Clinical Updates in Reproductive Health

Confirmation of success

Last reviewed: October 19, 2022

Recommendation:

  • Most people undergoing medical abortion with a recommended medication regimen will have a successful abortion; routine follow-up is not required.
  • Providers may perform a clinical assessment to assist in the confirmation of successful abortion.
  • Ultrasound or other testing is needed only in cases where the diagnosis is unclear.

Strength of recommendation: Strong

Quality of evidence: Moderate

In practice:

  • Individuals undergoing medical abortion should be given adequate information about when to seek additional care for a possible complication. This includes:
      • Heavy bleeding or soaking through more than 2 sanitary pads an hour for 2 hours in a row;
      • Fever or flu-like illness developing more than 24 hours after using misoprostol;
      • Severe or worsening pain, including pain which could indicate an undiagnosed ectopic pregnancy;
      • Unusual or foul-smelling vaginal discharge.
  • Individuals undergoing medical abortion should be given adequate information about signs and symptoms that might indicate an ongoing pregnancy for which clients should seek medical attention, including:
      • Experiencing no bleeding or only spotting in the 24 hours after using misoprostol;
      • Continuing to feel pregnant 1 week after using abortion medications.
  • Urine pregnancy tests may still have a positive result up to 4 weeks after a successful medical abortion.

Medical abortion with mifepristone and misoprostol

The success rate of mifepristone followed by misoprostol for medical abortion up to 10 weeks gestation is over 95%, with ongoing pregnancy rates of less than 2% (Chen & Creinin, 2015; Kulier et al., 2011; Raymond et al., 2012). The World Health Organization (WHO) states that routine follow-up after medical abortion with mifepristone and misoprostol is not required (2022), advising instead that individuals should be adequately informed about symptoms of ongoing pregnancy and other medical reasons to return for follow-up such as prolonged heavy bleeding, no bleeding at all with medical management of abortion, pain not relieved by medication, or fever. Multiple strategies have been examined to confirm a successful medical abortion and identify rare ongoing pregnancies when using the mifepristone and misoprostol regimen.

Self-assessment based on symptoms

Evidence indicates that individuals can accurately determine when their mifepristone and misoprostol medical abortion is successful—that is, whether pregnancy expulsion has occurred. In studies comparing self-assessments of expulsion based on their symptoms to those made by clinicians (Cameron et al., 2015; Clark et al., 2010; Perriera et al., 2010; Rossi, Creinin, & Meyn, 2004) and by ultrasound (Rossi et al., 2004), self-assessment has repeatedly proven to be nearly as accurate as both.

Clinical assessment

Providers may help confirm successful mifepristone and misoprostol abortion at a follow-up visit by reviewing the client’s history and performing a bimanual exam, if indicated. In studies comparing clinical assessment to ultrasound (Rossi et al., 2004; Pymar, Creinin, & Schwartz, 2001), clinicians determined pregnancy expulsion with high levels of accuracy.

Ultrasound

Ultrasound can be used to confirm successful abortion but is not necessary and can add to the cost and complexity of medical abortion, particularly where providers are inexperienced in reading post-medical abortion ultrasound (Kaneshiro et al., 2011). Ultrasound is helpful in cases where there is doubt about the presence of an ongoing pregnancy.

Serum pregnancy testing

Serum pregnancy testing has been used as an alternative to ultrasound to diagnose an ongoing pregnancy following mifepristone and misoprostol and compares favorably to ultrasound in reducing interventions at the time of follow-up (Clark et al., 2007; Dayananda et al., 2013; Fiala et al., 2003). Serum pregnancy testing is mostly useful when a pre-treatment hCG has been obtained for comparison; hCG declines by more than 90% seven days after mifepristone is administered in the case of a successful medical abortion (Pocius et al., 2016). A serum hCG level below 900 IU 14-21 days after early (<63 days gestation) medical abortion excludes ongoing pregnancy (Le Lous et al., 2018).

