Objectives

Medical Education Series © 2005 National Abortion Federation

E A R L Y O P T I O N

SA PROVIDER’S GUIDE TO MEDICAL ABORTION

Objectives

• Identify expected side effects and possible complications of medical abortion

• Discuss the management of the side effects and complications of medical abortion

Overview

• Background: safety, definitions, counseling issues

• “Expected” side effects and their management

• Complications and their management

• Case studies

Outstanding Safety Record

• Mifepristone/misoprostol– Impressive safety record in 400,000 U.S. women– Used safely by millions of women worldwide

• Methotrexate/misoprostol– More than 5,000 cases in the published literature– Used safely by tens of thousands of women

• Misoprostol alone– Important option where mifepristone and

methotrexate are not available or affordable

Definitions

Side EffectEffect of treatment, other than the

intended outcome, that might include physiological

or psychological consequences

ComplicationEffect resulting from treatment that has

potentially serious clinical consequences

and requires medical intervention

Abortion Counseling

• Women will be more involved in the process of medical abortion as compared to vacuum aspiration

• Preparing women for side effects is a critical component of counseling

• The quality of counseling correlates with the level of patient satisfaction with abortion care

Abortion Counseling

• Vacuum aspiration– Serious complications rare and usually result

from anesthesia or instrumentation of the uterus– Side effects rarely reported

• Medical abortion– Serious complications rare– Most side effects are medication-induced:

nausea, vomiting, diarrhea, fever– Process of aborting has “side effects”

Overview




• Case studies

Expected Side Effects of Medical Abortion

• Pain

• Bleeding

• Nausea, vomiting, diarrhea

• Short-term temperature elevation or chills

• Headache, dizziness

Management of Common Side Effects: Pain

• Cramping occurs in > 90% of patients1

• Provide pain medications with initiation of treatment

• Counseling and reassurance crucial to pain management

1Spitz, et al. New Engl J Med 1998

Management of Common Side Effects: Pain

• Medications for pain control– Non-narcotic analgesics

• Acetaminophen

• NSAIDs—can be used with misoprostol

– Narcotic analgesics

• Palliative measures– Heating pad– Hot water bottle– Relaxation techniques

Management of Common Side Effects: Bleeding

• Usually exceeds typical menstrual bleeding

– If patient saturates 2 maxipads/hour for 2 consecutive hours, contact provider

– Surgical intervention to control bleeding: 0.4% to 2.6%1,2

– Transfusion required: 0.2%2

• Longer duration than with vacuum aspiration• No significant difference in total blood loss between medical abortion & vacuum aspiration

1Ashok, et al. Hum Reprod 19982Spitz, et al. New Engl J Med 1998

Management of Common Side Effects: Nausea, Vomiting, and Diarrhea

• Usually short in duration

• Provide reassurance

• Rarely needs medication

Management of Common Side Effects: Fever/Chills

• Result of misoprostol or the abortion process

• Antipyretics as appropriate

• Suspect infection with: – Sustained fever > 100.4°F– Fever 24 hours or more after misoprostol

Overview




• Case studies

Medical Abortion: Complications

• Continuing pregnancy

• Persistent gestational sac• Persistent bleeding requiring surgical intervention• Hemorrhage• Infection• Undiagnosed ectopic pregnancy

Kahn, et al. Contraception 2000

Meta-Analysis: Various Regimens Mifepristone/Misoprostol (< 49 days)

96.0%

2.9% 1.1%

0%

25%

50%

75%

100%

Success IncompleteAbortion

ContinuingPregnancy

Kahn, et al. Contraception 2000

Management of Complications: Continuing Pregnancy

• The presence of a developing pregnancy 2 weeks after first medication

• Treatment: uterine aspiration• Incidence (meta-analysis):

– Mifepristone/oral or vaginal misoprostol

1.1% of cases ( 49 days’ gestation)– Methotrexate/vaginal misoprostol

2.7% of cases ( 49 days’ gestation)

