When to Set a Follow-up Appointment After Abortion With Pills?

You decided to abort your pregnancy with pills and already took them as recommended. What comes next? How to be sure that the pregnancy is successfully terminated? Should you arrange a follow-up appointment? Here are some important details to know about for the follow-up period after the use of abortion pills.

Abortion with pills is a safe method to terminate pregnancies in the first trimester. However, there can be complications. It is always recommended to know which symptoms are abnormal and may require medical attention.

Complications of abortion pills

Generally, abortion with pills is safe in the first trimester. Although they are rare, complications may still happen. For example, a large study from the USA has reported a 0.16% rate of major adverse events, including hospital admission, blood transfusion, infection, or death following abortion pill use.

Let's look at some side effects and complications of using abortion pills:

• Excessive and prolonged bleeding. After pregnancy tissue passes, vaginal bleeding should gradually decrease. In women with potential risk factors for reduced blood clotting and rare blood vessel abnormalities, prolonged and excessive vaginal bleeding may occur.
• Infection. The uterine cervix, which is the entry to the womb cavity, is usually closed. It prevents infections from reaching the uterus and beyond. The abortion medication dilates the cervix to deliver the fetus, thus opening the path for infections.
• Incomplete or failed abortion. Sometimes, pills may successfully initiate the abortion. However, they might not be enough to expel all conception products. Cases with failed abortion may present with ongoing pregnancy symptoms such as nausea, increased vaginal bleeding, or persistent pelvic cramping.
• Teratogenicity. Also, it must be remembered that abortion pills are teratogenic, meaning if the method fails, the pregnancy exposed to misoprostol may result in severe fetal abnormalities. Therefore, if the evaluation concludes that the pills were unsuccessful, an additional dose of abortion pills or uterine suction methods should be considered to finalize the termination.
• Mortality. Death is a rare complication in legal, induced abortions. Notably, this risk increases with each week of gestation. For example, statistics show that, in pregnancies younger than eight weeks, the death risk is only one patient per million procedures. However, in pregnancies above 21 weeks, there is almost a 90-fold increased risk.

When to seek further medical advice after abortion pills?

Cramps, vaginal bleeding, and a mild fever are expected symptoms when going through an abortion with pills. However, some important signs that could suggest that you may need medical attention.

• Abdominal pain and cramps. Almost all women using abortion pills experience abdominal pain and cramping. Misoprostol is the reason behind these birth contractions-like cramps. Generally, contractions are observed from the misoprostol administration until the expulsion of the abortion tissue. Cramps should relieve afterward. If pain is unrelieved and increases in severity after the tissue passes and the bleeding subsides, you should speak to your healthcare provider as you may need further medical evaluation.

• Bleeding. Vaginal bleeding after the medical abortion is typically heavier and longer than your periods and in 1% - 9% of cases, the duration of bleeding may prolong until 30-60 days. The volume of blood should gradually decrease after the abortion tissue is released. If you soak more than two maxi-pads for two consecutive hours, it is recommended to contact the healthcare provider.

• Infection symptoms. Following abortion, if you experience persistent fever above 38°C (100.4°F), chills, pelvic pain, or a purulent (foul-smelling) vaginal discharge, these might indicate infection requiring further medical assessment. You should note that in 23% - 69% of cases misoprostol may cause fever. Therefore, don't be initially alarmed if you have a temporary fever without other infection symptoms.

Follow-up after abortion pills

The main goal of a follow-up examination is to confirm complete abortion without retained tissue or a continuing pregnancy. In these visits, further contraceptive counseling may also be provided.

The follow-up practices differ in various healthcare systems. Some practices recommend in-clinic evaluation within 5 to 14 days after pill administration. Other institutions have adopted remote follow-up methods with a urine pregnancy test, which became more popular after the COVID-19 pandemic.

Remote follow-up with urine hCG measurements

• Urine pregnancy test. The most commonly used pregnancy tests only detect the presence of human chorionic gonadotropin (hCG) in the urine and may have only two answers: positive or negative. Typically, most over-the-counter urine pregnancy tests are high-sensitive and give a positive result if urine hCG is above 25mIU/mL. With this sensitivity, home pregnancy tests may show positive results even after four weeks following the abortion.

• A multilevel pregnancy test (MLPT) also measures urine hCG. However, its design allows estimating several ranges of hCG from <25 to >10,000. With these options MLPT becomes an invaluable tool in remote follow-up after medical abortion.

In-clinic follow-up

When available, serum hCG measurements and/or ultrasound imaging are used to confirm the complete abortion.

• Ultrasound imaging. USG may confirm the absence of the pregnancy sac in the womb cavity. If you had ultrasound imaging before the medical abortion, comparing the two results would also be helpful. In some cases, the pregnancy sac might be absent, but the inner layer of the uterus might be thicker than normal, indicating the presence of the remaining tissue.

• Serum hCG. hCG levels in the blood are measured on at least two occasions, one before the abortion pill administration and another within 5 to 14 days after. hCG values are compared to the baseline, and it is expected that after a successful termination, values will decrease and eventually become negative. If hCG values remain the same or increase, this might indicate the presence of ectopic pregnancy.