Written by Libby Wetterer, MD and Gabriele Ruzgas, MD

Medication abortion accounts for approximately 65% of abortions in the United States.¹ Most U.S. clinicians who provide medication abortion do so through 12 weeks gestation, though medication abortion can be used later in pregnancy. Data shows that up to 24 weeks fetal expulsion rates are 90% 24 hours after starting misoprostol, and major complications are infrequent (roughly 1%).² The World Health Organization (WHO), the Society of Family Planning (SFP), and the National Abortion Federation (NAF) provide guidance after 14 weeks.^3,4,5 The Reproductive Health Access Project has created an easy-to-follow resource for how to use medication abortion between 14-20 weeks that can be used to counsel patients on this topic.

Gestational dating is the first step and may be based on the first day of the last menstrual period; ultrasound should be considered if dating is uncertain. Before taking pills, people should be counseled regarding expected bleeding and pain, fetal expulsion, tissue disposal, indications for in-person evaluation, and support resources (e.g., a friend, Reprocare, Exhale). Rh(D)-negative people who desire future pregnancy should be advised to obtain Rh immune globulin within 72 hours of bleeding, if possible, or discuss risks and benefits with a clinician, such as through the Miscarriage and Abortion Hotline (M+A Hotline). 

The WHO protocol for the combined regimen recommends taking mifepristone 200 mg orally, followed 24–48 hours later by misoprostol 400 mcg buccally, sublingually, or vaginally every 3 hours until fetal and placental expulsion. People should have at least 12–16 misoprostol tablets available and avoid skipping doses; alarms may help. Time to expulsion ranges from several to 48 hours after starting misoprostol. 

If mifepristone is unavailable, misoprostol-only regimens are effective, but often require more doses. Misoprostol 400 mcg can be used buccally, sublingually, or vaginally every 3 hours until expulsion. Buccal or sublingual administration may be preferred because vaginal fragments can remain visible on pelvic exam. If in-person care is needed, people may attempt to remove fragments with a vaginal sweep using fingers and water. 

Clear fluid may pass before heavier bleeding and clots, followed by fetal and placental expulsion. People may choose not to view the pregnancy tissue if a support person is available to assist. Tissue from pregnancies < 15 weeks can generally be flushed; larger tissue can be wrapped securely (ideally with multiple layers of plastic) and placed in the garbage. Disposal may raise legal risk. Placental passage may take additional time, and people should be counseled not to pull on the umbilical cord.

Pain may be significant, particularly before fetal expulsion. Supportive medications include ibuprofen 800 mg and acetaminophen 1,000 mg starting 30 minutes before misoprostol and continued every 8 hours as needed. Antiemetics may also help with nausea, and antidiarrheals can be used for diarrhea.

Clinicians on the M+A Hotline can help determine whether an in-person evaluation is needed. Evaluation should be considered for failure to expel the pregnancy after completing misoprostol, retained placenta, persistent fever >24 hours after misoprostol, uncontrolled pain, or symptomatic heavy bleeding. 

Medication abortion after 14 weeks is more likely to require procedural completion or in-person evaluation, but people should be advised that there are no clinically available tests for mifepristone or misoprostol exposure, and medication abortion is clinically indistinguishable from miscarriage. Clinicians should discuss potential legal risks and refer people with concerns to the Repro Legal Helpline.

How To Use Abortion Pills Fact Sheet for 14-20 weeks (new!)