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Medication Abortion

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'Medication abortion' more accurately represents the family of safe and effective ... women will have a complete abortion within four hours of using ... – PowerPoint PPT presentation

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Title: Medication Abortion


1
Medication Abortion
  • A training module for health professionals

2
Ibis Reproductive Health
  • Ibis Reproductive Health aims to improve womens
    reproductive health, choices, and autonomy
    worldwide. Our work includes clinical and social
    science research, policy analysis, and
    evidence-based advocacy.

3
Objectives
  • Define medication abortion
  • Identify current medication abortion methods and
    present
  • Mechanisms of action
  • Regimens, efficacy, and safety
  • Eligibility requirements and contraindications
  • Side effects and complications
  • Provide general information on medication
    abortion methods
  • Outline references and resources

4
What is medication abortion?
  • Medication abortion, also known as non-aspiration
    or non-surgical abortion, refers to a family of
    safe and effective methods for terminating an
    early unwanted pregnancy. Through the use of a
    drug or combination of drugs that are
    administered orally, vaginally, and/or
    intramuscularly, medication abortion first causes
    the pregnancy to terminate and then causes the
    uterus to expel the products of conception.

5
Why medication abortion?
  • Non-aspiration or non-surgical abortion is
    commonly referred to as medical abortion.
    However, this phrase has led to confusion among
    both providers and the public, as the term
    medical is often associated with
    physician-based practices and/or medical
    necessity.
  • Medication abortion more accurately represents
    the family of safe and effective drug-based
    methods that can terminate an unwanted pregnancy
    and will be used throughout this presentation.

6
Methods of medication abortion
  • Mifepristone and misoprostol
  • Methotrexate and misoprostol
  • Misoprostol alone
  • Medication abortion methods can be used
    throughout early pregnancy (63 days gestation)

7
Medication abortionMethods of action of the
medications
  • Mifepristone
  • Anti-progestin that blocks the action of
    progesterone
  • Alters the uteral lining
  • Methotrexate
  • Anti-metabolite
  • Interferes with DNA synthesis and cell growth
  • Misoprostol
  • Prostaglandin E1 analog
  • Stimulates uterine contractions and induces
    cervical softening

8
Medication abortion Additional uses of the
medications
  • Mifepristone
  • Labor induction (under investigation)
  • Infertility treatment (under investigation)
  • Methotrexate
  • Treatment of neoplastic diseases
  • Treatment of rheumatoid arthritis
  • Misoprostol
  • Prevention of gastric ulcers
  • Obstetric and gynecologic indications

9
Mifepristone/misoprostol regimen

10
MifepristoneWorldwide approval
11
Mifepristone/misoprostol regimenGeneral protocol
  • Day 1 (Clinic)
  • Clinician counsels the woman, takes a medical
    history and performs an exam and lab tests
  • Mifepristone is orally administered
  • Day 2-4 (Home or clinic)
  • Misoprostol is administered
  • Day 7-14 (Clinic)
  • Patient returns to the clinic for follow-up
  • Clinician assesses for the completion of the
    abortion

12
Mifepristone/misoprostol regimensComparison of
protocols
13
Mifepristone/misoprostol regimenEfficacy and
safety
  • Approximately 95 of women will have a successful
    abortion when using mifepristone/misoprostol
    within 49 days gestation
  • Completion rates appear to decline slightly with
    increasing durations of pregnancy after 56 days
    gestation
  • Approximately 67 of women will have a complete
    abortion within four hours of using misoprostol
  • Approximately 90 of women will have a complete
    abortion within 24 hours of using misoprostol.

14
Mifepristone/misoprostol regimenEligibility for
use
  • Non-ectopic pregnancy of 63 days gestation
  • Absence of contraindications
  • Willingness to undergo vacuum aspiration or
    dilation and curettage (DC), if indicated

15
Mifepristone/misoprostol regimenContraindications
to use
  • Confirmed or suspected ectopic (extra-uterine)
    pregnancy
  • Allergy to either mifepristone or misoprostol
  • Presence of an intrauterine device (IUD)
  • Chronic systemic use of corticosteroids
  • Chronic adrenal failure
  • Coagulopathy or current therapy with
    anticoagulants
  • Inherited porphyria

16
Mifepristone/misoprostol regimenSide effects
  • Effects of abortion process
  • Cramping
  • Often described as similar to menstrual cramps
  • Vaginal bleeding
  • Median bleeding time 9-13 days
  • Often described as similar to a heavy period or
    spontaneous miscarriage
  • Common side effects
  • Nausea
  • Vomiting
  • Diarrhea
  • Headache
  • Dizziness
  • Fever, chills, hot flashes, warmth

17
Mifepristone/misoprostol regimenComplications
18
Mifepristone/misoprostol regimenSummary
  • Millions of women worldwide have safely used
    mifepristone/misoprostol
  • Mifepristone/misoprostol is more than 95
    effective in terminating early pregnancies
  • Mifepristone/misoprostol is widely acceptable to
    both patients and providers

