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Medical Abortion with Methotrexate and Misoprostol

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... and Second Trimester Abortion. Treatment of Early Pregnancy ... Medical Abortion with MTX and Misoprostol is Effective for Early ( 56 Days LMP) Gestations ... – PowerPoint PPT presentation

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Title: Medical Abortion with Methotrexate and Misoprostol


1
Medical Abortion with Methotrexate and Misoprostol
  • David Blair Toub, M.D.
  • Department of Obstetrics and Gynecology
  • Pennsylvania Hospital

2
Historical Perspective
  • 1985 and earlier Misoprostol
  • 1988 Mifepristone (RU-486) / Sulprostone
  • 1994 MTX / Misoprostol
  • 1996 RU-486 conditionally approved by FDA
  • 1997 Misoprostol for early pregnancy failure

3
Methotrexate Applications
  • Molar Pregnancy / GTN
  • Ectopic Pregnancy
  • Cancer Chemotherapy
  • Rheumatoid Arthritis
  • Psoriasis
  • First Trimester Abortion

4
Misoprostol Applications
  • Peptic Ulcer Disease
  • Induction of Labor
  • First and Second Trimester Abortion
  • Treatment of Early Pregnancy Failure

5
MTX / Misoprostol Abortion
  • Most Effective in Early Pregnancy
  • ( 56 days LMP)
  • 90-97 Effective
  • Requires Compliant Patient, Several Visits
  • Not Yet Covered By Most Insurers

6
MTX / Misoprostol Side Effects
  • MTX
  • Stomatitis
  • Gastritis
  • Alopecia
  • Elevated LFTs
  • Misoprostol
  • Diarrhea
  • Nausea

7
Advantages / Disadvantages of Medical Abortion
  • Advantages
  • Avoids Clinic Harassment
  • Avoids Surgical Risks
  • Relatively Inexpensive
  • Empowers Patient
  • Extends Abortion Access
  • May Treat Undiagnosed Ectopic Pregnancy (MTX)
  • Allows Early Termination
  • Disadvantages
  • Multiple Visits
  • 3-10 Require DE
  • Not Covered By Insurers
  • Bleeding May Be Unpredictable
  • Must Be Less Than 49-56 Days From LMP
  • May Be Completed With Karmen Cannula in Office

8
Advantages / Disadvantages of Suction Curettage
  • Advantages
  • Brief Procedure
  • Bleeding and Cramping Relatively Predictable
  • Requires Minimal Visits
  • Covered By Many Insurers
  • Safe High Success Rate
  • Disadvantages
  • Infrequent (But Occasioally Serious) Surgical
    Risks
  • More Often Performed in Targeted Outpatient
    Clinics
  • Availability Limited
  • At Times Restricted to 8 Weeks LMP

9
Patient Selection
  • 56 Days LMP
  • Compliant, with Reliable Phone Contact
  • No h/o Blood Dyscrasia, Liver Disease
  • No Significant Contraindications to DE

10
Misoprostol Alone is a Weak Abortifacient
400 mcg misoprostol PO, 56 days LMP (Norman et
al, 1991)
Percent
11
MTX / Misoprostol vs Misoprostol
(Crenin and Vittinghoff JAMA 2721190-1195, 1994)
Percent Complete Abortion
12
Abortion Rates by Misoprostol Routine (IM MTX)
(Schaff, et. al. 1996)
Percent Abortion
13
Evidence-Based Medicine
  • Class I At Least One Proper RCT
  • Class II Cohort Studies or Nonrandomized Trial
  • Class III Case Reports
  • A Good Evidence Exists
  • B Fair Evidence Exists
  • C Insufficient Evidence

14
Grimes Evidence-Based Summary
  • 800 mcg Misoprostol on Day 7 gt Day 3 (IA)
  • MTX Misoprostol gt Misoprostol (IA)
  • 800 mcg Misoprostol pv gt 600 mcg po (IIB)
  • MTX Alone Effective But Slow (IIIA)
  • Regimen Less Effective gt 56 Days LMP (IIIA)

15
Suggested Protocol
16
Patient Experiences(Adapted From Creinin and
Park, 1995)
  • 86 MTX/Misoprostol Patients, lt56 Days LMP
  • 85/86 (99) Completed Questionnaires
  • 48 Had Previous DE
  • 49 Cited Negative Experience with DE
  • 67/86 (79) Medical Abortion Positive
  • 12/86 (14) Negative Experience
  • 89 Would Choose Medical Abortion Again

17
Conclusions
  • Medical Abortion with MTX and Misoprostol is
    Effective for Early ( 56 Days LMP) Gestations
  • The Timing and Route of Misoprostol
    Administration Influences Success Rates
  • Patient Satisfaction is Generally Favorable
  • MTX and Misoprostol is an Available Alternative
    to Progesterone Antagonists (e.g. RU-486)

18
Future Dimensions
  • Increase Availability of Medical Abortion
  • Establish Absolute Upper Gestational Age Limit
  • Compare RU-486 with MTX
  • Work with Insurers to Establish Coverage

19
Thank You!
20
(No Transcript)
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