Options for first-trimester abortions

Publication
Article
Contemporary OB/GYN JournalVol 68 No 06
Volume 68
Issue 06

Clinicians need to stay up-to-date with medication and access issues.

Options for first-trimester abortions | Image Credit: © fizkes - © fizkes - stock.adobe.com.

Options for first-trimester abortions | Image Credit: © fizkes - © fizkes - stock.adobe.com.

In the United States, most abortions occur early in pregnancy; in 2020, approximately 93% occurred under 13 weeks’ gestation, with medication abortion accounting for 51% of all abortions.1 Individuals will continue to seek access to abortions even in restrictive settings.2 As access to abortion care and training becomes even more suppressed following recent political shifts, education for both patients and providers is critical.

Individuals who graduate from residency programs with opt-out abortion training are much more confident with performing uterine aspiration for induced abortion, early pregnancy loss, and incomplete abortions.3 Knowing how to remove pregnancy tissue from the uterus is an essential skill for an obstetrician-gynecologist, even if the physician does not intend to provide abortions in their practice.

In this article, we review first-trimester abortion options, recommended preprocedure considerations, pain management, and special considerations if access to medications continues to decrease nationwide.

Counseling

When talking with a patient about early pregnancy options, start by simply asking the patient’s feelings about being pregnant. When patients indicate they are considering an abortion, the clinician who is not comfortable or equipped to provide the services should promptly ensure appropriate referral. Providers who conscientiously refuse to refer for unbiased care have a duty to inform patients of their personal moral constraints.4-6 Timing is crucial because methods can vary and specific state regulations prohibit care after a certain point in the pregnancy.

If a patient is a candidate for both medication and procedural abortion, the decision of which method should be an integral component of counseling. A medication abortion allows the patient to control the start of the process, avoids a possible pelvic exam and medical procedure, and allows them to be at home with their support system. A suction aspiration procedure takes place in a clinical setting, has the option of anesthesia during the process, and offers quick and timely completion. Facilities may have options ranging from an office procedure with local anesthesia or moderate sedation to an operating room with deep sedation. When deciding on the method, topics to discuss include bleeding, pain, and possible complications.

Preabortion assessments

Gestational age can be determined by a certain last menstrual period, uterine examination, or ultrasonography if there is a clinical indication, such as an unsure last menstrual period.7 Routine laboratory assessments are not indicated. Even in patients with concerns for significant anemia or underlying medical conditions, clinical judgment can be used to decide if preoperative testing is necessary. The typical blood loss with an early aspiration procedure is low and a blood count assessment generally is not needed. For any patient at 12 weeks’ gestation or less, blood type and screen are also not indicated. Alloimmunization risk is so low in this gestational age range that the World Health Organization and the Society of Family Planning both recognize that Rh-immunoglobulin is not needed for Rh-negative patients at 12 weeks or less.7,8 For patients having a first-trimester procedure at more than 12 weeks, Rh-immunoglobulin 100 mcg is all that is needed.7

The use of universal prophylactic antibiotics prior to a first-trimester procedural abortion is recommended. In the United States, pelvic infection following an abortion occurs in less than 1% of patients.9-11 A variety of regimens demonstrate efficacy in reducing postabortal infections using doxycycline, metronidazole, or azithromycin, or a combination. More than 80% of providers use doxycycline.12 A well-proven regimen is 100 mg within a few hours prior to the procedure followed by a 200-mg dose with the next meal after the procedure.13 However, for patients with significant nausea and vomiting, a 200-mg dose the night prior to procedure with a meal results in decreased nausea with similar drug levels at the time of the procedure.14 There is no indication for antibiotic prophylaxis with medication abortion.15

Procedural abortion

First-trimester suction aspiration can be safely performed in an office setting with manual or electric vacuum aspiration. In clinical studies, participants experience similar amounts of pain and low rates of complication with either technique.16,17 Manual vacuum aspiration is associated with less noise, which may be preferable for some patients.18 Some physicians prefer electric vacuum aspiration in later first-trimester gestations,19 although a recent study demonstrated similar safety and procedure time at more than 10 weeks’ gestation with manual or electric vacuum.20 Typically the cannula size used will correlate with the gestational age by weeks or be 1 size smaller.

