Endometrial thickness following medical abortion is not predictive of subsequent surgical intervention

A Lexicon for First-Trimester US: Society of Radiologists in Ultrasound Consensus Conference Recommendations

The Society of Radiologists in Ultrasound convened a multisociety panel to develop a first-trimester US lexicon based on scientific evidence, societal guidelines, and expert consensus that would be appropriate for imagers, clinicians, and patients. Through a modified Delphi process with consensus of at least 80%, agreement was reached for preferred terms, synonyms, and terms to avoid. An intrauterine pregnancy (IUP) is defined as a pregnancy implanted in a normal location within the uterus. In contrast, an ectopic pregnancy (EP) is any pregnancy implanted in an abnormal location, whether extrauterine or intrauterine, thus categorizing cesarean scar implantations as EPs. The term pregnancy of unknown location is used in the setting of a pregnant patient without evidence of a definite or probable IUP or EP at transvaginal US. Since cardiac development is a gradual process and cardiac chambers are not fully formed in the first trimester, the term cardiac activity is recommended in lieu of 'heart motion' or 'heartbeat.' The terms 'living' and 'viable' should also be avoided in the first trimester. 'Pregnancy failure' is replaced by early pregnancy loss (EPL). When paired with various modifiers, EPL is used to describe a pregnancy in the first trimester that may or will not progress, is in the process of expulsion, or has either incompletely or completely passed.

A Lexicon for First-Trimester US: Society of Radiologists in Ultrasound Consensus Conference Recommendations

The Society of Radiologists in Ultrasound convened a multisociety panel to develop a first-trimester US lexicon based on scientific evidence, societal guidelines, and expert consensus that would be appropriate for imagers, clinicians, and patients. Through a modified Delphi process with consensus of at least 80%, agreement was reached for preferred terms, synonyms, and terms to avoid. An intrauterine pregnancy (IUP) is defined as a pregnancy implanted in a normal location within the uterus. In contrast, an ectopic pregnancy (EP) is any pregnancy implanted in an abnormal location, whether extrauterine or intrauterine, thus categorizing cesarean scar implantations as EPs. The term pregnancy of unknown location is used in the setting of a pregnant patient without evidence of a definite or probable IUP or EP at transvaginal US. Since cardiac development is a gradual process and cardiac chambers are not fully formed in the first trimester, the term cardiac activity is recommended in lieu of 'heart motion' or 'heartbeat.' The terms 'living' and 'viable' should also be avoided in the first trimester. 'Pregnancy failure' is replaced by early pregnancy loss (EPL). When paired with various modifiers, EPL is used to describe a pregnancy in the first trimester that may or will not progress, is in the process of expulsion, or has either incompletely or completely passed. © RSNA and Elsevier, 2024 Supplemental material is available for this article. This article is a simultaneous joint publication in Radiology and American Journal of Obstetrics & Gynecology. All rights reserved. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either version may be used in citing this article. See also the editorial by Scoutt and Norton in this issue.

How Effective Is Misoprostol Alone for Medication Abortion?

AbstractWith recent severe restrictions to abortion accessibility in the United States and a pending Supreme Court case challenging the Food and Drug Administration's approval of mifepristone, evidence-based strategies to protect and expand access to abortion care are needed. Two safe and effective regimens for medication abortion are widely used globally - misoprostol-only and misoprostol in combination with mifepristone. However, misoprostol-only regimens are rarely used in the United States. In 2023, the National Abortion Federation and the Society of Family Planning updated their recommended protocol for misoprostol-only for medication abortion to 800 μg of misoprostol administered buccally, sublingually, or vaginally every 3 hours for three or more doses. To characterize the data supporting this specific regimen, this article reviews the relevant literature to address the question of how effective misoprostol-only is for medication abortion. The authors conclude that the updated misoprostol regimen is highly effective and a potential strategy for expanding access to abortion.

Midwives Safeguarding Abortion Access: Establishing Medication Abortion Services

The abortion access landscape for patients has changed dramatically in the wake of the US Supreme Court Dobbs v. Jackson Women's Health Organization decision in June of 2022. In response, the Division of Midwifery at Baystate Medical Center in Springfield, Massachusetts, began a medication abortion service for both established patients and those who may seek care from out of state. This service increases access to abortion care now while also providing the clinical experience needed for student nurse-midwives to become future abortion providers. This article outlines the steps taken to implement a medication abortion service and ways it can be adopted by other midwifery practices. Strategies to address possible clinical, administrative, and logistical challenges are addressed. Finally, this article is a call to action because midwives are well qualified to provide high quality, safe, and comprehensive medication abortion within the midwifery model of care.

Early pregnancy loss medical management in clinical practice

OBJECTIVES

This study aimed to review clinical practice outcomes of early pregnancy loss (EPL) medical management using mifepristone and misoprostol outside of a clinical trial setting.

