Abortion Reversal - Protocol (Progesterone)

Progesterone Protocols for the Attempted Reversal of Mifepristone\n\nDo not prescribe Prometrium if the patient is allergic to peanuts, as it is made with peanut oil, instead follow intramuscular protocol.\n\nOral Protocol:\n1. Prometrium brand or progesterone generic micronized oral capsules 200mg, two capsules (400mg) by mouth ASAP and bedtime on day 1 (must be at least 5 hours apart). 200mg, two capsules (400mg) AM and PM on day 2 and 3. Oral progesterone should be taken with food to increase absorption.\n2. Continue progesterone 200mg, two capsules (400mg) at bedtime until the end of first trimester or according to your clinical judgement.\n\nVaginal Protocol (Capsules per vagina):\n1. If the patient is unable to take oral capsules or intramuscular injections, consider vaginal administration of oral capsules Prometrium brand or progesterone generic micronized oral capsules 200mg, two capsules (400mg) inserted vaginally ASAP and at bedtime day 1 (must be at least 5 hours apart). 200mg, two capsules (400mg) AM and PM on day 2 and 3.\n2. Continue progesterone 200mg, two capsules (400mg) inserted vaginally daily at bedtime until the end of first trimester or according to your clinical judgement.\n\nIntramuscular Protocol:\n1. Compounded progesterone in oil 200mg (100mg/mL or 50mg/mL) intramuscularly (IM) ventral or dorsal gluteal muscle, slowly over 2-3 minutes as soon as possible after the ingestion of mifepristone.\n2. Continue progesterone in oil, 200mg IM once a day for two more days.\n3. Continue progesterone in oil, 200mg IM every other day until 14 days after mifepristone ingestion.\n4. Continue progesterone in oil, 200mg IM twice a week until the end of the first trimester. Consider tapering the progesterone after the first trimester, according to your clinical judgement.\n5. Draw with 18 gauge needle, change needle to 22 gauge 1 1/2 inch for injection. No more than 2mL injections. Check for crystals. If present, do not use. Inject slowly (2-3 minutes) in gluteal muscle (upper outer quadrant). Alternate between left and right gluteal muscles with each injection. Store progesterone at room temperature in locked cabinet protected from light.\n\nAdditional Instructions:\n- If prescribing oral, prescribe enough for 1 week at a time with refills. One month's supply may be unaffordable if the patient's insurance does not cover.\n- Provide ultrasound per clinic protocol ASAP to confirm embryonic viability and intrauterine location. If less than 6 weeks since LMP and unable to confirm intrauterine pregnancy by ultrasound, consider monitoring serial HCG levels and simply do ultrasound at 6 weeks.\n- If bleeding or cramping occurs and an intrauterine location of pregnancy has not been confirmed, treat as an ectopic pregnancy and appropriately refer until an intrauterine location is confirmed.\n- For an ectopic pregnancy or an incomplete abortion, seek consultation as necessary.\n- Provide an ultrasound every 1-2 weeks during the first trimester to confirm continued viability.\n- The physician, midwife, PA or NP who prescribes should see the patient with 72 hours of the initiation of the protocol or ensure a plan of care is in place.