For most patients, there is no indication for cervical preparation prior to the procedure. and the cervix can be opened manually using rigid dilators at the time of the procedure. Patient characteristics may influence a provider’s decision to use other agents to prepare the cervix preoperatively, such as higher gestational age (more than 12 weeks), nulliparity, adolescent age, or known cervical stenosis. Although institutions and different organizations may have preferred cervical preparation methods, such as osmotic dilators or misoprostol (Cytotec; Pfizer), no standardized recommendation is best in the first trimester (Table 121). Although dilation may be improved with cervical preparation, it has not been shown to reduce pain during the procedure.21,22

When discussing first-trimester procedural abortion, options for sedation and pain management may influence a patient’s preference. Although some clinics offer deep sedation, most only offer this level of sedation in a surgery center or hospital operating room.19 In either setting, cervical anesthesia, commonly with lidocaine 1% 20 mL (although other agents can be used), as a paracervical or intracervical block significantly reduces procedural pain.23 A lidocaine 1% 20-mL solution is the equivalent of 200 mg, which is below the threshold for lidocaine toxicity. Methods to reduce toxicity include drawing back the syringe prior to injection to ensure the injection is not intravascular and monitoring for signs/symptoms of lidocaine toxicity (odd taste, ringing in ears, difficulty breathing, seizure, respiratory arrest).24,25 Patients interested in additional sedation in an office setting can be offered intravenous fentanyl and/or midazolam in the setting of appropriate cardiovascular monitoring.26 Fentanyl can be dosed initially at 50 mcg to 100 mcg, with a maximum of 200 mcg. Midazolam can be dosed initially at 1 mg to 3 mg and a maximum of 4 mg.27 Oral opioids, oral anxiolytics, and inhaled nitrous oxide are all significantly less effective than intravenous sedation.28-31

Medication abortion

The most effective medication abortion regimens are a combination of mifepristone and misoprostol, for which research supports use at any gestational age through 11 weeks (77 days) in a home setting.32 However, the efficacy declines substantially with advancing gestational age, which is important for counseling and may impact a patient’s decision when considering medications or a procedure. Mifepristone weakens the implantation site but rarely causes abortion by itself, which is why it is approved by the FDA to be used with misoprostol, which induces myometrial contractions that result in pregnancy expulsion.

Mifepristone, an antiprogestin, is provided in a 200-mg tablet that can be obtained in the United States through a physician’s office, clinic, or pharmacy (when prescribed by a physician) registered with the FDA to provide the drug.33 Misoprostol (provided as 4-mcg to 200-mcg tablets), a PGE1 analogue, is approved for buccal use 24 or more hours after mifepristone but is also highly effective when used vaginally or sublingually.34-36 Vaginal administration allows for efficacy with a shorter interval between the 2 drugs (for gestations less than 63 days, misoprostol can be used as early as desired by the patient) and fewer gastrointestinal adverse effects. Sublingual administration may result in greater efficacy at higher gestational ages, especially when administered with repeat doses at 3-hour intervals, but results in more gastrointestinal adverse effects.34,37,38

