Medication Abortion In Humanitarian Aid Settings

  • 1.1 Abortion in the Global Context
  • 1.2 Medication Abortion
  • 1.3 Woman-Centered Abortion Care
  • 2.1 Establishing Pregnancy and Gestational Age
  • 2.2 Assessing Eligibility
  • 2.3 Informed Consent
  • 2.4 Making a Plan
  • 3.1 Deciding on Which Regimen to Use
  • 3.2 HowToUse Abortion Pills before 13 Weeks: Mifepristone + Misoprostol
  • 3.3 HowToUse Abortion Pills before 13 Weeks: Misoprostol Only
  • 3.4 What to Expect
  • 3.5 When to Seek Medical Care
  • 4.1 Preparation and Set-Up
  • 4.2 Deciding on Which Regimen to Use
  • 4.3 HowToUse Abortion Pills between 13 and 22 Weeks: Mifepristone + Misoprostol
  • 4.4 HowToUse Abortion Pills between 13 and 22 Weeks: Misoprostol Only
  • 4.5 What to Expect
  • 4.6 Complications
  • 5.1 Follow-up
  • 5.2 Contraception the Day of the Abortion
  • 5.3 Mental Health after Abortion
  • 5.4 Returning to Routine Activities
Lesson 1: An Overview of Abortion

Lesson 1: An Overview of Abortion



This online course is designed to train humanitarian aid workers in how to safely provide medication abortion, or abortion with pills.


1.1) Abortion in the Global Context

Abortions can occur spontaneously, commonly referred to as a miscarriage, or as the result of a deliberate intervention, also known as an induced abortion.

Induced abortion is quite common. Studies show that around one in four pregnancies end in induced abortion.

Women and girls all around the world – of all ages, religions, nationalities, and social classes – have abortions.

An estimated 56 million induced abortions occur worldwide every year.

About half of these abortions (31 million) are safe abortions and about half (25 million) are unsafe.

According to the World Health Organization (WHO), an unsafe abortion is the termination of a pregnancy either:

  • by persons lacking the necessary skills, or
  • In an environment that does not conform to minimal medical standards,
  • or both.

Examples of unsafe abortion include:

  • Using traditional herbs
  • Drinking harmful toxic substances such as soap or chlorine
  • Incorrectly taking different medications
  • Inserting dangerous objects such as sticks, roots, needles, or broken glass into the vagina or anus.

Unsafe abortion is one of the main causes of maternal death worldwide, and the only cause that is almost entirely preventable.

In some contexts, up to 30% of maternal deaths are due to unsafe abortion.

According to the Guttmacher Institute, unsafe abortion leads to at least 22 800 deaths every year;

  • another 7 million women are hospitalized due to complications from unsafe abortion, such as heavy bleeding, infection, and injury to the genital tract and internal organs.

These complications can also lead to life-long consequences such as infertility and chronic pain.

Women with unwanted pregnancies often resort to unsafe abortion when they cannot access safe abortion care.

Barriers to safe abortion care include restrictive laws, poor availability of services, high cost, stigma, and unnecessary requirements such as mandatory waiting periods, mandatory counseling, and medically unnecessary tests that delay care.

Women living in low-income countries, poor women, and women in humanitarian settings are more likely to have an unsafe abortion.

97% of unsafe abortions happen in developing countries.

In Africa and Latin America, 3 out of 4 abortions are unsafe.

The risk of dying from unsafe abortion is the highest in Africa.

According to the WHO, abortions are considered safe if:

  • the person providing or supporting the abortion is trained; and
  • the abortion is provided via a WHO-recommended method that is appropriate to the pregnancy duration.

WHO-recommended methods for safe abortion include:

    Medication abortion , or an abortion with pills, which is the focus of this course; and

    Manual vacuum aspiration , or MVA, which is a simple outpatient procedure that involves inserting a narrow plastic tube into the uterus and safely removing the pregnancy using suction.

WHO-recommended methods for safe abortion include:

1.2) Medication Abortion

In medication abortion, pills are taken to cause the uterus to contract and push out the pregnancy in a process that is similar to a miscarriage.

Medication abortion has been a significant advancement in abortion care and has many advantages:

  • It is non-invasive and often seen as a more natural process.
  • It can be provided outside of, or with reduced visits to, a health care facility.
  • It can often occur in the woman’s home, allowing for more privacy and confidentiality.
  • It is highly effective and very safe.

