termination Flashcards
frequency of abortion
19% of unwanted pregnancies end in abortion
how many abortions are after the first trimester
9%
Ca limit for abortions
In California, legal limit of 2nd trimester abortion is 23 weeks 6 days.
1992 Planned Parenthood v. Casey
gave states the right to enact restrictions that do not create an “undue burden” for women seeking abortion
Parental consent or parental notification laws
Public funds for abortions for income qualifying women
No federal funding for abortions
state-mandated counseling
mandated counseling for abortion
long term mental health consequences in 8 states
purported link between abortion and breast cancer (5)
counseling the the fetuses ability to feel pain in (13)
AB-154
law that allows CNMS, nPs. and PAs to provide 1st trimester abortion
what % result in complications
The overall abortion complication rate is lower than those for wisdom tooth removal
if you don’t have ULS
Lemon 5-6 weeks,
medium 7-8 weeks grapefruit 9-10 weeks or fungal height
after 12 weeks uterus rises out
of pelvis at 20 weeks reaches umbilicus.
how can MSD be used to determine GA
GA (days)= MSD+30
non viable pregnancy
empty GS>25 mm in diameter
A normal early GS can be characterized by the FEEDS mnemonic, although meeting all criteria
does not exclude the possibility of ectopic pregnancy
what is FEEDS
F - Fundal - in mid or upper uterus
E - Ellpitical or round shape in 2 views
E - Eccentric to the endometrial stripe
D - Decidual reaction (surrounded by a thickened choriodecidual reaction; appears like a fluffy white cloud or ring surrounding the sac
S - Size > 4 mm (soft criteria)
yolk sac indicates
probably intrauterine
typically 5 1/2 weeks
embryo appears at
what is growth like from there and how is it measured
6 weeks and grows 1mm per day until 12-24 weeks
after that used BPD (fetal biparieal diameter)
cardiac activity
6.5 weeks
MAB
medical abortion
medication abortion
10 weeks 0 days gestation
surgical abortion is an option for
<13 weeks 6 days
risks of MAB
Similar to a first trimester surgical abortion, particularly:
Endometritis, infection, hemorrhage
No risk of cervical injury or uterine perforation
Increase in teratogenic risk to an ongoing pregnancy
May still need surgical aspiration to complete the termination
A safe and effective way to terminate a pregnancy up to ___ days gestation
A safe and effective way to terminate a pregnancy up to 70 days gestation
what is mifepristone approved for
The US Food and Drug Administration (FDA) has approved mifepristone for the termination of an intrauterine pregnancy up to 49d gestation.
2. Beyond this 49d gestation is considered off-label
CI to MAB
- Ectopic pregnancy
- Intrauterine device in place
- Patients with chronic adrenal failure or who are on concurrent long-term corticosteroid therapy
- History of hemorrhagic disorders, are on anticoagulant therapy, or on any medications that interfere with hemostasis
- History of porphyrias
- Lack of ability to comply with the regimen or access care in case of complication
- No data for women with chronic medical conditions (HTN, DM, cardiovascular, hepatic or renal disease) or cigarette smokers – labeling of mifepristone advises caution in women with these conditions
requirement for prescribing Mifepristone
The FDA requires mifepristone by prescribed* only by physicians (not NPs, PAs, or nurse midwives) who can:
- Make an accurate assessment of gestational age
- Diagnose ectopic pregnancy
- Provide surgical intervention in cases of severe bleeding or incomplete abortion OR make provisions to provide care through another provider
- Assure patient access to medical facilities equipped to perform blood transfusions and resuscitation
- *a physician may delegate another health professional to administer the drug
DI of mifepristone
- Mifepristone is metabolized by cytochrome P450 3A4 (CYP3A4) and can theoretically interact with agents that impact CYP3A4 function.
- No specific food or drug interactions with a single dose of mifepristone have been reported.
requirements after prescribing
a. Must sign a prescriber’s agreement with the manufacturer of mifepristone
b. Require that patients read the manufacturer’s Medication Guide and sign the Patient Agreement form
c. Report any ongoing pregnancy or serious events (eg hospitalization, infection, blood transfusion).
