Transcript Options for Therapeutic Abortion MVA and Medication Management

Options for Therapeutic Abortion:
Manual Vacuum Aspiration and
Medication Management
Association of Reproductive Health
Professionals
www.arhp.org
Expert Medical Advisory Committee
• Herbert P. Brown, MD
• Michelle Forcier, MD, MPH
• Emily Godfrey, MD, MPH
• Marji Gold, MD
• Jini Tanenhaus, PA, MA
Learning Objectives
• List four clinical indications for manual
vacuum aspiration (MVA)
• List four factors to consider when counseling
women about MVA versus medical
management of early pregnancy loss
more…
Learning Objectives (continued)
• List three conditions in a patient that should
cause a provider to use caution before
providing MVA or medical management of
early pregnancy loss
• List at least one medication regimen used for
early medication abortion
Module 1:
MVA Overview
Unintended Pregnancy in the United
States (2001)
6.3 million pregnancies
Intended
Unintended
Birth
Abortion
Fetal Loss
Finer LB, Henshaw SK. Perspect Sex Reprod Health. 2006.
Outcomes of Unintended
Pregnancies
Approximately 3 million annually in the
United States
Abortion
42%
44%
14%
Finer LB, Henshaw SK. Perspect Sex Reprod Health. 2006.
Birth
Miscarriage/
Fetal Demise
Abortions by Length of Pregnancy
1%
4%
6%
10%
61%
18%
Strauss LT, et al. MMWR. 2006
Weeks Gestation
≤8
9 to 10
11 to 12
13 to 15
16 to 20
≥21
What Is a Manual Vacuum
Aspirator?
Manual vacuum aspirator
• Has locking valve
• Is portable and reusable
• Vacuum is equivalent to
electric pump
• Efficacy is same as electric
vacuum (98%–99%)
• Has semi-flexible plastic cannula
Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet
Gynecol. 2004.’ Hemlin J, et al. Acta Obstet Gynecol Scand. 2001.
What Is an Electric Vacuum
Aspirator?
Electric vacuum aspirator
• Uses an electric pump or
suction machine connected
via flexible tubing
• Has a plastic or metal
cannula
• Typically used in centralized
settings with high caseloads
Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet
Gynecol. 2004.; Hemlin J, et al. Acta Obstet Gynecol Scand. 2001.
History of MVA
1973:
Helms Amendment
enacted
1980s:
MVA marketed
worldwide
1973:
USAID sponsors Ipas
1990s:
MVA used in
>100 countries
Bird ST, et al. Contraception. 2003.; Edwards J, et al. Curr Probl Obstet
Gynecol Fertil. 1997.; Karman H, et al. Lancet. 1972.
Comparison of EVA to MVA
Vacuum
Noise
Portable
Cannula
Capacity
EVA
Electric pump
Variable
Not easily
4–16 mm
350–1,200 cc
Suction
Constant
Dean G, et al. Contraception. 2003.
MVA
Manual aspirator
Quiet
Yes
4–12 mm
60 cc
Decreases to 80% (50 mL)
as aspirator fills
Products of Conception (POC)
Procedure is complete when POC are
identified
Electric Suction
Machine
Edwards J, et al. Am J Obstet Gynecol. 1997.
MacIsaac L, et al. Am J Obstet Gynecol. 2000.
MVA
Aspirator
Clinical Indications for MVA
• Uterine evacuation in the first trimester:
▪
▪
Induced abortion
Spontaneous abortion
• Incomplete medication abortion
• Uterine sampling
• Post-abortal hematometra
Creinin MD, et al. Obstet Gynecol Surv. 2001.; Edwards J, Creinin MD. Curr Probl Obstet
Gynecol Fertil.1997.; Castleman LD et al. Contraception. 2006; MVA Label. Ipas. 2007.
Complications with MVA
• Very rare
• Same as EVA
• May include:
▪
▪
▪
▪
▪
Incomplete evacuation
Uterine or cervical injury
Infection
Hemorrhage
Vagal reaction
MVA Label. Ipas. 2004.
Putting Abortion into Perspective…
Incident
Terminating pregnancy < 9 weeks
Chance of
death
1 in 500,000
Terminating pregnancy > 20 weeks
1 in 8,000
Giving birth
1 in 7,600
Driving an automobile
1 in 5,900
Using a tampon
1 in 350,000
Gold RB, Richards C. Issues Sci Technol. 1990.; Hatcher RA. Contracept
Technol Update. 1998.; Mokdad AH, et al. MMWR Recomm Rep. 2003.
Post-Abortion Care
• Women desiring pregnancy
▪
▪
Vitamin and diet recommendations
Toxic-exposure avoidance guidelines
• Women avoiding pregnancy
▪
▪
Contraceptive counseling
Contraception initiated on day of MVA
Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet Gynecol. 2004.;
Hemlin J, Moller B. Acta Obstet Gynecol Scand. 2001.
