Comparison of Telephone Follow-up With In-person Follow-up After Medical Abortion

Background: Medical abortions in Canada are provided using a standard regimen of methotrexate and misoprostol. After these medications are administered, patients are most commonly checked for termination of the pregnancy with an ultrasound and physical examination at an in-clinic follow-up appointment. These follow-up appointments can be inconvenient, costly, and take away from patient privacy. Furthermore, it has been suggested that these follow-up appointments may not be necessary for patients.

Objective: To determine whether remote follow-up, using telephone and blood testing is a feasible, safe, and effective method of follow-up after medical abortion, compared to standard care that requires an in-clinic visit and ultrasound.

This study offers women the option of remote follow-up by telephone combined with serum Beta-human chorionic gonadotropin (β-hCG) testing or standard in-clinic follow up. We will determine women's preferences for follow up, and compare adherence to the follow-up schedule, number of clinical contacts, and outcomes of the abortion. This study will be performed at two clinics in Toronto, the Bay Centre for Birth Control (BCBC) and the Choice in Health Clinic (CIHC).

Primary Hypothesis: Follow-up will be more successful with RFU, compared to SFU.

The protocol is altered for women who have an ultrasound that shows only a gestational sac (no yolk sac or fetal pole). Women in both follow-up groups will have β-hCG testing on the day of methotrexate injection and again in 8 days. If the level does not fall by 50% or they have concerning symptoms, they are asked to return to clinic for evaluation. If the β-hCG level falls by 50% or more, they will continue to be followed as per the protocol in their chosen group, but will be followed until their β-hCG becomes negative.

Eligibility Criteria:
Inclusion Criteria:

1. Requests a medical abortion and fulfills standard eligibility criteria for M\&M abortion:

   * Clear decision to have an abortion
   * Valid Ontario Health card
   * Willing to abstain for vaginal intercourse and alcohol for 14 days
   * Ability to insert misoprostol vaginal tablets
   * Emergency Contact number
   * Stop folic acid vitamins on initial contact
   * Good general health
   * Single intrauterine gestation less than or equal to 49 days as determined by transvaginal ultrasound
   * Telephone access
   * Access to emergency medical care within 30 minutes of home
   * Agrees to undergo a surgical abortion in case of failure of the medical abortion method
2. Ability to understand the protocol and consent
3. Willingness to comply with either the SFU or RFU follow-up schedule

Exclusion Criteria:

1. Factors that exclude women from eligibility for M\&M abortion:

   * Coagulopathy or hemoglobin less than 100, White Blood Cell count \< 4.0 platelet \<140,000
   * Allergy to methotrexate or misoprostol
   * Presence of an intrauterine device
   * Acute or chronic renal or hepatic disease
   * Acute inflammatory bowel disease
   * Uncontrolled seizure disorder
   * Sickle cell anemia
   * Breastfeeding
   * Chronic oral corticosteroid therapy
   * Any condition that in the opinion of the clinician investigator would compromise the safety of medical abortion for this patient
2. Requires the support of an interpreter