No-Test Medication Abortion: A Systematic Review

ABSTRACT The use of medication abortion has increased significantly in the past several years, in part due to the increased adoption of telemedicine during the COVID-19 pandemic. Several leading organizations have established recommendations for the practice of providing a medication abortion without a prior pelvic examination or ultrasonogram (no-test medication abortion). Evidence demonstrates that gestational age can be accurately measured with patient screening questions and the risk of ectopic pregnancy among women seeking medication abortion is very low. Given this paradigm shift in abortion access, increasing numbers of health care professionals worldwide have adopted these practices and published their results. This systematic review aimed to summarize the efficacy and safety outcomes of medication abortion performed without prior pelvic examination or ultrasound. Ongoing and published clinical trials were identified, and randomized control trials and comparative cohort trials discussing the provision of no-test medication abortion were eligible. The primary study outcome was successful medication abortion, defined as complete abortion without the need for surgical management. Failure was thus defined as the need for surgical intervention to complete the abortion. Medication regimens, efficacy rates, complication rates, and adverse events were abstracted from eligible studies. A total of 21 studies were included in this review, including cases performed in over 24 countries. Ultimately, 15 studies were sufficiently homogenous in terms of design and comparator to create aggregate data with summary statistics for the primary outcome. The overall efficacy rate of no-test medication abortion was found to be 96.4% (95% confidence interval [CI], 96.0–96.7) in the 10,693 patients included in this review. Among pregnancies at less than 70 days' gestation (n = 8166), the efficacy rate was 95.2% (95% CI, 94.7–95.7). The rate of surgical intervention was 4.4% (95% CI, 4.0–4.9), and at less than 70 days' gestation was 3.8% (95% CI, 3.3–4.3). The ectopic pregnancy rate was 0.06% (95% CI, 0.02–0.15), blood transfusion rate ranged from 0% to 0.7%, and there were no deaths reported. The results of this systematic review encompassing data on 10,693 patients showed demonstrate that no-test medication abortion is likely effective and safe. The rates of surgical evacuation and complication were comparable with the rate among those undergoing medication abortion with pretreatment ultrasound, and significantly lower than the rates seen with unsafe methods of abortion.