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    Female body reproductive system, stylized imageThis Medication Abortion course provides learners with the foundational knowledge required to provide medication abortion care in the first trimester of pregnancy. The course addresses the core competencies outlined in the World Health Organization (WHO) document “Sexual and reproductive health: Core competencies in primary care” and the tasks outlined in the WHO document “Health worker roles in providing safe abortion care and post-abortion contraception.” All components of this training (like all NextGenU.org trainings) are free, including registration, learning, testing, and a certificate of completion.

    This course is designed for healthcare providers with at least a foundational knowledge of physiology and pharmacology, clinical skills (history taking, physical exam), and basic ultrasound.  The course may be appropriate for advanced medical students, medical residents, or primary care-level providers, including advanced practice clinicians. Components of the course may also be suitable for auxiliary staff such as counselors, medical assistants, and nurses.

    There are six lessons to complete through online study and peer and mentored activities. These modules introduce counseling and informed consent; pre-abortion care: assessing eligibility for medication abortion; regimens for medication abortion; administering medication; follow-up; and logistics of providing medication abortion. At the end of this course, learners should have the knowledge needed to discuss abortion care options and informed consent; complete a pre-abortion evaluation and describe the eligibility criteria for medication abortion; identify medications used in medication abortion, along with their regimens; administer appropriate medications; and provide follow-up care to women seeking medication abortion.

    Practice quizzes are found in each module, and at the end of the course you’ll take a final exam and have a chance to assess this training. We will provide you with the results of your final exam, peer activities, and other assessments. We can report your testing information and share your work with anyone (school, employer, etc.) you request. We hope this is a wonderful learning experience for you and that your assessments will teach us how we can make it even better.

    Like all NextGenU.org courses, this course is competency-based, using competencies from the World Health Organization (WHO) and learning resources from world-class academic and governmental organizations such as the University of California, San Francisco, Bixby Center for Global Reproductive Health, and the World Health Organization.  The course developers include Sara Baird MD and Amelia Plant MPH, and the advisory committee includes Francine Coeytaux MPH, Marji Gold MD MPH, Gwewasang Martin, Wendy Norman MD MPH, and Linda Prine MD.  Our co-sponsoring organizations include the Clinical Training Center for Family Planning in Cameroon (CTC4FP), Plan C, the Reproductive Health Access Project (RHAP), TEACH, and The Center for Reproductive Health Education In Family Medicine (RHEDI). Some content from this course has been adapted from the Ipas courses "First Trimester Abortion with Mifepristone and Misoprostol" and/or "First Trimester Abortion with Misoprostol Only" (accessed December 2017). The original course material can be found at the IpasUniversity online learning platform at www.ipasu.org. For more information about Ipas, go to www.ipas.org.

    Before you begin the course, please take a moment to take the short knowledge pre-course survey and pre-course test  below. It allows us to assess various aspects of the course itself and is mandatory to receive your certificate upon completion of the course.



  • Unintended pregnancy affects many people who are on the spectrum of non-binary gender identity. Providers should be prepared and open to caring for all people in a non-judgmental and evidence-based way, regardless of gender identity. Gender-diverse people are more likely to have histories of abuse and stigma, and may have limited prior interaction with medical providers. Providers can take steps to be inclusive—inform yourself about care guidelines for transgender persons, communicate with the patient to discuss preferred pronouns and terminology, be respectful and inclusive, and work with patients to help choose care that fits their needs (for example, some patients may wish to avoid any vaginal exam).  

    NextGenU.org has a wide variety of learners from 193 (of 195) countries, including learners for whom English is a second language.  For clarity, this course uses gender-specific pronouns throughout.  

    Read more about transgender persons and medical care here: Center of Excellence for Transgender Health, UCSF

    More information can be found in the "Gender spectrum and pregnancy" section here: https://workbook.pressbooks.com/chapter/confidentiality-and-informed-consent/

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    You may view parts of the course as a guest. If you wish to take the course, click on the enroll button above.

    Before you begin the course, you must complete two short tasks: (1) the Pre-Course Survey, and (2) the Pre-Course Test. Please DO NOT proceed with the course unless you have filled out both. These allow us to access various aspects of the course itself and are MANDATORY to receive your certificate upon completion of the course. If you do not wish to receive a certificate, but are a qualified health provider who wishes to learn this information, please feel free to learn from the materials without registering or completing the pre-test. Thank you very much; we hope you find the course useful. 

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  • Concept of 'about', image of lightbulbs to indicate learning

    Please STOP. Before you begin the course, you must complete two short tasks: (1) the Pre-Course Survey, and (2) the Pre-Course Test. Please DO NOT proceed with the course unless you have filled out both. These allow us to evaluate various aspects of the course itself and are mandatory to receive your certificate upon completion of the course. If you do not wish to receive a certificate, but are a qualified health provider who wishes to learn this information, please feel free to learn from the materials without registering or completing the pre-test. Thank you very much.

