Very early medical abortion

Very early medical abortion (VEMA) refers to medical abortion when an ultrasound has not shown definite evidence of an intrauterine pregnancy (no evidence of a yolk sac or fetal pole in an intrauterine sac). This finding is termed a ‘pregnancy of unknown location’ (PUL) because the pregnancy may be intrauterine (but not yet visible) or ectopic.

Advantages of very early medical abortion include avoiding delay and reducing the risk of retained products of conception. It may also cause less pain and bleeding than later medical abortion, although evidence is currently lacking. Drug regimens used for very early medical abortion are the same as for gestations of up to 63 days (9 weeks) (see Medical abortion regimen).

Very early medical abortion should only be offered by experienced practitioners, because of the potentially increased risk of an undiagnosed ectopic pregnancy. Alternatively, medical abortion can be deferred until ultrasound confirms that the pregnancy is intrauterine.

Note: Very early medical abortion of PUL should only be offered by experienced practitioners who have clear follow-up protocols in place. Follow-up is critical to limit the risk of undetected ectopic pregnancy.

Very early medical abortion should not be undertaken if:

  • there are risk factors for ectopic pregnancy (eg previous ectopic pregnancy, intrauterine contraceptive device in place, a history of pelvic inflammatory disease or tubal surgery)
  • there are signs or symptoms of ectopic pregnancy (severe abdominal pain, unilateral pelvic or shoulder tip pain, onset of weakness, heavy bleeding)
  • the gestation estimated by dates is incompatible with the quantitative serum human chorionic gonadotrophin (hCG) measurement and the first ultrasound; see Ultrasound scan before medical abortion. An absent intrauterine sac on transvaginal ultrasound and a serum hCG measurement more than 1500 IU/L suggest an ectopic pregnancy; urgently refer to a specialist
  • the individual is unable to provide informed consent or comply with early follow-up.

Experienced practitioners must assess the possibility of an ectopic pregnancy on a case-by-case basis, and ensure close monitoring and follow-up. Management protocols should include:

  • clear advice to seek immediate medical attention if symptoms or signs of an ectopic pregnancy occur
  • follow-up by phone or in person within 3 days (see Follow-up after medical abortion)
  • a repeat quantitative serum hCG measurement in 3 to 5 days after mifepristone is taken.