STUDY DESIGN

In this retrospective cohort study, we reviewed a deidentified database of patients who received mifepristone-misoprostol for EPL from May 2018 to May 2021 at our academic center-based clinic, which was a study site for a multicenter mifepristone-misoprostol EPL trial completed in March 2018. All patients received mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, with clinic follow-up typically scheduled within 1 week. The primary outcome was successful medical management, defined as management without the need for aspiration, and the secondary outcomes included additional interventions and indications, follow-up ultrasonography findings, and adverse events requiring treatment.

RESULTS

We treated 90 patients with a median ultrasound-measured gestational size of 49 (range 30-80) days and median time from mifepristone to misoprostol of 24 (range 8-66) hours. Follow-up was completed in clinic by 80 (88.9%), completed remotely by five (5.6%), and not completed by five (5.6%) patients. Overall, 76 (95% CI 82.9%-96.0%) of 85 patients (89.4%) with follow-up were successfully managed without uterine aspiration. Eighty patients had initial follow-up ultrasonography interpreted as gestational sac expulsion; seven (8.8%) of these ultimately underwent aspiration, including one patient who had a previously undiagnosed cesarean scar ectopic pregnancy. Two patients had significant safety outcomes: one pelvic infection and one blood transfusion during aspiration in the patient with a cesarean scar ectopic pregnancy.

CONCLUSIONS

Outside of a clinical trial setting, medical management of EPL with mifepristone and misoprostol remains effective and safe.

IMPLICATIONS

Medical management of EPL with mifepristone and misoprostol is effective and safe outside of a clinical trial setting. A standardized protocol based on the best available clinical trial evidence can be used in clinical practice for the medical management of EPL.

Ultrasonographic features of the endometrium following successful medical termination of early pregnancy

OBJECTIVE

Ultrasonographic features of the endometrium are often assessed when deciding the necessity of surgical intervention following early medical abortion. Knowledge is therefore needed on the ultrasonographic appearance of the endometrium following successful medical abortion in order to avoid unnecessary surgical interventions. We aimed to assess endometrial thickness and echogenicity at multiple time points following successful early medical abortion.

STUDY DESIGN

We conducted a retrospective study in the largest office-based abortion providing clinic in Denmark. Using archived ultrasonographic images, we assessed endometrial thickness and echogenicity following all early medical abortions that did not need surgical intervention or repeated medication for completion during the years 2014-2017.

RESULTS

Ultrasonographic endometrial features were assessed 1854 times following 1074 early medical abortions. Median endometrial thickness in the 1st week from induction was 13 milimeters (mm; lower-upper quartile 11-17 mm). For the 2nd, 3rd, 4th, and >4th week, the median endometrial thickness was found to be 11 mm (9-15 mm), 11 mm (8-14 mm), 12 mm (9-16 mm), and 11 mm (8-14 mm), respectively. Of the ultrasonographic examinations performed in the 1st week from medical induction, 24.7 % showed a heterogenous endometrium. For 2nd, 3rd, 4th, >4th week, the frequency of heterogeneity was 23.9 %, 16.3 %, 21.3 %, 18.9 %, respectively. A total of 151 abortions (14.1 %) were each examined three times, median time of examination being day 7, 15, and 26 following induction. Among these abortions, the three most common patterns of change in endometrial thickness were "decreasing" (37.7 %), "increasing-decreasing" (23.2 %), and "decreasing-increasing" (21.9 %). Further, 49.7 % of the 151 abortions showed a homogenous endometrium at all three examinations, 17.2 % showed a heterogenous endometrium at first examination and a homogenous endometrium the following two examinations, and 9.9 % showed a heterogenous endometrium at the first two examinations followed by a homogenous endometrium.

CONCLUSION

In early medical abortions completed without secondary intervention, endometrial thickness and echogenicity varied clinically significantly for weeks following the medical induction. Every possible pattern of change in endometrial thickness and echogenicity was observed.

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.

Comparison of the effectiveness and safety of treatment of incomplete second trimester abortion with misoprostol provided by midwives and physicians: a randomised, controlled, equivalence trial in Uganda

Background

To address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda.

Methods

Our multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13–18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 μg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was –5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073.

Findings

Between Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was –2·3% (95% CI –4·4 to –0·3), and within our predefined equivalence range (–5% to 5%). Two women in the midwife group received blood transfusion.

Interpretation

Clinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care.

Funding

Swedish Research Council and THRiVE-2.

Expectant versus medical management for retained products of conception after medical termination of pregnancy: A randomized controlled study

BACKGROUND

Despite the rise of medical treatments for the termination of pregnancy, to-date no prospective trial has evaluated the efficacy of misoprostol in treating retained products of conception after induced termination of pregnancy.

OBJECTIVE

To compare medical management with misoprostol with expectant management for retained products of conception after first trimester medical termination of pregnancy.

STUDY DESIGN

An open-label randomized controlled trial conducted at a university-affiliated tertiary medical center. Consenting consecutive women who underwent a routine 3-week follow-up evaluation after medical termination of pregnancy and had a sonographic suspicion of retained products of conception, defined as sonographic evidence of intra-uterine remnant (>12 mm) with a positive Doppler flow, were recruited. The participants were randomized into a medical treatment group (800 mcg of sublingually administered misoprostol) or expectant management. They all underwent repeat ultrasound scans every 2 weeks until a maximum of 6 weeks, and those suspected for persistent retained products of conception were referred to operative hysteroscopy. The primary endpoint was successful treatment defined as no need for surgical intervention due to persistent retained products of conception within 8 weeks from pregnancy termination.