Management of Complications: Persistent Gestational Sac/Persistent Bleeding

• Perform ultrasound examination if clinically suspected

• Treatment options– Observation and re-evaluation– Repeat misoprostol – Uterine aspiration

Persistent Gestational Sac

Persistent Bleeding

Management of Complications: Hemorrhage

• Difficult to quantify amount of bleeding

• Guideline: patients should contact provider if they saturate 2 or more maxipads/hour for 2 consecutive hours

• Defining clinically significant hemorrhage– Drop in hemoglobin/hematocrit – Hypovolemia– Orthostatic hypotension

• Timing of heavy bleeding

Management of Complications: Infection

• Rarely occurs in medical abortion – 0.28% - 0.92%1

• Rule out retained products of conception

• Treatment: antibiotics

1Shannon, et al. Contraception 2004

Management of Complications: Undiagnosed Ectopic Pregnancy

• Providers should have established protocols for diagnosis and management

• Methotrexate > 90% effective

• Mifepristone, misoprostol not effective treatments

Proposed Criteria for Surgical Intervention in Medical Abortion

• Continuing pregnancy• Incomplete abortion unresponsive

to medical treatment • Orthostatic hypotension• Anemia, especially with ongoing blood loss• Patient unable to return; no access

to emergency services• Subjective symptoms unresponsive

to medical treatment• Patient preference

Timing of Surgical Intervention

• Emergent– Severe hemorrhage occurs

SHOULD BE DONE URGENTLY

• Nonemergent– Continuing pregnancy– Incomplete abortion without hemorrhage– Patient choice

CAN BE SCHEDULED AT CONVENIENCE OF PATIENT AND PROVIDER

Conclusion

• Medical abortion is safe and effective

• Establish guidelines for management of side effects and complications– Side effects are expected– Complications may occur but are uncommon

• Patients should have 24-hour access to backup care

• Clinicians must have arrangements established for vacuum aspiration, if needed

Overview




• Case studies

Optimal management would consist of which of the following?

1. Uterine aspiration

2. Reassurance and treatment with analgesics

3. Methergine, 0.2 mg IM

4. Uterine packing

• 23-year-old G2P1

• 200 mg mifepristone PO

• 800 µg misoprostol PV

(at home) 2 days later

• 3 hours after misoprostol,

patient complains of severe

cramping and bleeding (3

pads/2 hours)

• Pretreatment Hct: 37%

Case Study 1

The clinical picture is consistent with which of the following?

1 . Continuing pregnancy

2 . Persistent gestational sac

3 . Retained pregnancy tissue requiring vacuum

aspiration

Case Study 2


• 6 weeks LMP

• Medical abortion with

mifepristone/misoprostol

• Calls to report mild vaginal

bleeding 2 days after misoprostol

• Office visit 2 days later

Optimal management would consist of which of the following?

1 . Vacuum aspiration

2 . Observation

3 . Methergine, 0.2 mg IM

Case Study 3


• 42 days’ gestation

• Mifepristone/misoprostol

• No bleeding after misoprostol

• Ultrasound performed 12

days after misoprostol,

with cardiac activity present


• 34 days’ gestation

• Positive pregnancy test

• Pelvic exam normal

• Ultrasound obtainedAppropriate management consists of which of the following?

1 . Misoprostol 800 µg vaginally

2 . STAT -hCG levels

3 . Laparotomy

4 . Decline to perform an abortion, as the patient has miscarried

Case Study 4

Treatment options include all of the following except:

1. Vacuum aspiration

2. Trial of methergine, 0.2 mg IM

3. Repeat mifepristone

4. Expectant management


• 12 days status post mifepristone/misoprostol

• Reports continuous bleeding since taking misoprostol

• No persistent pain

• Afebrile (temp 98.70 F)

• BP 114/78; HR 74

• Hct: 31%

• Ultrasound: widened endometrial stripe (2 cm)

Case Study 5

Objectives

Documents

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