    Abortion is common. Globally, about 25% of all pregnancies ended in abortion between 2010 and 2014. Preventing unplanned births by the use of contraceptives and safe abortion has benefits at the individual, family, and societal levels. Women who are able to choose when to have children are better able to chart the courses of their own lives. They are more likely to complete higher levels of education, be more active in the workforce, and contribute more to a country’s economy (Reher, 2011). Limiting family sizes decreases household poverty, as more resources are available to educate, clothe, house, and feed existing family members (UNFPA, 2010).

    At the country level, as the number of children per household falls, the number of people in the workforce rises.  This results in a favorable economic situation that allows countries to develop (Bloom, Canning, & Sevilla, 2003). Historically, no country has successfully developed without a corresponding drop in fertility.

    Providing access to contraceptives goes a long way, but unplanned pregnancies cannot be eliminated altogether. A woman may experience an unplanned pregnancy for a number of reasons, including a lapse in access, contraceptive failure, reproductive coercion or sexual assault, or diagnosis of abnormal pregnancy. Safe abortion is essential to women’s emotional and physical health, family-level economic opportunities, and societal development. 

    Although legal abortion is safe and effective, complications from unsafe abortion are common in regions where abortion is illegal or highly restricted and is a leading global cause of death for women aged 15–19 (Guttmacher Institute, 2017). Increasing access to abortion and reproductive health information has even been shown to lower abortion rates (UNFPA, 2010). But even in settings where abortion is legal, restrictions often limit women’s access to care. The training of providers is an essential step to destigmatizing abortion care and expanding geographic access to care.

    Click here for the brief module introduction

    5 URLs
  • Image of chemical model of Misoprostol

    The course contains the following lessons:

    1. Counseling and Informed Consent
    2. Pre-abortion Care: Assessing Eligibility for Medication Abortion
    3. Regimens for Medication Abortion
    4. Administering Medication
    5. Follow-up
    6. Logistics of Providing Medication Abortion

    Click here for the brief module introduction
  • Image of pdf from the National Abortion Federation: A values clarification guideWho can provide abortions?

    Abortion providers may have a variety of background trainings. For more information about who can provide abortion services, read the documents listed below from the World Health Organization and the National Abortion Federation .


    Values Clarification

    Before beginning this course, take a moment to reflect on your own values as a provider. Many people have social, religious, cultural, and personal influences on their practice as an abortion provider.  These influences can consciously or subconsciously affect our patient interactions during counseling and care.

    Consider completing an individual values clarification workbook such as the one available through the U.S.-based National Abortion Federation, "A Values Clarification Guide for Health Care Professionals."

    It is also important to consider the values of your staff, colleagues, and patients before implementing abortion care. Resources for group values clarification workshops will be presented at the end of this course.

    Click here to start this module

    3 URLs
  • Learning objectives

    At the end of this lesson, learners will be able to:

    • Use patient-centered language to discuss early pregnancy options
    • Review early abortion options with patients
    • Describe steps of informed consent for women seeking medication abortion
    • Explain the overview of the medication abortion process to patients and provide aftercare instructions

    Click here to start this module


  • Key Points 
    • Providers should focus on good communication throughout the visit, both verbally, non-verbally, and with clear written materials. 

    Learning Objectives

          • Describe terms and phrases that can be used to nurture a non-judgmental and patient-centered environment
          • Describe how non-verbal communication can be used during an abortion visit
          • Use patient-centered language to discuss early pregnancy options
          • Describe concepts of confidentiality and how they may apply to the patient

    We will first review overall tips for effective and empathetic communication with patients.  The readings below include examples of verbal and non-verbal communication that can be utilized throughout a woman’s abortion visit. 


    Click here to start this module

    4 URLs, 1 Assignment

  • Key Points 
    • Women should receive counseling about aspiration versus medication abortion based on their individual factors.
    • Many women who choose medication abortion prefer it because it may feel more ‘natural,’ does not require instrumentation of the uterus, and is a process that can take place in the privacy of one’s home.
    • Women are more likely to have a successful medication abortion experience when they are well prepared for the process.

     

    Learning Objectives

    • Explain to a patient or colleague the risks and benefits of medication abortion versus a manual vacuum aspiration

    There are two main types of abortion, medication abortion (also called "medical abortion" or "pill abortion") and aspiration abortion (most commonly, manual vacuum aspiration, also called "surgical abortion" or "in-clinic abortion").

    • A woman may have many reasons for choosing one type of abortion over another.  These may include her prior experience, chronic medical conditions, and clinic availability. This lesson reviews some of the differences between medication and aspiration abortion and how to discuss these differences with patients to develop the right plan of care.


