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OB > termination > Flashcards

termination Flashcards

1
Q

frequency of abortion

A

19% of unwanted pregnancies end in abortion

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2
Q

how many abortions are after the first trimester

A

9%

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3
Q

Ca limit for abortions

A

In California, legal limit of 2nd trimester abortion is 23 weeks 6 days.

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4
Q

1992 Planned Parenthood v. Casey

A

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

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5
Q

state-mandated counseling

A

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)

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6
Q

AB-154

A

law that allows CNMS, nPs. and PAs to provide 1st trimester abortion

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7
Q

what % result in complications

A

The overall abortion complication rate is lower than those for wisdom tooth removal

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8
Q

if you don’t have ULS

A

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.

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9
Q

how can MSD be used to determine GA

A

GA (days)= MSD+30

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10
Q

non viable pregnancy

A

empty GS>25 mm in diameter

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11
Q

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

A

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)

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12
Q

yolk sac indicates

A

probably intrauterine

typically 5 1/2 weeks

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13
Q

embryo appears at

what is growth like from there and how is it measured

A

6 weeks and grows 1mm per day until 12-24 weeks

after that used BPD (fetal biparieal diameter)

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14
Q

cardiac activity

A

6.5 weeks

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15
Q

MAB

medical abortion

A

medication abortion

10 weeks 0 days gestation

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16
Q

surgical abortion is an option for

A

<13 weeks 6 days

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17
Q

risks of MAB

A

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

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18
Q

A safe and effective way to terminate a pregnancy up to ___ days gestation

A

A safe and effective way to terminate a pregnancy up to 70 days gestation

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19
Q

what is mifepristone approved for

A

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

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20
Q

CI to MAB

A
  1. Ectopic pregnancy
  2. Intrauterine device in place
  3. Patients with chronic adrenal failure or who are on concurrent long-term corticosteroid therapy
  4. History of hemorrhagic disorders, are on anticoagulant therapy, or on any medications that interfere with hemostasis
  5. History of porphyrias
  6. Lack of ability to comply with the regimen or access care in case of complication
  7. 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
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21
Q

requirement for prescribing Mifepristone

A

The FDA requires mifepristone by prescribed* only by physicians (not NPs, PAs, or nurse midwives) who can:

  1. Make an accurate assessment of gestational age
  2. Diagnose ectopic pregnancy
  3. Provide surgical intervention in cases of severe bleeding or incomplete abortion OR make provisions to provide care through another provider
  4. Assure patient access to medical facilities equipped to perform blood transfusions and resuscitation
  5. *a physician may delegate another health professional to administer the drug
22
Q

DI of mifepristone

A
  1. Mifepristone is metabolized by cytochrome P450 3A4 (CYP3A4) and can theoretically interact with agents that impact CYP3A4 function.
  2. No specific food or drug interactions with a single dose of mifepristone have been reported.
23
Q

requirements after prescribing

A

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).

24
Q

Two regimens for MAB

A

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

25
Q

how does mifepristone work

A

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.

26
Q

initial visit will involve

A

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

27
Q

prophylactic anbxs or MAB

A

azithro 500mg x1 day

doxy 100mg x7days

28
Q

follow up visit for MAB

A

Follow-up visit in approximately 2 weeks to confirm pregnancy was expelled – usually via history and pelvic exam or transvaginal ultrasound
Provide contraception

29
Q

first trimester abortion SE

A

Gastrointestinal discomfort: nausea, vomiting, diarrhea

Abdominal pain

Excessive vaginal bleeding

Some women experience headaches, dizziness, or fatigue.

30
Q

complications of MAB

A 
Hemorrhage
Infection
Incomplete abortion
Incomplete expulsion
Ongoing pregnancy
Unrecognized ectopic pregnancy
31
Q

hemorrhage with MAB can result from

A

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.

32
Q

tx for ectopic

A

methotrexate

33
Q

hgb done before MAB

A

because low hgb can’t have

34
Q

how soon after using MAB can a pt get pregnant

A

10 days

35
Q

types of surgical abortion

A

mechanical or manuel

36
Q

complication rates of surgical abortion

A

Complication rate of 0-3% and efficacy rate of 98-99%

takes 1 day

37
Q

risk of surgical abortion

A

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

38
Q

indications

A

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

39
Q

expectations after surgical abortion

A

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

40
Q

complications of surgical abortion

A 
Hemorrhage
     May result from cervical or 
       vaginal lacerations
       Uterine perforation
        Retained tissue
        Uterine atony
Infection
Incomplete abortion
41
Q

f/u for surgical abortion

A

Routine follow-up recommended in 2-4 weeks

42
Q

medications for discharge abortions

A

Discharge with medications (NSAIDs, methergine, doxycycline, contraception)

43
Q

should abstain for intercourse for surgical abortion

A

Abstain from vaginal intercourse or tampon use x 2 weeks.

44
Q

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

A

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.

45
Q

second trimester abortion

A 
Preprocedure preparation
Anesthesia and antibiotics
Procedure (focusing on D&amp;E)
Possible use of uterotonics
Assessment for retained products of conception
46
Q

Diagnosis of EPL is confirmed by one of the following: (3)

A

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

47
Q

medication management of early pregnancy loss (EPL)

A

with MAB medications Mife/Miso or Miso alone or Methotrexate (in settings of EPL vs ectopic) - need follow up ultrasound

48
Q

other options for EPL (other than medication)

A

Aspiration in out patient or OR setting - usually no follow up required

49
Q

ectopic tx

A

Treatment is usually methotrexate followed by serial HCGs.

50
Q

ectopics usually present

A

In all patients presenting with first trimester bleeding, ectopic pregnancy should be considered. Ectopic pregnancies often present at 6-8 weeks gestation.

OB (14 decks)

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