Because contraindications are infrequent, most patients desiring medication abortion should be eligible (Table 2).35 Prior to treatment, patients should be given accurate descriptions of bleeding and pain expectations. Bleeding and pain typically start about 2 to 3 hours after using misoprostol. Although bleeding will be heavier than a period, clinically significant bleeding is rare, with transfusion in less than 0.1% of patients.38 Patients should be counseled to contact their clinician if they experience bleeding that soaks more than 2 maxi-pads in 1 hour for 2 consecutive hours.39 Patients who have a medication abortion should expect acute, severe cramping pain. Patients who are nulliparous, have a higher baseline anxiety, or dysmenorrhea experience more pain during a medication abortion.40 With buccal misoprostol, the highest pain level occurs approximately 3.5 hours after misoprostol use. It lasts at that level for approximately 1 hour, and pain is significantly less within 24 hours after the misoprostol is taken.41,42 Ibuprofen is more effective than acetaminophen for pain management and does not impact treatment efficacy.43,44 Heating pads, hot showers, or hot baths can be helpful. Other alternatives, including acupressure and ambulation, have not demonstrated benefit.45,46 Studies suggest that low-dose narcotics (eg, oral oxycodone) do not reduce the pain; however, given the short and acute nature of the event, a higher dose over a shorter period of time may be a better suggestion should a nonsteroidal anti-inflammatory drug or alternatives not provide relief.47 Misoprostol is a known teratogen with increased risk to the fetus of developing limb defects and Möbius syndrome, so patients should be counseled about the potential effects if treatment fails and the pregnancy is continued.48,49 There are no known teratogenic effects with the use of mifepristone.39,50

If a patient wants to use telemedicine, medication abortion is safe and effective in patients with certain last menstrual periods that date the pregnancy as 10 weeks or less and lack any risk factors for an ectopic pregnancy (unilateral abdominal pain or spotting for past 5 days, intrauterine device [IUD] in place, history of tubal damage, or history of prior ectopic pregnancy). The general obstetric population has a 10 times higher risk of ectopic pregnancy athan patients seeking abortion, but any patient factors that may be concerning for an ectopic pregnancy should prompt clinic assessment with ultrasound imaging instead of a no-test medication abortion.51

Follow-up for a medication abortion is typically 1 week after the misoprostol, and clinic assessments typically involve ultrasound examination. Adverse outcomes do not differ with telemedicine visits compared with clinic follow-up. Patients prefer a telemedicine follow-up when given the option. The clinician can call a patient following administration of misoprostol to review symptoms. If the patient’s history is convincing of completed abortion, a home urine pregnancy test can be performed 3 weeks later.52-54 If the patient or clinician thinks that the pregnancy is continuing, an in-person visit is typically warranted. Ultrasonography is useful to assess for continuing pregnancy (eg, gestational sac presence) as well as for an ectopic pregnancy. There is no threshold of endometrial lining that correlates clinically to indicate an aspiration procedure is necessary following a medication abortion.55

Postabortion contraception

Patients may want to avoid another pregnancy immediately after an abortion. Ovulation can resume quickly, as soon as 10 days after a procedural abortion and 8 days after a medication abortion.56,57 As such, the ability to provide contraceptive counseling is key to ensuring full care. However, clinicians must also recognize that the majority (approximately two-thirds) of patients are not interested in discussing contraception at the time of their abortion.57 The low interest is not because they do not want contraception but is because of their interest in only abortion services at the time of the visit, already having a contraception method in mind, or wanting to follow up with their primary gynecologist for contraception.58,59

All forms of contraception can be discussed and offered to the patient. With procedural abortion, all methods can be initiated immediately after the abortion. IUDs can be placed at the same time as the procedure without any increased risk of expulsion or infection.60,61

With medication abortion, patient-controlled methods can be initiated after the abortion has occurred. IUDs can be placed when the abortion is confirmed to be completed, as soon as 48 hours following completion of a medication abortion with no difference in expulsion of the IUD when compared with IUDs placed 2 to 4 weeks following the medication abortion.62,63 Clinicians may question the impact of initiating a nondaily systemic progestin at the time mifepristone, an antiprogestin, is used. The implant does not impact any outcomes with medication abortion and can be placed at the time of mifepristone administration or later.64 A randomized trial showed an increase in ongoing pregnancies in patients who received injectable contraception with depot medroxyprogesterone acetate the same day as mifepristone in a medication abortion. However, the aspiration rate (11% among all patients who have medication abortions to 75 days) was not different.65 In this particular case, we would recommend discussing these findings with the patient to decide timing of injectable contraception.66