RESULTS

There were no significant differences in demographic characteristics between the study groups. The median sonographically demonstrated retained product length was 20 mm (interquartile range, [IQR] 17-25) in the medically managed group compared with 20 mm (IQR 17-26) in the expectantly managed group (P=.733). Treatment succeeded in 42/68 (61.8%) women in the medically managed group compared with 36/63 (57.1%) women in the expectantly managed group (relative risk [RR] = 1.12, 95% confidence interval [CI] 0.74-1.70; P=.590). There was no difference in adverse outcomes between the 2 groups.

CONCLUSION

There is no clinically meaningful advantage for medical treatment with misoprostol compared with expectant management after first trimester medical termination of pregnancy in women with suspected retained products of conception. Surgical intervention can be avoided in up to 60% of women who are managed expectantly over 8 weeks of follow-up.

[Evaluation of the success of medical abortion by a plasma hCG control threshold]

OBJECTIVES

In France, monitoring of the success of medical abortion is recommended 2 to 3 weeks after the procedure. However, there is no clear consensus on the modalities of this monitoring. The main objective of this study is to identify a threshold of serum hCG (human chorionic gonadotropin) control for medical abortions ≤7 weeks of gestation below which success can be confirmed without recourse to pelvic ultrasound.

METHODS

This is a retrospective multicenter study conducted over a 14-month period. The serum hCG level, measured between the 15th and 25th day following the abortion, was compared with the results of the pelvic ultrasound performed at the follow-up visit. Ultrasound failure was defined as retention or persistent pregnancy.

RESULTS

Among the 624 women included, the failure rate was 22.3%, including 86.3% of retentions, 8.6% of pregnancies stopped and 5% of pregnancies progressed. Using a ROC curve, the threshold value of hCG found to exclude failure at 95% was 253 IU/l (AUC=0.9202, sensitivity=84.17%, specificity=85.95% and positive predictive value [PPV]=63%).

CONCLUSIONS

A serum hCG level ≤253 IU/l is sufficient to affirm the efficacy of medical abortion. However, since PPV is only 63% for this threshold, ultrasound should be reserved for women with high hCG levels.

Evaluating the agreement of ultrasound imaging and beta-human chorionic gonadotropin (β-hCG) measurement in confirming completed medical abortion: cross-sectional study

Objective: Clinical methods that are generally used to evaluate the completeness of medical abortion are not reliable. Ultrasound imaging and beta-human chorionic gonadotropin (β-hCG) measurements are used to diagnose completed medical abortion, but a precise evaluation of these two methods has shown contradictory results. The purpose of this study is to evaluate the agreement of serum β-hCG measurement and ultrasound imaging to confirm complete medical abortion.

Materials and Methods: This study was conducted on pregnant women who had been referred to our center for medical abortion from 2015 to 2017. All cases occurred in the first trimester of pregnancy. They obtained one or two doses of vaginal misoprostol for medical abortion. Success rate of medical abortion was measured by both transvaginal ultrasound imaging and consecutive serum β-hCG measurements two to four weeks after initial treatment.

Results: Among the 275 women who completed the study, complete medical abortion was confirmed by serum β-hCG in 231 women (84.3%) and transvaginal ultrasound imaging in 195 women (70.8%) after two weeks. All remaining cases completed the medical abortion after an additional two weeks, confirmed by both transvaginal ultrasound imaging and serum β-hCG. The sensitivity, specificity, positive, and negative predictive values of β-hCG were 95.2%, 86.7%, 84%, and 70%, respectively; and these values for transvaginal ultrasound imaging were 68.5% 64.5%,77%, and 30.%, respectively, for the diagnosis of completed medical abortion.

Conclusion: Serum β-hCG measurement is as effective as transvaginal ultrasound imaging to confirm successful medical abortion in early pregnancy.

Management of Postabortion Complications for the Emergency Medicine Clinician

Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.

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.

Treatment of first trimester miscarriage: a prospective cohort study in a large tertiary care center in Northern Italy

