Purpose This module covers the knowledge, attitudes and skills health-care providers need in order to provide pharmacological methods for first-trimester uterine evacuation.
Objectives By the end of this module, learners should be able to: • List the eligibility requirements for medication abortion with mifepristone and misoprostol. • List the contraindications to medication abortion. • Recognize expected side effects and potential complications of medication abortion.
Objectives (cont.) 4. Demonstrate good counseling skills for women seeking medication abortion. • Discuss regimens for medication abortion using mifepristone plus misoprostol and misoprostol alone. • List effective pain-management medications and approaches for medication abortion.
Objectives (cont.) • Explain the care and services to be provided at each visit to women undergoing medication abortion. • Conduct a routine medication abortion follow-up visit.
Mifepristone • First developed and approved for clinical use in 1988 in France (RU-486). • Blocks progesterone activity in the uterus, leading to detachment of the pregnancy. • Causes the cervix to soften and uterus to contract.
Misoprostol • Prostaglandin analogue that stimulates uterine contractions. • Inexpensive, stable at room temperature and readily available in the market. • Easily absorbed orally or vaginally. • Commonly used for treatment of gastric ulcers.
Effectiveness • Combination of two drugs more effective than either used alone. • Combined regimen is 92 to 98 percent effective in pregnancies ≤ nine weeks since last menstrual period (LMP) (Von Hertzen et al., 2003).
Diagnose and Date Pregnancy • Confirm that the pregnancy is 63 days/nine weeks or less since the LMP. • Date pregnancy through medical history, pregnancy test and bimanual exam. • Ultrasound used to date pregnancy can be helpful but is not required.
Contraindications • Ectopic pregnancy (confirmed or suspected) or undiagnosed adnexal mass • Allergy to mifepristone, misoprostol or other prostaglandin • Current use of long-term systemic corticosteroid • Chronic adrenal failure
Contraindications (cont.) • Hemorrhagic disorder • Current anticoagulant therapy • Inherited porphyria • IUD in place (remove before giving mifepristone)
Counseling Should Include • Eligibility, regimen, effectiveness, protocols • Side effects and complications • Ensuring access to emergency care • Contraceptive needs • Informed consent
Administration of Mifepristone • Administer 200mg mifepristone orally. • Most women will feel no change after taking the pill. • Some women will begin bleeding before taking the next pill (misoprostol). • A few women will abort after the mifepristone alone.
Administration of Misoprostol • There is a range of options in route, dosage and timing. • Institutional or national policy determines instructions to be followed. • Client safety and convenience should be considered.
Administration of Misoprostol (cont.) • After seven weeks LMP, vaginal doses are more effective than oral doses. • Up to 90% of women will expel tissue within six hours of vaginal dose (WHO, 2003).
Protocol for Misoprostol Administration Day 1 is defined as the day mifepristone is taken. (Schaff et al., 2000; Schaff et al., 1997; Ashok et al., 1998; and Creinin et al., 1999.)
Instructions for Vaginal Insertion • Empty the bladder. • Wash hands. • Insert misoprostol tablets, one after the other. • Push tablets far up into the vagina. • Tablets may not fully dissolve.
Misoprostol Alone • Effectiveness: 85 to 90% ≤ 63 days/ nine weeks LMP • Current recommended regimen: • 800mcg misoprostol vaginally, taken twice at 24-hour intervals (1600mcg total) (Gynuity Health Projects and Reproductive Health Technologies Project, 2003)
Pain During Medication Abortion • Pain usually begins one to three hours after taking the misoprostol. • Cramping occurs during uterine contractions and POC expulsion. • Pain levels vary greatly among women. • Pain diminishes after abortion is complete.
Managing the Pain • Verbal support: • Counseling about what to expect • Reassurance during the abortion • Low heat to the abdomen or lower back • Hot-water bottle • Warm cloths • Hot bath or shower
Pain Medications • Should be taken before cramping begins • Non-narcotic and narcotic analgesics can be used: • Paracetamol (acetaminophen), with or without codeine • Ibuprofen • Codeine • NSAIDs do not interfere with misoprostol
Medication-Abortion Complications • Medication abortion is associated with few serious complications. • Occasional complications include: • Failed abortion • Hemorrhage • Infection
What Women Need to Know Before Leaving the Clinic • When to return for a routine but important follow-up visit. • How to recognize warning signs; when and where to seek medical help. • That they can become pregnant again as early as 10 days after the abortion. • That most women can begin contraception before the follow-up visit.
Warning Signs During or After Abortion • Excessive bleeding (for example, soaking more than two or three thick pads per hour for two consecutive hours) • Persistent fever of 38C/100.4F or higher or fever beginning more than eight hours after taking misoprostol • No bleeding within 24 hours of taking misoprostol
Follow-Up Visit • Inquire about the woman’s experience with the abortion. • Assess the completeness of the abortion. • Review any laboratory test results with the woman. • Discuss contraception and provide a contraceptive method, if she desires one.
Assess Completeness of Abortion • Ask the woman if she thinks the abortion was complete. • Take a history: Amount and duration of bleeding, cramping, passage of clots. • Conduct a physical examination. • If it is unclear whether the abortion is complete, perform ultrasound or check -hCG levels (if done prior to the abortion as well).
Continuing Pregnancy • If the pregnancy continues, terminate the pregnancy through other means, preferably vacuum aspiration.
Failed Abortion • If there is a persistent gestational sac, treatment options include: • Expectant management, giving more time for expulsion of the POC • A repeat dose of vaginal misoprostol • Vacuum aspiration (preferable to sharp curettage)
Inform the Woman About Failure • Small risk that medication abortion will not work. • Slight risk that medications could cause birth defects if the pregnancy continues. • If medication abortion does not work, she should undergo vacuum aspiration.