Medical Abortion Flashcards
Medical Abortion Pill: MifegymisoÒ
Pharmacists can’t prescribe mifegymiso, but can dispense
- Can’t adapt
n Health Canada approved protocol in July 2015, became available inJanuary 2017
n Available in over 70 countries worldwide.
n Several changes to Health Canada requirements since 2017:
§ Pharmacists can dispense Mifegymiso directly to patients.
§ Extension of timelines for indication.
§ No longer need to observe patient directly when taking.
§ Ultrasound no longer required to confirm pregnancy
note: 30% of patients may need ultrasound to rule out ectopic pregnancy
what does Mifegymiso contain?
Gestational age = time of last period
Fetal age = 14 days since last period
§ mifepristone 200 mg oral
§ misoprostol 800 mcg buccal
Mifepristone: Progesterone antagonist on the endometrium and myometrium (also has antiglucocorticoid properties)
- Inhibits progesterone from being able to maintain pregnancy
Misoprostol (synthetic prostaglandin): Induces uterine contractions, At high dose, causes cervix to soften
n Indication: termination of a intra-uterine pregnancy up to gestational age of nine weeks (63 days)
§ 95 – 98% effective
But can be effective up to 10 weeks (70 days)
MifegymisoÒ: Contraindications
Absolute Contraindications:
n Ambivalence about abortion (Need to be confident abt abortion)
n Ectopic pregnancy
n Uncontrolled asthma (Antiglucorcorticoid effect by mifepristone, Airway inflamm)
n Chronic adrenal failure
n Inherited porphyria (Body has problem making heme)
n Allergy to mifepristone or misoprostol
Relative Contraindications:
n Unconfirmed gestational age
n IUD inserted* (needs removal)
n Long term corticosteroid use
n Hemorrhagic disorder or
anticoagulant therapy (more bleed from pill)
n Anemia
MifegymisoÒ: Drug Interactions
Metabolized by CYP3A4
Single dose- hard to tell clinical signifcance
§ Potential clinical interactions:
§ CYP3A4 inducers (ie rifampin, some anticonvulsants, etc)
§ CYP3A4 inhibitors (ie erythromycin, ketoconazole, etc)
n Others: Long term corticosteroids: steroid effectiveness may be
reduced for 3 – 4 days
MifegymisoÒ: Patient Assessment by
Prescriber*
n Medical history: check for risk factors for ectopic pregnancy, check for contraindications
n Confirm gestational age:
§ pregnancy test + last menstrual period
§ Clinical physical exam
n Rule out ectopic pregnancy:
§ Risk factors for ectopic pregnancy, clinical symptoms
(abdominal pain (very severe pain), vaginal bleeding)
§ Ultrasound required if suspect ectopic pregnancy
Risk factors for ectopic pregnancy:
Previous ectopic pregnancy
Tubal surgery
Pregnancy through assisted
reproduction techniques
IUD in place
History PID or salpingitis
*Prescriber of Mife: physician, nurse practitioners, possibly midwives in future
MifegymisoÒ: Administration
Protocol:
§ Day 1: mifepristone 200 mg orally
§ Day 2 or 3: misoprostol 800 mcg between cheek and gums (buccal) for 30 minutes then swallow fragments with water (four tablets – 2 on each side)
2 tabs on each side
§ Day 7 – 14: Follow up with prescriber to ensure
expulsion is complete, pregnancy test
conscientious objection
explain
MifegymisoÒ: Patient Education
What should patient expect after taking MifegymisoÒ
n Pregnancy will pass within 2 – 24 hours after taking.
n Cramping will typically begin in 2 – 3 hours.
n Bleeding starts within few hours after misoprostol (note: bleeding may start 1 – 48 hours) Start up to 2 days after
n Bleeding may last 2 – 4 hours and be heavier than normal
n Can take analgesic as required for pain/cramping (ie NSAID like ibuprofen).
NSAID preferable anagesic (helps w bleed)
n Recommended to rest for 3 hours.
Use maxipads, not tampons or mesntrual cup, Hard to tell how much bleeding w tampons
Other common side effects
prostaglandin (vasodilation) effects from
misoprostol
§ Hot flashes/chills
§ Nausea/vomiting,
§ Diarrhea
§ Dizziness/headache
§ Fatigue
Can take loperamide or diphenhydramine to help with these side effects
vasolidation
Misoprostol is a synthetic prostaglandin E1 analogy that replaces protective prostaglandins consumed with prostaglandin-inhibiting therapies (eg. NSAIDs)
Has been shown to induce uterine contractions
When to seek urgent care?
n Soaking 2 maxi-pads per hour for consecutive 2 hours
n Large clots (ie size greater than a lemon)
n Pain not relieved with pain meds
n Fever (>38C) for more than 6 hours
n Vomiting, diarrhea or weakness > 24 hours
When can patient start using other contraceptives after
Mifegymiso?
n Return to ovulation is quick (as quick as 8 days)
n Start CHC soon after misoprostol doses
n For IUD’s wait until abortion is confirmed
Summary of patient education:
n Mifepristone and misoprostol must be taken in order
n Side effects to expect
n Follow-up in 7 – 14 days
n Return to fertility and when to start using contraceptives
n Both mifepristone and misoprostol are embryotoxic – failure may require surgical abortion
n Where to go for urgent care
If patient vomits:
n mifepristone: If vomiting less than one hour after taking
mifepristone, the dose should be repeated (and antinausea med provided)
n misoprostol: if during buccal absorption then will need a
new misoprostol prescription
n misoprostol: if after swallowing fragments (after 30
minutes buccal), then no action required as it has been
absorbed
Other Options for Medical Abortion
Methotrexate/Misoprostol
n This combination has been used off label for medical abortion (up to 63 days gestation) and ectopic pregnancies. 10 wks
n May be an alternate in individuals who do not tolerate mifepristone or have difficulty accessing.
n Mean time to completion may be longer than with Mifegymiso (ie 7 days vs 3 days)
7 day duration is logner
Doses: methotrexate 50 mg po or im, followed by misoprostol 4 x200 ug administered high in the vagina on days 4, 5 or 6.
May see more side effects because of methotrexate.
Folic acid not needed
Misoprostol alone
n Has been used alone for medical abortions
n Less effective when used alone
n Often needs repeated doses When no cramping
n Start with 800 ug (4 x 200 ug) either SL or vaginally, if no response after 3 – 24 hours repeat dose.