Objective: To assess acceptability, efficacy, and short- and medium-term complications of vaginal misoprostol therapy for the treatment of first trimester miscarriage.Study design: A prospective cohort study including women admitted to the Unit of Obstetrics, MBBM Foundation, San Gerardo Hospital (Monza, Italy) for medical or surgical treatment of first trimester miscarriage between October 2014 and March 2018. As per Institutional protocol, patients in the medical therapy group received 800 µg of misoprostol vaginally. A second dose could be considered 3 days after the first administration if that was ineffective. Surgical treatment consisted of uterine vacuum aspiration. Success of misoprostol treatment was defined as the expulsion of the gestational sac with no need for subsequent surgery.Results: During the study period, 967 patients were diagnosed with first trimester miscarriage and were included in the study. Of these, 514 (53.2%) women were eligible for and consented to medical therapy. Surgical treatment was performed in the remaining 453 (46.8%) patients due to either medical contraindication to misoprostol or patient's choice. Acceptance of misoprostol as first therapeutic choice increased over time, becoming the preferred treatment after approximately 18 months of use in clinical practice. One dose of misoprostol was successful in 69.8% (n = 359) of patients, whereas 20 women required urgent surgery for bleeding (n = 19) or suspected infection (n = 1). Among the remaining 135 patients, 20 (14.8%) refused the second dose of misoprostol and opted for surgery. Expulsion of the gestational sac was obtained in 74 additional cases who completed the medical protocol, for an overall success rate of 87.7% (433/494). The majority of women receiving misoprostol did not experience any short-term complication (92.0%) or side effect (93.8%). Eight (1.6%) cases requiring delayed surgery (hysteroscopy or vacuum aspiration) for retained product of conception were identified at the postmedical treatment follow up, thus leading to an actual success rate of misoprostol of 86.0% (n = 425).Conclusions: This is the first study assessing the acceptability, efficacy, and complication rate of medical management of first trimester miscarriage in an Italian tertiary care center. Our results confirm that misoprostol alone is an effective as well as a safe therapeutic option for the treatment of first trimester miscarriage.

Online access to abortion medications: a review of utilization and clinical outcomes

We performed a search in PubMed and Web of Science on the self-use of abortion medication after online access. Studies published between January 1, 1995, and March 31, 2019, were considered. We included studies of online services that were (i) led by healthcare staff (n = 14), (ii) led by non-healthcare staff (n = 4), and (iii) providing noninteractive access (n = 17). Our outcomes were utilization (frequency and demand for services), acceptability for women, safety, and success rate. Key findings: Women are increasingly using the Internet to access abortion medication. Available services are of varying quality. Women accessing noninteractive services report feelings of distress related to the lack of medical guidance, and the demand for interactive guidance through the abortion process is high. Women using services led by healthcare staff report high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.

Evaluating the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians: study protocol for a randomized controlled equivalence trial

BACKGROUND

A large proportion of abortion-related mortality and morbidity occurs in the second trimester of pregnancy. The Uganda Ministry of Health policy restricts management of second-trimester incomplete abortion to physicians who are few and unequally distributed, with most practicing in urban regions. Unsafe and outdated methods like sharp curettage are frequently used. Medical management of second-trimester post-abortion care by midwives offers an advantage given the difficulty in providing surgical management in low-income settings and current health worker shortages. The study aims to assess the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians.

METHODS

A randomized controlled equivalence trial implemented at eight hospitals and health centers in Central Uganda will include 1192 eligible women with incomplete abortion of uterine size > 12 weeks up to 18 weeks. Each participant will be randomly assigned to undergo a clinical assessment and treatment by either a midwife (intervention arm) or a physician (control arm). Enrolled participants will receive 400 μg misoprostol administered sublingually every 3 h up to five doses within 24 h at the health facility until a complete abortion is confirmed. Women who do not achieve complete abortion within 24 h will undergo surgical uterine evacuation. Pre discharge, participants will receive contraceptive counseling and information on what to expect in terms of side effects and signs of complications, with follow-up 14 days later to assess secondary outcomes. Analyses will be by intention to treat. Background characteristics and outcomes will be presented using descriptive statistics. Differences between groups will be analyzed using risk difference (95% confidence interval) and equivalence established if this lies between the predefined range of - 5% and + 5%. Chi-square tests will be used for comparison of outcome and t tests used to compare mean values. P ≤ 0.05 will be considered statistically significant.

DISCUSSION

Our study will provide evidence to inform national and international policies, standard care guidelines and training program curricula on treatment of second-trimester incomplete abortion for improved access.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03622073 . Registered on 9 August 2018.

Self-assessment of success of early medical abortion using a self-performed urine pregnancy test

Purpose: The European Society of Contraception Expert Group on Abortion identified as one of its priorities the need to disseminate up-to-date evidence-based information on the use of urine pregnancy tests by women for the self assessment of the success of early medical abortion (EMA). Methods and materials: A concise communication was produced which summarises the latest research in an easy-to-read format suitable for busy clinicians. Information about individual urinary pregnancy tests is presented in boxes for ease of reference. Results: Urinary pregnancy tests (low sensitivity, high sensitivity and multilevel) can be used in combination with signs and symptoms of pregnancy to exclude an ongoing pregnancy after EMA. Conclusion: Women are able to determine the success of early medical abortion (EMA) themselves using a combination of signs, symptoms and a urine pregnancy test. This simplifies EMA, expands the range of professionals able to provide EMA and most importantly gives women greater control over their bodies and treatment.