    Click here to start this module

    3 URLs

  • Key Points 
    • During informed consent, the provider should explain risks and safety information with the patient, and confirm a patient’s understanding of the process of medication abortion.
    • Review any legal restrictions that may apply to your clinical practice about informed consent, such as required counseling content or mandatory forms.

     

    Learning Objectives

    • Describe the importance of clear communication with patients
    • Review the key components of informed consent for medication abortion
    • Identify sample resources that can be utilized to develop your own informed consent document for clinical practice

    Click here to start this module

    2 URLs, 1 Forum

  • Key Points
    • Before making a decision on the type of abortion, some women want more detail about what to expect from the medication abortion process.
    • Women who are informed and prepared report having a better experience with medication abortion.

     

    Learning Objectives

      • Learn how to describe the medication abortion process to patients
      • Review aftercare instructions, including warning signs, with patients

    This lesson reviews what additional information should be shared with the patient before a medication abortion. The material discussed here may come up at different times during the counseling process.  Some women may ask for more details when choosing between aspiration and medication abortion.  Others will choose to have a medication abortion and only need more detail later during the informed consent process.

    The information here is an overview. After completing the remaining lessons, please review this lesson and reconsider the informed consent process.

    Click here to start this module

    4 URLs, 1 Forum

  • Key Points

    Lesson 1.1

    • Providers should focus on good communication throughout the visit, both verbally, non-verbally, and with clear written materials.

     Lesson 1.2

    • Women should receive counseling about aspiration versus medication abortion based on their individual factors.
    • Many women who choose medication abortion prefer it because it may feel more ‘natural,’ does not require instrumentation of the uterus, and is a process that can take place in the privacy of one’s home.
    • Women are more likely to have a successful medication abortion experience when they are well prepared for the process.

     Lesson 1.3

    • During informed consent, the provider should explain risks and safety information with the patient, and confirm a patient’s understanding of the process of medication abortion.
    • Review any legal restrictions that may apply to your clinical practice about informed consent, such as required counseling content or mandatory forms. 

    Lesson 1.4

    • Before making a decision about which type of abortion she may want, some women want more detail about what to expect from the medication abortion process. 
    • Women who are informed and prepared report having a better experience with medication abortion.


  • Clipboard with paper, checkmarks to indicate checking of different criteria to indicate assessment factors in making decisions

    Learning Objectives

    At the end of this lesson, learners will be able to:

    • Identify the general eligibility criteria for medication abortion, and be able to find the eligibility criteria for medication abortion in their country
    • Describe how to diagnose and date a pregnancy
    • Explain how to screen for ectopic pregnancy
    • Describe the contraindications to medication abortion
    • Identify the recommended laboratory testing prior to medication abortion

    This lesson provides information on assessing a woman’s eligibility to obtain a medication abortion. 

    Click here for the brief module introduction


  • Key Points
    • A history and physical should focus on obtaining information about gestational age, identifying contraindications and risk factors for complications.
    • Most laboratory tests are not a required part of evaluation before abortion.  Labs performed prior to medication abortion may include hemoglobin and Rh testing; these tests are considered mandatory in some settings (in the United States, for example) but may be considered optional depending on the clinical setting and patient factors.

     

     Learning Objective:

    • Describe the components of a pertinent history and physical exam for patients seeking an abortion
    The first step to assessing a woman’s eligibility for the medication abortion is obtaining information about her medical history, focusing on information that may affect her eligibility.

    Click here to start this module

    2 URLs

  • Key Points
    • Last menstrual period (LMP) in conjunction with a bimanual exam can reliably estimate gestational age in most patients.
    • When the bimanual exam findings do not correlate to the expected gestational age (by LMP) it is important to consider inaccurate dating, as well as alternative diagnoses.  Ultrasound should be considered in this setting.
    • In some settings where it is easily available, ultrasound is considered the standard of care.

     

    Learning Objectives

    • Describe different methods of diagnosing pregnancy
    • Describe the benefits and limitations of using the last menstrual period (LMP), bimanual exam, or ultrasound for early pregnancy dating
    • Assess gestational age and confirm pregnancy is in the first trimester
    • Describe the expected human chorionic gonadotrophin (hCG) and ultrasound findings for normal intrauterine pregnancies at varying gestational ages

    Gestational dating is an important part of preparation for medication abortion.  The clinician should follow three steps when estimating gestational age:

    1. Confirm that the patient is pregnant
    2. Confirm that the pregnancy is intrauterine
    3. Estimate gestational age

    Medication regimens and gestational age limitations will be discussed in detail in Lesson 3. While reading these materials on gestational dating, however, you may wish to keep in mind that in many regions, women are eligible for medication abortion (the focus of this course) only up to 70 days gestation (or 10 weeks from the LMP).

