Suspected continuing pregnancy after medical abortion

Continuing pregnancy occurs in around 0.8% of people undergoing medical abortion. It is suspected if bleeding is absent or lighter than expected or pregnancy symptoms are present. Indicators include:

  • at 24 hours after misoprostol:
    • bleeding is absent or less than a normal period
    • no clots (or only those less than grape size) have been passed
    • no products of conception passed (especially if gestation is 7 weeks or more)
  • initial bleeding has stopped within 4 days of taking misoprostol
  • other indicators:
    • symptoms of pregnancy persist: nausea still present at 48 hours after misoprostol or breast tenderness persists at 14 days
    • serum hCG concentration increases above baseline or shows a small relative drop at 7 days after mifepristone is taken (rather than falling to below 20% of baseline level, as expected with a successful medical abortion).

Consider the possibility of ectopic pregnancy, which requires emergency management. If an intrauterine pregnancy was confirmed on the ultrasound scan performed before the abortion, the likelihood of a concurrent ectopic pregnancy is extremely low. Symptoms of an ectopic pregnancy include:

  • severe abdominal pain
  • unilateral pelvic or shoulder tip pain
  • onset of weakness
  • heavy bleeding.

In all individuals with suspected continuing pregnancy, order a repeat ultrasound scan.

If the repeat ultrasound confirms ongoing intrauterine pregnancy, advise completing the abortion process because misoprostol is a known teratogen.

If the pregnancy is 63 days’ (9 weeks’) or less gestation, a repeat dose of mifepristone and misoprostol, or surgical abortion are options. If the repeated mifepristone and misoprostol is unsuccessful, organise surgical abortion.

If the pregnancy is over 63 days’ gestation, organise a surgical abortion.

If the individual indicates an intention to continue the pregnancy, specialist referral is recommended.

If intrauterine pregnancy is not confirmed on the repeat ultrasound scan, but retained products of conception are visible, manage as for retained products of conception. If neither intrauterine pregnancy nor retained products are visible, seek specialist advice.