Conclusions

The landscape of abortion care is shifting. Safe, effective methods are now inaccessible to many patients and providers. As this article is being written, there is an effort underway to revoke the FDA approval of mifepristone. This would result in resorting to alternative regimens (misoprostol only) that have higher failure rates and increasing morbidity for patients.66,67

References

  1. Kortsmit K, Nguyen AT, Mandel MG, et al. Abortion surveillance - United States, 2020. MMWR Surveill Summ. 2022;71(10):1-27. doi:10.15585/mmwr.ss7110a1
  2. Bearak J, Popinchalk A, Ganatra B, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019. Lancet Glob Health. 2020;8(9):e1152-e1161. doi:10.1016/S2214-109X(20)30315-6
  3. Horvath S, Turk J, Steinauer J, Ogburn T, Zite N. Increase in obstetrics and gynecology resident self-assessed competence in early pregnancy loss management with routine abortion care training. Obstet Gynecol. 2022;139(1):116-119. doi:10.1097/AOG.0000000000004628
  4. Combs MP, Antiel RM, Tilburt JC, Mueller PS, Curlin FA. Conscientious refusals to refer: findings from a national physician survey. J Med Ethics. 2011;37(7):397-401. doi:10.1136/jme.2010.041194
  5. Brauer SG, Yoon JD, Curlin FA. US primary care physicians’ opinions about conscientious refusal: a national vignette experiment. J Med Ethics. 2016;42(2):80-84. doi:10.1136/medethics-2015-102782
  6. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 385 November 2007: the limits of conscientious refusal in reproductive medicine. Obstet Gynecol. 2007;110(5):1203-1208. doi:10.1097/01.AOG.0000291561.48203.27
  7. Abortion care guideline. World Health Organization. March 8, 2022. Accessed May 1, 2023. https://www.who.int/publications/i/item/9789240039483
  8. Horvath S, Goyal V, Traxler S, Prager S. Society of Family Planning committee consensus on Rh testing in early pregnancy. Contraception. 2022;114:1-5. doi:10.1016/j.contraception.2022.07.002
  9. Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol. 1990;76(1):129-135.
  10. Hodgson JE. Major complications of 20,248 consecutive first trimester abortions: problems of fragmented care. Adv Plan Parent. 1975;9(3-4):52-59.
  11. Wulff GJ Jr, Freiman SM. Elective abortion. Complications seen in a free-standing clinic. Obstet Gynecol. 1977;49(3):351-357.
  12. O’Connell K, Jones HE, Simon M, et al;National Abortion Federation Members. First-trimester surgical abortion practices: a survey of National Abortion Federation members. Contraception. 2009;79(5):385-392. doi:10.1016/j.contraception.2008.11.005
  13. Levallois P, Rioux JE. Prophylactic antibiotics for suction curettage abortion: results of a clinical controlled trial. Am J Obstet Gynecol. 1988;158(1):100-105. doi:10.1016/0002-9378(88)90787-9
  14. Reeves MF, Lohr PA, Hayes JL, Harwood BJ, Creinin MD. Doxycycline serum levels at the time of dilation and evacuation with two dosing regimens. Contraception. 2009;79(2):129-133. doi:10.1016/j.contraception.2008.09.006
  15. Achilles SL, Reeves MF; Society of Family Planning. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception. 2011;83(4):295-309. doi:10.1016/j.contraception.2010.11.006
  16. Dean G, Cardenas L, Darney P, Goldberg A. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception. 2003;67(3):201-206. doi:10.1016/s0010-7824(02)00485-7
  17. Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol. 2004;103(1):101-107. doi:10.1097/01.AOG.0000109147.23082.25