The risk of severe, life-threatening complication is extremely low (less than 1%).

  • It does not cause infertility or affect future pregnancies.
  • It does not need surgically-trained health care professionals, sterile instruments, or hygiene requirements.
  • The pills are low-cost and do not require refrigeration or a cold chain.

For all these reasons, medication abortion has expanded access to safe abortion care for women across the world

  • especially in low-resource and humanitarian settings – and has allowed women to play a greater role in their own care.

The two drugs involved in medication abortion are mifepristone and misoprostol.

Mifepristone: Mifepristone blocks progesterone, the main hormone of pregnancy.

The risk of severe, life-threatening complication is extremely low (less than 1%).

  1. The pregnancy to separate from the inside of the uterus;
  2. The cervix to soften and open; and
  3. The uterus to be more sensitive to misoprostol.

Misoprostol: Misoprostol is a prostaglandin that stimulates the uterus to contract and push out the pregnancy.

Misoprostol is available in most places and can also be used for other purposes, such as inducing labor, managing bleeding after delivery, and treating stomach ulcers.

Misoprostol is stable at room temperature but can rapidly deteriorate when exposed to high humidity or high temperature.

Therefore misoprostol should be kept in double aluminum blister packaging and stored in a cool, dry place.

1.3) Woman-Centered Abortion Care

Woman-centered abortion care approaches the person undergoing the abortion not only as a patient but as a whole person, taking into account their physical, emotional, and social well-being and adapting care to their needs and circumstances.

Women undergo abortion for many different reasons.

Most women have already thought about their options and made the decision to have an abortion before seeking care.

Each woman’s reason for ending a pregnancy is different and providers should be empathetic and non-judgmental towards a woman’s situation and decision.

Abortion providers’ values and attitudes can have an important influence on the way they interact with women having abortions.

Studies show that positive encounters with empathetic, respectful providers increase women’s satisfaction with their care, improve the likelihood that information is understood, and make women more likely to seek health care in the future.

Abortion providers should continuously reflect upon and identify their own subconscious biases in order to try to minimize their influence on the care they provide.

To ensure positive interactions, abortion providers should:

  • Ensure privacy and confidentiality
  • Speak neutrally and respectfully
  • Listen attentively
  • Ask thoughtful, open-ended questions
  • Use simple, non-technical language
  • Show empathy and kindness to all women in their care
Lesson 2: Before the Abortion

Lesson 2: Before the Abortion



2.1) Establishing Pregnancy and Gestational Age

The easiest and quickest way to confirm pregnancy in most settings is a simple urine pregnancy test.

Most urine pregnancy tests can be used 7-10 days after a missed menstrual period.

If urine pregnancy tests are not available, pregnancy can be assumed based on the woman having symptoms of pregnancy, such as missing a menstrual period, breast tenderness, nausea, and fatigue.

Once pregnancy is established, estimate the duration of the pregnancy, also known as the gestational age.

Pregnancies are dated in weeks starting from the first day of the last menstrual period, and not from fertilization, as some people might think.

In order to provide accurate information and the correct dose of medications, it is important to determine if the gestational age is:

  • Between 13 and 22 weeks.
  • Between 13 and 22 weeks.

Ask the woman for the first day of bleeding during her last menstrual period and calculate the number of weeks from the last menstrual period to today’s date using a calendar.

This is the gestational age.

Research in many settings has shown that using the last menstrual period to estimate gestational age is accurate and acceptable.

Trained health care workers can also estimate the gestational age by palpating the abdomen and feeling where the top of the uterus is.

  • At around 12 weeks, the uterus can be felt just over the pubic symphysis (front part of the pubic bone).
  • At around 20 weeks, the uterus should be near the umbilicus (belly button).

If the gestational age is unclear based on the last menstrual period and/or abdominal palpation, then it can be assessed via pelvic examination or ultrasound performed by trained health care providers.

Routine ultrasound is not required before providing medication abortion.

Ultrasound may limit access to abortion and reduce confidentiality – especially in humanitarian settings.

Additionally, routine ultrasound does not necessarily increase safety or improve results.

As medication abortion is safe and effective over a range of gestational ages, small differences of one to two weeks do not significantly affect clinical outcomes.

Keep in mind that ultrasound is also less accurate as gestational age increases.

