Medical abortions + EC Flashcards
When can medical abortions occur?
Termination in 1st or 2nd trimester (up to 9 wks)
Alternative to surgical –> privacy and autonomy, supported by telemedicine
What medications are used for Medical abortions?
Mifepristone 1 dose orally
36-48 hrs later –> misoprostol 4 tabs bucally (cheek and gum, swallow after 30 mins)
What are the C/I to medical abortions?
Anticoagulants or haemorrhagic disorder
IUD in place that can’t be removed
Long-term oral glucocorticoid use
Travel time to hospital >12 in next 14 days after mifepristone
Confirmed/suspected ectopic pregnancy
What are the precautions for medical abortions?
Severe anaemia
Diabetes req insulin (risk of N/V, possible dehydration)
Epilepsy (those w/ seizures induced by pain/vom)
Unstable asthma or long-term preventer therapy
What is the MOA/effect of mifepristone (RU486)?
down-reg of progesterone-dependent genes w/ decidual necrosis, detachment of products of conception
block progesterone action
Softens/dilates cervix, inc uterine activity and inc sensitivity to misoprostol
Generally, discuss dosing/ADRs/counselling of mifepristone
Single oral dose used as first step in medical abortions
If vomit w/in 1 hour of ingestion –> dose must be repeated
only 5% preg expelled before taking misoprostol (2nd step)
What is the MOA/effect of misoprostol?
It is a synthetic prostaglandin E1 derivative = oral, buccal, sublingual, or vaginal administration
MOA = act to dilate cervix and induce contraction
What is the counselling for misoprostol?
Expect: cramping pain, within 1-4 hrs of taking, followed by bleeding, blood clots
Conceptus not always seen, may be distressing
Bleed similar to menstruation for 5-7 days before dec, stops by day 14 (~65% cases)
Light bleeding or spotting persist for 4-5 wks
When should those who have taken MS-2 Step present to the ED?
Very heavy bleeding, passing clots size/greater than lemons, feeling faint
severe abdominal or pelvic pain, pain in tips of shoulder
What should patients avoid 7 days following MS-2 step?
sex, tampons, swimming, bath, spa
What is the follow up for MS-2 step?
Serum HCG
Low sensitivity urine preg test (threshold of 1000mlU/mL
What are the available emergency contraceptives?
(hormonal) Levonorgestrel, Ulipristal = both S3, only prevent or delay ovulation
(non-hormonal) copper IUD = most effective, up to 120 hrs, interfere sperm motility/viability, ova viability, preventing fertilisation
What is the efficacy timelines for ulipristal and levonorgestrel EC?
Levonorgestrel = up to 72 hrs, evidence for 96 hrs
Ulipristal = up to 120 hrs, most effect, can prevent ovulation after LH surge
What can be done if EC levonorgestrel is not available?
Can give 2 doses of 25 tablets (50 tablets in total) of 30mcg levonorgestrel 12 hours apart
What are the drug interactions for Levonorgestrel EC?
CYP3A4 inducers w/in previous 4wks (anti-seizures drugs, rifampicin, St John’s wort)
Griseofulvin “
Ulipristal = reduces the effectiveness
What is an alternative indication for ulipristal?
treatment of uterine fibroids
What are the drug interactions for ulipristal EC?
CYP3A4 inducers w/in previous 4wks (anti-seizures drugs, rifampicin, St John’s wort)
Griseofulvin “
Glucocorticoids, progestogens (levonorgestrel EC, hormonal contraception)
What are some questions you can ask for EC?
Time since UPSI?
When was your last period? Regular?
Any incidence of other UPSI in same cycle?
Any medical conditions? (breast cancer, unexplained vaginal bleeding)
Other meds? hormonal contraception?
Breastfeeding?
Can ulipristal or levonorgestrel cause abortion of established pregnancy?
NOPE
they only work during the ovulatory phase of the menstrual cycle
How do drug interactions influence EC choice?
Glucocorticoids for asthma = Levonorgestrel (LNG)
Cyp3A4-inducers = copper IUD, or LNG off label use
Progesterone containing OC or POP = LNG
LNG recently used (w/in 7 days) = LNG
Ulipirstal used w/in 5 days = ulipristal
What emergency contraceptives can breastfeeding and postpartum mothers use?
LNG (levon) is safe otherwise copper IUD is good
UPSI <21 days pp = no EC req
What EC should be used if UPSI occurred twice in same menstrual cycle?
- LNG, 2. ulipristal
theoretical hepatoxicity concern
What are some EC ADRs?
Headache, abdominal pain, dysmenorrhea
breast tenderness, abnormal vaginal
bleeding or spotting
nausea, vomiting
next menstrual cycle may be earlier or later
When can levonorgestrel OC be resumed after levonorgestrel EC?
Immediately after taking levon
Barrier method should be used during the 7 days after resuming OC (vaginal ring, implant, DMPA, COC, POP)
Preg test 3-4 weeks after EC if resuming cyproterone-containing COC
When can POP/COC be resumed after ulipristal EC?
Progesterone containing COC can be resumed after 5 days
Barrier method should be used for 5 days and up until: 7 active COC/POP, 7 days vaginal ring/implant, DMPA
Preg test 3-4 weeks after EC if resuming cyproterone-containing COC
What is some EC counselling/follow-up advice?
EC does not protect against STI
Menstrual period can be 1 wk earlier/later
Seek further medical advice if no period 3wks after pill
EC is not ongoing protection against UPSI
Is there a limit to recurrent EC use?
Levonorgestrel = no limit in the same cycle, repeated use is less effective than proper contraception
Ulipristal = manufacturer not rec repeated use w/in same cycle
When should EC not be supplied and referral should be made?
Patient doesnt have mature understanding of what is proposed
Presentation >120 hrs, severe asthma w/ oral glucocorticoids + UPSI >96 hrs ago
BMI>30 or weight >85kg
Recent CYP3A4 inducer use, Malabsorption disorders
Ulipristal more than once in cycle (hepatotox), insufficient time between ulipristal and progestogen
Victim or sus SA
