Outcome of first trimester medical termination of pregnancy: definitions and management

Figures & data

Table 1. MToP outcome definitions.

Outcome	Gynuity Health Projects [13]	HAS [15]	WHO [8]
Success	Complete termination of pregnancy without the need for a surgical procedure	Complete termination of pregnancy without the need for a surgical procedure
Failure	Recourse to a surgical procedure: may be the result of ongoing pregnancy, incomplete expulsion, heavy bleeding, judgement of the provider that procedure should be terminated surgically, or request of the woman	Surgery for any of the following: ongoing pregnancy, incomplete expulsion, heavy bleeding requiring surgical haemostasis, surgery requested by the woman Better assessment: rate of ongoing pregnancies
Complete abortion			All products of conception (embryo/fetus, placenta and membranes) are expelled
Incomplete abortion			Although the fetus is expelled, part or all the placenta is retained
Missed abortion			Pregnancy where the fetus has died but fetal tissue and placenta are retained in the uterus

Empty boxes correspond to no guideline definitions.

Table 2. Management of abortion outcome up to 13 weeks at follow-up: guidelines.

Guideline	Ongoing pregnancy	Incomplete abortion	Missed abortion
WHO [9]	Re-administration of misoprostol or surgery	Expectant management, or Misoprostol 400 µg sublingually or 600 µg orally, or Surgery
WHO [10]	Uterine evacuation	Expectant management, or Vacuum aspiration, or Misoprostol 600 µg orally, 400 µg sublingually or 400-800 µg vaginally if vaginal bleeding is minimal	Expectant management, or Vacuum aspiration, or Misoprostol
IPPF [11]		Misoprostol 800 µg orally or vaginally
FIGO [12]	Uterine evacuation	Additional misoprostol 600 µg orally or 400 µg sublingually, or Vacuum aspiration
RCOG [17]		Vacuum aspiration, or Misoprostol 600 µg orally or 400 µg sublingually
SFOG [18]		Medical treatment (misoprostol 400 µg sublingually or 600 µg vaginally), or Vacuum aspiration and pretreatment with misoprostol 400 µg sublingually	Misoprostol 800 µg vaginally or 600 µg sublingually, or Vacuum aspiration and pretreatment with misoprostol 400 µg sublingually

Empty boxes correspond to no guideline recommendations.

Figure 1. Management of MToP outcome. PG, prostaglandin; US, ultrasound.

Figure 2. Vaginal ultrasound. (a) Uterine cavity immediately after aspiration of an 8-week pregnancy. (b) Presence of blood clots in the same woman 10 days after surgical abortion.

Figure 3. Vaginal ultrasound. (a) Uterus with an intrauterine pregnancy corresponding to 6 weeks after the last menstrual period, with yolk sac visible and serum hCG 32,000 IU/l. (b) Gestational sac of the same woman expelled on day 3. (c) Uterine cavity diameter 12 mm in the same woman 8 days after intake of mifepristone in an MToP procedure. Serum hCG had dropped to 837 IU/l. The gestational sac that was visible in the uterine cavity prior to the procedure is gone.

Table 3. Proposed definitions of outcome of MToP (or medical abortion).

Outcome of MToP	Definition
Success	Expulsion without the need for additional treatment (repeat MToP, misoprostol alone, or surgical)
Failure	Ongoing pregnancy
Need for additional treatment
Additional treatment needed to complete MToP: incomplete abortion (products of conception are retained but gestational sac/embryo is expelled), missed abortion (persistent non-evolving pregnancy)	Situation that is not considered a complication and needs additional treatment, which may be medical (repeat MToP or misoprostol alone) or surgical (aspiration)
Complications leading to additional treatment	Heavy or prolonged bleeding; infection; persistent, significant pain
Woman’s request for additional treatment

For research protocols, outcomes should be assessed at standardised time points (follow-up including self-assessment).

Gynuity Health Projects. Medical abortion guidebook. 2009 [cited 2017 Nov 29]. Available from: http://gynuity.org/resources/info/medical-abortion-guidebook.

 Google Scholar

Haute Autorité de Santé. Interruption volontaire de grossesse par méthode médicamenteuse. Argumentaire. 2010 [cited 2017 Nov 29]. Available from: www.has-sante.fr/portail/upload/docs/application/pdf/2011-04/ivg_methode_medicamenteuse_-_recommandations_-_mel_2011-04-28_11-39-11_882.pdf.

 Google Scholar

World Health Organization. Managing incomplete abortion. Education material for teachers of midwifery. Midwifery education modules. 2nd ed. Geneva: WHO; 2008.

 Google Scholar

World Health Organization. Safe abortion: technical and policy guidance for health systems. 2nd ed. Geneva: WHO; 2012.

 Google Scholar

World Health Organization. Clinical practice handbook for safe abortion. Geneva: WHO; 2014.

 Google Scholar

International Planned Parenthood Federation. First trimester abortion guidelines and protocols. Surgical and medical procedures. 2008 [cited 2017 Nov 29]. Available from: www.ippf.org/resource/First-Trimester-Abortion-Guidelines-and-Protocols.

 Google Scholar

FIGO Working Group on Prevention of Unsafe Abortion and its Consequences; International Federation of Gynecology and Obstetrics. The combination of mifepristone and misoprostol for the termination of pregnancy. Int J Gynaecol Obstet. 2011;115:1–4.

 PubMed Web of Science ®Google Scholar

Royal College of Obstetricians and Gynaecologists. Best practice in comprehensive abortion care. Best practice paper no. 2. 2015 [cited 2017 Nov 29]. Available from: www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-2.pdf.

 Google Scholar

Work and Reference Group for Family Planning, Swedish Society of Obstetrics and Gynaecology. Induced abortion. Guideline no. 78 [in Swedish]. 2018 [2018 Oct 4]. Available from: www.sfog.se/natupplaga/ARGrappor9792c7d5-5648-475e-bee6-81478b0d9323.pdf.

 Google Scholar