Urine pregnancy testing

A negative urine pregnancy test is reassuring that an abortion has been successful. Rarely, however, a pregnancy test is negative but a person is still pregnant (false negative). Both high-sensitivity and low-sensitivity urine pregnancy tests can have positive results even when the medical abortion has been successful (false positive) due to hcg levels that remain elevated for at least 18 days after a medical abortion (Cameron et al., 2012; Clark et al., 2010; Godfrey et al., 2007; Perriera et al., 2010; Raymond et al., 2021). In a case series including 258 people with successful medical abortions who performed a high-sensitivity pregnancy test four weeks after taking mifepristone, 19% had a false positive result (Raymond et al., 2021). A number of studies have examined use of low-sensitivity (Cameron et al., 2012, Cameron et al., 2015; Constant et al., 2017; Iyengar et al., 2015; Michie & Cameron, 2014) and semi-quantitative or multi-level (Anger et al., 2019; Chong et al., 2020; Oppegaard et al., 2015; Raymond et al., 2017a; Raymond et al., 2017b) urine pregnancy tests, often in combination with a symptom checklist, to confirm a successful abortion or identify an ongoing pregnancy without returning for follow-up. One small trial randomized 88 participants with pregnancies of less than 63 days to independently use a low-sensitivity or a multi-level pregnancy test to determine medical abortion success, finding that individuals could correctly use and accurately interpret the results of these tests (Fok et al., 2021). A 2018 systematic review assessed the accuracy of using low-sensitivity pregnancy testing to identify ongoing pregnancy after medical abortion (Raymond, Shocket, & Bracken, 2018a), finding that a positive or invalid low-sensitivity pregnancy test had only moderate sensitivity for detecting ongoing pregnancy. A subsequent diagnostic accuracy study found that a low-sensitivity pregnancy test performed two weeks after mifepristone administration correctly identified all continuing pregnancies in a cohort of 558 people between 64 and 70 days gestation; the false positive rate was 15% (Whitehouse, Shochet, & Lohr, 2022). A 2017 meta-analysis, which included seven studies that examined use of multi-level pregnancy tests to confirm abortion success when using the combined regimen up to 9 weeks gestation, found that the tests identified all continuing pregnancies (21 out of 1,599 participants, 1.3%) and that most people can successfully perform the tests themselves at home (Raymond et al., 2017a). Multi-level pregnancy tests measure the approximate concentration of urinary hcg; a decline in hcg concentration between a test performed immediately before and one to two weeks after medical abortion indicates abortion success. Because hcg levels naturally fall in the late first trimester, multilevel pregnancy tests can only be used in the early first trimester (Chong, et al., 2020).

Two  systematic reviews in 2019 compared outcomes for women who self-assessed medical abortion success at home using a low-sensitivity or semi-quantitative urine pregnancy test in combination with a pictorial instruction sheet, symptom checklist or no checklist, to women who received routine clinic follow- up (Baiju et al., 2019; Schmidt-Hansen et al., 2019). Both reviews included four studies and more than 5,000 women and agreed that there were no differences in successful abortion, ongoing pregnancy, need for surgical intervention, or incidence of infection or hemorrhage between self-assesment and clinic follow-up groups. 

Medical abortion with misoprostol only

The WHO states that routine follow-up after medical abortion with misoprostol alone is not required (2022), advising instead that individuals should be adequately informed about symptoms of ongoing pregnancy and other medical reasons to return for follow-up such as prolonged heavy bleeding, no bleeding at all with medical management of abortion, pain not relieved by medication, or fever. Due to the lower success rate (80-85%) and higher rate of ongoing pregnancy following misoprostol-only medical abortion before 13 weeks gestation (von Hertzen et al., 2007), more people using misoprostol alone for their medical abortion will require additional care than those using the combined mifepristone and misoprostol regimen.

Follow-up assessment

There are no studies examining different strategies to determine abortion success when using the misoprostol-only regimen. Possible follow-up strategies, extrapolated from studies about the combined regimen (detailed above) and programmatic data, include a history and physical examination, bimanual examination, ultrasound and/or a serum or urine pregnancy testing to rule out an ongoing pregnancy.

