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Insights: Medication Abortion Without Ultrasound: A Safe and Approachable Framework to Support the Expansion of Access

Written by Kohar Der Simonian

The COVID-19 pandemic paved the way for major changes in abortion provision. One important change included modifications to clinic workflows emphasizing that routine use of ultrasound is no longer a requirement for the safe and effective provision of first-trimester abortion care.¹

Abortion without the routine use of ultrasound expands the ability to perform medication abortions in clinical settings where on-site ultrasound or trained sonographic professionals are not available, or to provide via telehealth appointments. It reduces delays in patient care, as well as reducing financial burdens on both patients and clinics.²

In this move to an ultrasound-as-needed model of abortion care, screening and history become essential. Gestational age can almost always be estimated using a combination of patient history, last menstrual period (LMP), and a bimanual exam.³

Consider ultrasound for following reasons:

  1. Gestational age is determined to be > 77 days by patient’s reported LMP (to determine accurate dating and confirm eligibility for medication abortion vs uterine aspiration).
  2. The patient is without menses, and it has been more than 77 days since a prior delivery or abortion.
  3. Pregnancy occurs while on a method of birth control (OCP, the shot, implant, IUD), as the use of a contraceptive makes it more difficult to reliably predict gestational age.
  4. Concerns or risk factors for ectopic pregnancy (including prior ectopic, prior tubal infection or surgery, IUD in place, signs or symptoms of an ectopic including unilateral pain and bleeding).

Follow-up studies have shown that with a transition to an ultrasound-as-needed or telehealth medication abortion, there is no evidence of worse outcomes in ongoing pregnancy rates, hemorrhage, need for surgery, or failure to detect ectopic pregnancy.²

History-based screening creates a more equitable and trauma-informed approach to abortion care: decreasing unnecessary pelvic examinations and increasing the types of clinicians capable of providing services and clinical locations able to safely offer this service – all without sacrificing efficacy or patient outcomes.

RHAP Resources:

Protocol for Medication Abortion Using Mifepristone and Misoprostol

Telehealth Care for Medication Abortion Protocol

Algorithm to Diagnose and Treat Ectopic Pregnancy

Indications for Sonography for Medication Abortion


1. National Abortion Federation, Clinical Policy Guidelines for Abortion Care, 2020

2. Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study. JAMA Intern Med. 2022;182(5):482-491

3. Raymond EG, Grossman D, Mark A, et al. Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception. 2020;101(6):361-366. doi:10.1016/j.contraception.2020.04.005

4. Bracken H, Clark W, Lichtenberg ES, et al. Alternatives to routine ultrasound for eligibility assessment prior to early termination of pregnancy with mifepristone-misoprostol. BJOG. 2011;118(1):17-23. doi:10.1111/j.1471-0528.2010.02753.x

Pharma-free: The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or products. The information in the Insights is unbiased, based on science alone.

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