19
Methotrexate/misoprostol regimen

20
MethotrexateWorldwide availability
21
Methotrexate/misoprostol regimenEvidence-based
protocol
  • Day 1 (Clinic)
  • Clinician counsels the woman, takes a medical
    history and performs an exam and lab tests.
  • Methotrexate is administered either orally (50
    mg) or intramuscularly (50 mg/m2)
  • Day 3-7 (Home)
  • Misoprostol is self-administered vaginally at
    home.
  • Day 8 (Clinic)
  • Clinician performs a vaginal ultrasound to
    determine if the abortion is complete.
  • If abortion is complete (75 of women) no further
    visits are required.
  • If the abortion is incomplete additional
    misoprostol is given and patient returns
  • On Day 15 if cardiac activity is detected
  • On Day 28-45 if no cardiac activity is detected
    on ultrasound

22
Methotrexate/misoprostol regimenEvidence-based
protocol continued
  • Day 15 (Clinic, if necessary)
  • Patient is assessed for continued pregnancy.
  • If cardiac activity is detected, a aspiration
    termination is performed.
  • If no cardiac activity is detected, patient
    returns in three weeks.
  • Day 28-45 (Clinic, if necessary)
  • The patient is assessed for continued pregnancy.
  • If the abortion is incomplete (5 of cases), a
    aspiration termination is performed.

23
Methotrexate/misoprostol regimenEfficacy and
safety
  • Approximately 95 of women will have a complete
    abortion when using methotrexate/misoprostol up
    to 49 days gestation.
  • Medication abortion completion rates decline with
    increasing gestational age
  • Approximately 20 of patients using
    methotrexate/misoprostol will experience a
    complete abortion three to four weeks after
    misoprostol administration.

24
Methotrexate/misoprostol regimenEligibility for
use
  • Pregnancy of 49 days gestation
  • Methotrexate/misoprostol is preferable for women
    with ectopic pregnancies
  • Absence of contraindications
  • Willingness to undergo vacuum aspiration or
    dilation and curettage (DC), if indicated

25
Methotrexate/misoprostol regimenContraindications
to use
  • Allergy to either methotrexate or misoprostol
  • Presence of an intrauterine device (IUD)
  • Coagulopathy or current severe anemia
  • Acute or chronic renal or hepatic disease
  • Acute inflammatory bowel disease
  • Uncontrolled seizure disorders.

26
Methotrexate/misoprostol regimenSide Effects
  • Effects of abortion process
  • Cramping
  • Often described as similar to menstrual cramps
  • Vaginal bleeding
  • Median bleeding time 2-3 weeks
  • Often described as similar to a heavy period or
    spontaneous miscarriage
  • Common side effects
  • Nausea
  • Vomiting
  • Diarrhea
  • Headache
  • Dizziness
  • Fever, chills, hot flashes, warmth
  • Oral ulcers
  • Fetal malformations

27
Methotrexate/misoprostol regimenComplications
(49 days gestation)
28
Methotrexate/misoprostol regimenSummary
  • Methotrexate/misoprostol is approximately 95
    effective in terminating pregnancies 49 days
    gestation
  • Methotrexate/misoprostol is the preferred
    medication abortion method for confirmed or
    suspected ectopic pregnancies
  • Methotrexate/misoprostol is widely acceptable to
    both patients and providers

29
Misoprostol-only regimen

30
MisoprostolWorldwide availability
31
Misoprostol-only regimenEvidence-based protocols
  • No consensus exists on optimal protocol
  • Various regimens, dosing schedules and routes of
    administration are currently under investigation
  • Most commonly used protocol
  • Vaginal administration of 800 µg of misoprostol
  • If abortion fails, misoprostol dose is repeated
    every 24 hours, up to three doses

32
Misoprostol-only regimenEfficacy and Safety
  • Efficacy varies widely (65-93)
  • Efficacy varies by route of administration, dose,
    dosing schedule, and gestational age
  • Misoprostol-only regimens are not as effective as
    either mifepristone/misoprostol or
    methotrexate/misoprostol regimens

33
Misoprostol-only regimenEligibility for use
  • Non-ectopic pregnancy of 63 days gestation
  • Absence of contraindications
  • Willingness to undergo vacuum aspiration or
    dilation and curettage (DC), if indicated
  • Lack of access to either mifepristone or
    methotrexate

34
Misoprostol-only regimenContraindications for use
  • Confirmed or suspected ectopic pregnancy
  • Allergy to misoprostol
  • Presence of an intrauterine device (IUD)
  • Uncontrolled seizure disorder
  • Inflammatory bowel disease