2.2) Assessing Eligibility

Almost everyone can undergo a medication abortion safely, including:

  • Young women
  • Women without children
  • Women living with HIV
  • Breastfeeding women
  • Women with a prior Cesarean delivery
  • Overweight or underweight women
  • Women with stable chronic conditions such as diabetes, high blood pressure, or asthma

There are very few contraindications to medication abortion.

In most cases, asking the woman some simple questions is sufficient to ensure that she can safely proceed with a medication abortion.

Routine laboratory tests are not required before providing an abortion with pills.

You can start by asking the woman, 'Do you have any other health problems?'

check in with her throughout the consultation and be attentive to verbal and non-verbal cues.

Inherited porphyria, chronic adrenal failure, or severe uncontrolled asthma

These rare conditions are contraindications to mifepristone.

Women with one of these conditions should receive either the misoprostol-only regimen or MVA.

There is no need to do specific blood tests or screening to exclude these conditions before providing a medication abortion.

Usually a woman knows if she has any of these medical conditions.

Irregular vaginal bleeding and/or unilateral abdominal pain

These are signs of a possible ectopic pregnancy, an uncommon condition where the pregnancy develops outside the uterus.

Although infrequent, if an ectopic pregnancy ruptures, it can be life-threatening.

Women with these symptoms during this pregnancy should be evaluated by a health care worker to confirm the location of the pregnancy (e.g. by physical exam or ultrasound) before undergoing a medication abortion.

However, if a woman with a previously unrecognized ectopic pregnancy takes abortion pills, the pills will not harm her or cause the ectopic pregnancy to rupture.

Bleeding disorder or severe anemia.

Women with these conditions can have a medication abortion, but the risks might be higher than normal.

These women may need closer monitoring or support during the abortion process.

Again, there is no need to do blood tests to exclude these conditions before providing a medication abortion.

History of two or more Cesarean deliveries

If a woman has had two or more Cesarean deliveries in the past, and she is between 13 and 22 weeks pregnant, she may have an increased chance of complications with medication abortion.

Therefore, a reduced dose of misoprostol is recommended, and will be discussed in more detail later in the course.

Women who have had two or more Cesarean deliveries but are less than 13 weeks pregnant can take the normal dose of misoprostol.

If she has an IUD in place

The IUD should be removed prior to taking the abortion pills.

2.3) Informed Consent

Inform the woman of the risks and benefits of medication abortion and ensure she voluntarily gives her consent.

Informed consent is a process, not a single act.

Check in with her throughout the consultation and be attentive to verbal and non-verbal cues.

If she is accompanied by a partner or family member, speak with her in private to ensure there is no coercion.

2.4) Making a Plan

Although medication abortion is relatively simple and involves very low risks, it is a good idea to make a plan ahead of time.

Before an abortion, a woman should think about and decide:

  • If she would like someone to be with her during the abortion.

Many women find it helpful to ask a partner, close friend or family member to provide emotional support and help in case there is a complication.

For some women, informing a partner or family member could result in violence, isolation, or being blocked from care. So it is up to her.

  • Where to undergo the abortion. She will need a safe, comfortable and private place while she experiences bleeding and cramping.

This can be her home, but also the home of a friend or family member or someone else she trusts.

If she prefers, she can also undergo the abortion at a health care facility or shelter.

  • When is the best time or day for the abortion when she is free from work, school or other obligations and can take care of herself.
  • What supplies she might want to make her more comfortable, like menstrual pads or a hot water bottle for comfort.

She may also want to prepare food and light snacks ahead of time.

  • Where is the nearest health care facility and how to get there (e.g. by car, motorcycle, taxi) should that be needed.

Note: If a woman seeks medical attention, she does not have to say she used pills to cause an abortion.

She can simply say she is having a miscarriage, and she should receive the appropriate care.

The symptoms of medication abortion are very similar to a miscarriage and there is no way to tell the difference.

In humanitarian settings, women may need additional support preparing for medication abortions.

For example, women living in refugee camps might not have access to menstrual pads or adequate latrines.

They may also have additional protection needs.

Talk with her about her situation and provide the necessary support and/or refer to other services as appropriate.