  18. Edelman A, Nichols MD, Jensen J. Comparison of pain and time of procedures with two first-trimester abortion techniques performed by residents and faculty. Am J Obstet Gynecol. 2001;184(7):1564-1567. doi:10.1067/mob.2001.114858
  19. White KO, Jones HE, Lavelanet A, et al. First-trimester aspiration abortion practices: a survey of United States abortion providers. Contraception. 2019;99(1):10-15. doi:10.1016/j.contraception.2018.08.011
  20. Grentzer J, McNicholas C, Eisenberg DL, Peipert JF, Paul R, Madden T. Comparison of procedure time between manual and electric vacuum aspiration for pregnancy termination between 10-14 weeks: A randomized trial. Contraception. 2022;113:108-112. doi:10.1016/j.contraception.2022.03.025
  21. Allen RH, Goldberg AB. Cervical dilation before first-trimester surgical abortion (<14 weeks’ gestation). Contraception. 2016;93(4):277-291. doi:10.1016/j.contraception.2015.12.001
  22. Panchal HB, Godfrey EM, Patel A. Buccal misoprostol for cervical ripening prior to first trimester abortion. Contraception. 2010;81(2):161-164. doi:10.1016/j.contraception.2009.10.002
  23. Renner RM, Nichols MD, Jensen JT, Li H, Edelman AB. Paracervical block for pain control in first-trimester surgical abortion: a randomized controlled trial. Obstet Gynecol. 2012;119(5):1030-1037. doi:10.1097/AOG.0b013e318250b13e
  24. Xylocaine. FDA. Updated February 2010. Accessed March 8, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/006488s074lbl.pdf
  25. Allen RH, Singh R. Society of Family Planning clinical guidelines pain control in surgical abortion part 1 - local anesthesia and minimal sedation. Contraception. 2018;97(6):471-477. doi:10.1016/j.contraception.2018.01.014
  26. Cansino C, Denny C, Carlisle AS, Stubblefield P. Society of Family Planning clinical recommendations: pain control in surgical abortion part 2 - Moderate sedation, deep sedation, and general anesthesia. Contraception. 2021;104(6):583-592. doi:10.1016/j.contraception.2021.08.007
  27. National Abortion Federation. 2022 clinical policy guidelines for abortion care. Washington DC. Accessed May 18, 2023. https://prochoice.org/wp-content/uploads/2022-CPGs.pdf
  28. Allen RH, Fitzmaurice G, Lifford KL, Lasic M, Goldberg AB. Oral compared with intravenous sedation for first-trimester surgical abortion: a randomized controlled trial. Obstet Gynecol. 2009;113(2 Pt 1):276-283. doi:10.1097/AOG.0b013e3181938758
  29. Renner RM, Jensen JTJ, Nichols MDN, Edelman A. Pain control in first trimester surgical abortion. Cochrane Database Syst Rev. 2009;2009(2):CD006712. doi:10.1002/14651858.CD006712.pub2
  30. Allen RH, Kumar D, Fitzmaurice G, Lifford KL, Goldberg AB. Pain management of first-trimester surgical abortion: effects of selection of local anesthesia with and without lorazepam or intravenous sedation. Contraception. 2006;74(5):407-413. doi:10.1016/j.contraception.2006.06.002
  31. Rawling MJ, Wiebe ER. A randomized controlled trial of fentanyl for abortion pain. Am J Obstet Gynecol. 2001;185(1):103-107. doi:10.1067/mob.2001.115860
  32. Raymond EG, Grossman D, Mark A, et al. Commentary: no-test medication abortion: a sample protocol for increasing access during a pandemic and beyond. Contraception. 2020;101(6):361-366. doi:10.1016/j.contraception.2020.04.005
  33. Mifepristone: approved risk evaluation and mitigation strategies (REMS). FDA. Updated March 23, 2023. Accessed May 17, 2023. https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390
  34. von Hertzen H, Huong NT, Piaggio G, et al; WHO Research Group on Postovulatory Methods of Fertility Regulation. Misoprostol dose and route after mifepristone for early medical abortion: a randomised controlled noninferiority trial. BJOG. 2010;117(10):1186-1196. doi:10.1111/j.1471-0528.2010.02636.x
