medical abortion Flashcards
medical abortion is achieved by a combination of
oral mifepristone (a progesterone receptor blocker) and buccal misoprostol (a prostaglandin analogue), available as a composite pack (mifepristone and misoprostol [MS-2 Step]
this regimen induces the miscarriage of an intrauterine pregnancy by
preventing progesterone from supporting the pregnancy
softening and dilating the cervix
increasing uterine contractility
In the primary care setting, medical abortion is only approved by the Australian Therapeutic Goods Administration (TGA) for intrauterine pregnancies of up to
63 days (9weeks) gestation
very early medical abortion
medical abortion when an ultrasound has not shown definite evidence of an intrauterine pregnancy. The drug regimens used are the same as for gestations of up to 63 days (9 weeks)
why is very early medical abortion risky
Very early medical abortion should only be offered by experienced practitioners, because of the increased risk of an undiagnosed ectopic pregnancy. Alternatively, abortion can be deferred until ultrasound confirms that the pregnancy is intrauterine.
benefits of medical abortion
usually avoids invasive procedure and surgical complications (eg. uterine perforation, anaesthetic risk)
may be safer in obesity or distortion of the uterine cavity
may be more widely accessible
usually less costly
usually allows abortion to take place at home
benefits of surgical option
less likely to require subsequent evacuation of retained products
requires only one appointment and is usually performed under sedation
causes less pain, bleeding resolves after a few days
less risk of severe bleeding
avoids potential distress of seeing the gestational sac
contraindications to medical abortion iin general practice
travel time >2 hours to nearest hospital emergency
suspected ectopic
IUD in place
uncertainty about gestational age
haemorrhagic disorders or anticoagulants
porphyria
hypersensitivity to mifepristone, misoprostol or any prostaglandin
long term use of oral corticosteroid
why is current IUD a contraindication for medical abortion
mifepristone and misoprostol cause strong uterine contractions, which can cause injury if IUD is in place.
other risk factors for uterine rupture (including previous c/s and other uterine surgery) are not contraindications for medical abortion `
precautions for medical abortion
poorly controlled asthma
well controlled asthma (increase inhaled corticosteroids because mifepristone has antiglucocoticoid affects)
severe anaemia
epilepsy
IHD, heart disease of hepatic, kidney orr resp disease
diabetes on insulin (additional glucose monitoring and nausea prevention required)
investigations before medical abortion
US scan (transvaginal or transabdominal)
qHCG
haemoglobin if risk factors for anaemia
screening for STIs
monitoring qHCG
before medical abortion, provider should perform baseline gHCG (ifeally day before mife is taken)
compare to gHCG 7 days after mife is taken
drop to below 20% of baseline confirms no continuing pregnancy
rhesus testing before medical abortion
evidence is insufficient to recommend routine use of rhesus D immunoglobulin for medical abortion before 10 weeks gestation
U/S scan before medical abortion
routinely recommended to determine gestataion and viability and confirm pregnancy is intrauterine
heterotopic pregnancy define
simultaneous ectopic and intrauterine pregnancies can occur
very rare
confirmation of intrauterine pregnancy via U/S does not technically rule out ectopic
empty gestational sac
an intrauterine sac without a yolk sac or fetal pole as seen on ultrasound
causes of empty gestational sac
- very early intrauterine pregnancy (yolk sac and fetal pole are not seen before 5 weeks)
- ectopic pregnancy, which can cause a collection of fluid in the uterus (psuedosac)
- nonviiable pregnancy
VEMA
very early medical abortion
can be performed by experienced providers, bearing in mind that pregnancy could be ectopic or non viable
serum gHCG is also useful for
for very early gestations, to guide timing of US scan (if the HCG is <1500, US sould be delayed unless suspicion of ectopic or non viable pregnancy
what to do depending on qHCG
if <1500, delay US unless suspicion of ectopic or nonviable pregnancy
if >1500, can usually detect a intrauterine gestational sac
if around 5400 - 90% likleihood that high quality transvaginal US will detect a yolk sac
premedication and supportive treatment
analgesia, consider oral opoiod
NSAID unless contraindicated
antiemetic - ondansetron or metaclopramide
action of mifepristone
blocks progesterone, the hormone necessary for continuing a pregnancy
also softens and dilates the cervix, and increases uterine activity (by increasing prostaglandin concentrations and uterine sensitivity to prostaglandins)
action of misoprostol
synthetic prostaglandin E1 analogue that increases uterine contractility and softens the cervix
effects are enhanced by the preceding dose of mifepristone
how is misoprostol given
given buccaly
oral dosing is less effective and causes more GI adverse effects (eg. nausea and vomiting)
to induce medical abortion, use
mifepristone 200 mg orally
FOLLOWED BY
misoprostol 800 micrograms buccally, 36 to 48 hours after taking mifepristone.