35
Misoprostol-only regimenSide effects
  • Effects of abortion process
  • Cramping
  • Often described as similar to menstrual cramps
  • Often described as more severe than the cramping
    of either mifepristone/misoprostol or
    methotrexate/misoprostol regimens
  • Vaginal bleeding
  • Median bleeding time 2 weeks
  • Often described as similar to a heavy period or
    spontaneous miscarriage
  • Common side effects
  • Nausea
  • Vomiting
  • Diarrhea
  • Headache
  • Dizziness
  • Fever and chills
  • Rashes
  • Pelvic pain
  • Fetal malformations

36
Misoprostol-only regimenComplications
  • Approximately 10-35 of women will require an
    aspiration intervention
  • Misoprostol-only regimen is less effective in
    terminating early pregnancy than when used in
    combination with either mifepristone or
    methotrexate

37
Misoprostol-only regimenSummary
  • Misoprostol used in conjunction with either
    mifepristone or methotrexate is more effective at
    terminating early pregnancy than misoprostol
    alone
  • Efficacy varies widely
  • Optimal regimen has yet to be determined
  • Misoprostol-only regimen is an important
    alternative for women who do not have access to
    other medical or aspiration abortion methods

38
Medication abortion General issues

39
Medication abortionComparing the three regimens
40
Medication abortionSpecial considerations for
early pregnancy termination
  • Determine eligibility for medication abortion
  • Diagnose and accurately date of early pregnancy
  • Discuss medical and aspiration options
  • Inform patients of potential side effects,
    complications, and follow-up requirements
  • Provide adequate follow-up and post abortion care
  • Aspiration intervention, if necessary
  • Family planning services

41
Methods for determining gestational age
  • For all medication abortion methods, accurate
    pregnancy dating is important
  • Methods for determining gestation age include
  • Last menstrual period
  • Bimanual examination
  • Serum ß-hCG testing
  • Ultrasound

42
Alternatives to medication abortionAspiration
abortion
  • Types of aspiration abortion
  • Manual vacuum aspiration
  • Dilation and curettage (DC)
  • Aspiration procedure
  • Cannula is inserted into the uterus
  • Uterine contents are emptied through suction
  • Can be used throughout the first trimester
  • Highly effective (99) in terminating pregnancy

43
Medication abortion vs. aspiration
abortionAdvantages and disadvantages
44
Medication abortionConditions requiring clinical
assessment and/or intervention
  • Fever
  • Excessive or prolonged bleeding
  • Incomplete abortion
  • Retained fetal tissue
  • Persistent gestational sac on ultrasound
  • Continued pregnancy

45
Medication abortion regimensAcceptability
  • Generally well-accepted by patients who report
  • High satisfaction
  • Desire to use the method again
  • Intention to recommend method to a friend or
    relative
  • Both mifepristone/misoprostol and
    methotrexate/misoprostol regimens are
    well-accepted by providers

46
Medication abortion regimensBest and worst
reported features
  • Women report the best features as
  • Ability to avoid surgery and anesthesia
  • Perception that the process is more natural
  • Privacy
  • Convenience
  • Women report the worst features as
  • Length and degree of bleeding
  • Number of clinic visits
  • Uncertainty as to whether or not the procedure
    had resulted in a complete abortion.

47
Medication abortionFuture directions for
research and clinical practice
  • Expand worldwide access to medication abortion
    medications
  • Establish optimal misoprostol-only regimens
  • Expand programs to educate women, health
    professionals, and policy makers about medication
    abortion
  • Train health professionals in medication abortion
    provision

48
Medication AbortionConclusions
  • Medication abortion regimens have been used by
    millions of women worldwide to safely and
    effective terminate early pregnancy
  • Medication abortion regimens expand pregnancy
    termination options for women and health
    professionals
  • Medication abortion regimens are highly
    acceptable to both women and providers
  • Future research is needed to improve regimens and
    expand services

49
Medication AbortionReferences and resources
  • The Alan Guttmacher Institute www.agi-usa.org
  • This site provides numerous studies on abortion
    in the US and worldwide.
  • American College of Obstetricians and
    Gynecologists www.acog.org
  • This website provides information on the medical
    management of abortion and resources on practice
    guidelines.
  • Ibis Reproductive Health www.ibisreproductivehea
    lth.org
  • The home page of Ibis Reproductive Health, this
    site provides information on the organization and
    contains a database of articles published by
    staff. Ibis also provides educational materials
    on medication abortion in English, Arabic,
    French, and Spanish.
  • IPAS www.ipas.org
  • IPAS manufactures and distributes manual vacuum
    aspiration equipment and trains providers in
    early abortion techniques worldwide.
  • National Abortion Federation www.earlyoptions.or
    g
  • This site provides medication abortion
    educational materials for both providers and
    patients.
  • Population Council www.popcouncil.org
  • The Population Council provides information on
    reproductive health issues worldwide, including
    publications on medication abortion methods and
    acceptability.
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