Lecture - 1 Intro/Abortion

Question 1

Hyde Amendment Codification Act (1976)

Answer 1

you can use federal funds for an abortion, unless:

• the pregnancy was a result of rape or incest
• the woman suffers from a life-endangering physical disorder, illness, or injury

Question 2

Title X

Answer 2

allows clinics that get federally funding to change fees depending on how much the person makes to make it more affordable for those that need it
CA screening and birth control

Question 3

Federal Abortion Ban of 2003

Answer 3

partial birth abortion

could be charged as a criminal as a provider for doing this

Question 4

What is a minor and what can they consent for?

Answer 4

12 - 17 years of age

can consent (without parental consent)

• contraception
• STI services
• prenatal care
• adoption
• abortion

regulations vary by state

say the pt came in and said “i want to start BC, and also I have a sore throat. NO. I will give you BC, but you have to go to your pediatrician for the sore throat”

Question 5

What is considered the “reproductive years”?

Answer 5

ages 19-39

Question 6

Cervical cytology guidelines

Answer 6

21 - 29 q 3 years
q5 years with HPV 30-65
stop at age 65

Question 7

Why do we stop HPV screening at 65?

Answer 7

since the cancer is so slow growing the risk and hardship of treating don’t outweigh the benefits

Question 8

When does clinical breast exam start?

Answer 8

19 years old

Question 9

___% of all pregnancies are unintended

Answer 9

45

unintended includes mistimed and unwanted

Question 10

Which age groups have the highest unintended pregnancies?

Answer 10

18-24 years old

Question 11

1 in ___ women will have an abortion by the age 45

Answer 11

4

Question 12

How do you test for pregnancy?

Answer 12

UPT - urine pregnancy test (qualitative)
-detects serum BhCG levels >25 mIU/mL

BhCG quantitative blood test
<5 mIU/mL is negative
>25 mIU/mL is definitely positive
between the two its most likely pregnant

Question 13

For a pregnant pt, what do you expect to see in regards to their BhCG?

Answer 13

levels should double every 2-3 days

Question 14

After confirming the pt is pregnant, what is the first test you do?

Answer 14

H and H to make sure the pt isnt anemic

Rh status –if negative give Rhogam

Question 15

TV US

Answer 15

Transvaginal ultrasound

you can see IUP (intrauterine pregnancy)
>1500 to 2000 BhCG level

this US is needed to confirm that the pregnancy is in the uterus

Question 16

What level does the BhCG need to be in order to see anything on US?

Answer 16

1500 to 2000 mIU/mL

Question 17

What medication abortion can be done in the first trimester?

Answer 17

pills - mifepristone (mifeprex) + misoprostol (cytotec)

injection - methotrexate + misoprostol

Question 18

MIfespristone

Answer 18

Mifeprex - antiprogesterone - stops growth

medical abortion pill that must be given in the office under supervision

can be performed up to 9 weeks gestation

involves heavy bleeding and passage of pregnancy at home
requires Hbg >10

contraindications:
- ectopic pregnancy
- severe anemia
- coagulopathy
- anticoag therapy
- long tern corticosteroid use
- current IUD in place
- adrenal failure

Question 19

What are the contraindications of Mifepristone?

Answer 19

• ectopic pregnancy
• severe anemia
• coagulopathy
• anticoag therapy
• long tern corticosteroid use
• current IUD in place
• adrenal failure

Question 20

When can you used Mifespristone?

Answer 20

for uterine pregnancies up to 9 weeks

Question 21

Misoprostol

Answer 21

this is the second part of the mifespristone-misoprostol treatment pill abortion
synthetic prostaglandin (PGE1)
4 bills to be dissolved in the cheek 6-48 hours after mifespristone treatment in the office

expect heavy cramping and bleeding within 1-4 hours

Question 22

In addition to mifepristone and misoprostol, what else are you giving these pts?

Answer 22

doxycycline twice daily for 7 days

remember that doxycycline is a category D drug

Question 23

You gave the pt mifepristone in the office and sent them home on misoprostol and doxycycline, when do you need to see the pt again?

Answer 23

In 2 weeks to follow up and confirm with TV US to confirm complete

Question 24

What are complications of medication induce abortion?

