Early Options: Case Presentation 1

Early Options - A Provider's Guide to Medical Abortion

A 28-year-old woman received 600 mg of mifepristone and returned to a clinic 2 days later to take misoprostol 400 µg orally. At that point, she elected to return home rather than remain in the clinic for monitoring. She called the clinic 3 hours after taking misoprostol to report severe cramps and pelvic discomfort. She also described moderate vaginal bleeding and nausea. The patient took 600 mg of ibuprofen 45 minutes prior to her call and obtained minimal relief. She wanted to know if her pain was "normal" and how long it would last.

The patient was concerned that ibuprofen did not adequately relieve her pain. She wanted to know if her symptoms were normal and when she could expect to feel better. Based on published studies indicating that over 90% of women undergoing medical abortion report cramping, the provider felt confident reassuring her that pain and cramping are a normal and expected aspect of the process. The provider also explained that pain suggests the medications are working to induce an abortion, and that pain most commonly occurs after misoprostol administration.

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While pain as an isolated symptom rarely indicates an impending complication, providers need to consider the differential diagnosis any time a patient reports side effects. In some situations, pain signals an incomplete abortion, infection, or, rarely, an ectopic pregnancy. Inquiring about other symptoms, such as fever, and asking patients to describe their pain and bleeding in more detail will help determine if further evaluation is needed.

Resolution of Case 1

Both non-narcotic and narcotic analgesics can be used for pain control. In this instance, the provider had prescribed acetaminophen with codeine at the initial visit for the patient to use if non-narcotic analgesics were ineffective. As instructed, the patient had filled the prescription prior to using the misoprostol. The provider reminded the patient to use the acetaminophen with codeine, and also told her she could try using a heating pad or hot water bottle for pain relief. The patient was encouraged to call back if the pain persisted.

The provider took the initiative to contact the patient a few hours later to check on her progress, at which time her cramping and pain had resolved.

Return to Expected Side Effects of Medical Abortion.