References

Anger, H., Dabash, R., Pena, M., Coutino, D., Bousieguez, M., Sanhueza, P., & Winikoff, B. (2019). Use of an at-home multilevel pregnancy test and an automated call-in system to follow-up the outcome of medical abortion. International Journal of Gynaecology and Obstetrics, 144(1), 97-102.

Baiju, N., Acharya, G., D’Antonio, F., & Berg, R. C. (2019). Effectiveness, safety and acceptability of self-assessment of the outcome of first-trimester medical abortion: A systematic review and meta-analysis. BJOG : An International Journal of Obstetrics and Gynaecology, 126(13), 1536-1544.

Cameron, S. T., Glasier, A., Dewart, H., Johnstone, A., & Burnside, A. (2012). Telephone follow-up and self-performed urine pregnancy testing after early medical abortion: A service evaluation. Contraception, 86(1), 67-73.

Cameron, S. T., Glasier, A., Johnstone, A., Dewart, H., & Campbell, A. (2015). Can women determine the success of early medical termination of pregnancy themselves? Contraception, 91, 6-11.

Chong, E., Sheldon, W.R., Lopez-Green, D., Gonzalez, H.C., Castillo, B.H., Ogando, M.G., Tuladhar, N., & Blum, J. (2020). Feasibility of multilevel pregnancy tests for telemedicine abortion service follow-up: A pilot study. International Perspectives on Sexual and Reproductive Health, 46(Supple1), 67-75.  

Clark, W., Bracken, H., Tanenhaus, J., Schweikert, S., Lichtenberg, E. S., & Winikoff, B. (2010). Alternatives to a routine follow-up visit for early medical abortion. Obstetrics & Gynecology, 115(2 Pt 1), 264-272.

Clark, W., Panton, T., Hann, L., & Gold, M. (2007). Medication abortion employing routine sequential measurements of serum hCG and sonography only when indicated. Contraception, 75(2), 131-135.

Chen, M. J., & Creinin, M. D. (2015). Mifepristone with buccal misoprostol for medical abortion: A systematic review. Obstetrics & Gynecology, 126(1), 12-21.

Constant, D., Harries, J., Daskilewicz, K., Myer, L., & Gemzell-Danielsson, K. (2017). Is self-assessment of medical abortion using a low-sensitivity pregnancy test combined with a checklist and phone text messages feasible in South African primary healthcare settings? A randomized trial. PLoS One, 12(6), e0179600. Doi: 10.1371/journal.pone.0179600.

Dayananda, I., Maurer, R., Fortin, J., & Goldberg, A. B. (2013). Medical abortion follow-up with serum human chorionic gonadotropin compared with ultrasonography: A randomized controlled trial. Obstetrics & Gynecology, 121(3), 607-613.

Fiala, C., Safar, P., Bygdeman, M., & Gemzell-Danielsson, K. (2003). Verifying the effectiveness of medical abortion; ultrasound versus hCG testing. European Journal of Obstetrics andGynecology and Reproductive Biology, 109(2), 190-195.

Fok, W.K., Lerma, K., Shaw, K.A., & Blumenthal, P.D. (2021). Comparison of two home pregnancy tests for self-confirmation of medication abortion status: A randomized trial. Contraception, 104(3), 296-300.

Godfrey, E. M., Anderson, A., Fielding, S. L., Meyn, L., & Creinin, M. D. (2007). Clinical utility of urine pregnancy assays to determine medical abortion outcome is limited. Contraception, 75(5), 378-382.

Iyengar, K., Paul, M., Iyengar, S. D., Klingberg-Allvin, M., Essen, B., Bring, J., … Gemzell-Danielsson, K. (2015). Self-assessment of the outcome of early medical abortion vs. clinic follow-up in India: A randomised, controlled, non-inferiority trial. Lancet Global Health, 3(9), e537-545.

Kaneshiro, B., Edelman, A., Sneeringer, R. K., & Gómez Ponce de León, R. (2011). Expanding medical abortion: Can medical abortion be effectively provided without the routine use of ultrasound? Contraception, 83(3), 194-201.