Lesson 3: Medication Abortion before 13 Weeks

Lesson 3: Medication Abortion before 13 Weeks



3.1) Deciding on Which Regimen to Use

There are two options for providing an abortion with pills:

Option 1: Combination of two drugs: mifepristone and misoprostol

Option 2: Using repeated doses of misoprostol only

Mifepristone and Misoprostol

Highly effective with success rates over 95%

The risk of the pregnancy continuing is very low (<1 %)

Very low risk of severe complications (<1%)

Misoprostol only

3.2) HowToUse Abortion Pills before 13 Weeks: Mifepristone + Misoprostol

Give one tablet of mifepristone 200mg and eight tablets of misoprostol 200mcg with the following instructions on how to take them.

When giving the tablets, do not take them out of their blister packaging, as this makes them less effective.

Step 1: Swallow one pill of mifepristone (200mg) with water.

Some women may experience light bleeding after taking mifepristone.

However, most women do not feel any effects after taking mifepristone, and this is normal.

It doesn’t mean that the pill didn’t work.

Some women may experience nausea after taking mifepristone.

  • If she vomits within one hour of swallowing the mifepristone pill, it is unlikely to work and she should come back for another dose.
  • If she vomits more than an hour after swallowing the mifepristone pill, she does not need to repeat the dose.

Step 2: Wait 1-2 days.

While she waits, she can do the things that she normally does in her everyday life, like taking care of family or going to work or school.

Step 3: The day of the abortion, put 4 misoprostol pills (200mcg each) directly under your tongue and keep them there as they dissolve for 30 minutes.

Do not eat or drink for these 30 minutes.

Swallow any additional saliva that forms and do not spit out anything.

After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.

The abortion process should start within 1-4 hours.

Take the misoprostol even if you experienced bleeding and cramping after taking the mifepristone on Day 1.

Step 4: If the abortion process is not complete after 1-2 days, take the remaining 4 misoprostol pills (200mcg each) as in Step 3.

Misoprostol works with similar effects whether it is taken as little as 12 hours or as long as 72 hours after mifepristone.

In some situations, taking mifepristone and the first dose of misoprostol together may also be a useful strategy.

It is also possible to take misoprostol pills vaginally by inserting the pills into the vagina as far as they will go and waiting for 30 minutes.

Women who use the vaginal route should be informed that pieces of the pills may remain in the vagina for several hours or even days.

If there is a complication and the woman seeks medical care, these pill fragments may suggest to a health care worker that the woman induced her abortion.

This can be avoided by using the sublingual (under the tongue) route.

It is important to pick one route and use that one only, and not split the pills between different routes.

3.3) HowToUse Abortion Pills before 13 Weeks: Misoprostol Only

Dispense 12 tablets of misoprostol 200mcg with the following instructions.

When giving the tablets, do not take them out of their blister packaging, as this makes them less effective.

Step 1: The day of the abortion, put 4 misoprostol pills (200mcg each) directly under your tongue and keep them there as they dissolve for 30 minutes.

Do not eat or drink anything for these 30 minutes.

Swallow any extra saliva that forms and do not spit out anything.

After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.

Step 2: Wait 3 hours.

Step 3:After 3 hours, even if you have started cramping or bleeding, take 4 more pills by placing them under the tongue as described in Step 1.

Step 4: Wait another 3 hours.

Step 5: After an additional 3 hours (i.e. 6 hours from taking the first misoprostol), take the last 4 pills as described in Step 1.

Make sure you take all 12 misoprostol pills, even if you are cramping and bleeding and you think the pregnancy has started to come out.

Note: The vaginal route is also possible for the misoprostol-only method as explained earlier.

3.4) What to Expect

Being informed about what to expect during a medication abortion will help prepare a woman for the process and will also help her to distinguish what is normal from what is abnormal so she knows when to seek medical care.

Bleeding

Most women will start bleeding within 1-3 hours of taking misoprostol.

Bleeding is usually heavier than a menstrual period and often accompanied by blood clots.

The heaviest bleeding typically occurs 4-6 hours after taking misoprostol and usually slows within 24 hours.

While this is the most typical bleeding pattern, every woman is different and may have a different experience.

Some women may bleed more or less than this, and that is also normal.

Women will likely experience more bleeding the farther along in the pregnancy they are.

Some women may pass clots days or even weeks later.

This is common and not dangerous, as long as there are no symptoms of a complication.

If there is no bleeding or only light bleeding after 72 hours, it probably means the abortion did not work.

Cramping

Medication abortion causes mild to very strong cramping throughout and after the process.

Cramping is the sign that the uterus is contracting and that the medication is working.

Cramping is usually strong for 4-8 hours after taking misoprostol.

