Medical abortions + EC

Question 1

When can medical abortions occur?

Answer 1

Termination in 1st or 2nd trimester (up to 9 wks)

Alternative to surgical –> privacy and autonomy, supported by telemedicine

Question 2

What medications are used for Medical abortions?

Answer 2

Mifepristone 1 dose orally

36-48 hrs later –> misoprostol 4 tabs bucally (cheek and gum, swallow after 30 mins)

Question 3

What are the C/I to medical abortions?

Answer 3

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

Question 4

What are the precautions for medical abortions?

Answer 4

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

Question 5

What is the MOA/effect of mifepristone (RU486)?

Answer 5

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

Question 6

Generally, discuss dosing/ADRs/counselling of mifepristone

Answer 6

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)

Question 7

What is the MOA/effect of misoprostol?

Answer 7

It is a synthetic prostaglandin E1 derivative = oral, buccal, sublingual, or vaginal administration

MOA = act to dilate cervix and induce contraction

Question 8

What is the counselling for misoprostol?

Answer 8

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

Question 9

When should those who have taken MS-2 Step present to the ED?

Answer 9

Very heavy bleeding, passing clots size/greater than lemons, feeling faint

severe abdominal or pelvic pain, pain in tips of shoulder

Question 10

What should patients avoid 7 days following MS-2 step?

Answer 10

sex, tampons, swimming, bath, spa

Question 11

What is the follow up for MS-2 step?

Answer 11

Serum HCG

Low sensitivity urine preg test (threshold of 1000mlU/mL

Question 12

What are the available emergency contraceptives?

Answer 12

(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

Question 13

What is the efficacy timelines for ulipristal and levonorgestrel EC?

Answer 13

Levonorgestrel = up to 72 hrs, evidence for 96 hrs

Ulipristal = up to 120 hrs, most effect, can prevent ovulation after LH surge

Question 14

What can be done if EC levonorgestrel is not available?

Answer 14

Can give 2 doses of 25 tablets (50 tablets in total) of 30mcg levonorgestrel 12 hours apart

Question 15

What are the drug interactions for Levonorgestrel EC?

Answer 15

CYP3A4 inducers w/in previous 4wks (anti-seizures drugs, rifampicin, St John’s wort)

Griseofulvin “

Ulipristal = reduces the effectiveness

Question 16

What is an alternative indication for ulipristal?

Answer 16

treatment of uterine fibroids

Question 17

What are the drug interactions for ulipristal EC?

Answer 17

CYP3A4 inducers w/in previous 4wks (anti-seizures drugs, rifampicin, St John’s wort)

Griseofulvin “

Glucocorticoids, progestogens (levonorgestrel EC, hormonal contraception)

Question 18

What are some questions you can ask for EC?

Answer 18

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?

Question 19

Can ulipristal or levonorgestrel cause abortion of established pregnancy?

Answer 19

NOPE

they only work during the ovulatory phase of the menstrual cycle

Question 20

How do drug interactions influence EC choice?

Answer 20

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

Question 21

What emergency contraceptives can breastfeeding and postpartum mothers use?

Answer 21

LNG (levon) is safe otherwise copper IUD is good

UPSI <21 days pp = no EC req

Question 22

What EC should be used if UPSI occurred twice in same menstrual cycle?

Answer 22

1. LNG, 2. ulipristal

theoretical hepatoxicity concern

Question 23

What are some EC ADRs?

Answer 23

Headache, abdominal pain, dysmenorrhea

breast tenderness, abnormal vaginal

bleeding or spotting

nausea, vomiting

next menstrual cycle may be earlier or later

Question 24

When can levonorgestrel OC be resumed after levonorgestrel EC?

Answer 24

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

Question 25

When can POP/COC be resumed after ulipristal EC?

Answer 25

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

Question 26

What is some EC counselling/follow-up advice?

Answer 26

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

Question 27

Is there a limit to recurrent EC use?

Answer 27

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

Question 28

When should EC not be supplied and referral should be made?

Answer 28

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