  35. Information about mifepristone for medical termination of pregnancy through ten weeks gestation. FDA. March 23, 2023.
  36. Medical management of abortion. World Health Organization. 2018. Accessed May 1, 2023. https://apps.who.int/iris/bitstream/handle/10665/278968/9789241550406-eng.pdfhttps://apps.who.int/iris/bitstream/handle/10665/278968/9789241550406-eng.pdf?ua=1
  37. von Hertzen H, Honkanen H, Piaggio G, et al. WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: efficacy. BJOG. 2003;110(9):808-818. doi:10.1111/j.1471-0528.2003.02430.x
  38. Cleland K, Creinin MD, Nucatola D, Nshom M, Trussell J. Significant adverse events and outcomes after medical abortion. Obstet Gynecol. 2013;121(1):166-171. doi:10.1097/aog.0b013e3182755763
  39. Medication abortion up to 70 days of gestation. Contraception. 2020;102(4):225-236. doi:10.1016/j.contraception.2020.08.004
  40. Arena A, Moro E, Degli Esposti E, et al. How much will it hurt? Factors associated with pain experience in women undergoing medication abortion during the first trimester. Contraception. 2023;119:109916. doi:10.1016/j.contraception.2022.11.007
  41. Jackson E, Kapp N. Pain control in first-trimester and second-trimester medical termination of pregnancy: a systematic review. Contraception. 2011;83(2):116-126. doi:10.1016/j.contraception.2010.07.014
  42. Friedlander EB, Raidoo S, Soon R, et al. The experience of pain in real-time during medication abortion. Contraception. 2022;110:71-75. doi:10.1016/j.contraception.2022.03.003
  43. Livshits A, Machtinger R, David LB, Spira M, Moshe-Zahav A, Seidman DS. Ibuprofen and paracetamol for pain relief during medical abortion: a double-blind randomized controlled study. Fertil Steril. 2009;91(5):1877-1880. doi:10.1016/j.fertnstert.2008.01.084
  44. Creinin MD, Shulman T. Effect of nonsteroidal anti-inflammatory drugs on the action of misoprostol in a regimen for early abortion. Contraception. 1997;56(3):165-168. doi:10.1016/s0010-7824(97)00120-0
  45. Westhoff CL, Nelson IS, Suarez-Rodriguez A, Gold MA. Auricular acupressure and acupuncture as adjuncts for pain management during first trimester medication abortion: a randomized three-arm trial. Contraception. 2021;103(5):348-355. doi:10.1016/j.contraception.2020.12.003
  46. Ojha K, Gillott DJ, Wood P, Valcarcel E, Matah A, Talaulikar VS. Clinical outcomes from a prospective study evaluating the role of ambulation during medical termination of pregnancy. Contraception. 2012;85(4):398-401. doi:10.1016/j.contraception.2011.08.008
  47. Colwill AC, Bayer LL, Bednarek P, Garg B, Jensen JT, Edelman AB. Opioid analgesia for medical abortion: a randomized controlled trial. Obstet Gynecol. 2019;134(6):1163-1170. doi:10.1097/AOG.0000000000003576
  48. Gonzalez CH, Vargas FR, Perez AB, et al. Limb deficiency with or without Möbius sequence in seven Brazilian children associated with misoprostol use in the first trimester of pregnancy. Am J Med Genet. 1993;47(1):59-64. doi:10.1002/ajmg.1320470113
  49. Pastuszak AL, Schüler L, Speck-Martins CE, et al. Use of misoprostol during pregnancy and Möbius’ syndrome in infants. N Engl J Med. 1998;338(26):1881-1885. doi:10.1056/NEJM199806253382604
  50. Bernard N, Elefant E, Carlier P, et al. Continuation of pregnancy after first-trimester exposure to mifepristone: an observational prospective study. BJOG. 2013;120(5):568-574. doi:10.1111/1471-0528.12147
