Medication Abortion Between 14 0/7 and 27 6/7 Weeks of Gestation
Publication Date: October 9, 2023
Last Updated: October 13, 2023
Conclusions and Recommendations
We recommend mifepristone 200 mg orally (where available) 24 to 48 hours before misoprostol, followed by misoprostol 400 mcg every 3 hours vaginally, sublingually, or buccally for medication abortion between 14 0/7 and 23 6/7 weeks of gestation. (1, A)
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When mifepristone 200 mg orally is not available 24 to 48 hours prior to the first misoprostol dose, we recommend administering mifepristone and vaginal misoprostol simultaneously. (1, B)
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If mifepristone is unavailable, we recommend misoprostol 400 mcg vaginally, sublingually, or buccally every 3 hours for medication abortion between 14 6/7 and 23 6/7 weeks of gestation. A loading dose is not recommended, as it does not hasten abortion times or improve outcomes. (1, B)
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We suggest mifepristone 200 mg (where available) plus misoprostol 200 mcg vaginally or buccally every 3 hours for medication abortion between 24 0/7 and 27 6/7 weeks of gestation. (2, C)
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If mifepristone is unavailable, we suggest misoprostol 200 mcg vaginally or buccally every 3 hours for medication abortion between 24 0/7 and 27 6/7 weeks of gestation. (2, C)
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We do not suggest oxytocin-based regimens for medication abortion unless misoprostol with or without mifepristone is unavailable or contraindicated (e.g., allergy). (2, C)
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We suggest against osmotic dilator use prior to or concurrent with misoprostol (with or without mifepristone), gemeprost, or high-dose oxytocin, with the possible exception of fetal demise. (2, B)
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We suggest considering Foley catheter placement with misoprostol-only regimens. (2, B)
There is insufficient evidence to make a recommendation for Foley catheter placement when used with mifepristone in combination with misoprostol.
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There is insufficient evidence to recommend a change in misoprostol regimen for people with more than one prior cesarean in high-resource settings. Expert opinion suggests reducing misoprostol doses at higher gestational durations (at or over 24 weeks of gestation or uterine size). We suggest mifepristone pretreatment when it is available, although this does not eliminate uterine rupture risk. We suggest individualizing care and reduced misoprostol dosing in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). (2, C)
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We recommend routinely offering pain management to people undergoing medication abortion. (1, B)
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We recommend a step-wise multimodal approach to address pain. We recommend using shared decision-making with the patient to determine whether opioid medications are indicated. (1, B)
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We suggest that appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure. (2, B)
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We recommend the initiation of most contraceptive methods immediately following medication abortion per patient preference. Surgical considerations may affect permanent contraception timing, and in cases of infection, IUD placement and permanent contraception should be deferred until resolution. (1, A)
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The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Title
Medication Abortion Between 14 0/7 and 27 6/7 Weeks of Gestation
Authoring Organization
Society of Family Planning
Publication Month/Year
October 9, 2023
Last Updated Month/Year
November 6, 2023
Country of Publication
US
Document Objectives
The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.
Target Patient Population
Pregnant women between 14 0/7 and 27 6/7 weeks of gestation
Inclusion Criteria
Female, Adolescent, Adult
Health Care Settings
Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Diseases/Conditions (MeSH)
D000028 - Abortion, Induced, D016595 - Misoprostol
Keywords
abortion, induced abortion, misoprostol, medication abortion, Induction termination
Source Citation
Zwerling B, Edelman A, Jackson A, Burke A, Prabhu M. 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 Oct 9:S0002-9378(23)00726-3. doi: 10.1016/j.ajog.2023.09.097. Epub ahead of print. PMID: 37821258.
Methodology
Number of Source Documents
106
Literature Search Start Date
January 1, 2008
Literature Search End Date
June 1, 2022