5.5 Unintended Pregnancy: Options Counseling, Medication & Procedural Abortion

Options Counseling

When a patient has an unintended or uncertain pregnancy, the WHNP:

1. Confirms the pregnancy and estimates gestational age from the LMP. Ultrasound is needed when dating is uncertain or ectopic risk factors or symptoms are present.
2. Provides nondirective counseling on all three options: continuing the pregnancy and parenting, continuing the pregnancy and placing for adoption, and abortion. The patient's values guide the decision.
3. Screens for coercion and safety, including reproductive coercion and intimate partner violence, and talks with the patient alone.
4. Refers promptly for the chosen option, because both medication and procedural abortion are safer and more available earlier in pregnancy. A clinician with a conscientious objection must still give accurate information and a timely referral, and must never delay emergency care.

The Legal Landscape

Dobbs v. Jackson Women's Health Organization (June 24, 2022) ended the federal constitutional right to abortion, so legality now depends on state law: some states ban abortion with narrow exceptions, some set gestational limits, and some protect access and clinicians through shield laws. Rules on telehealth prescribing, parental involvement for minors, and waiting periods also vary by state. The WHNP must know the law where they practice and where the patient lives.

---

Medication Abortion

Standard Regimen

• Mifepristone 200 mg orally, a progesterone receptor antagonist that detaches the pregnancy and softens the cervix, then
• Misoprostol 800 mcg buccally (or vaginally or sublingually) 24–48 hours later, a prostaglandin E1 analog that causes uterine contractions and expulsion.
• FDA-approved through 70 days (10 weeks) from the LMP; complete abortion occurs in about 95%–98%. Evidence-based protocols extend use to 77 days with a second misoprostol dose.
• Misoprostol-only regimens (800 mcg every 3 hours for several doses) are less effective but are used where mifepristone is unavailable.

Contraindications to Mifepristone

• Confirmed or suspected ectopic pregnancy: mifepristone does not treat ectopic pregnancy.
• An IUD in place (remove it first).
• Chronic adrenal failure or long-term systemic corticosteroid therapy.
• Hemorrhagic disorders or current anticoagulant therapy.
• Inherited porphyria.
• Allergy to mifepristone or misoprostol.

Counseling: Expected Effects and Warning Signs

Cramping and bleeding heavier than a menstrual period are expected, usually starting within hours of misoprostol, along with possible nausea, diarrhea, and transient fever or chills on the misoprostol day. NSAIDs relieve cramps. Seek care for:

• Soaking two thick pads per hour for 2 consecutive hours.
• Fever of 100.4 °F (38 °C) or higher lasting more than 4 hours in the days after treatment, or feeling ill, weak, or nauseated several days later (rare serious infection, including Clostridium sordellii sepsis, can occur without fever). A brief temperature rise on the misoprostol day is expected.
• No bleeding within 24 hours of misoprostol, which may mean an ongoing or ectopic pregnancy.

Follow-Up

Confirm completion by a symptom check plus a serial serum hCG decline, ultrasound, or a low-sensitivity home pregnancy test about 4 weeks later. An ongoing pregnancy needs repeat medication or aspiration; persistent retained tissue with heavy bleeding may need aspiration.

Regulation

Mifepristone is dispensed under an FDA Risk Evaluation and Mitigation Strategy (REMS). The January 2023 REMS modification removed the in-person dispensing requirement and created pharmacy certification, so certified prescribers can have mifepristone dispensed by certified pharmacies, including by mail. As of 2026 this framework remains in effect: in May 2026 the Supreme Court declined to let a lower-court order reinstate in-person dispensing, and an FDA review of the REMS that began in 2025 is ongoing. State laws can still prohibit or restrict prescribing.

---

Procedural (In-Clinic) Abortion

• Aspiration (manual or electric vacuum): Used in the first trimester and early second trimester; takes about 5–10 minutes under a paracervical block, with or without sedation; complete in more than 99%.
• Dilation and evacuation (D&E): Used in the second trimester after cervical preparation with misoprostol or osmotic dilators.
• Complications are uncommon: retained tissue, hemorrhage, infection (reduced by routine prophylactic doxycycline), and rarely perforation or cervical injury. Legal induced abortion has a lower mortality rate than continuing a pregnancy to birth.

---

Rh Status

ACOG's 2024 Clinical Practice Update suggests forgoing routine Rh testing and Rho(D) immune globulin for abortion or pregnancy loss before 12 weeks, because fetal red-cell exposure is too small to cause sensitization; it may be offered on request. At 12 weeks or later, give anti-D immune globulin to unsensitized Rh(D)-negative patients.

---

Contraception After Abortion

Fertility returns quickly; ovulation can occur within about 2 weeks.

---

Adoption and Parenting

• Adoption: Discuss open (ongoing contact) versus closed adoption, the birth parent's rights, and the timing of relinquishment, which is set by state law and allowed only after birth. Safe Haven laws let a parent leave a newborn at designated locations within a state-defined period.
• Parenting: Start prenatal care, folic acid, and screening promptly, and connect the patient with WIC, Medicaid, and social support.