Medical Abortion Flashcards
Does access to medical abortion increase abortion rates
no
What population factors are associated with LOWER abortion rates (5)
- Living in North America or Europe
- High contraception use
- High economic development
- High levels of gender equality
- Well developed health infrastructures
Generally, what does mifepristone do? then what does misoprostol do?
Mifepristone: end pregnancy
Misoprostol: push uterus contents out
What kind of activity does Mifepristone have? What does it cause?
Is a progestone receptor modulator
- Strong antiprogestin and antiglucocorticoid activity
Causes
- endometrial degenartaion
- Resumption of PG activity (uterine contractions)
- Softening/dilation of the cervix
Role of progesterone with uterine contractions
Prevents Prostaglandins which prevents uterine contractions
What does it mean that Mifepristone is a CYP3A4 substrate? When is it less effective? What meds causes more N/V side effects?
Less effective if patient is on
- rifampicin
- CBZ
- barbiturates
- St. John’s Wort
More N/V side effects when
- ketoconazole
- Erythromycin
- Grapefruit juice
What does it mean the mifepristone is an irreversible inhibitor of CYP 3A4
Increase side effects/toxicity of drugs metabolized by CYP 3A4
Mifepristone has anti-glucocorticoid effect. What does this mean?
Can block effects of corticosteroids
Explain the MOA of misoprostol. What does it cause?
Synthetic prostaglandin
Causes:
- cervical ripening
- uterine contractions
- Gi smooth muscle stimulation (diarrhea)
What can decrease bioavailability of misoprostol?
Antacids
What are the 3 steps for assessing medical abortion
- Establish pregnancy
- Determine Gestational AGE ( 9 weeks max)
- last menstrual period (sufficient alone)
- Pelvic exam
- Ultrasound (gold standard; prefered when uncertain with LMP or pelvic exam)
- Beta-HCG levels (inc of this means inc of G. age) - Rule out ectopic pregnancy
When is LMP accurate? when is it inaccurate
Accurate when:
- Typical menses are regular and recorded
- LMP occurred at expected time, usual duration
Inaccurate when:
- Menses is lighter than usual
- Not on expected date
- If they are taking or stopping hormonal contraception
- If patient is breastfeeding (hormones imbalance)
What is the main way to rule out ectopic pregnancy?
Ultrasound
How to rule out an ectopic pregnancy if Ultrasound is not available? What is the pregnancy called? is it contraindicated?
Called Pregnancy of unknown location PUL (NOT CONTRAINDICATED)
- Consider LMP, clinical symptoms, risk factors, beta-HCG levels
What are clinical symptoms of ectopic pregnancy? How to treat?
- First trimester bleeding AND/OR abdominal pain
- may be asymptomatic
Treat: methotrexate, surgery
What are risk factors of ectopic pregnancy?
Anything that causes inflammation and uterus
- previous ectopic pregnancy
- Tubal surgery/ligation
- Pregnancy conceived with assisted
- Reproduction techniques
- IUD IN PLACE
- History of salpingitis or pelvic inflammatory
What are contraindications of abortion (8)? When to avoid (1)
- Ectopic pregnancy
- Presence of an IUD
- Unconfirmed gestational age (less effective later in pregnancy)
- Bleeding (bc Mifepristone causes more bleeding)
- Chronic adrenal failure (avoid if patient is using long-term systemic glucocorticoid)
- Inherited poryphyria [disease in which hemeglobin is abnormally metabolized; dark] (can affect early components of heme synthesis)
- Allergy to MIFE or MISO
- Uncertainty of abortion
Avoid if you have uncontrolled asthma
Doses for Medical abortion?
Day 1: MIFE 200mg orally
Day 2-3: 4x MISO 200mcg tabs placed in cheek for 30 min
What to expect for bleeding during abortion
- Usually starts within 1-2 hours of MISO (may start after MIFE) (means sucessful)
- Usually heavier than typical menses
When should you go to the hospital for bleeding
- If Soaking 2 maxi pads/hour for 2 hours OR if dizzy, lightheaded or heart racing
What are some symptom management for medical abortion to dispense
Maxi pads NOT tampons (or anything inserted into vagina)
NSAIDs
Dimenhydrinate (gravol)
Loperimide for diarrhea
- Ask about contraception plans
Patient can ovulate as soon as 8 days after - Wait 1-2 weeks before intercourse
What to do if patient vomits within 1hr of mifepristone
take a 2nd dose with antimetic (gravol)
What to do if the patient vomits in the first 30 min while misoprostol
Assess symptoms within 1-2 hours
- MISO absorbed quickly
- if vaginal bleeding occurs no need 2nd dose
- If not, prescriber reassess
When can you start contraception after abortion? when can you insert an IUD?
The day misoprostol is taken
IUD at the follow-up visit in 7-14 days
