Module 2: Early Medical Abortion

5. Aftercare and management of complications

Verification of completion of abortion

Continuing pregnancy after EMA is uncommon (1–3%) but important not to miss. Clinical signs of continuing pregnancy include: 1) having only scant bleeding after taking the medicines; 2) patients who despite significant bleeding are still experiencing ongoing pregnancy related symptoms such as nausea, tiredness, frequent urination and breast tenderness; and 3) people who do not have a return of menses at 4–6 weeks (taking into account any possible changes due to the method of contraception used post abortion).

It is important to verify completion of abortion by one of the following methods:

• Serum βhCG drop of >80% 7 to 14 days after administration of mifepristone (check baseline serum βhCG on day of mifepristone)
• Negative low sensitivity urine pregnancy test 2 to 4 weeks after abortion
• Absence of gestational sac on ultrasound scan which was present before
• Clinical history and examination, e.g. self-reported: the gestational sac was seen to pass, bleeding is settling, pregnancy symptoms have gone, and the uterus is involuted on vaginal examination
• It is the expectation of the Midwifery Council that midwives offer in person follow up post abortion

From 1 December, 2024, β-hCG low sensitivity urine tests (checkToP^®) are funded for use both in the community and in Health New Zealand Te Whatu Ora hospitals. The checkToP^® test kits are designed for home use after EMA, as an alternative to a blood test, and are not suitable for use for other pplications such as miscarriage management. The tests detect β-hCG levels below 1000 mIU/mL and give a result within 5 to 10 minutes. They provide a simple alternative to a blood test, particularly for those who may have limited access to blood test facilities or other barriers to accessing healthcare for EMA follow-up.

The β-hCG low sensitivity urine tests (checkToP^®) are listed in Section B on the Pharmaceutical Schedule, and available via prescription and Practitioner’s Supply Order (PSO, up to 15 tests). Health practitioners, including midwives, GPs and nurse practitioners can prescribe and order the tests for use in primary care. 

If the pregnancy is found to be ongoing following an EMA the patient must be advised of their options; these include to repeat the EMA procedure if they are under 10 weeks, to undergo a surgical abortion or if they choose to continue the pregnancy, they must be referred for ongoing pregnancy care and advised of the risks to the pregnancy including miscarriage and the need for a detailed early scan for limb malformations.

Additional follow-up

Reporting

To comply with the Contraception, Sterilisation, and Abortion Act 1977 abortion service providers must submit a notification to the Ministry of Health within one month of an abortion. The Ministry of Health collates the national data on abortions and uses this to report on issues such as timely and equitable access to abortion services.

There is a guide provided on the Ministry of Health Abortion Reporting webpage to completing and submitting the notification report, via an online form. A PDF version of the form is also available on request.

For further information, see the module 1 section on legal reporting requirements.

Signs and management of complications

All abortion providers should have a plan in place for referring a pregnant person to a hospital for emergency assessment and admission if required. Patients should be provided with sufficient information about the EMA procedure to allow another health practitioner elsewhere to manage complications in an emergency situation.

Retained products of conception (RPOC) is the most common complication after EMA. Problematic cramping, pain and/or bleeding in the first week is common (2–9%) but may continue to occur for 2–5 weeks after the medicines. This extended duration of bleeding may result from retained pregnancy tissue (i.e. RPOC). A slow to drop serum βhCG may also suggest RPOC.

• Check how much bleeding is occurring (how long has it been going on, how often are they changing pads, are the pads completely soaked through? Are they faint and dizzy when they stand up?)
• Check pulse and blood pressure
• Do a vaginal speculum examination to look for RPOC at the cervical os and assess amount of bleeding

If the patient feels unwell or is haemodynamically unstable provide immediate emergency care as appropriate and refer urgently to secondary care.

If the patient feels well and is haemodynamically stable offer a choice of treatments:

• Explain, reassure and manage conservatively (wait to pass spontaneously)
• Give another dose of misoprostol (400 micrograms buccally or sublingually, not vaginally)
• Refer to secondary care for further assessment and management

A previously undiagnosed ectopic pregnancy is a rare but important not to miss life-threatening condition. Be alert to this possibility when a person without a confirmed intrauterine pregnancy has an EMA. Ectopic pregnancy may be asymptomatic, and an ectopic pregnancy may only be detected when the follow-up βhCG is not falling as expected. Patients may present with symptoms of pelvic pain, vaginal spotting/bleeding or with tachycardia, hypotension and shock. Refer all patients with these findings urgently to the nearest hospital.

Endometritis/ pelvic inflammatory disease after EMA is uncommon but important not to miss. Patients may present with fever, abdominal pain and/or a malodourous vaginal discharge and have uterine or adnexal tenderness on bimanual examination. In cases of suspected endometritis/pelvic inflammatory disease urgent treatment as per guidelines is recommended.