Medication abortion, often referred to as the abortion pill, is a common and highly effective method for ending an early pregnancy. This process relies on a two-drug regimen: mifepristone blocks the hormone progesterone necessary for pregnancy continuation, and misoprostol causes the uterus to contract and expel the pregnancy. While successful for the vast majority of people, the procedure does not work 100% of the time. When the process does not go as planned, specific medical guidance and immediate follow-up care are necessary to ensure the patient’s health and safety.
Defining Treatment Success and Failure
A successful medication abortion is defined as the complete termination of the pregnancy and the full expulsion of all tissue from the uterus. For most people, the medication works as intended, with effectiveness rates consistently reported between 95% and 99% for those in the early weeks of pregnancy. Success is typically confirmed during a follow-up appointment, often through a blood test to check for a sufficient drop in pregnancy hormone levels (hCG) or an ultrasound to confirm the uterus is empty.
Treatment failure is a low-probability outcome that requires further intervention. This failure is categorized into two distinct medical situations, both of which mean the pregnancy has not been completely terminated. The first, and more common issue, is an incomplete abortion where some tissue remains inside the uterus. The second, which is much rarer, is an ongoing pregnancy, meaning the fetus continues to develop.
Managing an Incomplete Abortion
An incomplete abortion occurs when the pregnancy has ended, but the uterus retains some tissue, medically known as retained products of conception. This is the most frequent reason for a follow-up procedure after a medication abortion, affecting an estimated 2% to 6% of patients. Symptoms often include heavy bleeding that continues for a prolonged period, or cramping that does not resolve or intensifies after the initial process.
The primary risk of retained tissue is the potential for infection, which can be signaled by a fever, persistent severe pain, or foul-smelling vaginal discharge. Healthcare providers have three main options for resolving an incomplete abortion, with the choice depending on the patient’s clinical stability and preference:
- Expectant management: The provider monitors the patient, allowing the body to pass the remaining tissue naturally over time.
- Medical management: An additional dose of misoprostol is administered to stimulate further uterine contractions and expel the remaining tissue.
- Surgical management: If bleeding is heavy or expectant and medical management are not appropriate, a minor surgical procedure called vacuum aspiration may be necessary. This outpatient procedure uses gentle suction to quickly and safely remove the retained tissue.
Addressing Ongoing Pregnancy
The most serious type of failure is an ongoing pregnancy, which occurs in less than 1% of medication abortion cases. This happens when the medication has not successfully stopped the development of the fetus. Confirming an ongoing pregnancy requires an urgent follow-up, typically involving an ultrasound to check for fetal viability and heartbeat.
If the patient still wishes to end the pregnancy, a surgical procedure, such as vacuum aspiration, becomes the necessary next step. Taking additional medication is generally not a reliable option at this stage, and a surgical method ensures the termination is complete.
Alternatively, a patient may choose to continue the pregnancy after learning the medication failed. This decision requires immediate and detailed consultation with a healthcare provider or genetic counselor due to the fetus’s exposure to the medication. Exposure to mifepristone alone has not been clearly shown to cause fetal malformations. However, misoprostol exposure is associated with a small increased risk of certain birth defects if the pregnancy continues, such as Mobius sequence and terminal transverse limb defects. While the overall risk remains very small, detailed counseling is imperative for the patient to make a fully informed decision.
Necessary Follow-Up Care
The mandatory follow-up appointment is a non-negotiable part of the medication abortion process, regardless of whether the patient believes the pill worked successfully. This check-up ensures the procedure is complete and the patient’s recovery is progressing normally. The follow-up typically occurs one to two weeks after taking the medication and may involve a blood test or ultrasound.
Patients are instructed to monitor themselves closely for signs of complications following the procedure. Immediate medical attention is required for emergency symptoms:
- Soaking through two or more thick sanitary pads in one hour for two consecutive hours.
- Passing blood clots larger than a lemon.
- Severe abdominal pain unrelieved by medication.
- A fever lasting more than 24 hours.
- Unusual, foul-smelling vaginal discharge.
Experiencing a failed medication abortion can be an emotionally distressing and confusing event. Providers understand that the need for a second procedure can be taxing, and emotional and psychological support is an important component of comprehensive care. This support helps patients process the unexpected turn of events and ensures their overall well-being.