    Click here to start this module

    3 URLs

  • Key Points
    • Patients should be screened for ectopic pregnancy by history and physical exam, and additional testing including ultrasound should be done if indicated.
    • Medication or aspiration abortion will NOT treat ectopic pregnancy.  All patients with suspected or confirmed ectopic pregnancy should be emergently referred to an experienced provider where appropriate evaluation and treatment can be performed.

     

    Learning Objectives

    • Describe the history and physical exam findings that suggest ectopic pregnancy

    Ectopic Pregnancy

    As discussed in the previous lesson, ultrasound is not a requirement of medication abortion. Patients who do not get ultrasound (and some who do) are managed as a “pregnancy of unknown location.”  All patients should be screened for ectopic pregnancy by history and physical exam, and additional testing, including ultrasound, should be performed if indicated.

    Ectopic pregnancy, which occurs when a fertilized egg attaches outside the uterus (most often in a fallopian tube), can be challenging to identify or rule out. Vacuum aspiration or medical abortion cannot terminate an ectopic pregnancy, and may delay diagnosis.

    Click here to start this module

    1 URL

  • Key Points
    • There are few absolute contraindications to medication abortion.
    • Special consideration should be given to patients with certain conditions, such as severe anemia.  The decision to proceed with the medication abortion will depend on the clinical setting and available resources.

     

    Learning Objectives

    • Describe the relative and absolute contraindications for medication abortion

    In this lesson, you will review some of the medical conditions important to ensuring safety for women seeking medication abortion.

    Most contraindications to medication abortion are related to medication interactions. The two medications most commonly used for medication abortion are mifepristone and misoprostol.  These medications will be reviewed in detail in Lesson 3, but are discussed here in the context of contraindications.

    Few absolute contraindications exist with respect to medication abortion. Screening for the following conditions should be a routine part of the patient’s history and physical. When absolute or relative contraindications are present, women should be informed of the relative risk/s, and counseling about the risks and benefits of surgical versus medication abortion must take these conditions into account.

    Click here to start this module

    1 URL

  • Key Point
    • While there are no absolute lab requirements prior to abortion, many providers perform Rh testing (when Rh immunoglobulin is available) and a hemoglobin test, along with offering screening for sexually transmitted infection (e.g., chlamydia, gonorrhea, HIV).

     

    Learning Objectives

    • Describe the recommended laboratory testing prior to medication abortion

    Recommendations for laboratory testing may vary by geographical standard of care. Medically speaking, no lab tests are absolutely required prior to abortion (medication or aspiration). Nonetheless, lab tests are frequently performed, primarily focusing on public health (screening for sexually transmitted infection) and/or screening for contraindications (e.g., hemoglobin). Abortions should not be delayed beyond the same day while waiting for screening lab results. This does not apply to labs that are done for diagnostic purposes and, as always, is at the discretion of the provider.

    Click here to start this module

    2 URLs

  • Key Points 

    Lesson 2.1

    • A history and physical should focus on obtaining information about gestational age, identifying contraindications and risk factors for complications.
    • Most laboratory tests are not a required part of evaluation before abortion.  Labs performed prior to medication abortion may include hemoglobin and Rh testing; these tests are considered mandatory in some settings (in the United States, for example) but may be considered optional depending on the clinical setting and patient factors.

     
    Lesson 2.2

    • Last menstrual period (LMP) in conjunction with a bimanual exam can reliably estimate gestational age in most patients.
    • When the bimanual exam findings do not correlate to the expected gestational age (by LMP) it is important to consider inaccurate dating, as well as alternative diagnoses.  Ultrasound should be considered in this setting.
    • In some settings where it is easily available, ultrasound is considered the standard of care.

     
    Lesson 2.3

    • Patients should be screened for ectopic pregnancy by history and physical exam, and additional testing including ultrasound should be done if indicated.
    • Medication or aspiration abortion will NOT treat ectopic pregnancy.  All patients with suspected or confirmed ectopic pregnancy should be emergently referred to an experienced provider where appropriate evaluation and treatment can be performed.

     
    Lesson 2.4

    • There are few absolute contraindications to medication abortion.
    • Special consideration should be given to patients with certain conditions, such as severe anemia.  The decision to proceed with the medication abortion will depend on the clinical setting and available resources.

     
    Lesson 2.5

    • While there are no absolute lab requirements prior to abortion, many providers perform Rh testing (when Rh immunoglobulin is available) and a hemoglobin test, along with offering screening for sexually transmitted infection (e.g., chlamydia, gonorrhea, HIV).


  •  

    Learning Objectives

    At the end of this lesson, learners will be able to:

    • Describe in detail the steps required to provide a medication abortion using mifepristone and misoprostol
    • Describe indications and methods for medication abortion using misoprostol alone
    • Describe indications and methods for medication abortion using methotrexate

    Click here for the brief module introduction


  • Key Points
    • Mifepristone and misoprostol together represent a safe and effective method for medication abortion—the preferred method when these medications are available.
    • In most countries, the mifepristone/misoprostol regimen is available for use up to 70 days gestation.
    • The recommended dosing for maximum efficacy is 200 mg mifepristone orally, followed in 24–48 hours by 800 mcg misoprostol via buccal, sublingual, or vaginal route.
    • Evidence also supports an alternative protocol of 200 mg mifepristone, followed in 6–72 hours by 800 mcg misoprostol vaginally.

