Early Medical Abortion at Home (EMAH)

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Please note: The guidance below is being updated to come in line with COVID-19; the new, draft guidance, awaiting approval from CEG, is available in the COVID-19 section

Clinical Protocol for Early Medical Abortion at Home up to 8 weeks + 6 Days gestation (EMAH)

Scottish Abortion Care Providers (SACP) Network Guidelines for early medical abortion with self-administration of misoprostol in the home setting for NHS Highland

Inclusion Criteria:
  • Certain of decision to have abortion and wishes to administer the second part of treatment at home
  • Fulfils the criteria set out in the Abortion Act 1967
  • Lives within 30 mile radius from Raigmore Hospital
  • Up to 8 weeks + 6 days confirmed pregnancy on the day of mifepristone administration
  • 18 years of age or above, unless considered clinically appropriate
  • Can provide contact details required for follow-up
  • Adult to be at home with them following the self-administration of misoprostol
  • No significant medical conditions or contraindications to medical abortion
  • Is able to understand all information given and to follow instructions for misoprostol administration
  • No cause for concern regarding wellbeing at home
  • Fully understands the need to confirm the success of the procedure in line with local protocols.
Contra-Indications / Caution for mifepristone / misoprostol:

Mifepristone and misoprostol should be used with caution in certain conditions.  Please refer to the table below:

Absolute contra-indications

Caution required in the following circumstances (discuss with senior medical staff)

Inherited porphyria

Chronic adrenal failure

Known or suspected ectopic pregnancy

Uncontrolled severe asthma

Previous allergic reaction to one of the drugs involved

 

Woman on long term corticosteroids

Asthma (avoid if severe)

Haemorrhagic disorder or anticoagulant therapy

Prostethic heart valve or history of endocarditis

Pre existing heart disease

Hepatic or renal impairment

Severe anaemia

Severe inflammatory bowel disease eg. Crohns

IUCD in place (remove pre procedure)

Attendance at Clinic:
  1. Confirm that patient is certain of decision to proceed with abortion, including the self-administration of misoprostol at home. Obtain consent in line with local policy.
  2. Check that patient will have an adult at home with them after they self-administer misoprostol. If there is no adult available to be at home with the patient then treatment as EMAH should not proceed. Admission should be arranged instead.
  3. Discuss contraception options and provide on-going contraception in line with national guidelines.
  4. Check blood group. If blood group not known, undertake blood group testing.
  5. If there are symptoms or signs of anaemia, check full blood count (FBC) and defer starting treatment until haemoglobin is confirmed to be more than 10g/dl
  6. Undertake sexually transmitted infection (STI) screening.
  7. Ensure that a plan for follow up has been made with the patient.
    Arrange a telephone follow up and obtain a reliable contact number. Agree the date and time for telephone follow up.
    Ensure the patient understands how to perform the pregnancy test according to instructions.
  8. Advise patient on signs and symptoms that should warrant re-attendance to hospital as an emergency.
  9. Advise patient that they should contact the clinic if they have any of the following as the procedure may not have been effective:
  • If they do not bleed within 24 hours of receiving misoprostol tablets
  • If they have less than 4 days of bleeding
  • If they still ‘feel’ pregnant at the end of one week or have symptoms of pregnancy such as sore breasts, sickness, tummy growing, etc.
  • If the low sensitivity pregnancy test is positive or ‘invalid’
  • If the next period does not come one month after treatment
  • If they remain concerned that they may still be pregnant
  • If they fail to take the misoprostol as instructed

10.Advise those patients breastfeeding that milk should be discarded for 6 hours after misoprostol administration.

11. Complete EMAH paperwork detailing the patient understanding of treatment and provide patient information leaflet with advice on what to expect at home, including contact information for advice/concerns.

Day of Mifepristone administration:
  1. Check blood group and administer Anti D if necessary. If considering giving mifepristone in clinic and blood group is not known, defer mifepristone administration until results available.
  2. Check STI test results if available. If administering mifepristone in clinic, advise patient of follow up arrangements for positive results. Arrange follow up if required with Health Adviser at Highland Sexual Health.
  3. Check choice of contraception and provide on-going contraception.
  4. Administer 200mg mifepristone orally. Advise the patient that if vomiting occurs within 2 hours then she should return for mifepristone dose to be repeated (consider if patient requires admission for day case instead of EMAH).
  5. Dispense take home pack of prophylactic antibiotics in line with local policy. Advise regarding analgesia.
  6. Dispense take home pack of misoprostol tablets. Traditional administration has been by the vaginal route, but sublingual and buccal routes are as effective and the patient should be advised on how to self administer by the preferred route.
  1. If vaginal administration is unacceptable to the patient, then the same dose of misoprostol may be administered sublingually or buccally with similar efficacy. Please note that oral administration (swallowing) of misoprostol has lower efficacy and so oral administration should only be used if the pregnancy is less than 7 weeks gestation and if vaginal, sublingual or buccal routes of administration of misoprostol are unacceptable to the patient.
  2. The patient should be made aware that administration by sublingual or buccal route is associated with a higher likelihood of headache. Misoprostol tablets administered buccally or sublingually may take approximately 20 minutes to dissolve, may not dissolve fully and are associated with an unpleasant taste in the mouth.

7. The patient should be advised of the standard dosing interval between mifepristone and misoprostol is 24 to 48 hours, based upon efficacy.

Misoprostol should thus normally be administered 24 to 48 hours after mifepristone.

  1. Longer dosing interval (more than 48 to 72 hours): there is evidence that (less than 63 days gestation) the time interval between mifepristone and misoprostol can be prolonged up to 72 hours after mifepristone with similar efficacy, although the likelihood of heavy bleeding by this time is increased.
  2. Longer dosing intervals (more than 48 to 72 hours) should only be used if the patient is aware of the likelihood of heavy bleeding with treatment this way and the standard (24 to 48 hours) dosing interval is not acceptable to the patient.

8. Provide patient with patient information leaflet with advice on what to expect at home. Remind patient of when to contact the clinic/ward if they have any signs/symptoms related to the procedure not being effective.

9. Ensure the patient has been provided with:

  • Complete drug regime
  • Emergency contact number
  • Contact information for routine advice and queries
  • Advice on how to self-administer misoprostol
  • EMAH information leaflet
  • Contraception of their choice
  • Pregnancy test
  • Advice about how to administer a pregnancy test

10. Discharge the patient and ensure a discharge letter has been completed.

In the case of an invalid or lost pregnancy test, women should be seen as soon as possible by Social Gynaecology.

If an on-going pregnancy is confirmed then the woman should be offered the next available date for abortion by the most appropriate method for her gestation.

If the patient does not complete their follow up plan, then her GP may be notified.

Glossary
Abbreviation Meaning
IUCD Intrauterine contraceptive device
Editorial Information

Last reviewed: 30 April 2019

Next review: 30 April 2020

Author(s): Social Gynaecology Team

Version: 1

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Specialty Doctor

Document Id: TAM427