Milder cramps may continue for several days.

Painkillers can and should be taken immediately after taking the first dose of misoprostol.

Ibuprofen is the most effective painkiller and does not have any influence on the abortion or amount of bleeding.

One possible regimen for ibuprofen is 800mg orally (swallowed) every 8 hours for 3 days.

Paracetamol, aspirin, and buscopan are less effective and not helpful.

It is important to treat pain as early as possible – she should not to wait until the pain is unbearable before taking painkillers.

There are several other things that women can do to relieve pain during a medication abortion, including:

  • Using a hot water bottle or heating pad on the belly
  • Sitting or lying in a comfortable environment
  • Listening to music or watching videos
  • Receiving support from friends or family

What She Might See

Depending on the gestational age, the woman might not see any recognizable shape (up to 7 weeks) or they might see an embryo up to 2 cm (9 weeks gestation).

Women can choose not to look at the pad, wrap it up, and dispose of it as they would during a menstrual period.

During expulsion, it is possible that a small white streak that might look like a small piece of sponge is seen, which is likely the gestational sac.

Common Side Effects

Fever, chills, dizziness, headache, nausea, vomiting, and diarrhea are all common side effects of misoprostol.

These side effects usually last for a few hours and then go away on their own within 24 hours.

She can reduce these symptoms by drinking a lot of water before and during the abortion, eating light dry food regularly, and lying down in a comfortable place.

Women with severe vomiting can be given anti-nausea medications like metaclopromide.

Duration of the Abortion

The pregnancy is usually expelled within 24 hours of taking the last misoprostol pills.

The pregnancy is usually expelled within 24 hours of taking the last misoprostol pills.

The pregnancy is usually expelled within 24 hours of taking the last misoprostol pills.

3.5) When to Seek Medical Care

As mentioned earlier, medication abortion is very safe, and major complications are rare.

As mentioned earlier, medication abortion is very safe, and major complications are rare.

As mentioned earlier, medication abortion is very safe, and major complications are rare.

  • Fever or other side effect for more than 24 hours
  • Very little or no bleeding at all 72 hours after taking all the abortion pills
  • Continued heavy bleeding and cramping that doesn’t decrease after 7 days
  • Pregnancy symptoms that don’t go away (she still feels pregnant)

These are symptoms of possible undesirable outcomes or complications that should be evaluated by a health care worker but are typically not emergencies or life-threatening.

She can wait until the following day or so to get care.

A woman should seek emergency medical care immediately if she experiences any of the following warning signs:

  • Excessive bleeding: soaking more than two menstrual pads per hour for two hours in a row, especially if accompanied by dizziness, lightheadedness, or fatigue
  • Excessive bleeding: soaking more than two menstrual pads per hour for two hours in a row, especially if accompanied by dizziness, lightheadedness, or fatigue
  • Excessive bleeding: soaking more than two menstrual pads per hour for two hours in a row, especially if accompanied by dizziness, lightheadedness, or fatigue

These are signs of complications that are possibly life-threatening.

She should immediately go to carea health care facility as soon as possible.

In many cases, a trained health provider can address the problem with limited intervention.

In very rare cases, women may require hospitalization, additional surgical intervention, blood transfusion, or other advanced care.

It is important to reassure her that if she seeks medical attention, she does not have to say she used pills to cause an abortion if she does not want to.

She can simply say she is having a miscarriage, and she should receive the appropriate care.

The management of complications related to miscarriage is the same as the management of complications related to medication abortion.

Lesson 4: Medication Abortion between 13 and 22 Weeks

Lesson 4: Medication Abortion between 13 and 22 Weeks



While abortions at or after 13 weeks comprise a minority (10-15%) of the total abortions worldwide, they are responsible for the majority of serious complications from unsafe abortion.

Women who present for abortions after 13 weeks are more likely to be young girls, victims of sexual violence, have detected their pregnancy later, and/or have financial or logistical barriers to care.

Therefore, these women and girls are disproportionately underserved and vulnerable, and it is important for humanitarian aid workers to provide the care they need.


4.1) Preparation and Set-Up

While medication abortions less than 13 weeks can be provided almost anywhere and with very few resources, providing medication abortions between 13 and 22 weeks requires more planning and set-up.

Provision of medication abortion between 13 and 22 weeks is very effective and very safe, with a major complication rate of less than 1%.

