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Woman-Centered Abortion Care

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Confirm that the pregnancy is 63 days/nine weeks or less since the LMP. ... Ectopic pregnancy (confirmed or suspected) or undiagnosed adnexal mass ... – PowerPoint PPT presentation

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Title: Woman-Centered Abortion Care


1
Woman-Centered Abortion Care
2
Purpose
  • This module covers the knowledge, attitudes and
    skills health-care providers need in order to
    provide pharmacological methods for
    first-trimester uterine evacuation.

3
Objectives
  • By the end of this module, learners should be
    able to
  • List the eligibility requirements for medication
    abortion with mifepristone and misoprostol.
  • List the contraindications to medication
    abortion.
  • Recognize expected side effects and potential
    complications of medication abortion.

4
Objectives (cont.)
  • 4. Demonstrate good counseling skills for women
    seeking medication abortion.
  • Discuss regimens for medication abortion using
    mifepristone plus misoprostol and misoprostol
    alone.
  • List effective pain-management medications and
    approaches for medication abortion.

5
Objectives (cont.)
  • Explain the care and services to be provided at
    each visit to women undergoing medication
    abortion.
  • Conduct a routine medication abortion follow-up
    visit.

6
Medication-Abortion Pills
7
Mifepristone
  • First developed and approved for clinical use in
    1988 in France (RU-486).
  • Blocks progesterone activity in the uterus,
    leading to detachment of the pregnancy.
  • Causes the cervix to soften and uterus to
    contract.

8
Misoprostol
  • Prostaglandin analogue that stimulates uterine
    contractions.
  • Inexpensive, stable at room temperature and
    readily available in the market.
  • Easily absorbed orally or vaginally.
  • Commonly used for treatment of gastric ulcers.

9
Effectiveness
  • Combination of two drugs more effective than
    either used alone.
  • Combined regimen is 92 to 98 percent effective in
    pregnancies nine weeks since last menstrual
    period (LMP) (Von Hertzen et al., 2003).

10
Diagnose and Date Pregnancy
  • Confirm that the pregnancy is 63 days/nine weeks
    or less since the LMP.
  • Date pregnancy through medical history, pregnancy
    test and bimanual exam.
  • Ultrasound used to date pregnancy can be helpful
    but is not required.

11
Contraindications
  • Ectopic pregnancy (confirmed or suspected) or
    undiagnosed adnexal mass
  • Allergy to mifepristone, misoprostol or other
    prostaglandin
  • Current use of long-term systemic corticosteroid
  • Chronic adrenal failure

12
Contraindications (cont.)
  • Hemorrhagic disorder
  • Current anticoagulant therapy
  • Inherited porphyria
  • IUD in place (remove before giving mifepristone)

13
Counseling Should Include
  • Eligibility, regimen, effectiveness, protocols
  • Side effects and complications
  • Ensuring access to emergency care
  • Contraceptive needs
  • Informed consent

14
Administration of Mifepristone
  • Administer 200mg mifepristone orally.
  • Most women will feel no change after taking the
    pill.
  • Some women will begin bleeding before taking the
    next pill (misoprostol).
  • A few women will abort after the mifepristone
    alone.

15
Administration of Misoprostol
  • There is a range of options in route, dosage and
    timing.
  • Institutional or national policy determines
    instructions to be followed.
  • Client safety and convenience should be
    considered.

16
Administration of Misoprostol (cont.)
  • After seven weeks LMP, vaginal doses are more
    effective than oral doses.
  • Up to 90 of women will expel tissue within six
    hours of vaginal dose (WHO, 2003).

17
Protocol for Misoprostol Administration
Day 1 is defined as the day mifepristone is taken.
(Schaff et al., 2000 Schaff et al., 1997 Ashok
et al., 1998 and Creinin et al., 1999.)
18
Instructions for Vaginal Insertion
  • Empty the bladder.
  • Wash hands.
  • Insert misoprostol tablets, one after the other.
  • Push tablets far up into the vagina.
  • Tablets may not fully dissolve.

19
Provide Instruction for Pills
20
Write Out Instructions
21
Misoprostol Alone
  • Effectiveness 85 to 90 63 days/ nine weeks
    LMP
  • Current recommended regimen
  • 800mcg misoprostol vaginally, taken twice at
    24-hour intervals (1600mcg total)
  • (Gynuity Health Projects and Reproductive
    Health Technologies Project, 2003)

22
Cramping Side Effect
23
Pain During Medication Abortion
  • Pain usually begins one to three hours after
    taking the misoprostol.
  • Cramping occurs during uterine contractions and
    POC expulsion.
  • Pain levels vary greatly among women.
  • Pain diminishes after abortion is complete.

24
Managing the Pain
  • Verbal support
  • Counseling about what to expect
  • Reassurance during the abortion
  • Low heat to the abdomen or lower back
  • Hot-water bottle
  • Warm cloths
  • Hot bath or shower

25
Pain Medications
  • Should be taken before cramping begins
  • Non-narcotic and narcotic analgesics can be used
  • Paracetamol (acetaminophen), with or without
    codeine
  • Ibuprofen
  • Codeine
  • NSAIDs do not interfere with misoprostol

26
Fever Side Effect
27
Medication-Abortion Complications
  • Medication abortion is associated with few
    serious complications.
  • Occasional complications include
  • Failed abortion
  • Hemorrhage
  • Infection

28
What Women Need to Know Before Leaving the Clinic
  • When to return for a routine but important
    follow-up visit.
  • How to recognize warning signs when and where to
    seek medical help.
  • That they can become pregnant again as early as
    10 days after the abortion.
  • That most women can begin contraception before
    the follow-up visit.

29
Supply Contraception
30
Warning Signs During or After Abortion
  • Excessive bleeding (for example, soaking more
    than two or three thick pads per hour for two
    consecutive hours)
  • Persistent fever of 38?C/100.4?F or higher or
    fever beginning more than eight hours after
    taking misoprostol
  • No bleeding within 24 hours of taking misoprostol

31
Follow-Up Visit
  • Inquire about the womans experience with the
    abortion.
  • Assess the completeness of the abortion.
  • Review any laboratory test results with the
    woman.
  • Discuss contraception and provide a contraceptive
    method, if she desires one.

32
Offer Contraceptive Methods
33
Assess Completeness of Abortion
  • Ask the woman if she thinks the abortion was
    complete.
  • Take a history Amount and duration of bleeding,
    cramping, passage of clots.
  • Conduct a physical examination.
  • If it is unclear whether the abortion is
    complete, perform ultrasound or check ?-hCG
    levels (if done prior to the abortion as well).

34
Continuing Pregnancy
  • If the pregnancy continues, terminate the
    pregnancy through other means, preferably vacuum
    aspiration.

35
Failed Abortion
  • If there is a persistent gestational sac,
    treatment options include
  • Expectant management, giving more time for
    expulsion of the POC
  • A repeat dose of vaginal misoprostol
  • Vacuum aspiration (preferable to sharp curettage)

36
Inform the Woman About Failure
  • Small risk that medication abortion will not
    work.
  • Slight risk that medications could cause birth
    defects if the pregnancy continues.
  • If medication abortion does not work, she should
    undergo vacuum aspiration.

37
Illustrations by Stephen C. Edgerton.
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