California Hospital Begins Medication Abortions in the ED -- A Possible First

SAN FRANCISCO -- A California hospital has initiated at least 50 elective, non-emergent medication abortions in the emergency department (ED) since February, a physician reported here.

Stanford University Medical Center may be the first in the nation both to facilitate non-emergent medication abortions within the ED -- patients are seen and discharged from there -- and have a protocol to do so, said Monica Saxena, MD, JD, of Stanford University School of Medicine in California, at the American College of Emergency Physicians (ACEP) annual meeting.

"Now that we have established proof of concept, we are working with other emergency departments to implement medication abortion protocols at their institutions," she said.

Medication abortions are extremely common, accounting for an estimated 54% of abortions in the U.S. in 2020, up from 39% in 2017, according to the Guttmacher Institute. As the institute notes on its website, "patients initiate a medication abortion by taking mifepristone [Mifeprex], followed by misoprostol [Cytotec] one or two days later, as directed by a provider or the manufacturer's instructions."

Typically, American EDs only perform emergency abortions -- not medication abortions or elective, non-urgent surgical abortions.

The Stanford protocol starts when a patient comes into the ED and is confirmed to be pregnant. "We get the basic labs, obviously, and we need a transvaginal ultrasound confirming the pregnancy," Saxena told MedPage Today. "We also test the blood type to make sure they don't need RhoGAM. Then we engage in the options for counseling. And if a patient wishes to continue with the pregnancy, we refer them to prenatal care. If they do wish to seek an abortion, and they are less than 10 weeks, the protocol comes into play."

At this point, she said, emergency physicians can refer the patient to an outside provider or page the obstetrics (OB) department for a consult. "We have to have OB come down to the bedside and give that medication [mifepristone]," Saxena said. "OB also arranges for the outpatient prescription of the second medication [misoprostol] as well as follow-up care." Then the ED discharges the patient.

Saxena said the medical center began the medication abortion protocol in February 2022 after a survey of emergency physicians there in December 2021. A total of 97 physicians responded (63% of the total), including 48 attendings, 10 fellows, and 39 residents, according to data presented at ACEP.

More than two-thirds (68%) of those responding said they explored whether pregnant patients wanted to be pregnant, and 30% said they had counseled pregnant patients about options regarding their pregnancies. A total of 60% of those who responded said they were interested in performing abortions in the ED, and 80% said they were interested in doing more counseling.

Saxena dismissed any concerns that EDs are already overwhelmed and shouldn't take on a new burden. "Our job is to treat all comers no matter their medical issue or their station in life," she said. "The protocol is responding to a need and a barrier at a systems level. That's what we do as ED doctors -- we help patients."

Why do ob/gyns need to assist? "Federal and state regulations mandate who can provide abortions," she said. "Mostly it is ob/gyns or family practice doctors unless an emergency medicine physician or other specialty doctor has received specialized training."

No individual emergency physicians at Stanford University Medical Center have objected to facilitating medication abortions, Saxena said. "If an ED physician did not want to be involved in the care of a patient receiving an elective abortion, they could simply transfer the care to another physician."

Saxena said she and her colleagues are working to change California state law to allow emergency physicians to provide abortion services.

Gov. Gavin Newsom (D) has signed several bills protecting and expanding abortion access in the months since the U.S. Supreme Court overturned federal abortion protections established by Roe v. Wade. According to Politico, "the [California] state budget includes more than $200 million to train clinicians and build or expand clinics." Next month, California voters will decide whether to protect abortion rights in the state constitution.

"The next step would be to take this national," Saxena said. "We've been talking to physicians in Illinois and Michigan, about applying the protocol, and I think it'll have more utility there. Both states continue to make abortion legal, but are surrounded by states where it is banned."

What about performing surgical abortions in the ED? "There would have to be some significant logistical streamlining," Saxena said. "In every ED in the country, patient flow is very important. We need to stabilize, treat, and either discharge or admit patients so we can treat everyone who walks through our doors."

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