But it is also more complicated: for example, it will usually take more time, the bleeding may be heavier, and the expulsed pregnancy will be larger and more recognizable as a fetus.

Preparing for these aspects ahead of time will help to ensure successful provision of medication abortion between 13 and 22 weeks.

It is recommended that women having medication abortions between 13 and 22 weeks undergo the abortion in a health care facility.

The health care facility should be open and staffed by trained health care workers around-the-clock and should have adequate hygiene, infection prevention and control measures in place.

However, this is not always feasible, especially in humanitarian settings.

In this case, the guiding principles should be woman-centered care and harm reduction.

This means the focus is on helping the woman to avoid an unsafe abortion and to be as safe and healthy as possible given the constraints of the situation.

For example, if a health care facility is only open and staffed during the day, the timing of the abortion drugs can be adjusted to increase the chance the expulsion will happen during the day.

Women undergoing medication abortions at or after 13 weeks outside a health care facility or at home should understand what to expect and have a clear plan in place, especially for seeking emergency medical care if needed.

4.2) Deciding on Which Regimen to Use

The same medication regimens – combination of mifepristone and misoprostol or misoprostol only – work for abortions between 13 and 22 weeks as well.

However, between 13 and 22 weeks, mifepristone has an even greater impact on increasing the effectiveness of a medication abortion, which is why it should be used whenever possible.

4.3) HowToUse Abortion Pills between 13 and 22 Weeks: Mifepristone + Misoprostol

Give the abortion pills in their blister packaging with the following instructions on how to take them:

Step 1: Swallow one pill of mifepristone (200mg) with water.

Some women may experience light bleeding after taking mifepristone.

However, most women do not feel any effects after taking mifepristone, and this is normal. It doesn’t mean that the pill didn’t work.

Some women may experience nausea after taking mifepristone.

  • If she vomits more than an hour after swallowing the mifepristone pill, she does not need to repeat the dose.
  • If she vomits more than an hour after swallowing the mifepristone pill, she does not need to repeat the dose.

Step 2: While she waits, she can do the things that she normally does in her everyday life, like taking care of family or going to work or school.

While she waits, she can do the things that she normally does in her everyday life, like taking care of family or going to work or school.

The morning of the abortion, put 2 misoprostol pills (200mcg each) directly under your tongue and keep them there as they dissolve for 30 minutes.The morning of the abortion, put 2 misoprostol pills (200mcg each) directly under your tongue and keep them there as they dissolve for 30 minutes.

Do not eat or drink anything for these 30 minutes.

Swallow any saliva that is formed and do not spit out anything.

After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.

Note: The dose of misoprostol for medication abortions between 13 and 22 weeks is lower than the dose for medication abortions before 13 weeks.

This is because as gestational age increases, the uterus is larger and more sensitive to misoprostol, so a lower dose is needed to have the same effect and to avoid complications.

Step 4: Wait 3 hours.

Step 5: Take 2 more misoprostol pills (200mcg each) as in Step 3.

Step 6: Wait 3 hours.

Step 7: Keep repeating Steps 5 and 6 (take 2 misoprostol pills, wait 3 hours) until both the fetus and the placenta have expulsed.

There is no limit to the number of misoprostol doses that can be taken.

With the combined mifepristone and misoprostol regimen between 13 and 22 weeks, on average, 3-4 doses of misoprostol will be needed.

But some women will need more.

Avoid pauses or delays in misoprostol doses, as this will increase the length of time it takes.

Most women will complete the abortion within 24 hours.

Note: The timing between mifepristone and misoprostol is more important for medication abortions between 13 and 22 weeks.

To increase effectiveness, try to ensure that at least 24 hours passes between the mifepristone and the first dose of misoprostol.

As in medication abortions before 13 weeks, it is also possible to take misoprostol pills vaginally.

This route may be even more effective than the sublingual route for pregnancies between 13 and 22 weeks.

It is important to pick one route and use that one only, and not split the pills between different routes.

Again, if the vaginal route is used, pill fragments may remain in the vagina.

Women who have had Cesarean deliveries in the past have a slightly increased risk of uterine rupture, which is a condition where the wall of the uterus tears and opens.

While the risk of uterine rupture is very low, if it happens, it can be life-threatening.

Therefore, women who have had two more Cesarean deliveries and are undergoing medication abortion between 13 and 22 weeks should take a reduced dose of misoprostol: only 1 pill (200mcg) every 3 hours.