Medical versus surgical treatment of first trimester spontaneous abortion: A cost-minimization analysis

Background

Traditionally the gold-standard technique for the treatment of spontaneous abortion has been uterine evacuation by aspiration curettage. However, many studies have proposed medical treatment with misoprostol as an alternative to the conventional surgical treatment. The aim of this study was to apply cost minimization methods to compare the cost and effectiveness of the use of vaginal misoprostol as a medical treatment for first trimester spontaneous abortion with those of evacuation curettage as a surgical treatment.

Methodology/Principal findings

We present a longitudinal, prospective and quasi-experimental research study including a total of 547 patients diagnosed with first-trimester spontaneous abortion, in the period from January 2013 to December 2015. Patients were offered medical treatment with 800 mg vaginal misoprostol or evacuation curettage. Patients treated with misoprostol were followed-up at 7 days and a transvaginal ultrasound was performed to confirm the success of the treatment. If it failed, a second dose of 800 mg of vaginal misoprostol was prescribed and a new control ultrasound was performed. In case of failure of medical treatment after the second dose of misoprostol, evacuation curettage was indicated. The effectiveness of each of the treatment options was calculated using a decision tree. The cost minimization study was carried out by weighting each cost according to the effectiveness of each branch of the treatment. Of the 547 patients who participated in the study, 348 (64%) chose medical treatment and 199 (36%) chose surgical treatment. The overall effectiveness of medical treatment was 81% (283/348) and surgical treatment of 100%. The estimated final cost for medical treatment was € 461.92 compared to € 2038.72 for surgical treatment, which represents an estimated average saving per patient of € 1576.8.

Conclusions/Significance

Medical treatment with misoprostol is a cheaper alternative to surgery: in the Spanish Public Healthcare System, it is five times more inexpensive than curettage. Given its success rates higher than 80%, mild side effects, controllable with additional medication and the high degree of overall satisfaction, it should be prioritized over the evacuation curettage in patients who meet the treatment criteria.

Serum hCG threshold to assess medical abortion success

OBJECTIVES

The main aim of the study was to establish a threshold for serum human chorionic gonadotropin (hCG) level that ruled out ongoing pregnancy after induced medical abortion (MA). The secondary aim was to discover risk factors for the need for uterine aspiration.

METHODS

This prospective study included women who underwent MA with mifepristone-misoprostol at ≤9 weeks of gestation between 2012 and 2014. Serum hCG levels were measured 14-21 days after MA. The main outcome measure, ongoing pregnancy, was defined as the presence of an embryo with cardiac activity on transvaginal ultrasonography after MA. The receiver operating characteristic curve was plotted to determine the optimal serum hCG threshold. Risk factors for the need for uterine aspiration were calculated using multivariate logistic regression and expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The study included 814 women. Mean gestational age was 46.5 ± 7.4 days for ongoing pregnancies and 44.2 ± 4.8 days for MA success (p = .43). The ongoing pregnancy rate after MA was 0.9%. A serum hCG threshold ≥900 IU/l to diagnose ongoing pregnancy gave 100% sensitivity and 81.5% specificity, compared with 85.7% sensitivity and 83.5% specificity using a threshold ≥1000 IU/l. Independent risk factors for uterine aspiration requirement were: gravidity (OR 3.8; 95% CI 1.1, 13.2; p = .001), gestational age >6 weeks (OR 6.0; 95% CI 1.8, 6.0; p = .006) and previous surgical abortion (OR 2.4; 95% CI 1.1, 5.2; p < .001).

CONCLUSION

Serum hCG measurement <900 IU/l, 14-21 days after MA, is an efficient strategy for excluding ongoing pregnancy after first trimester MA.

Outcomes During Early Implementation of Mifepristone-Buccal Misoprostol Abortions up to 63 Days of Gestation in a Canadian Clinical Setting

OBJECTIVE

In January 2017, mifepristone became available in Canada. The goal of this study was to determine the effectiveness and safety of mifepristone-misoprostol abortion during its early implementation in a Canadian setting.

METHODS

This retrospective chart review included the first 477 patients who had a mifepristone-misoprostol abortion from March 13 to October 31, 2017, in an urban sexual health clinic. Women with pregnancies up to 63days of gestation had an initial dating ultrasound and β-human chorionic gonadotropin determination. They were provided mifepristone 200 mg orally in clinic, followed 24-48hours later with misoprostol 800 µg buccally at home. Follow-up, 7-14days later, in clinic or by telephone, used symptom review and follow-up β-human chorionic gonadotropin or ultrasound. The primary outcome was successful abortion, defined as expulsion of pregnancy without uterine aspiration.

RESULTS

Of 477 consecutive mifepristone abortions, 422 women (88.5%) had documented follow-up, with 408 (96.7%) successful abortions, including eight in women who had a repeat dose of misoprostol. Fourteen (3.3%) unsuccessful abortions required uterine aspiration, two (0.5%) for ongoing pregnancy and 12 (2.8%) for incomplete abortion or persistent bleeding. Seventeen women (4.0%) had emergency department visits, one (0.2%) of whom was hospitalized and three (0.7%) of whom received blood transfusion. Four women (1.0%) were treated for infection.

CONCLUSION

Mifepristone-misoprostol medical abortion was safe and effective during early implementation in Canada, comparable to previously published outcomes.

Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Assessment of completion of early medical abortion using a text questionnaire on mobile phones compared to a self-administered paper questionnaire among women attending four clinics, Cape Town, South Africa

In-clinic follow-up to assess completion of medical abortion is no longer a requirement according to World Health Organization guidance, provided adequate counselling is given. However, timely recognition of ongoing pregnancy, complications or incomplete abortion, which require treatment, is important. As part of a larger trial, this study aimed to establish whether women having a medical abortion could self-assess whether their abortion was complete using an automated, interactive questionnaire on their mobile phones. All 469 participants received standard abortion care and all returnees filled in a self-assessment on paper at clinic follow-up 2-3 weeks later. The 234 women allocated to receive the phone messages were also asked to do a mobile phone assessment at home ten days post-misoprostol. Completion of the mobile assessment was tracked by computer and all completed assessments, paper and mobile, were compared to providers' assessments at clinic follow-up. Of the 226 women able to access the mobile phone assessment, 176 (78%) completed it; 161 of them (93%) reported it was easy to do so. Neither mobile nor paper self-assessments predicted all cases needing additional treatment at follow-up. Prediction of complete procedures was good; 71% of mobile assessments and 91% of paper assessments were accurate. We conclude that an interactive questionnaire assessing completion of medical abortion on mobile phones is feasible in the South African setting; however, it should be done later than day 10 and combined with an appropriate pregnancy test to accurately detect incomplete procedures.

[Role of ultrasound in elective abortions]

Ultrasound plays a fundamental role in the management of elective abortions. Although it can improve the quality of post-abortion care, it must not be an obstacle to abortion access. We thus studied the role of ultrasound in pregnancy dating and possible alternatives and analyzed the literature to determine the role of ultrasound in post-abortion follow-up. During an ultrasound scan, the date of conception is estimated by measurement of the crown-rump length (CRL), defined by Robinson, or of the biparietal diameter (BPD), as defined by the French Center for Fetal Ultrasound (CFEF) after 11 weeks of gestation (Robinson and CFEF curves) (grade B). Updated curves have been developed in the INTERGROWTH study. In the context of abortion, the literature recommends the application of a safety margin of 5 days, especially when the CRL and/or BPD measurement indicates a term close to 14 weeks (that is equal or below 80 and 27mm, respectively) (best practice agreement). Accordingly, with the ultrasound measurement reliable to±5 days when its performance meets the relevant criteria, an abortion can take place when the CRL measurement is less than 90mm or the BPD less than 30mm (INTERGROWTH curves) (best practice agreement). While a dating ultrasound should be encouraged, its absence is not an obstacle to scheduling an abortion for women who report that they know the date of their last menstrual period and/or of the at-risk sexual relations and for whom a clinical examination by a healthcare professional is possible (best practice agreement). In cases of intrauterine pregnancy of uncertain viability or of a pregnancy of unknown location, without any particular symptoms, the patient must be able to have a transvaginal ultrasound to increase the precision of the diagnosis (grade B). Various reviews of the literature on post-abortion follow-up indicate that the routine use of ultrasound during instrumental abortions should be avoided (best practice agreement). If it becomes clear immediately after the procedure that the endometrial thickness exceeds 8mm, immediate reaspiration is necessary. Ultrasound examination of the endometrium several days after an instrumental elective abortion does not appear to be relevant (grade B). An analysis of the literature similarly shows that routine ultrasound scans after medical abortions should be avoided. If a transvaginal ultrasound is performed after a medical abortion, it should take place at least two weeks afterwards (best practice agreement). The only aim of an ultrasound examination during follow-up should be to determine whether a gestational sac is present (best practice agreement). Finally, if an ultrasound is performed at any point during pre- or post-abortion care, a report should be drafted, specifying any potential gynecologic abnormalities found, but its absence must not delay the scheduling of the abortion (best practice agreement).

Marked improvement in the success rate of medical management of early pregnancy failure following the implementation of a novel institutional protocol and treatment guidelines: a follow-up study

Purpose

To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period.

Methods

A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36–48 h. We followed-up with our patients using a written questionnaire.

Results

167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive.

Conclusion

The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

What is the right timing for ultrasound evaluation after pregnancy termination with mifepristone?

OBJECTIVE

To determine the timing for ultrasound evaluation after medical termination of pregnancy (MTOP).

STUDY DESIGN

The records of 301 consecutive women who underwent MTOP between July 2010 and July 2011 were studied retrospectively. The follow-up protocol included ultrasound evaluation 2 weeks after MTOP. Surgical termination was offered when pregnancy was found to be ongoing, and either hysteroscopy/curettage or a repeat ultrasound 2 weeks later was offered when the ultrasound findings were suspicious for retained products of conception. Pathology reports were used to confirm the presence of retained products of conception.

