Medication Abortion In Early Pregnancy

1
Medication Abortion In Early Pregnancy

• Induced termination
• of early intrauterine pregnancy
• using medications

2
6.4 Million Pregnancies/Year in the U.S.
24 Unintended Used Contraception
51 Intended
25 Unintended Used No Contraception
Finer, 2006 (2002 data)
3
Unintended pregnancy rate by race/ethnicity/incom
e
Unintended pregnancies per 1,000 women
Finer, 2006
4

Outcomes of Unintended Pregnancies(Approximately
3.1 Million Annually)
of unintended pregnancies
Finer, 2006 (2002 data)
5
89 of abortions occur in the first 12 weeks of
pregnancy
11-12 weeks
9-10 weeks
Under 9 weeks
Guttmacher Institute, 2004 data
6
Abortion Access

• 87 of counties have
• no abortion provider
• 35 of women live in
• these counties
• 25 of women travel gt 50 miles to find provider

of Women in Counties with No Abortion Provider
Source Jones et al., 2008 Kaiser Family
Foundation
7
Primary care shortage areas
with
and
without family physicians
Graham Center, 2000
8
Abortion in Family MedicineTraining Issues
9
Could training family physicians in medication
abortion make a difference?
10
Abortion in Family Medicine Implementation
Issues
11
Wanted versus unwanted pregnancy consequences
12
Medication Aspiration Abortionboth safe and
effective
13
Safety of Abortion

• First trimester abortions DO NOT increase risk
  of
• Infertility
• Ectopic pregnancy
• Miscarriage
• Birth defect
• Preterm or low-birth-weight delivery

Sources Boonstra, 2006 Virk, J et al, NEJM, 2007
14
Medication Abortion RegimensThree Choices
Mifepristone Misoprostol
Methotrexate Misoprostol
Misoprostol alone
15
Most common med abortion regimen in US
Mifepristone/Misoprostol
16
Medication Abortion Advantages

• 95-99 effective
• Avoids surgical and anesthetic risk
• Greater patient autonomy privacy
• Less invasive
• More natural

17
Aspiration Abortion Advantages
Slightly more effective (about 99) Shorter time
to completion Shorter bleeding duration Can be
performed later in gestation
18
Mifepristone-Misoprostol Regimens
FDA Protocol Alternate Protocol
Gestational age limit 49 days 63 days
Mifepristone dose 600 mg. oral 200 mg. oral
Misoprostol dose, route, and timing 400 mcg. oral Office administration 48 hours later 800 mcg. vaginal or buccal Home self-administration 6 - 72 hours later (vaginal) 24 - 36 hours later (buccal)
Office follow-up visit 10-15 days after mifepristone 4-10 days after mifepristone
Minimum office visits 3 2
Cost of medications 270 for mifepristone 2.00 for misoprostol 90 for mifepristone 4.00 for misoprostol
19
MIFEPRISTONE Causes progesterone blockade
Cervical Ripening
Decidual Necrosis
Detachment
MISOPROSTOL Causes uterine cramping expulsion
20
Misoprostol
21
Yolanda
22 years old Requests a pregnancy test
22
Counseling issues
Review all options Assure that decision is hers
23
Establish gestational age
24
Rule out contraindications

• Allergy to meds
• Adrenal insufficiency
• Current steroid use
• Coagulopathy or anticoagulant use
• IUD in place
• No access to follow-up

25
Indications for sonography
26
Yolanda
Gestational age 6 weeks
27
Patient agreement
28
Yolanda takes mifepristone in your office
29
At homeYolanda takes pain medication, then
misoprostol
30
Follow-up visit

• 4 - 14 days later
• Assure completion
• Process experience
• Review contraceptive
• choice

31
Phone calls after medication abortion
32
Clostridium sordellii

• 6 deaths in North America due to toxic shock with
  Clostridium following medication abortion
• Similar deaths, however, also seen following
• miscarriage, childbirth, trauma, surgery
• CDC no causal link between medications and these
  incidents

Source CDC 2006, FDA 2006
33
Methotrexate Misoprostol medication abortion
34
Misoprostol-only medication abortion
800 mcg vaginally gt 1 dose may be needed
35
Conclusion

• From pregnancy diagnosis through week nine,
  medication abortion is safe and effective. As its
  success depends on accessibility and counseling,
  medication abortion is well suited to the family
  medicine home.