CLINICAL ORAL ABSTRACTS: Comparison of clinical outcomes among patients who did and did not have screening ultrasound or pelvic exam before obtaining medication abortion via direct-to-patient telemedicine and mail

Abstract

<h3>Introduction</h3> Until recently, standard guidelines for provision of medication abortion (MA) required an ultrasound or pelvic exam be done prior to treatment to confirm intrauterine pregnancy and that the gestational age is within the recommended timeframe for outpatient MA. However, requiring these tests can introduce financial and logistical obstacles for patients. During the COVID-pandemic, use of "no test medication abortion" (NTMA) became more common, including in the TelAbortion study, a multicenter trial that provides MA by direct-to-patient telemedicine and mail. We compared clinical outcomes among study patients who had NTMA or who had an ultrasound or pelvic exam prior to MA. <h3>Method</h3> This prospective, observational study examined the association between use of screening ultrasound or pelvic exam and the occurrence of selected clinical events after MA. We included all participants in the TelAbortion study who were enrolled from March 25 to September 15, 2020 and who received services from a participating site that provided at least 2 NTMAs during the analysis period. The primary outcome was procedure abortion or ongoing pregnancy after MA. Other outcomes included a composite outcome of hospitalization and/or blood transfusion, ongoing pregnancy after MA, diagnosis of ectopic pregnancy after shipment of abortion medications, and receipt of clinical care after abortion medications were mailed. We compared outcomes for the 2 groups by calculating adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) using a logistic regression model with inverse probability weighting according to the propensity score and incorporating generalized estimating equations to adjust for clustering by study site. Propensity score weighting was done to increase comparability of the study groups with respect to age, race/ethnicity, prior pregnancies (any versus none), patient residence ≥150 miles from the study site, gestational age by date of last menstrual period, and whether patient used insurance to pay for the abortion service. <h3>Results</h3> We included 5 of the 9 participating TelAbortion sites. We analyzed outcomes among 384 TelAbortion patients, including 278 who had NTMA and 106 who had a screening ultrasound or pelvic exam before shipment of abortion medications. A procedure abortion or ongoing pregnancy after MA was reported for 16/278 (5.8%) NTMA patients compared to 2/106 (1.9%) patients who had screening ultrasound or pelvic exam (aOR = 3.23, 95% CI: 0.58–17.97). There were no diagnoses of ectopic pregnancy in either study group. Hospitalization and/or blood transfusion occurred in 2/276 (0.7%) and 1/106 (0.9%) of patients who had NTMA and screening ultrasound or pelvic exam, respectively (aOR = 1.13, 95% CI: 0.48–2.65). Ongoing pregnancy after MA was detected in 4/278 (1.4%) and 2/106 (1.9%) of patients who had NTMA and screening ultrasound or pelvic exam, respectively (aOR = 0.76, 95% CI: 0.08–7.16). More NTMA patients had unplanned clinical encounters after shipment of abortion medication (33/276, 12.0%) compared to patients who had screening ultrasound or pelvic exam (6/106, 5.7%, aOR = 2.91, 95% CI: 1.72–4.91). Of 264 patients who answered questions related to satisfaction, all 183 NTMA patients and 81 patients who had a screening ultrasound or pelvic exam reported being satisfied or very satisfied with the MA service. <h3>Conclusions</h3> Individuals who obtain NTMA may be more likely to have a procedure abortion or ongoing pregnancy and have unplanned clinical encounters following MA compared to individuals who obtain a screening ultrasound or pelvic exam. However, NTMA was not associated with an increased risk of ongoing pregnancy or of hospitalization and/or blood transfusion. Moreover, more than 94% of NTMA patients had complete abortion without a procedural intervention. NTMA could increase access to MA without serious consequences for patient safety or satisfaction.