Two regimens for MAB
Mifepristone 600mg orally, followed 48 hours later by misoprostol 400mcg orally. Both administered by a clinician
Alternative regimen, referred to as the evidenced-based regimen
preferred **
Mifepristone 200mg orally administered by a clinician, followed 24-72 hours later by misoprostol 800mcg buccal, administered by a healthcare provider or self-administered in a non-clinical setting
how does mifepristone work
It is a derivative of norethindrone (a synthetic progestin) that acts as an antiprogestin.
It binds to the progesterone receptor with greater affinity than progesterone itself.
However, the receptor does not activate, thus blocking the action of progesterone which is needed to establish and maintain placental attachment.
initial visit will involve
confirm GA
counseling and informed consent
STI testing
blood typing/verification and
administration of Rh immune globuline if needed although there id a debate over if this is really needed
prophylactic anbx administration
prophylactic anbxs or MAB
azithro 500mg x1 day
doxy 100mg x7days
follow up visit for MAB
Follow-up visit in approximately 2 weeks to confirm pregnancy was expelled – usually via history and pelvic exam or transvaginal ultrasound
Provide contraception
first trimester abortion SE
Gastrointestinal discomfort: nausea, vomiting, diarrhea
Abdominal pain
Excessive vaginal bleeding
Some women experience headaches, dizziness, or fatigue.
complications of MAB
Hemorrhage Infection Incomplete abortion Incomplete expulsion Ongoing pregnancy Unrecognized ectopic pregnancy
hemorrhage with MAB can result from
Can be related to uterine atony or retained products of conception
For patients with excessive or prolonged bleeding, incomplete abortion should be excluded.
Generally, blood loss is not severe enough to require therapy.
In a large study, blood transfusion was required in only 0.05% of procedures.
tx for ectopic
methotrexate
hgb done before MAB
because low hgb can’t have
how soon after using MAB can a pt get pregnant
10 days
types of surgical abortion
mechanical or manuel
complication rates of surgical abortion
Complication rate of 0-3% and efficacy rate of 98-99%
takes 1 day
risk of surgical abortion
Similar to MABs
Endometritis
Life threatening infections are rare, but have occurred more often with surgical abortion
Hemorrhage occurs at similar rates to MABs, but cause is usually related to cervical laceration or uterine injury due to instrumentation
indications
Very Early Abortion (VEA): from the time of positive pregnancy test up to 6 weeks
Very Early Abortion (VEA): from the time of positive pregnancy test up to 6 weeks
can do a diagnostic abortion
expectations after surgical abortion
Most women experience mild lower abdominal cramping for 2-4 days post-procedure
Women should be informed that vaginal passage of small amounts of tissue and blood can be expected post-procedure
complications of surgical abortion
Hemorrhage
May result from cervical or
vaginal lacerations
Uterine perforation
Retained tissue
Uterine atony
Infection
Incomplete abortionf/u for surgical abortion
Routine follow-up recommended in 2-4 weeks
medications for discharge abortions
Discharge with medications (NSAIDs, methergine, doxycycline, contraception)
should abstain for intercourse for surgical abortion
Abstain from vaginal intercourse or tampon use x 2 weeks.
pts should be advised to return to clinic if pregnancy symptoms have not resolved within___ week or if not return to normal menses by ___ weeks post procedure
Return to clinic if pregnancy symptoms have not resolved within one week of procedure or if normal menses has not returned by 6 weeks post-procedure.
second trimester abortion
Preprocedure preparation Anesthesia and antibiotics Procedure (focusing on D&E) Possible use of uterotonics Assessment for retained products of conception
Diagnosis of EPL is confirmed by one of the following: (3)
1) US confirmation of an embryonic gestation or fetal demise in the uterus in conjunction with falling serial HCGs,
2) absence of previously seen IUP on US
3) Tissue exam confirming expulsion from uterus
medication management of early pregnancy loss (EPL)
with MAB medications Mife/Miso or Miso alone or Methotrexate (in settings of EPL vs ectopic) - need follow up ultrasound
other options for EPL (other than medication)
Aspiration in out patient or OR setting - usually no follow up required
ectopic tx
Treatment is usually methotrexate followed by serial HCGs.
ectopics usually present
In all patients presenting with first trimester bleeding, ectopic pregnancy should be considered. Ectopic pregnancies often present at 6-8 weeks gestation.
