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Woman-Centered Abortion Care 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:

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purpose
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
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
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 cont5
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
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
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
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
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
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
Contraindications (cont.)
  • Hemorrhagic disorder
  • Current anticoagulant therapy
  • Inherited porphyria
  • IUD in place (remove before giving mifepristone)
counseling should include
Counseling Should Include
  • Eligibility, regimen, effectiveness, protocols
  • Side effects and complications
  • Ensuring access to emergency care
  • Contraceptive needs
  • Informed consent
administration of mifepristone
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
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
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
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
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
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 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
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
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 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
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
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 38C/100.4F or higher or fever beginning more than eight hours after taking misoprostol
  • No bleeding within 24 hours of taking misoprostol
follow up visit
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
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
Continuing Pregnancy
  • If the pregnancy continues, terminate the pregnancy through other means, preferably vacuum aspiration.
failed abortion
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
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.