Last reviewed: February 7, 2021
Recommendation:
- Most women undergoing abortion with a combined regimen of mifepristone and misoprostol have a successful abortion; routine follow-up is not required.
- Women using a misoprostol-only regimen for medical abortion need follow-up with a clinician to ensure the abortion was successful.
- 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
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, Shannon, Weaver, & Winikoff, 2012). The World Health Organization (WHO) states that routine follow-up after medical abortion with mifepristone and misoprostol is not required (2014). Multiple strategies have been examined to confirm a successful medical abortion and identify rare ongoing pregnancies when using the mifepristone and misoprostol regimen.
Women’s assessment of successful abortion
Evidence indicates that women can accurately determine when their mifepristone and misoprostol medical abortion is successful—that is, whether pregnancy expulsion has occurred. In studies comparing women’s assessments of expulsion based on their symptoms to those made by clinicians (Cameron, Glasier, Johnstone, Dewart, & Campbell, 2015; Clark et al., 2010; Perriera et al., 2010; Rossi, Creinin, & Meyn, 2004) and by ultrasound (Rossi et al., 2004), women have 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 a patient 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, Edelman, Sneeringer, & Gómez Ponce de León, 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, Panton, Hann, & Gold, 2007; Dayananda, Maurer, Fortin, & Goldberg, 2013; Fiala, Safar, Bygdeman, & Gemzell-Danielsson, 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 woman 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) (Cameron, Glasier, Dewart, Johnstone, & Burnside, 2012; Clark et al., 2010; Godfrey, Anderson, Fielding, Meyn, & Creinin, 2007; Perriera et al., 2010). A number of studies have examined use of low-sensitivity (Cameron et al., 2012, Cameron et al., 2015; Constant, Harries, Daskilewicz, Myer, & Gemzell-Danielsson, 2017; Iyengar et al., 2015; Michie & Cameron, 2014) and semi-quantitative or multi-level (Anger et al., 2019; 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. A 2018 systematic review assessed the accuracy of using low-sensitivity pregnancy testing to identify ongoing pregnancy after medical abortion (Raymond, Shocket, & Bracken, 2018a); it found that a positive or invalid low-sensitivity pregnancy test had only moderate sensitivity for detecting ongoing pregnancy. 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 women can successfully perform the tests themselves at home (Raymond et al., 2017a).
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, Acharya, D’Antonio, & Berg, 2019; Schmidt-Hansen, Cameron, Lohr, & Hasler, 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. However, a 2018 prospective cohort study found that 14% of women, when directed to use a symptom analysis and multi-level pregnancy test to determine abortion success, failed to implement these measures correctly, although none of the women had an ongoing pregnancy or serious adverse event (Raymond et al., 2018b).
Medical abortion with misoprostol only
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), WHO recommends routine clinic follow-up for all women undergoing medical abortion with misoprostol only to ensure success of the abortion (WHO, 2014).
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
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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.
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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.
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