     

    Learning Objectives

    • Identify different regimens involving the use of both mifepristone and misoprostol for medication abortion
    • Describe in detail the current evidence-based regimen options to provide a medication abortion using mifepristone and misoprostol
    • Identify what regional regulations of mifepristone and misoprostol will apply to your clinical practice, and identify the local standard of care

    When legal and available, the use of mifepristone and misoprostol in a combined regimen is recommended for medication abortion. Different regimens for medication abortion using mifepristone and misoprostol are used around the world. The required readings below are based on data supported by clinical trials and evidence-based practice. Note that the majority of evidence supports the use of mifepristone and misoprostol under 70 days gestation. There is some evidence for medication abortion in higher gestational ages, although this is not legally available in all regions, including the United States and Canada. The final reading, from the World Health Organization, examines regimens for gestational ages > 70 days, which may be used in some settings. Always consult your regional laws and restrictions, which may affect what regimen is available in your practice area.

    Click here to start this module

    3 URLs, 1 Forum

  • Key Points

    • Misoprostol-only abortion is a safe and effective alternative in settings where mifepristone is not available, but it is less effective than the mifepristone/misoprostol combined regimen.
    • In most countries, the misoprostol regimen is available.
    • The misoprostol regimen is most effective before 63 days gestation but can be used at higher gestational ages when permitted.
    • In the first trimester, the recommended dosing for misoprostol-only abortion is 800 mcg by vaginal, buccal or sublingual route, repeated every 3 to 12 hours, for up to 3 doses.

     

    Learning Objectives

    • Identify indications for use of a misoprostol-only regimen for medication abortion
    • Identify the relative effectiveness of a misoprostol-only regimen versus combined mifepristone/misoprostol for first-trimester abortion
    • Describe the recommended regimens to provide a medication abortion using misoprostol alone
    • Identify what regional regulations of misoprostol will apply to your clinical practice, and identify the local standard of care

    Although misoprostol-only regimens are not as effective in completing abortion than mifepristone-misoprostol combined regimens, it is a good option for medication abortion in settings where mifepristone is not available.  There are legal and political barriers worldwide that limit the availability of mifepristone, while misoprostol is more widely available (given its other uses), is inexpensive and does not require refrigeration.

    The reading below will go over, in more detail, the history and recommended protocol for providing a medication abortion using misoprostol only


    One of the recommended dosing protocols for misoprostol-only medication abortion is 800 mcg by vaginal, buccal, or sublingual route, repeated every 3-12 hours for up to 3 doses or until the passage of POC. There are other protocols which can be used, and are reviewed further in the reading.

    Because misoprostol-only medication abortion is not as effective as the combined regimen, all patients should have follow up to confirm abortion completion. 

    Click here to start this module

    3 URLs, 1 Forum

  • Key Points
    • Methotrexate can be used for medication abortion, but has more side effects than other regimens.
    • The use of methotrexate has been limited since the introduction of mifepristone.

     

    Learning Objectives

    • Describe indications and methods for medication abortion using methotrexate
    • Identify what regional regulations of methotrexate will apply to your clinical practice, and identify the local standard of care

    Methotrexate is now an infrequently used method for medication abortion, although it was more heavily utilized prior to the introduction of mifepristone.

    Currently, the main clinical application of methotrexate is for management of ectopic pregnancy. Methotrexate for medication abortion is sometimes also used in the management of pregnancies of unknown location for women with an undesired pregnancy.  The current lesson is designed as a general overview of methotrexate.

    Click here to start this module

    1 URL, 1 Forum

  • Key Points

    Lesson 3.1

    • Mifepristone and misoprostol together represent a safe and effective method for medication abortion—the preferred method when these medications are available.
    • In most countries, the mifepristone/misoprostol regimen is available for use up to 70 days gestation.
    • The recommended dosing for maximum efficacy is 200 mg mifepristone orally, followed in 24–48 hours by 800 mcg misoprostol via buccal, sublingual, or vaginal route.
    • Evidence also supports an alternative protocol of 200 mg mifepristone, followed in 6–72 hours by 800 mcg misoprostol vaginally

     
    Lesson 3.2

    • Misoprostol-only abortion is a safe and effective alternative in settings where mifepristone is not available, but it is less effective than the mifepristone/misoprostol combined regimen.
    • In most countries, the misoprostol regimen is available.
    • The misoprostol regimen is most effective before 63 days gestation but can be used at higher gestational ages when permitted.
    • In the first trimester, the recommended dosing for misoprostol-only abortion is 800 mcg by vaginal or sublingual route, repeated every 3 to 12 hours, for up to 3 doses.