Moisten the mouth, then place 2 tablets (400 micrograms) on each side between the teeth and the gums and hold in place for 30 minutes. Remaining tablet fragments may be swallowed with a glass of water.
if vomiting occurs within 1 hour of mifepristone administration
provide a repeat prescription for mifepristone and misoprostol, with an antiemetic administered beforehand.
if products of conception are expelled in the time between taking mifepristone and misoprostol
in 5% of patients, products of conception are expelled in the time between taking the mifepristone and misoprostol
miso should be taken regardless to minimise the risk of retained products of conception
can normal activities continue while taking medical abortion
normal activities can continue after taking mifepristone, but the inidivdual should be at home with access to a toilet one miso is taken.
they may need an additional 1-2 days off work
a support person is recommended once the miso is taken until the heaviest bleeding has been settled, to help access emergency treatment if required.
for 14 days after taking mife, the individual should be within 2 hours of emergency services
effects after taking mifepristone
a small portion of individuals experience cramping and light bleeding
in 5% of users, products of conception are expelled before taking miso
expected effects after taking misoprostol
central lower abdominal craping begins within 2-4 hours
pain generally decreases once the products have passed
if pain persists or worsens a weeks or more after taking miso, consider infection
adverse effects of medical abortion
can cause short term nausea and vomiting (as well as transient fevers, chills, and diarrhoea)
vomiting does not significantly reduce effectiveness because the medication is absorbed buccally, provided the tablets dont fall out during vomiting
advice to give to patients
written outline of symptoms they may experience
list of symptoms that reuire urgent medical review
24 hour helpline number (included in the MS 2 step after information)
access to hospital emergency services within 2 hours travel time for 14 days after mife
advise that once medical abortion is started, it must be completed
provide path request for folllow up qHCG for 7 days after mife
advise presence of bleeding does not always imply success
is medical abortion safe during breastfeeding
yes
no need to express and discard
what should patient avoid after misoprostol
for 7 days after taking misoprostol, to reduce the risk of infection, avoid
- sexual intercourse
- use of tampons or menstrual cups
- swimming
- taking a bath or using a spa
when to go to an emergency department
if very heavy bleeding ie. filling more than 2 large pads in an hour for more than 2 hours in a row, passing clots the size of a small lemon, feeling faint
any sympoms suggestive of ectopic: severe abdo pain, pain in pelvis on one side, pain in tips of shoulders
things that indicate the medical abortion has failed
at 24 hours there is little to no bleeding (less than a normal period), or no clots larger than a small grape
at 48 hours you still have nausea
bleeding stopped within 4 days
at 14 days you still have breast tenderness
symptoms implying retained tissue
at 7 days after miso you are still passing clots, still have cramping pain, still have bleeding heavier than a period, bleeding that has stopped and restarted
at 14 days bleeding is as heavy as when it started
at 4 to 5 weeks you have not returned to normal menstrual cycle
symptoms indicating infection of the uterus
pelvic pain
pain during sex
unusual vaginal discharge
fever > 38
tenderness on touching abdomen
nausea or vomiting or feeling unwell
if serum qHCG is more than 20% baseline at folllow up
pelvic US to assess possible causes which may include
- continuing pregnancy
- retained products
- rarer causes: heterotopic, trophoblastic disease, placenta accreta
complications of medical abortion
retained products of conception
continuing pregnancy
haemorrhage
upper genital tract infection
medical management of retained products of conception
repeat dosing of buccal misoprostol with analgesia and premedication
(combination mife and miso not required or advised)
surgical evacuation for retained products
for line for people with
- haemorrhage
- significant retained products confirmed on US with moderate bleeding, mild anaemia or concurrent infection
- heavy ongoing bleeding even if retained products are not visible on US
- moderate to severe anaemia
- prefers surgery
nonviable pregnancy
suggested or confirmed by US in conjunction with date of LMP and qHCG
management options are expectant, medical or surgical
VEMA should not be done if there is
risk factors for ectopic e.g previous ectopic, IUD in place, hx of PID, tubal surgery
signs or symptoms of ectopc pregnancy
gestation is incompatiible with qHCG and furst US
individual is unable to given informed consent or comply with follow up
