollment, and we abstracted medical chart data.

RESULTS

Between January 2020 and April 2021 we enrolled 240 participants and obtained clinical outcome information for 227 (94.6%); 3 reported not taking either medication. Of those with abortion outcome information (N = 224), 216 (96.4%) completed day-3 and 212 (94.6%) day-14 surveys. Of the 224 that took medications, none reported taking past 70 days' gestation, and complete medication abortion occurred for 217 participants (96.9%, 95% CI 93.7%-98.7%). Most received medications within three days (82.1%, 95% CI 76.5%-86.9%). In the day-3 survey, 95.4% (95% CI 91.7%-97.8%) reported being very (88.4%) or somewhat (6.9%) satisfied with receiving medications by mail. In the day-14 survey, 89.6% (95% CI 84.7%-93.4%) said they would use the mail-order service again if needed. Eleven (4.9%, 95% CI 2.5%-8.6%) experienced adverse events; two were serious (one blood transfusion, one hospitalization), and none were related to mail-order pharmacy dispensing.

CONCLUSIONS

Medication abortion with mail-order pharmacy dispensing of mifepristone appears effective, feasible, and acceptable to patients.

IMPLICATIONS

The in-person dispensing requirement for mifepristone, codified in the drug's Risk Evaluation and Mitigation Strategy, should be removed.

Provision of medication abortion in Hawai'i during COVID-19: Practical experience with multiple care delivery models

Objective

To demonstrate the effectiveness of medication abortion with the implementation of telemedicine and a no-test protocol in response to the COVID-19 pandemic.

Study design

This is a retrospective cohort study of patients who had a medication abortion up to 77 days gestation at the University of Hawai‘i between April and November 2020. Patients had the option of traditional in clinic care or telemedicine with either in clinic pickup or mailing of medications. During this time, a no-test protocol for medication abortion without prior labs or ultrasound was in place for eligible patients. The primary outcome was the rate of successful medication abortion without surgical intervention. Secondary outcomes included abortion-related complications.

Results

A total of 334 patients were dispensed mifepristone and misoprostol, 149 (44.6%) with telemedicine with in-person pickup of medications, 75 (22.5%) via telemedicine with medications mailed, and 110 (32.9%) via traditional in person visits. The overall rate of complete medication abortion without surgical intervention was 95.8%, with success rates of 96.8, 97.1, and 93.6% for the clinic pickup, mail, and clinic visit groups, respectively. Success for those without an ultrasound performed prior to the procedure was 96.6%, compared to 95.5% for those with ultrasound. We obtained follow-up data for 87.8% of participants.

Conclusions

Medication abortion was safe and effective while offering multiple modes of care delivery including telemedicine visits without an ultrasound performed prior to dispensing medications.

Implications

Incorporating telemedicine and a no-test protocol for medication abortion is safe and has the potential to expand access to abortion care. All care models had low rates of adverse events, which contradicts the idea that the Risk Evaluation and Mitigation Strategyincreases the safety of medication abortion.