     
    Lesson 3.3

    • Methotrexate can be used for medication abortion, but has more side effects than other regimens. 
    • The use of methotrexate has been limited since the introduction of mifepristone.


    • Learning Objectives

      At the end of this lesson, learners will be able to:

      • Explain to a patient what to expect from the medication abortion process, including what to expect in the clinic, at home, and during follow-up
      • Explain to a patient the range of potential side effects, and what warning signs to look for to return to the clinic for evaluation
      • Describe pharmacologic and non-pharmacologic methods for pain control
      • Describe the evidence for antibiotic prophylaxis during medication abortion
      • Describe the evidence for anti-D immunoglobulin use
      • Counsel women on contraceptive options after medication abortion
      • List all appropriate regimens for medication abortion, including for in-clinic and at-home use

      Click here for the brief module introduction


    • Key Points
      • The expected effects of medication abortion may include bleeding with clots, cramping, diarrhea, headache, and vomiting.
      • woman should call the clinic immediately if she experiences excessive bleeding, fever > 24 hours after taking misoprostol, bad-smelling discharge, severe abdominal pain, or if she otherwise is feeling very ill.

       

      Learning Objectives

      • Explain to a patient what to expect from the medication abortion process, including what to expect in clinic, at home, and during follow-up
      • Explain to a patient what side effects she may experience and what warning signs to look for to return to clinic for evaluation

      Click here to start this module

      5 URLs

    • Key Points
      • Pain control is an important part of counseling a woman for medication abortion so that she maintains appropriate expectations and knows how to manage her symptoms.
      • Most women take one dose of at least ibuprofen for pain during the heaviest bleeding after misoprostol. Some women will also take an oral opiate analgesic if available. Anxiolytics may also be considered.
      • Non-pharmacologic pain control options include heating pads, support persons, and a supportive environment (acceptable child care, safe housing, and available bathrooms and sanitary supplies).

       

      Learning Objectives

      • Describe pharmacologic and non-pharmacologic methods for pain control during medication abortion

      Click here to start this module

      1 URL

    • Key Points
      • Insufficient data exist to recommend the routine use of prophylactic antibiotics during medication abortion.
      • Although rare, serious infections do occur, antibiotics are unlikely to play a prophylactic role; providers and patients should be informed about this risk, and any symptoms of infection should be managed aggressively.
      • Some clinics or regions will direct the use of antibiotic prophylaxis as protocol or the standard of care. As always, be aware of your regional requirements.

       

      Learning Objectives

      • Describe the evidence for antibiotic prophylaxis during medication abortion, and how to prescribe when indicated
      • Identify the local regulations and standard of care regarding use of antibiotics in your practice area

      Click here to start this module

      1 URL, 1 Forum

    • Key Points
      • No data indicate that Rh alloimmunization occurs during first-trimester abortion or miscarriage.
      • Rh testing is routinely done and is the standard of care in many settings where anti-D immunoglobulin is readily available for patients.
      • Rh testing and anti-D (rh) immunoglobulin are not requirements for medication abortion and are not administered in many settings, especially where anti-D immunoglobulin is not readily available.

       

      Learning Objectives

      • Describe the evidence for anti-D immunoglobulin use during medication abortion, and how to prescribe when indicated
      • Identify the local regulations and standard of care regarding use of Rh testing and anti-D immunoglobulin in your practice area

      Click here to start this module


    • Key Points
      • Contraception should be offered to women at the time the medication abortion is initiated (at the time of mifepristone), as ovulation may occur soon after the abortion is complete.
      • Combined contraceptives, the progestin-only implant, and medroxyprogesterone injections are all safe methods to give at the time of mifepristone, and do not appear to decrease the efficacy of the medication abortion.
      • Progestin or copper intrauterine devices should be inserted at follow-up as soon as ongoing pregnancy has been reliably excluded.

       

      Learning Objectives

      • Describe the contraceptive methods available after medication abortion
      • Describe when to initiate each contraceptive method after medication abortion

      Click here to start this module

      4 URLs
    • Learning Objectives

      • List all appropriate medicines for medication abortion, including for in-clinic and at-home use
      • Make a “to-do” checklist for pre-abortion and abortion care that is pertinent to your practice area

      Click here to start this module

      1 Forum

    • Key Points

      Lesson 4.1

      • The expected effects of medication abortion may include bleeding with clots, cramping, diarrhea, headache, and vomiting.
      • woman should call the clinic immediately if she experiences excessive bleeding, fever > 24 hours after taking misoprostol, bad-smelling discharge, severe abdominal pain, or if she otherwise is feeling very ill.

