Abortion Flashcards
A 26 yo G1 P0 reports a last menstrual period of 4-5 weeks ago. She has performed a pregnancy test and noted it was positive. She is adamant she wishes to terminate the pregnancy, and asks you for advice about what method she should use, and where she should go.
You discuss with her the various options with your patient after examining her. The patient chooses a medication abortion. You refer her to a clinic that you know and trust. She calls you to tell you that all went well, and takes a home pregnancy test four weeks later that she reports was negative.
morally opposed to termination
-If you do not support abortion, you cannot be compelled to perform one
-However:
-If your patient requests a termination, you are obligated to refer the patient to a practitioner who can perform a termination
-You may be required to care for a patient before or after a termination of pregnancy
New York State Reproductive Health Act of 2019
-Permits voluntary terminations of pregnancy (VTOPs) >24 weeks if
-A health care professional determines that the health or life of the mother is at risk, OR
The fetus is not viable
-Repealed portions of law that stated that
-Abortions after 12 weeks be performed in a hospital
-Only physicians can perform abortions
-The Act states that
-“A health care practitioner licensed, certified or authorized under Title 8 of the education law, acting within his or her lawful scope of practice, may perform an abortion.”
-Includes physician assistants, nurse practitioners, and licensed midwives
New York State Equal Rights Amendment of 2024 (underlining added for emphasis by me)
§ 11.a.No person shall be denied the equal protection of the laws of this state or any subdivision thereof. No person shall, because of race, color,ethnicity, national origin, age, disability,creed [or],religion,or sex, including sexualorientation, gender identity, genderexpression,pregnancy, pregnancy outcomes, and reproductive healthcareand autonomy,be subjected to any discrimination in [his orher]theircivilrights by any other person or by any firm, corporation, or institution, or by the state or any agencyor subdivision of the state, pursuant to law.
b. Nothing in this section shall invalidate or prevent the adoption of any law, regulation, program, or practice that is designed to prevent or dismantle discrimination on the basis of a characteristic listed in this section, nor shall any characteristic listed in this section be interpreted to interfere with, limit, or deny the civil rights of any person based upon any other characteristic identified in this section.
epidemiology
-1 in 4 U.S. patients capable of pregnancy will have an abortion at some point in their lifetime
-60% of all abortions performed in the U.S. takes place at <10 weeks EGA
-39% of all U.S. abortions are accomplished via medication alone
first trimester abortion
-Medication abortion- Includes self-managed abortion
-Dilation and suction curettage
-Dilation and manual vacuum aspiration
-pregnancy should be <70 days EGA as assessed by US
-if the pt can confirm LMP within 8-9 wks prior, that is acceptable
-Mifepristone and misoprostol are used together
medication abortion agents used: mifepristone
-Selective progesterone receptor modulator that is an antiprogestin at the uterus, and thus causes:
-Necrosis of the decidual tissue
-Softening of the cervix
-Increased sensitivity to prostaglandins
-Increased uterine contractility
-The FDA restricts access to mifepristone via its risk evaluation and mitigation strategy (REMS)
-As per the FDA, mifepristone may now be made available at retail pharmacies
medication abortion agents used: misoprostol
-cytotec
-Prostaglandin E1 analogue that causes:
-Softening of the cervix
-Increased uterine contractility
-While 1st trimester medication abortion can be accomplished with misoprostol alone, it usually takes longer and may result in more blood loss than when misoprostol is used with mifepristone
contraindications to medication abortion
->70 days gestational age as measured by ultrasound of pelvis
-Suspected or confirmed ectopic gestation
-IUD in situ
-Long term steroid therapy
-Adrenal insufficiency
-Coagulopathy
-Anticoagulation
-Sensitivity to mifepristone or misoprostol
-Porphyria
counseling and testing prior to medication abortion
-determine Rh status unless it is already known
-give Rho(D) immune globulin if needed
-check CBC if anemia is known or suspected
-pt can take both mifepristone and misoprostol at home if desired
-Counsel pt about risks, benefits and alternatives
-Inform pt that if they soak 2 pads/hr for at least 2 hours, they should contact the clinician
-1% of pts using mifepristone and misoprostol require uterine evacuation
-Inform pt that if they develops flu-like sx >24 hrs after taking misoprostol, they should notify the clinician -> Potential for Clostridial toxic shock
medication abortion doses
outcomes with mifepristone and misoprostol
-at higher GA (64-74 days), btwn 3.1-3.4% of pregnancies continue despite administration of both mifepristone and misoprostol
-there is no evidence of teratogenicity with mifepristone alone -> BUT misoprostol has been assoc with limb defects when used in first trimester
f/u after medication abortion
-Pt may begin using most contraceptive methods (except DMPA, IUDs or sterilization) on the same day that she takes mifepristone
-Follow-up in person or via telemedicine or phone in 1 week
-Home pregnancy test in 4 weeks
1st trimester surgical abortion
-Dilation and manual vacuum aspiration
-Causes less disruption to embryonic tissue for pathological exam
-Dilation and suction curettage
-Either may be done in office with paracervical block with lidocaine for anesthesia with ibuprofen, or in OR with propofol
-Obtain Rh
-Antibiotics (doxycycline, others) should be administered
-Many regimens exist (doxycycline 100 mg PO x 1 dose, Q12H x 3 days, 5 days, or 7 days)
-May begin hormonal contraception on the day of surgery
-Rho(D) immune globulin, if indicated
-Follow-up in 2-4 weeks
2nd trimester abortion
-Discuss with pt risks, benefits, and alternatives
-Obtain U/S for dating
-Obtain Rh unless already known
-Administer Rho (D) immune globulin at the time of procedure, if needed
-Offer medical abortion or surgical abortion
-95% are surgical abortions
-greater risk of complications with medication abortion
-Medication abortion:
-rarely performed
-mifepristone with misoprostol -> oxytocin amy also be used later in course
-Surgical abortion:
-dilation and evacuation (D&E)
-Laminaria (hygroscopic dilators- pic) are placed in cervix 24 hrs prior to procedure
-Reduces laceration to cervix
-often under general anesthesia or deep sedation
-often under U/S guidance
-Fetus is dismembered and removed through cervix
-requires skilled, experiences surgeon -> technically difficult procedure
-fewer complications (4%) than medication abortion used misoprostol (29%)
-In rare cases if other methods are CI -> surgical abortion via hysterotomy or hysterectomy
-Antibiotics (doxycycline, others) should be given
complications of VTOP
-mortality- 0.6/100,000 legal induced VTOPs
-childbirth has a maternal mortality rate 14x higher than VTOP
MC sequelae of abortion
-Hemorrhage
-Cervical laceration (surgical abortion)
-Uterine perforation (surgical abortion)
-Uterine rupture (2nd trimester medical abortion)
-Retained products of conception
-Sepsis
-Pulmonary embolus
which of the following best identifies that GA by which first trimester medication abortion must take place
-49 days
-56 days
-63 days
-70 days!!!
