This protocol aims to describe the provision of medical abortion (MA) in a setting where direct access to abortion providers may be difficult, particularly during a period of social disruption or a pandemic. This protocol may deviate from approved indications or previous clinical practice.# When a request for abortion is received:
- Confirm patient identity and ensure patient has privacy and safety to discuss 2. Provide written information (for example, by email or fax) on medication and surgical abortion as well as instructions on medication abortion (), in advance of consultation 3. If not already done, ask the patient to obtain and take a qualitative urine high sensitivity pregnancy test from pharmacy 4. Schedule a first virtual visit via telephone or video to provide consultation

# Pre-abortion assessment via telephone or video (consultation):
- Review pregnancy options counselling 1 2. Establish pregnancy and gestational age: a. Review date of last menstrual period (LMP), and date of positive qualitative pregnancy test b. Review relevant medical history, particularly risk factors and signs/symptoms for ectopic pregnancy and method of contraception used at the time of conception if any c. If either intrauterine device (IUD) or intrauterine system (IUS) is present, arrange an ultrasound and appointment for IUD/IUS removal or consider surgical abortion 3. Determine need for an ultrasound;   h. Allergy to mifepristone, misoprostol or other prostaglandins 5. Determine the need for laboratory investigation prior to MA (a 2 nd pre-abortion assessment via telephone or video may be required): a. Complete blood count is required if suspected severe anaemia or hemoglobinopathy i. Hemoglobin should be over 9,5 g/dl before starting MA b. Rhesus (Rh) status can be considered if not documented elsewhere (e.g. donor card, previous results) AND if patient would accept Rh immunoglobulins: according to current evidence, Rh testing is required when gestational age (GA) is over 56 days. 5,6 However, during the COVID-19 pandemic, expert opinion recommends that Rh testing may be withheld up to 70 days GA. 7,8 c. Sexually transmitted infection (STI):
i. If the patient must come to the office for any reason, offer screening of Chlamydia and gonorrhea ii. If the patient does not have to be seen in person, but there are risk factors for STI, consider remote testing if available, and discuss the potential need for antibiotic prophylaxis (such as Doxycycline 100 mg twice a day for 7 days, starting the same day as 

# Follow-up #1 -7 days post-treatment via telephone or video:
- Review abortion experience and progress with patient: a. Dates of taking mifepristone and misoprostol b. Side effects of medication c. Bleeding pattern since taking mifepristone and misoprostol d. Pain during the process and current pain, if any e. Whether or not expulsion occurred f. Presence of current symptoms of pregnancy g. Warning signs of ectopic pregnancy or infection 2. Advise an urgent assessment or emergency visit if signs of ectopic pregnancy, signs of pelvic infection, heavy bleeding, excessive pain 3. Obtain an ultrasound if history suggests failed abortion or ongoing pregnancy and consider additional dose of misoprostol or surgical aspiration as needed 4. If history suggest successful abortion, no current symptoms of pregnancy, normal bleeding and pain, and no warning signs, instruct the patient to perform a first qualitative urine pregnancy 3 weeks from now, which is 4 weeks after taking misoprostol. Ensure that the patient will have her first pregnancy test result available at the time of follow-up #2
Follow-up #2 -4 weeks post-treatment via telephone or video:
- Review the date first pregnancy test was done. Ensure test was performed at least 3 weeks after misoprostol was taken 2. If first pregnancy test is negative, reassure the patient that abortion is complete. Do not repeat pregnancy test 3. If first pregnancy test is positive, review signs and symptoms of retained product of conception, ongoing pregnancy or ectopic pregnancy: a. If present, consider evaluation with ultrasound and/or serum hCGs and: i. Retained product of conception: consider additional dose of misoprostol or surgical aspiration ii. Ongoing pregnancy: consider surgical aspiration iii. Ectopic pregnancy suspected or confirmed: manage accordingly and refer to gynecologist as needed iv. Negative ultrasound: consider new pregnancy, have the patient repeat urine pregnancy test (second) in one week. Ensure that the patient will have her second pregnancy test result available at the time of follow-up #3 b. If no warning signs and no ultrasound: have the patient repeat urine pregnancy test (second) in one week. Ensure that the patient will have her second pregnancy test result available at the time of follow-up #3 Follow-up #3 -5 weeks post-treatment via telephone or video:
- Review the date second pregnancy test was done. Ensure test was performed 1 week after last (first) pregnancy test 2. If second urine pregnancy is negative, reassure the patient that abortion is complete.

# Contraception provision of long acting reversible contraception:
- Plan an in-clinic follow-up contact for insertion of implant, IUD or IUS once abortion is deemed completed or according to clinician's advice, and following patient's preference and consent for long acting reversible contraception (LARC).