       
      Lesson 4.2

      • Pain control is an important part of counseling a woman for medication abortion so that she maintains appropriate expectations and knows how to manage her symptoms.
      • Most women take one dose of at least ibuprofen for pain during the heaviest bleeding after misoprostol. Some women will also take an oral opiate analgesic if available. Anxiolytics may also be considered.
      • Non-pharmacologic pain control options include heating pads, support persons, and a supportive environment (acceptable child care, safe housing, and available bathrooms and sanitary supplies).

       
      Lesson 4.3

      • Insufficient data exist to recommend the routine use of prophylactic antibiotics during medication abortion.
      • Although rare, serious infections do occur, antibiotics are unlikely to play a prophylactic role; providers and patients should be informed about this risk, and any symptoms of infection should be managed aggressively.
      • Some clinics or regions will direct the use of antibiotic prophylaxis as protocol or the standard of care. As always, be aware of your regional requirements.


      Lesson 4.4

      • No data indicate that Rh alloimmunization occurs during first-trimester abortion or miscarriage.
      • Rh testing is routinely done and is the standard of care in many settings where anti-D immunoglobulin is readily available for patients.
      • Rh testing and anti-D (rh) immunoglobulin are not requirements for medication abortion and are not administered in many settings, especially where anti-D immunoglobulin is not readily available.


      Lesson 4.5

      • Contraception should be offered to women at the time the medication abortion is initiated (at the time of mifepristone), as ovulation may occur soon after the abortion is complete.
      • Combined contraceptives, the progestin-only implant, and medroxyprogesterone injections are all safe methods to give at the time of mifepristone, and do not appear to decrease the efficacy of the medication abortion.
      • Progestin or copper intrauterine devices should be inserted at follow-up as soon as ongoing pregnancy has been reliably excluded.


      • Learning Objectives

        At the end of this lesson, learners will be able to:

        • Identify steps needed to confirm completion of medication abortion
        • Describe the most common outcomes of medication abortion
        • Describe the most common complications of medication abortion
        • Describe management of complications after medication abortion
        • Discuss myths about abortion care complications and describe where to find data to help counteract those myths

        Click here to start this module


      • Key Points
        • Follow-up requirements will vary by geographic region – but in any setting, each woman should be offered a follow-up visit if she prefers.
        • During the follow-up visit, providers can confirm that the abortion is complete, manage any side effects or complications, answer any questions, and address contraception.
        • Assessing abortion completion can be done either by trending bhCG, repeating an ultrasound, or repeating the bimanual exam. The medication abortion process and symptoms of ongoing pregnancy should be assessed in all patients.
        • A follow-up ultrasound should not show any residual gestational sac or products of conception (POC). A thin endometrial stripe or a thickened heterogeneous lining may be present. Neither finding warrants intervention unless the patient is having symptoms. Any finding of retained POC or sac warrants intervention.
        • Quantitative serum hCG levels should drop by 50% within 48 hours of bleeding, or by 80% within 7 days of bleeding.
        • On bimanual exam, if the woman has had a pregnancy up to 7 weeks, the uterus should feel non-pregnant within 2 weeks of bleeding. If gestation was 8 weeks or more, the uterus should feel smaller within 2 weeks of bleeding.

         

        Learning Objectives

        • Identify the steps needed to confirm successful medication abortion

        Click here to start this module

        2 URLs

      • Key Points
        • The most common outcome after medication abortion is that the woman is no longer pregnant and has no abnormal symptoms.
        • The most common abnormal findings at follow-up are problematic bleeding, ongoing pregnancy, and persistent pain.
        • Problematic bleeding (not hemorrhage) can be treated with watchful waiting, repeating a dose of misoprostol, or aspiration.
        • Vacuum aspiration is recommended for ongoing pregnancy after mifepristone/misoprostol. Repeat misoprostol or vacuum aspiration are options for women with retained POC, such as a non-viable pregnancy or a retained sac.
        • Women with ongoing pain after medication abortion should be worked up for etiology, which may include infection, ectopic pregnancy, or trapped tissue in the cervix.
        • Infection is rare. Endometritis should be treated as PID, per local guidelines. Severe infection is rare, but may be caused by Clostridium sordellii bacteria and can be fatal; symptoms should be treated rapidly and aggressively.

         

        Learning Objectives

              • Describe the most common outcomes of medication abortion
              • Describe common situations that may warrant additional intervention, and describe the treatment options available
              • Describe the potential, more serious complications of medication abortion
              • Describe the general management of each complication

          Click here to start this module

          3 URLs, 2 Forums
        • Learning Objectives

          • Identify several of the common myths about abortion and abortion complications

          As you approach the end of this course, consider again the patients whose lives are affected by abortion and by restricted abortion access. In the introduction, some of these stories were revealed; you also read about several abortion myths. Keeping in mind the material you have learned since then, we revisit some of these myths to present a fuller picture of the factors impacting women’s ability to access abortion.

