medical abortion

Question 1

Up to how many weeks is this typically performed?

Answer 1

Up to 10 weeks

Question 2

What are the advantages and disadvantages of medical vs surgical abortion?

Answer 2

Aspiration: completed in 1 visit, <15 min duration, >99% completion rate. May be riskier if uterine abnormalities.

Medical: can avoid surgical procedure and anesthesia, more ‘natural,’ greater control over process and manage at home. Takes longer and may be increased blood loss/tissue passage (esp later on).

Question 3

What is the success rate of medical abortion?

Answer 3

95-95% with 2-5% requiring further intervention with repeat misoprostol or D+C.

Question 4

What is the dose of mifepristone?

Answer 4

200 mg

Question 5

what is the MOA of mifepristone?

Answer 5

Progesterone receptor antagonist that acts by softening and dilation of the cervix which acts to increase the sensitivity of the uterine and cervical muscle to misoprostol.

Question 6

What is the rate of mifepristone failure if used alone?

Answer 6

> 25%

Question 7

What is the MOA of misoprostol?

Answer 7

PGE1 that induces contraction of uterine/cervical muscles.

Question 8

What are the teratogenic risks of misoprostol and mifepristone?

Answer 8

None known for mifepristone. Misoprostol known to be teratogenic. Pts must be counseled that if medical termination fails, there is a high risk of congenital abnormalities if the pregnancy continues and they are highly recommended to undergo surgical abortion.

Question 9

What are contraindications to medical abortion? (6)

Answer 9

Suspected ectopic, significant anemia, those with bleeding d/o or on anticoagulants, IUD in place, inability to access medical care if problems arise

Question 10

Is asthma a contraindication to misoprostol?

Answer 10

No

Question 11

What happens at the first visit for potential medical abortion?

Answer 11

Confirm pregnancy and r/o contraindications, counsel on options, get blood type and give rhogam if indicated. Give single dose of mifepristone (200 mg). Consider getting hcg if IUP not confirmed or if using serial values at f/u to confirm expulsion.

Question 12

What dose of misoprostol should be given and when?

Answer 12

800 mcg (buccal) 24-48 hrs after taking mifepristone. Give detailed instructions about how to take medication ‘buccally’ and only swallow what remains after 30 min.

Question 13

How should GA be determined prior to giving medications?

Answer 13

Menstrual history and/or clinical exam. Consider pelvic US if available and duration of pregnancy is uncertain or ectopic is suspected.

Question 14

What should you do if pt has an IUD?

Answer 14

IUD MUST be removed prior to initiating medical abortion.

Question 15

If a pt vomits after taking mifepristone, should another dose be given?

Answer 15

Only if vomiting has occurred within 30 min of taking medication.

Question 16

Can mifepristone be ‘reversed’ with progesterone?

Answer 16

No. This is stupid.

Question 17

What should women expect in terms of bleeding after taking mifepristone?

Answer 17

minimal bleeding until after taking misoprostol

Question 18

What ‘premedications’ should be taken before misoprostol?

Answer 18

NSAID and anti-emetic 30 min beforehand (reduce abdo pain and GI SE).
2-3 doses narcotic analgesia if NSAID not effective.

Question 19

What normal symptoms may occur after taking misoprostol?

Answer 19

GI upset (n/v/d). Bleeding and cramping typically heavier in later GA. Pt is likely to abort within the next several hours.

Question 20

When should pts present for emergency f/u?

Answer 20

Severe abdo pain persisting after pregnancy tissue has passed or if pain persists and no bleeding or tissue has passed. Call if bleeding dose not decrease after pregnancy tissue has passed or if soaking 2 maxis pads per hour for 2-4 consecutive hours.

Question 21

When should f/u be organized?

Answer 21

5-14 days after mifepristone administration.

Question 22

What should take place at follow up?

Answer 22

Either TV U/S to confirm termination or repeat hCG. Aska bout ongoing bleeding, pain, fever.

Question 23

What should you expect from hcg after medical abortion?

Answer 23

Should drop by 50-70% within 72 hrs of mifepristone if successful abortion and by >50% within 24 of pregnancy expulsion.

Question 24

‘Typical’ hcg by week

Answer 24

3 wks LMP: 5 - 50
4 wks: 5 - 425
5 wks: 18 - 7,340
6 wks: 1080 - 56,600

Question 25

What potential complications should one be aware of?

Answer 25

Hemorrhage, infection, incomplete abortion, unrecognized ectopic.

Question 26

Describe the ‘bimodal’ bleeding pattern with misoprostol?

Answer 26

Heavy bleeding in hours to days after misoprostol then again 30-60 days later (menstrual event finalizes expulsion process of any residual villi or thickened decidua).

Question 27

How long can women expect bleeding to last after misoprostol?

Answer 27

8-17 days but may be more prolonged. Consider retained products if lasting >12 wks or bleeding is increasing with time.