Answer 24

incomplete abortion –requires suction aspiration surgery

bleeding - may require transfusion –can occur up to 4 weeks later

Question 25

Methotrexate

Answer 25

injection for ectopic abortion

used for ectopic pregnancy ONLY

send pt home on misoprostol

Question 26

Vacuum Aspiration

Answer 26

same surgical procedure done for miscarriage

first trimester surgical

suction curettage, suction aspiration, D and C

misoprostol used 13+ weeks to soften and dilate cervix

performed up to 16 weeks gestation

done in office –pt given Versed –can stay awake if they wish –will be uncomfortable

low complication rate

Question 27

Manual Vacuum Aspiration

Answer 27

MVA
rarely used surgical first trimester abortion

can be used in third world countries since you don’t need electricity

performed BEFORE 6 week gestation

Question 28

Second trimester surgical abortion

Answer 28

D and E - dilation and evacuation

D and X - dilation and extraction

Question 29

D and E

Answer 29

Dilation and evacuation

performed after 16 weeks gestation (16-21 weeks)

banned in 2 states

requires cervical dilation via laminaria (compressed seaweed)

Question 30

D and X

Answer 30

dilation and extraction (partial birth abortion)
performed after 21 weeks gestation
pretty sure this is illegal

requires 1-2 days of laminaria

Question 31

What are potential complications of surgical abortion?

Answer 31

incomplete abortion 
uterine perforation 
cervical trauma 
infection - endometritis 
bleeding 
anesthesia related 
intrauterine adhesions

Question 32

When is intrauterine adhesion complications the highest?

Answer 32

after multiple procedures leading to miscarriage

Question 33

How does abortion affect your ability to get pregnant?

Answer 33

you can GET pregnant again but your ability to STAY pregnant is at risk d/t scar tissue and integrity of cervix

Question 34

SAB

Answer 34

spontaneous abortion or miscarriage

pregnancy loss before 20th week of gestation

MC complication of early pregnancy

Chromosomal abnormalities account for 50% of all miscarraiges

Question 35

What is the most common complication of early pregnancy?

Answer 35

SAB - miscarriage

50% d/t chromosomal abnormalities

pregnancy loss before 20th week of gestation

Question 36

What are the 3 most serious risk factors of miscarriage?

Answer 36

advanced maternal age
previous spontaneous abortion (SAB)
maternal smoking

Question 37

Complete SAB?

Answer 37

sxs: abdominal cramping, vaginal bleeding
PE: cervical os closed, no visible POC (product of conception)
US: empty

Tx: none

• BC education
• supportive counseling

Question 38

Incomplete SAB?

Answer 38

miscarriage in progress
sxs: abdominal cramping, vaginal bleeding +/- tissue
signs: cervical os open; POC visible in cervical canal
might see POC from cervical os or in vagina
US: no IUP; debris in uterine cavity
Tx: intervention to complete process
- D and C or suction aspiration
- Misoprostol if < 12 weeks

follow up in a week or so

Question 39

What is the treatment for incomplete spontaneous abortion?

Answer 39

intervention to complete process

D and C or suction aspiration
Misoprostol if <12 weeks

Question 40

Missed abortion

Answer 40

non-viable pregnancy that has not yet expelled 
sxs: none, cervix closed 
US: embryo with no cardiac activity 
Labs: declining hCG levels 
tx: medication or surgical intervention 
-misoprostol 
-suction aspiration 
-expectant management

Question 41

Blighted Ovum

Answer 41

missed abortion

• anembryonic pregnancy
• fertilized egg implants in uterus, but embryo never develops

sxs: non, cervix closed
US: large GS with yolk sac; no embryo
Labs: declining hCG levels

tx: suction aspiration, misoprostol, or expectantly

Question 42

Threatened abortion

Answer 42

vaginal bleeding without cervical changes
sxs: spotting, cervical os closed
US: viable IUP

tx: watch and wait

Question 43

Inevitable abortion

Answer 43

vaginal bleeding with cervical changes 
sxs: abdominal cramping, mod-heavy bleeding 
cervical os open 
US: viable IUP 
tx: expectantly manage 
suction aspiration 

since the cervix is open there is nothing you can do
if the pt was >24 weeks we would intervene but not really any earlier

Question 44

How does threatened abortion differ from inevitable abortion?

Answer 44

threatened has light bleeding while inevitable has mild to heavy bleeding

threatened has closed cervical os

inevitable abortion is open os