Woman-Centered Abortion Care

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Woman-Centered Abortion Care
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Purpose

• This module covers the knowledge, attitudes and
  skills health-care providers need in order to
  provide pharmacological methods for
  first-trimester uterine evacuation.

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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.

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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.

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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.

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Medication-Abortion Pills
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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.

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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.

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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).

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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.

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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

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Contraindications (cont.)

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

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Counseling Should Include

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

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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.

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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.

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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).

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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.)
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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.

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Provide Instruction for Pills
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Write Out Instructions
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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)

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Cramping Side Effect
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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.

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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

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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

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Fever Side Effect
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Medication-Abortion Complications

• Medication abortion is associated with few
  serious complications.
• Occasional complications include
• Failed abortion
• Hemorrhage
• Infection

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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.

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Supply Contraception
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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

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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.

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Offer Contraceptive Methods
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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).

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Continuing Pregnancy

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

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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)

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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.

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Illustrations by Stephen C. Edgerton.