Women who have had only one Cesarean delivery and are undergoing medication abortion between 13 and 22 weeks can take the normal dose of misoprostol: 2 pills (400mcg) every 3 hours.

4.4) HowToUse Abortion Pills between 13 and 22 Weeks: Misoprostol Only

Give the abortion pills in their blister packaging with the following instructions on how to take them:

Step 1: The day of the abortion, put 2 misoprostol pills (200mcg each) directly under your tongue and keep them there as they dissolve for 30 minutes.

Do not eat or drink anything for these 30 minutes.

Swallow any saliva that is formed and do not spit out anything.

After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.

Step 2: Wait 3 hours.

Step 3: Take 2 more misoprostol pills (200mcg each) as in Step 1.

Step 4: Wait 3 hours.

Step 5: Keep repeating Steps 3 and 4 (take 2 misoprostol pills, wait 3 hours) until both the fetus and the placenta have expulsed.

There is no maximum to the number of misoprostol doses that can be taken.

With the misoprostol-only regimen between 13 and 22 weeks, on average, 5-6 doses of misoprostol will be needed.

But some women will need more.

Avoid pauses or delays in misoprostol doses, as this will increase the length of time it takes.

Most women will complete the abortion within 24 hours.

Again, misoprostol can also be taken vaginally as explained earlier.

Also, women who have had two more Cesarean deliveries and are undergoing medication abortion between 13 and 22 weeks should take a reduced dose of misoprostol: only 1 pill (200mcg) every 3 hours.

4.5) What to Expect

Bleeding and Cramping

Just like with medication abortions before 13 weeks, the main expected symptoms of a medication abortion between 13 and 22 weeks are bleeding and cramping.

However, between 13 and 22 weeks, there will likely be more bleeding and cramping than a heavy menstrual period.

In addition to ibuprofen, other painkillers like codeine and tramadol may be needed.

It may also take more time and more doses of misoprostol before the cramping and bleeding starts.

Common side effects

Fever, chills, headache, nausea, vomiting, and diarrhea are all common side effects of misoprostol.

These side effects usually last for a few hours and then go away on their own within 24 hours.

Women with severe vomiting can be given anti-nausea medications like metaclopromide.

Duration of the Abortion

When the combination of mifepristone and misoprostol is used, the average time to expulsion is around 6-10 hours from the first misoprostol dose.

Studies show that 94% of women will complete expulsion by 24 hours, and 97% of women will complete expulsion by 48 hours.

When the misoprostol-only option is used, the average time to expulsion is around 10-15 hours from the first misoprostol dose.

Studies show that 80-85% of women will complete expulsion by 24 hours, and up to 90% of women will complete expulsion by 48 hours.

With both regimens, a wide range of times is possible.

Some women will need significantly more time, even multiple days, to complete the abortion.

Women who have not been pregnant before, older women, and women with pregnancies of higher gestational ages are more likely to need more time.

Rarely, a woman will not expulse in 48 hours and may need even more doses of misoprostol to complete the abortion successfully.

The keys to reducing the time it takes to complete the abortion are using the combined regimen (mifepristone + misoprostol) and not pausing or interrupting the misoprostol doses.

As long as there are no warning signs, she can continue taking misoprostol doses every 3 hours.

Managing the Expulsion

As the woman keeps taking misoprostol, cramping will start and gradually increase.

Cramping means that the uterus is contracting and working to open the cervix and push out the pregnancy.

In time, the contractions will become strong enough and the cervix will become open enough that the fetus and placenta are expelled.

There is no need to examine the cervix or vagina to monitor progress.

Between 13 and 22 weeks gestation, the pregnancy is larger, more developed, and more recognizable as a fetus and placenta.

Often, the fetus and the placenta come out at the same time.

If the fetus comes out without the placenta, do not pull on the cord.

The placenta should come out spontaneously within a few hours.

As long as the woman is stable and bleeding is minimal, she can continue taking misoprostol 400mcg every 3 hours.

In the rare case that 4 hours have passed and the placenta has not come out, it may need to be removed by a trained health care worker using forceps or MVA.

There is no need for routine medication to prevent further bleeding, or any routine intervention or ultrasound.

After the Expulsion

Depending on the woman’s wishes, the fetus can be wrapped for her to hold, or wrapped and kept out of sight and removed.