  51. Aiken A, Lohr PA, Lord J, Ghosh N, Starling J. Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study. BJOG. 2021;128(9):1464-1474. doi:10.1111/1471-0528.16668
  52. Perriera LK, Reeves MF, Chen BA, Hohmann HL, Hayes J, Creinin MD. Feasibility of telephone follow-up after medical abortion. Contraception. 2010;81(2):143-149. doi:10.1016/j.contraception.2009.08.008
  53. Chen MJ, Rounds KM, Creinin MD, Cansino C, Hou MY. Comparing office and telephone follow-up after medical abortion. Contraception. 2016;94(2):122-126. doi:10.1016/j.contraception.2016.04.007
  54. Schmidt-Hansen M, Cameron S, Lohr PA, Hasler E. Follow-up strategies to confirm the success of medical abortion of pregnancies up to 10 weeks’ gestation: a systematic review with meta-analyses. Am J Obstet Gynecol. 2020;222(6):551-563.e13. doi:10.1016/j.ajog.2019.11.1244
  55. Boyd EF Jr, Holmstrom EG. Ovulation following therapeutic abortion. Am J Obstet Gynecol. 1972;113(4):469-473. doi:10.1016/s0002-9378(15)32496-0
  56. Schreiber CA, Sober S, Ratcliffe S, Creinin MD. Ovulation resumption after medical abortion with mifepristone and misoprostol. Contraception. 2011;84(3):230-233. doi:10.1016/j.contraception.2011.01.013
  57. Matulich M, Cansino C, Culwell KR, Creinin MD. Understanding women’s desires for contraceptive counseling at the time of first-trimester surgical abortion. Contraception. 2014;89(1):36-41. doi:10.1016/j.contraception.2013.09.013
  58. Cansino C, Lichtenberg ES, Perriera LK, Hou MY, Melo J, Creinin MD. Do women want to talk about birth control at the time of a first-trimester abortion? Contraception. 2018;98(6):535-540. doi:10.1016/j.contraception.2018.08.005
  59. Bednarek PH, Creinin MD, Reeves MF, et al; Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364(23):2208-2217. doi:10.1056/NEJMoa1011600
  60. Roe AH, Bartz D. Society of Family Planning clinical recommendations: contraception after surgical abortion. Contraception. 2019;99(1):2-9. doi:10.1016/j.contraception.2018.08.016
  61. Betstadt SJ, Turok DK, Kapp N, Feng KT, Borgatta L. Intrauterine device insertion after medical abortion. Contraception. 2011;83(6):517-521. doi:10.1016/j.contraception.2010.10.006
  62. Hogmark S, Liljeblad KL, Envall N, Gemzell-Danielsson K, Kallner HK. Placement of an intrauterine device within 48 hours after early medical abortion-a randomized controlled trial. Am J Obstet Gynecol. 2023;228(1):53.e1-53.e9. doi:10.1016/j.ajog.2022.07.063
  63. Sothornwit J, Eamudomkarn N, Lumbiganon P, Jampathong N, Festin MR, Salang L. Immediate versus delayed postabortal insertion of contraceptive implant. Cochrane Database Syst Rev. 2022;5(5):CD013565. doi:10.1002/14651858.CD013565.pub2
  64. Raymond EG, Weaver MA, Louie KS, et al. Effects of depot medroxyprogesterone acetate injection timing on medical abortion efficacy and repeat pregnancy: a randomized controlled trial. Obstet Gynecol. 2016;128(4):739-745. doi:10.1097/AOG.0000000000001627
  65. American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women, and the Contraceptive Equity Expert Work Group. Access to postabortion contraception: ACOG committee opinion, number 833. Obstet Gynecol. 2021;138(2):e91-e95. doi:10.1097/AOG.0000000000004475
  66. Raymond EG, Harrison MS, Weaver MA. Efficacy of misoprostol alone for first-trimester medical abortion: a systematic review. Obstet Gynecol. 2019;133(1):137-147. doi:10.1097/AOG.0000000000003017
  67. Raymond EG, Mark A, Grossman D, et al. medication abortion with misoprostol-only: a sample protocol. Contraception. 2023;121:109998. doi:10.1016/j.contraception.2023.109998
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