RESULTS

Women with ultrasound findings suspicious for retained products of conception were significantly older than women with negative ultrasound findings (30.9±7.7 years vs 24.8±6 years, p<0.0001). Two weeks after MTOP, ultrasound findings were negative in 236 women and suspicious in 66 women. This rate declined as the interval between ultrasound evaluation and MTOP increased (up to 10 weeks). Of the 18 women (5.98%) who underwent hysteroscopy/curettage, pathology reports indicated that 15 (83.3%) had true residua.

CONCLUSIONS

At 2 weeks after MTOP, ultrasound findings suspicious for retained products of conception do not conclusively indicate failure of the procedure. Ultrasound evaluation should be repeated 4-6 weeks later (6-8 weeks after MTOP) in women with suspected residua before diagnosing failure of the procedure.

Clinical follow-up compared with self-assessment of outcome after medical abortion: a multicentre, non-inferiority, randomised, controlled trial

BACKGROUND

Medical abortion with mifepristone and prostaglandins is well established. We compared clinical assessment with self-assessment of abortion outcome.

METHODS

This randomised, controlled, non-inferiority trial was done in four clinics in Austria, Finland, Norway, and Sweden, between Aug 16, 2011, and Jan 31, 2013. Women aged 18 years and older who had requested medical termination of a pregnancy up to 63 days of gestation were eligible. Computer-generated block randomisation (block size ten) assigned women in a 1:1 ratio to attend routine clinical follow-up or to self-assess outcome at home with a semiquantitative urine human chorionic gonadotropin (hCG) test 1-3 weeks after abortion. The primary outcome was the percentage of women with complete abortion not requiring further medical or surgical intervention within 3 months. Analysis was per protocol and by intention to treat. The non-inferiority margin was five percentage points. This trial is registered with ClinicalTrials.gov, number NCT01487213.

FINDINGS

924 women were assigned routine follow-up (n=466) or self-assessment (n=458) and included in the intention-to-treat analysis. 901 were included in the per-protocol analysis (n=446 and n=455, respectively). Complete abortion was reported in 432 (95%) of 455 in the routine follow-up group and 419 (94%) of 446 women in the self-assessment group (crude difference -1·0, 95% CI -4·0 to 2·0). 20 (4%) women in the routine follow-up group and 17 (4%) in the self-assessment group required surgery. No women in the routine follow-up group versus three in the self-assessment group had undetected continuing pregnancies. Eight (1·8%) and one (0·2%) women, respectively, had infections (p=0·038).

INTERPRETATION

Self-assessment was non-inferior to routine follow-up and could save resources.

FUNDING

Nordic Federation of Obstetrics and Gynaecology, European Society of Contraception, Helsinki University Central Hospital, Helse Finnmark, Swedish Research Council, and Stockholm County Council and Karolinska University Hospital.

Can women determine the success of early medical termination of pregnancy themselves?

OBJECTIVE

To determine the outcome of early medical termination of pregnancy (TOP) among women who choose a "self assessment" follow up comprising a self-performed low sensitivity urine pregnancy test with instructions on signs/symptoms that mandate contacting the TOP service.

STUDY DESIGN

A retrospective review of computer databases of 1726 women choosing self-assessment after early medical TOP (<9 weeks) in the UK. The main outcome measures were (a) number of women choosing self-assessment, (b) contact rates with TOP service and (c) time to presentation with an ongoing pregnancy (failed TOP).

RESULTS

Ninety-six percent of women having an early medical TOP and going home to expel the pregnancy chose self-assessment. Two percent of women made unscheduled visits to the TOP service. One hundred and eighty-eight women (11%) telephoned the service about concerns related to complications or the success of treatment. There were eight ongoing pregnancies (0.5%; 95% confidence interval 0.2-0.9%). Four were detected within 4 weeks of treatment; the remainder were not detected until one or more missed menses after the procedure.

CONCLUSIONS

Most women having an early medical TOP, who go home to expel the pregnancy, choose self-assessment. Relatively few women make unscheduled visits or telephone the TOP service. Most ongoing pregnancies are recognized at an early stage, although late presentation (as with all methods of follow up) does still occur.

IMPLICATIONS STATEMENT

If women are given clear instructions on how and when to conduct a urine pregnancy test and on signs/symptoms that mandate contacting the TOP service, then they can confirm the success of early medical TOP themselves. Late presentation due to failure to recognize an ongoing pregnancy is rare.

Three-dimensional Doppler sonography in asymptomatic and symptomatic women after medical termination of pregnancy

OBJECTIVES

To characterize the 3D Doppler sonographic appearance of the uterine cavity in asymptomatic and symptomatic women after administration of mifepristone and misoprostol for medical termination of pregnancy.

METHODS

A prospective observational study was performed. Women admitted for medical termination of pregnancy underwent transvaginal sonography 15 days after the procedure. Volumes were acquired, and offline analyses of the 3D vascularization indices were performed. Outcomes were collected at the follow-up scan and by telephone after the termination. Women were subclassified as asymptomatic or symptomatic according to the presence/absence of fever, vaginal bleeding, abdominal/pelvic pain, and infections. Spotting was defined as any episodic vaginal bleeding that was less than an expected menstruation and not regarded as a symptom.

