(And in real life urban or rural practice. It’s intimidating to start at first but very straightforward.)
Confirm gestational age. Ultrasound is no longer required for on-label use. You can confirm gestational age by a certain LMP and bimanual examination OR by ultrasound.
Exclude ectopic pregnancy. Assess for risk factors. Assess for symptoms. If the patient is at risk ultrasound is recommended. If they are symptomatic urgent ultrasound is required!
Assess for contraindications. Mifepristone is an anti-glucocorticoid so most contraindications are glucocorticoid based: uncontrolled asthma, chronic adrenal failure, chronic corticosteroid use. Hematologic disorders (coagulopathies, anticoagulant use and porphyria) are also contraindications. If there is an IUD in situ it must be removed before proceeding. Ectopic pregnancy is a contraindication as it is not successfully treated by mifepristone/misoprostol.
Advise how to take the medication and what to expect. Mifepristone is taken first and usually causes no side effects. Misoprostol is taken 24-48h later. Bleeding and cramping generally start within a few hours of misoprostol use. Bleeding may be heavy and blood clots are to be expected. Cramping and pain may be severe. Consider prescribing analgesia prophylactically. Once the pregnancy is passed the bleeding and cramping will lessen but may be ongoing for days. Misoprostol commonly causes side effects specifically nausea, vomiting, diarrhea, fever and chills.
Advise of risks. Surgical evacuation may be required in the event of retained products of conception or heavy bleeding (5%) or ongoing pregnancy (<1%). Heavy bleeding requiring transfusion is rare (0.1%). Infection is rare (1%) and severe infection/sepsis extremely rare (.01%).
Advise of emergency plan. Provide your on-call contact information. Heavy bleeding (>2 pads/hr for >2hrs), severe prolonged pain uncontrolled by analgesia, or signs and symptoms of infection more than 24h after taking misoprostol require urgent assessment.
Arrange follow-up. A follow-up visit must occur to ensure completion. Completion can be assessed by history in combination with either ultrasound or serial bHCG levels. If serial bHCG is being used (this is most practical for most family physicians) a bHCG should be drawn on the day of mifepristone administration and 7 days post mifepristone. A fall of 80% or more in 7 days indicates completion.
Don’t forget your ABCs: Always Be Contracepting! Ovulation can occur within days following successful medical abortion. Don’t wait for their period to resume to start contraception, you may be too late!
Ordering lab tests:
SOGC Medical Abortion guidelines available at: https://www.jogc.com/article/S1701-2163(16)00043-8/fulltext
Mifegymiso prescriber monograph: https://pdf.hres.ca/dpd_pm/00050659.PDF
Another good resource for those wanting to prescribe is the SOGC medical abortion training module: https://www.sogc.org/en/rise/Events/event-display.aspx?EventKey=MATP
(Free if you don’t want the CME credits and a nominal fee if you do.)