As maternity and OB/GYN deserts spread across the United States, medication abortion to expel the fetus and placenta from the uterus without a surgical procedure is possible and can work safely and well between 14 weeks and nearly 28 weeks of gestation.1
There are few absolute contraindications to medication abortion from 14 to 27 weeks of gestation, according to the Society of Family Planning and Society of Maternal-Fetal Medicine’s new clinical recommendation.1
“This isn’t controversial. It’s standard practice,” says Blake Zwerling, MD, MSc, an assistant clinical professor at UC Davis Health in Sacramento. “Medication abortion between 14 and 27 weeks is primary in most parts of the world — not in the United States because abortion care has been siloed. We often induce it in the inpatient setting for fetal anomalies and pregnancy complications, but there is no reason you couldn’t do it for other indications, as well, except often hospital policy is limiting.”
The recommendation is for the use of mifepristone 200 mg orally, 24 to 28 hours before misoprostol, followed by misoprostol 400 mcg every three hours vaginally, sublingually, or buccally, between 14 weeks and 23 weeks of gestation.1
“These guidelines were not focusing on safety. Overall, it’s a very safe procedure — safer than carrying a pregnancy to term,” Zwerling says. “It’s comparable to procedural abortion D&C [dilation and curettage] — overall very safe and can even be done in outpatient settings, only limited by logistical concerns.”
The chief challenge is political. “Abortion care is political and controversial right now, and it depends on state and hospital regulations,” Zwerling says. “People often choose medication abortion in gestational limitation if they want to do an autopsy or hold their baby in case of severe anomalies.”
The Society of Family Planning’s recommendation does not apply to self-managed, at-home medication abortion, which has been approved by the Food and Drug Administration through 11 weeks. “Generally, these later gestation medication abortions are performed with clinician oversight, largely because of pain considerations,” Zwerling explains. “Complications are rare, but when they do happen, it’s nice to have all the resources of a clinic or hospital setting.”
Medication abortion in a clinic setting is a good option for patients. “We really think patients should have a choice in how they choose to terminate their pregnancies,” Zwerling says.
The recommendation suggests that even when mifepristone cannot be given 24 hours before misoprostol, it should still be given to the patient. “Also, nurse practitioners and physician assistants can do this care,” Zwerling notes. “There are very few contraindications to contraception after medication abortion, so most patients can receive contraception at the same visit.”
Because of abortion bans across the United States, mifepristone may not be available in some states. “For those cases where mifepristone is not available, we give recommendations for misoprostol-only regimens,” Zwerling explains.
There also are recommendations for pregnancy beyond 24 weeks duration and for considerations like prior cesarean delivery. “Most clinics don’t have the capacity to offer medication abortion in the U.S. after 11 weeks,” Zwerling says. “It’s a very complicated situation to access abortion in a hospital setting. Often, hospital administrators are not supportive or there aren’t sufficient staff willing to participate in care.”
There are state laws that limit public institutions from providing abortion care. “We’re limited at the federal level by the Hyde Amendment and can’t apply federal dollars to abortion care, so access has become more challenging in the past year,” Zwerling says.
Hospitals, providers, and reproductive health organizations should start a larger and more nuanced conversation about abortion access. They need to address the EMTALA law and how that would apply to pregnant women in medical distress. “How sick do they need to be for abortion to be life-saving care? Do you need to wait for them to get sicker and sicker?” Zwerling asks. The recommendation also discussed reducing misoprostol doses for some patients beyond 24 weeks and noted what to do in cases of a uterine scar.
California has seen an influx of out-of-state patients visiting abortion clinics and hospitals for medication abortion because of severe fetal anomalies for which they could not receive care in their own states. “It’s important to get this information out so we can make this experience as easy and streamlined as possible,” Zwerling adds.
REFERENCE
- Zwerling B, Edelman A, Jackson A, et al. Society of Family Planning clinical recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine. Am J Obstet Gynecol 2023:S0002-9378(23)00726-3.
As maternity and OB/GYN deserts spread across the United States, medication abortion to expel the fetus and placenta from the uterus without a surgical procedure is possible and can work safely and well between 14 weeks and nearly 28 weeks of gestation. There are few absolute contraindications to medication abortion from 14 to 27 weeks of gestation, according to the Society of Family Planning and Society of Maternal-Fetal Medicine’s new clinical recommendation.
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