          Click here to start this module

          3 URLs

        • Key Points

          Lesson 5.1

          • Follow-up requirements will vary by geographic region – but in any setting, each woman should be offered a follow-up visit if she prefers.
          • During the follow-up visit, providers can confirm that the abortion is complete, manage any side effects or complications, answer any questions, and address contraception.
          • Assessing abortion completion can be done either by trending bhCG, repeating an ultrasound, or repeating the bimanual exam. The medication abortion process and symptoms of ongoing pregnancy should be assessed in all patients.
          • A follow-up ultrasound should not show any residual gestational sac or products of conception (POC). A thin endometrial stripe or a thickened heterogeneous lining may be present. Neither finding warrants intervention unless the patient is having symptoms. Any finding of retained POC or sac warrants intervention.
          • Quantitative serum hCG levels should drop by 50% within 48 hours of bleeding, or by 80% within 7 days of bleeding.
          • On bimanual exam, if the woman has had a pregnancy up to 7 weeks, the uterus should feel non-pregnant within 2 weeks of bleeding. If gestation was 8 weeks or more, the uterus should feel smaller within 2 weeks of bleeding.

           
          Lesson 5.2

          • The most common outcome after medication abortion is that the woman is no longer pregnant and has no abnormal symptoms.
          • The most common abnormal findings at follow-up are problematic bleeding, ongoing pregnancy, and persistent pain.
          • Problematic bleeding (not hemorrhage) can be treated with watchful waiting, repeating a dose of misoprostol, or aspiration.
          • Vacuum aspiration is recommended for ongoing pregnancy after mifepristone/misoprostol. Repeat misoprostol or vacuum aspiration are options for women with retained POC, such as a non-viable pregnancy or a retained sac. 
          • Women with ongoing pain after medication abortion should be worked up for etiology, which may include infection, ectopic pregnancy, or trapped tissue in the cervix.
          • Infection is rare. Endometritis should be treated as PID, per local guidelines. Severe infection is rare, but may be caused by Clostridium sordellii bacteria and can be fatal; symptoms should be treated rapidly and aggressively.


          • Learning Objectives

            At the end of this lesson, learners will be able to:

            • List many common barriers to providing medication abortion services
            • Describe resources and support organizations to help mitigate these barriers
            • Describe alternative methods of abortion provision, including telemedicine or self-administered medication abortion
            • Identify sources of logistical support to facilitate initiation of medication abortion services

            Click here to start this module

          • It is important to recognize the potential barriers to providing abortion care.  This list is not comprehensive - many barriers are geographically-dependent, and you need to consider your own practice area’s limitations.

            In general, barriers can be:

            1. Provider barriers
            2. Patient barriers
            3. Clinic barriers
            4. Legal barriers (which can be related to any of the first 3 categories)

            Click here to start this module

            3 URLs, 1 Forum
          • Learning Objectives

            • Describe how telemedicine can be an effective method to expand access to medication abortion
            • Describe how self-managed abortion can be a safe effective method to expand access to medication abortion

            Click here to start this module

            9 URLs
          • Not available

            There is no required reading for this section.  Instead, this lesson is to provide you with a list of resources that you may choose to use in entirety or to adapt to your specific clinical needs.  This list is not exhaustive, and many additional resources exist. If there is a resource you think should be included, let us know at NextGenU.org.

          • There is no required reading for this section.  Instead, this lesson is to provide you with a list of resources that you may choose to use in entirety or to adapt to your specific clinical needs.  This list is not exhaustive, and many additional resources exist. If there is a resource you think should be included, let us know at NextGenU.org.

            Click here to start this module

            98 URLs
          • 1 Questionnaire
            1. Achilles SL, Reeves MF. Society for Family Planning guidelines: Prevention of infection after induced abortion. Contraception. 2011;83(4):295-309. doi:10.1016/j.contraception.2010.11.006.
            2. Guiahi M, Davis A. Society for Family Planning guidelines: First-trimester abortion in women with medical conditions. Contraception. 2012;86(6):622-630. doi:10.1016/j.contraception.2012.09.001.
            3. Kerns J, Steinauer J. Management of postabortion hemorrhage. Contraception. 2013;87(3):331-342. doi:10.1016/j.contraception.2012.10.024.
            4. Fox MC, Krajewski CM. Society for Family Planning guidelines: Cervical preparation for second-trimester surgical abortion prior to 20 weeks’ gestation. Contraception. 2014;89(2):75-84. doi:10.1016/j.contraception.2013.11.001.
            5. Allen RH, Goldberg AB. Society for Family Planning guidelines: Cervical dilation before first-trimester surgical abortion (<14 weeks’ gestation). Contraception. 2007;76(2):139-156. doi:10.1016/j.contraception.2007.05.001.

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