Early abortion medication use shortens time to abortion in pregnancy of unknown location
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Starting abortion medication before knowing the location of an unwanted pregnancy was associated with shorter time to abortion and quicker exclusion of ectopic pregnancy, according to a retrospective cohort study in Obstetrics & Gynecology.
However, early implementation was associated with a greater likelihood that abortion would fail and need to be reinitiated.
“Traditionally, health care providers have first ‘ruled out’ ectopic pregnancy, with serial blood tests and a repeat ultrasound before offering abortion pills,” Alisa B. Goldberg, MD, MPH, an OB/GYN at Brigham and Women’s Hospital and an associate professor of obstetrics, gynecology and reproductive biology at Harvard Medical School, both in Boston, told Healio. “This delays the abortion and is a resource-intensive diagnostic process. To remove unwanted delays and barriers to abortion access, some health care providers have begun offering immediate initiation of abortion pills in the setting of pregnancy of unknown location, while simultaneously ‘ruling out’ ectopic pregnancy with serial blood tests.”
Defining a cohort
Goldberg, also the director of the family planning fellowship at Harvard Medical School, and colleagues reviewed the electronic medical records of 5,619 patients who requested medication abortion at the Planned Parenthood League of Massachusetts between 2014 and 2019 and who were 42 days or less from their last menstrual period.
In the case of 452 patients whose pregnancies could not be located on an initial ultrasonogram, clinicians either immediately started abortion with mifepristone and misoprostol and simultaneously excluded ectopic pregnancy with serial serum human chorionic gonadotropin (hCG) testing or attempted to determine the pregnancy location by using serial hCG and repeating ultrasonogram before administering abortion medication (delay-for-diagnosis group).
Incidence of ectopic pregnancy
Among patients with a pregnancy of unknown location, 394 patients (87.8%) were in the delay-for-diagnosis group and 55 (12.2%) started abortion medication immediately. There was an overall incidence rate of 35 ectopic pregnancies, with 31 occurring in patients with pregnancy of unknown location. Notably, all pregnancies diagnosed later were in the delay-for-diagnosis group.
“If the ectopic rate were comparable between groups, we would have expected to see a few ectopic pregnancies in the immediate initiation group,” Goldberg said. “This was a retrospective study, so perhaps this finding was due to confounding or chance, but perhaps early use of mifepristone and misoprostol might facilitate self-resolution of tubal pregnancy.”
Abortion timeline, outcomes
Among 432 patients without major ectopic pregnancy risk factors, time to diagnosis was shorter in patients who immediately started abortion medication compared with those who delayed for diagnosis (median, 5 days vs. 9 days; P = .005). There were no significant differences in ED visits or non-adherence between the delay-for-diagnosis group and the immediate start group.
For 270 patients who proceeded with abortion, time to complete abortion was shorter in those who started abortion immediately compared with those who waited for diagnosis (median, 5 days vs. 19 days; P < .001).
“We were ... surprised that in the delay-for-diagnosis group, 26% of patients never required an abortion (18% because of early pregnancy loss and 8% because of ectopic) and a minority (only 41%) eventually proceeded with the medication abortion they initially sought, with many switching to uterine aspiration along the way,” Goldberg said.
Abortion outcomes were recorded for 170 patients. Compared with patients in the delay-for-diagnosis group, patients who immediately initiated abortion medication had a lower rate of success (96.7% vs. 85.4%; P = .013) and a higher rate of ongoing pregnancy (2.5% vs. 10.4%; P = .041).
“We hope this data will help shift practice and encourage health care providers to initiate abortion pills as early as possible for patients who want them, even before ectopic pregnancy has been ruled out,” Goldberg said. “Not only can this remove a barrier to abortion, but speeding up the ‘rule out ectopic’ diagnostic process may also reduce patient and provider anxiety and health care costs.”
Moving forward, Goldberg suggested future research examine the clinical and financial effects of implementing immediate abortion medication on a large scale.
Perspective
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Katharine O'Connell White, MD, MPH
Abortion has long been considered safer the earlier in pregnancy it is performed. This study addresses the dearth of evidence about the safety of abortion in very early pregnancy, when an intrauterine location of the pregnancy cannot be confirmed. It is reassuring to find that mifepristone and misoprostol administered to a patient with a PUL hastens the time to diagnosis and was not associated with any serious adverse events. Hopefully this study will increase clinicians’ comfort in initiating medication abortion for patients with PUL, thereby increasing access to abortion care.
Treating a PUL with mifepristone and misoprostol may lead to a higher risk of ongoing pregnancy. Yet all methods of abortion carry risks (though none as great as continuing the pregnancy). Patients should be fully counseled about the risks and benefits of each approach — immediate initiation of medication vs. delay to confirm diagnosis — and should be able to decide for themselves which route best fits their preferences. Close follow-up for all PULs, including those treated with medications for abortion, continues to be warranted.
Perspective
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Laura MacIsaac, MD, MPH, FACOG
This study contributes a crucial missing piece to the management of problems encountered early in pregnancy. Management of pregnancy of unknown location (PUL) has not changed in decades and is expensive and burdensome for patients and health systems.
This study by Goldberg and colleagues provides evidence of safety, effectiveness, advantages and disadvantages of early initiation of medication abortion with mifepristone/misoprostol for patients with PUL who present for abortion.
The advantages were clear: time to diagnosis of intrauterine pregnancy [IUP], early pregnancy loss [EPL] or ectopic was cut almost in half (5 days vs. 9 days), and time to complete abortion was shorter.
Similar to use of mifepristone/misoprostol for EPL, success of complete uterine evacuation was lower in the PUL patients, and more patients will have an ongoing pregnancy. Patients will have to accept the higher failure rate of a medication abortion regimen when initiating the medications this early during implantation, thus the need for careful surveillance until resolution of the PUL.
However, the take-home message is that whether a pregnancy is an IUP, an EPF or a PUL, treatment with mifepristone/misoprostol results in complete uterine evacuation with few complications most of the time. In fact, in this study, the cohort of routine care — observation until diagnosis — had higher complications, including hospitalizations and laparoscopy/laparotomy. Although not powered for rare complications, these data describe more risk in the conservative watchful/waiting approach.
This study does have inherent limitations: Although a large data set, it is a retrospective in nature and there were no ectopic pregnancies diagnosed in the early mifepristone/misoprostol treatment regimen, which is likely because women with risk factors or symptoms suggestive of ectopic were excluded from the immediate treatment option.
Women with PUL who do not want to be pregnant now have more choices.
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