Medication management of early pregnancy loss and medication abortion has become increasingly common since the U.S. Food and Drug Administration (FDA) approval of mifepristone (Mifeprex) in 2000. Medication abortion now accounts for 60% of all abortions completed before 10 weeks' gestation.¹ The most effective medication regimens combine mifepristone, a progesterone receptor antagonist that causes decidual necrosis and uterine contractions, and misoprostol (Cytotec), a prostaglandin E₁ analogue that causes cervical ripening and uterine contractions. These regimens are safe and acceptable to patients and can be prescribed by primary care clinicians in the outpatient setting.^2–4 Primary care clinicians are uniquely positioned to counsel patients and provide access to medications, with their wide geographic distribution, skills in shared decision-making, and longitudinal relationships with patients; however, only 1% of abortions currently occur in clinicians' offices.¹

Determining Eligibility

Before prescribing mifepristone and misoprostol, clinicians should determine gestational age, evaluate for contraindications, provide patient-centered counseling on management options, and assess the need for laboratory testing.

Regimens using mifepristone and misoprostol are effective up to 84 days' gestation for early pregnancy loss,^2,3 and up to 77 days' gestation for medication abortion.^5–8 Ultrasonography is indicated to establish the diagnosis and confirm gestational dating before using medications for early pregnancy loss. Ultrasonography, if needed, or menstrual dating can establish that gestational age is less than 77 days before a medication abortion is provided.^9–11 Ultrasonography should be performed in patients at risk of ectopic pregnancy or if gestational age cannot be confirmed using clinical data alone (Table 1).^9–11

There are few contraindications to using mifepristone and misoprostol¹² (Table 2^4,12,13). Medication management research has excluded patients with severe hepatic, renal, respiratory, or cardiovascular disease, or with hemoglobin levels of less than 10 g per dL (100 g per L). Laboratory testing should be considered for patients with symptoms of or at risk of anemia or sexually transmitted infections. An initial quantitative beta human chorionic gonadotropin (β-hCG) level is needed if serial β-hCG will be used to confirm completed abortion. The standard of care has been to administer Rh_O(D) immune globulin (Rhogam) to all patients who are Rh-negative and who are undergoing early pregnancy loss or abortion.¹⁴ However, according to preliminary research findings, the risk of alloimmunization in early gestation may be negligible.¹⁵ If future research confirms this finding, testing for Rh status may not be indicated when prescribing mifepristone and misoprostol in the first trimester.¹⁶

Providing Counseling and Consent

Patients with early pregnancy loss or unintended pregnancy should receive patient-centered counseling on all management options because patients who are included in the decision-making process and whose treatment preferences are honored have better mental health outcomes.^17,18 The risks and benefits of treatment options for early pregnancy loss (i.e., expectant management, medication management, and uterine aspiration) are reviewed at https://www.aafp.org/afp/2019/0201/p166.html. For an in-depth discussion of the options for unintended pregnancy, including parenting, adoption, and medication or aspiration abortion, see https://www.aafp.org/afp/2015/0415/p544.html. All patients should be interviewed alone to ensure they are not being coerced by a partner or anyone else to decide against their will.¹⁹ The FDA requires patients who use mifepristone to sign a patient agreement that is available on the drug manufacturers' websites.^20,21