The fetus may demonstrate some transient signs associated with life like breathing, grunting, or spontaneous movements.

These signs usually go away after a few minutes, but can be upsetting for those who are present.

This possibility should be discussed with women, families, and staff ahead of time so they can be prepared and the appropriate arrangements can be made to minimize distress and respect their wishes.

The fetus and placenta should be handled respectfully and in accordance with infection prevention and control standards.

In low-resource settings, the fetus and placenta can be placed in a properly built and maintained placenta pit or incinerated.

Health care facilities that conduct vaginal deliveries should already have necessary waste management systems, including a placenta pit, in place.

If sterilization paper or other biodegradable cloth is available, the fetus can be wrapped in this material after the expulsion before placing in a placenta pit.

Rarely, a woman may want to take the fetus home and bury it herself.

In this case, her wishes should be respected.

However, health care workers should not force women to take the fetus home if she does not want to.

There is no mandatory amount of time that a woman needs to stay in the health care facility after an uncomplicated medication abortion between 13 and 22 weeks.

Typically, 1-2 hours is enough to ensure she is stable and that there is minimal bleeding.

4.6) Complications

As mentioned earlier, medication abortion between 13 and 22 weeks is very safe, and major complications are rare.

But complications do occur more often and more seriously than during abortions at earlier gestations.

Most complications can usually be treated effectively with prompt emergency care, either on-site or through transfer to a higher-level facility.

Possible severe complications include hemorrhage (severe bleeding) and infection.

The management of these complications is very similar to the management of the same complications when they occur after a vaginal delivery.

In many cases, a trained health care provider can address these conditions with limited intervention.

In very rare cases, women may require surgical intervention, blood transfusion or other advanced care.

A plan should be in place regarding how these complications will be managed if they do occur and how, when, and where a woman will be transferred if needed.

Lesson 5: After the Abortion

Lesson 5: After the Abortion



5.1) Follow-up

Women who have medication abortions generally do not need a routine follow-up visit with a health care worker.

So long as she no longer feels pregnant, she feels in good health, and her bleeding isn’t heavy, then everything is most likely fine.

Women should be informed that they can visit a health care worker at any time if they don’t feel well or if they have any other questions or concerns.

Urine pregnancy tests can stay positive for up to 3-4 weeks after a successful abortion.

Routine follow-up ultrasound is not needed and may lead to unnecessary interventions.

5.2) Contraception the Day of the Abortion

A woman can become pregnant again as soon as 8 days after an abortion.

Therefore it is important to address contraception when providing abortion care services.

Start by asking if she would like to talk about contraception today.

Some women may want to talk about contraception and choose and start a method that same day.

In this case, discuss her options and provide the method she chooses that day if that is what she wants.

Implants and injections can be provided that same visit, even before the abortion pills have been taken.

If she wants oral contraceptive pills, give her at least a 3 month supply and inform her she can start taking the pills the day after the abortion is complete.

IUDs and tubal ligations can be provided after 1-2 weeks once the medication abortion is complete.

Studies show that some women prefer to think about it more and come back later, or they may not want to discuss contraception at all that day, which is also fine.

Let her know that she can come back to the clinic at any time to discuss or start contraception.

Abortion providers should not pressure women into starting a contraceptive method the day of the abortion.

5.3) Mental Health after Abortion

Millions of women around the world have abortions and have no psychological problems afterwards.

Studies show that the most commonly reported emotion after an abortion is relief.

In the first weeks after the abortion, a woman may have many different emotions, including relief, sadness, or happiness.

Most women can cope with these feelings, especially with the support of friends and family.

Some women may have more difficulties coping and may benefit from speaking with a trained health care worker or mental health counselor.

Routine consultation with a mental health provider is not necessary.

Studies show that most women have no lasting or long-term negative feelings after an abortion.

5.4) Returning to Routine Activities

Most women return to work or school the day after the abortion.

However, every woman’s body is different.

A woman should listen to her body.

If she does a lot of physical lifting and heavy work, or just feels more tired than normal, she might need more than one day away from work.

During the first two days after a medication abortion, women are advised to not take a bath, swim, use tampons, or have sex.

These are standard precautionary measures to avoid possible infection, but there is no conclusive evidence to support this.

Women can take a shower at any time.

Most women will have their next menstrual period after 4-6 weeks, but for some women, it can take longer.

The first menstrual period after a medication abortion may also be slightly heavier than normal.

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