Kulier, R., Kapp, N., Gulmezoglu, A. M., Hofmeyr, G. J., Cheng, L., & Campana, A. (2011). Medical methods for first trimester abortion. The Cochrane Database of Systematic Reviews (11), CD002855.

Le Lous, M., Gallinand, A. C. , Laviolle, B., Peltier, L., Nyangoh Timoh, K., & Lavoue, V. (2018). Serum hCG threshold to assess medical abortion success. The European Journal of Contraception & Reproductive Health Care, 23(6), 458-463.

Michie, L., & Cameron, S. T. (2014). Simplified follow-up after early medical abortion: 12 months experience of a telephone call and self-performed low sensitivity urine pregnancy test. Contraception, 89(5), 440-445.

Oppegaard, K. S., Qvigstad, R., Fiala, C., Heikinheimo, O., Benson, L., & Gemzell-Danielsson, K. (2015). Clinical follow-up compared with self-assessment of outcome after medical abortion: A multicentre, non-inferiority, randomised, controlled trial. The Lancet, 385(9969), 698-704.

Perriera, L. K., Reeves, M. F., Chen, B. A., Hohmann, H. L., Hayes, J., & Creinin, M. D. (2010). Feasibility of telephone follow-up after medical abortion. Contraception, 81(2), 143-149.

Pocius, K. D., Bartz, D., Maurer, R., Stenquist, A., Fortin, J., & Goldberg, A. B. (2016). Serum human chorionic gonadotropin (hCG) trend within the first few days after medical abortion: A prospective study. Contraception, 94(4), 394-395.

Pymar H., Creinin, M. D., Schwartz, J. L. (2001). Mifepristone followed on the same day by vaginal misoprostol for early abortion. Contraception, 64, 87-92.

Raymond, E.G., Anger, H.A., Chong, E., Haskell, S., Grant, M., Boraas, C., Tocce, K., Banks, J., Kaneshiro, B., Baldwin, M.K., Coplon, L., Bednarek, P., Shochet, T., & Platais, I. (2021). “False positive” urine pregnancy test results after successful medication abortion. Contraception, 103(6), 400-403.

Raymond, E. G., Shannon, C., Weaver, M. A., & Winikoff, B. (2012). First-trimester medical abortion with mifepristone 200 mg and misoprostol: A systematic review. Contraception, 87(1), 26-37.

Raymond, E. G., Shochet, T., Blum, J., Sheldon, W. R., Platais, I., Bracken, H., … Winikoff, B. (2017a). Serial multilevel urine pregnancy testing to assess medical abortion outcome: A meta-analysis. Contraception, 95(5), 442-448.

Raymond, E. G., Shochet, T., & Bracken, H. (2018a). Low-sensitivity urine pregnancy testing to assess medical abortion outcome: A systematic review. Contraception, 58, 30-35.

Raymond, E. G., Tan, Y. L., Grant, M., Benavides, E., Reis, M., Sacks, D., … Weaver, M. A. (2018b). Self-assessment of medical abortion outcome using symptoms and home pregnancy testing. Contraception, 97, 324-328.

Rossi, B., Creinin, M. D., & Meyn, L. A. (2004). Ability of the clinician and patient to predict the outcome of mifepristone and misoprostol medical abortion. Contraception, 70(4), 313-317.

Schmidt-Hansen, M., Cameron, S., Lohr, P. A., & Hasler, E. (2019). Follow-up strategies to confirm the success of medical abortion of pregnancies up to 10 weeks’ gestation: A systematic review with meta-analyses. American Journal of Obstetrics and Gynecology, 222(6):551-563..

von Hertzen, H., Piaggio, G., Huong, N. T., Arustamyan, K., Cabezas, E., Gomez, M., & Peregoudov, A. (2007). Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: A randomised controlled equivalence trial. The Lancet, 369(9577), 1938-1946.

Whitehouse, K.C., Shochet, T., & Lohr, P.A. (2022). Efficacy of a low-sensitivity urine pregnancy test for identifying ongoing pregnancy after medication abortion at 64 to 70 days of gestation. Contraception, 110, 21-26.

World Health Organization. (2022). Abortion care guideline. Geneva: World Health Organization.

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