Early Medical Abortion at Home (EMAH) (Guidelines)

• Certain of decision to have abortion and treatment at home
• Fulfils the criteria set out in the Abortion Act 1967
• Less than 10 weeks’ gestation on the day of mifepristone administration
• At least 16 years of age
• Adult to be at home with them following the self-administration of misoprostol
• Has a working phone, in order to contact the gynaecology ward or an ambulance in an emergency
• No significant medical conditions or contraindications to medical abortion
• No symptoms or history of ectopic pregnancy (if this has not already been excluded by ultrasound scan)
• 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 and available for follow-up
• Agrees to GP notification (GP will be notified if unable to contact for follow-up)

Please refer to the table below.

When arranging EMAH: 

1. Confirm that patient is certain of decision to proceed with EMAH. Obtain consent.
2. Ensure that all inclusion criteria for EMAH are met.
3. Discuss and provide (or arrange provision for) contraception
4. Offer STI screening (Chlamydia/Gonorrhoea self-taken swab +/- BBV screen).  Self-taken swab can  be performed by patient on collecting medications from Raigmore.  Self-taken postal kit will be  provided with medications when collecting from Belford,Broadford and Caithness Hospitals and patient will return by post.
5. Arrange a telephone follow-up appointment and obtain a reliable contact number. Inform the patient that their GP will be alerted if we are unable to contact them for follow-up.
6. Advise patient on signs and symptoms that should warrant attendance to hospital as an emergency.
7. Advise re analgesia
8. 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’ at follow-up
   • 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
9. Anti-D is not required for patients having medical management at this gestation.

1. Medications can be collected from Raigmore, Caithness General Hospital, Belford Hospital or Broadford Hospital (Medications are also prepared in the Western Isles for collection there).
2. Both mifepristone and misoprostol can be taken at home.
3. Patients will be advised when to take their treatment and a patient information leaflet is provided with medications. Leaflet
4. Patient first takes 200mg mifepristone orally. Advise the patient that if vomiting occurs within 2 hours then she should return for mifepristone dose to be repeated with antiemetic.
5. Patient to take 800micrograms of misoprostol (four tablets) 36 to 48hrs after mifepristone. This can be taken vaginally, sublingually or buccally.
6. 4 hours later they should take 400micrograms of misoprostol (two tablets) vaginally, sublingually or buccally (avoid vaginal route if bleeding heavily).
7. 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
   • Patient information leaflet on EMAH
   • Contraception of their choice
   • Pregnancy test and written information on how to use it
   • STI self-taken swab test, if accepted

Follow up

• Patients are advised to do a urine pregnancy test on the day of their follow-up appointment (approximately two weeks after their misoprostol).
• If positive they will be invited for an ultrasound scan in the Unintended Pregnancy Clinic.
• If the patient is not contactable for their follow-up appointment, their GP will be notified.
• At the follow up appointment, any outstanding STI screening results should be checked and patient informed.
• If the patient has a negative pregnancy test at follow up but ongoing bleeding, they should be advised:

• • If symptoms are mild and settling, it is reasonable to observe for up to four weeks after misoprostol prior to arranging a scan.
  • If any signs of infection or retained pregnancy tissue (pain/fever/offensive loss/ worsening bleeding) they should be invited in for a medical review asap with the oncall team and a pelvic scan should be arranged to check for retained pregnancy tissue.
  • If the patient is unwilling to travel, then they should be sign-posted to local services (GP or local hospital) and the rationale for a review explained
  • See “Readmission after termination of pregnancy guideline” for advice in this situation. Intranet https://intranet.nhsh.scot.nhs.uk/Clinical/Maternity_GynaeServices/GynaeGuidelines/Gynaecology%20Guidelines/Readmission%20After%20Termination%20of%20Pregnancy%20Gynaecology%20Protocol.pdf

Anti-D: Anti-D immunoglobulin (used to prevent Rh sensitisation)
BBV: Blood Borne Virus
EMAH: Early Medical Abortion at Home
Hrs: Hours
IUCD: Intrauterine Contraceptive Device
mg: milligrams
STI: Sexually Transmitted Infection
Swab +/- BBV screen: Swab with or without Blood Borne Virus screening