RESULTS

A total of 104 women who underwent medical termination of pregnancy between 6 and 9 weeks' gestation were enrolled in the study. The termination procedure was successful in 98% of cases; among them, 9 women (8.6%) were symptomatic due to bleeding. Two asymptomatic women required surgery; 1 had sonographic evidence of suspected retained products of conception (endometrial thickness ≥ 15 mm or power Doppler vascularization presence). Fifty-seven women (55%) presented with retained products of conception. All the women with suspected retained products regained normal menses; of these, 3 symptomatic women with retained products (2.9%) underwent a 1-month sonographic follow-up. The symptomatic status was not associated with endometrial thickness, 3D intrauterine mass volume, or 2-dimensional (2D) and 3D power Doppler appearances.

CONCLUSIONS

The necessity of surgery after medical termination of pregnancy cannot be predicted by sonography. In cases with sonographic evidence of suspected retained products of conception, endometrial thickness, 2D Doppler findings, and the 3D vascularization indices correlated poorly with bleeding symptoms. Long-term follow-up should be considered in symptomatic women, and it can avoid any unnecessary surgical intervention.

Medical abortion follow-up with serum human chorionic gonadotropin compared with ultrasonography: a randomized controlled trial

OBJECTIVE

To estimate whether follow-up with serum human chorionic gonadotropin (hCG) results in fewer unplanned visits and interventions than follow-up with ultrasonography.

METHODS

Women were randomized to either in-clinic serum hCG or ultrasound follow-up after medical abortion. The primary outcome, unplanned interventions and visits, was measured as a composite binary outcome including: additional clinic or emergency room visits, repeat dosing of misoprostol, and surgical evacuation of the uterus. Surveys were administered at initial follow-up and again 1 month after abortion to inquire about unscheduled visits, interventions, and patient satisfaction. Medical records were reviewed for evidence of additional interventions and visits.

RESULTS

A total of 376 patients was randomized. Most participants were white (56%), single (83%), nulliparous (63%), and had completed high school (96%). Average participant age was 26±6 years and average gestational age was 46±6 days. Within 2 weeks of abortion, there was no significant difference in the rate of unplanned interventions and visits between arms, 8.2% (13/159) in the serum hCG arm compared with 6.6% (10/151) in the ultrasound arm (relative risk 1.23, 95% confidence interval [CI] 0.56-2.73, P=.60). By 4 weeks postabortion, 4.4% (6/135) in the ultrasound arm and 1.4% (2/142) in the hCG arm had undergone surgical evacuation (relative risk 0.32, 95% CI 0.07-1.54, P=.16). The majority in both the serum hCG (88%) and ultrasound (95%) arms was satisfied with their assigned follow-up method.

CONCLUSION

Medical abortion follow-up with serum hCG does not reduce the rate of unplanned interventions and visits compared with ultrasonography. Overall, the number of unplanned interventions is low and both methods of follow-up are acceptable to women.

Feasibility of telephone follow-up after medical abortion

BACKGROUND

This study was conducted to assess the feasibility of using telephone calls combined with high-sensitivity urine pregnancy testing as a primary method of follow-up after medical abortion.

METHODS

We enrolled 139 women up to 63 days of gestation to receive mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, per their choice. Participants were contacted by phone one week after mifepristone administration and interviewed using standardized questions. If the subject or clinician thought the pregnancy was not expelled, the subject returned for an ultrasound examination. Otherwise, subjects performed high-sensitivity home urine pregnancy testing 30 days after the mifepristone and were called within 3 days of the test. Those with positive pregnancy tests returned for an ultrasound examination. Those with negative tests required no further follow-up.

RESULTS

Six of the 139 (4.3%, 95% CI 1.6-9.1%) subjects presented prior to Phone Call 1 for an in-person visit. All 133 (100%, 95% CI 97.8-100%) subjects eligible for their first telephone follow-up were contacted. Eight of the 133 (6.1%, 95% CI 2.6-11.5%) women were asked to return for evaluation and all did so (100%, 95% CI 63.1-100%). Eight of the 133 women eligible for the 30 day phone call presented for an interim visit prior to the call. After 30 days, 116 of the 117 (99.1%, 95% CI 97.5-100%) eligible subjects were contacted. One subject was not reached for the day 30 phone call. Twenty-seven of the 116 (23.3%, 95% CI 15.6-31.0%) subjects had a positive pregnancy test and required follow-up. Two of these subjects (7.4%, 95% CI 1.0-24.2%) did not return for in-person follow-up. Two of the 116 (1.7%, 95% CI 0.2-6.1%) subjects had inconclusive pregnancy tests and were asked to return for follow-up. One of these subjects (50%, 95% CI 1.2-98.7%) did not return. Complete follow-up was achieved in 135 of the 139 subjects (97.1%, 95% CI 94.3-99.9%). None of the 26 women evaluated for a positive or inconclusive pregnancy test had a gestational sac or continuing pregnancy.

CONCLUSION

Telephone follow-up combined with urine pregnancy testing after medical abortion is a feasible alternative to routine ultrasonography or serial serum hCG measurements.