MVA vs. EVA Complication Rates
Methods
• Vacuum aspiration for abortion up to 10 wks
LMP
• Retrospective cohort analysis
• Choice of method (MVA vs. EVA) up to
physician
• n = 1,002 for MVA; n = 724 for EVA
• Charts reviewed for complications
more…
Goldberg AB, et al. Obstet Gynecol. 2004.
MVA vs. EVA Complication Rates
(continued)
Complications
• 2.5% for MVA
• 2.1% for EVA (p = 0.56)
• No significant difference
*Elective not spontaneous studies
Goldberg AB, et al. Obstet Gynecol. 2004.
more…
MVA vs. EVA Complication Rates
(continued)
Choice of MVA vs EVA in
procedures
• Attendings:
52% MVA
• Gyn residents: 59% MVA
• Other residents: 76% MVA
(p<0.001)
*Elective not spontaneous studies
Goldberg AB, et al. Obstet Gynecol. 2004.
Conventional Wisdom and Abortion
Care
1970s
Today
• Wait 7+ weeks for
lowest risk of
complications
• Ultra-sensitive
pregnancy tests
• POC inspection
• Ultrasound
• Medication abortion
• MVA
• No reason to wait
Depineres T, Stewart F. NAF. 2002. ; Castadot RG. Fertil Steril. 1986.
Edwards J, Creinin MD. Curr Probl Obstet Gynecol Fertil. 1997.
What Services Do You Provide?
Use index cards provided to answer the
following. Do not write your name.
• Does your facility currently provide vacuum
aspiration abortions before 6 weeks?
▪
Yes/No
• Are there clinical or program-related barriers
to providing early abortion with vacuum
aspiration?
▪
Yes/No (If yes, list the most significant barriers.)
Earlier Procedures Are Safer
Abortions at <8 weeks = lowest risk of death
Gestational Age
Strongest risk factor
for abortion-related
mortality
Bartlet L, et al. Obstet Gynecol. 2004.
Offering Services as Early as
Possible
“…Because access to abortions
even one week earlier reduces the risk
of death…increased access to early
abortion services may increase the
proportion of abortions performed at
the lower-risk, early gestational ages
and help reduce maternal deaths.”
Bartlet L, et al. Obstet Gynecol. 2004.
Early Abortion with Vacuum
Aspiration
Author
Paul et al.
Edwards &
Carson
Edwards &
Creinin
Hemlin &
Moller
Laufe
Date
N
Gestational
Age
2002
1,132
(MVA+EVA)
<6
98%
1997
1,530 MVA
<6
99%
1997
2,399 MVA
<6
99%
2001
91 MVA
<8
98%
1977
12,888
“About 6”
98%
Efficacy
Baird TL, Flinn SK. 2001.; Edwards J, Carson SA. Am J Obstet Gynecol. 1997.
Edwards J, Creinin MD. Curr Probl Obstet Gynecol Fertil. 1997. Hemlin J, Moller B.
Acta Obstet Gynecol Scand. 2001.; Paul ME, et al. Am J Obstet Gynecol. 2002.
Early Abortion with MVA: Study
• Methods
▪
▪
2,399 MVA procedures, < 6 weeks LMP
Meticulous inspection of POC immediately after
MVA
• Results
▪
▪
▪
99.2% effective in terminating pregnancy
6 repeat aspirations (0.25%)
14 ectopic pregnancies (0.6%) diagnosed and
treated
Edwards J, Creinin MD. Curr Probl OIbstet Gynecol Fertil. 1997.
Early Abortion with MVA or EVA:
Study
Methods
• 1,132 women, ≤ 6 weeks LMP
• Of 1,093 procedures:
▪
▪
▪
52% MVA
40% EVA
8% both
• Examination of POC immediately after
procedure
more…
Paul ME, et al. Am J Obstet Gynecol. 2002.
Early Abortion with MVA or EVA:
Study (continued)
Results
Required re-aspiration
2.3% of study population
more…
Paul ME, et al. Am J Obstet Gynecol. 2002.
Early Abortion with MVA or EVA:
Study (continued)
Failure rates by technique among women
with follow-up (95% CI):
1.1%
2.9%
7.5%
(0.4%-3.0%)
(1.4%-5.7%)
(2.1%-18.2%)
EVA
Both used
MVA
more…
Paul ME, et al. Am J Obstet Gynecol. 2002.
Early Abortion with MVA or EVA:
Study (continued)
Of the 750 women with follow-up,
13 experienced other complications:
• 4 incomplete abortions
• 2 unrecognized ectopic pregnancies
• 1 hematometra
• 4 pelvic infections
• 3 re-aspirations for pain and bleeding
despite negative pathology
Paul ME, et al. Am J Obstet Gynecol. 2002.
MVA and POC: Study
• In group overall
▪
n = 1,726, up to 10 weeks LMP
• Complication rates between MVA and EVA
▪
▪
▪
37 patients at < 6 weeks’ gestation
In 35 of 37, provider chose MVA
No re-aspirations needed in patients < 6 weeks
more…
Goldberg AB, et al. Obstet Gynecol. 2004.
MVA and POC: Study (continued)
“…Significantly more re-aspirations
for inability to accurately identify the
pregnancy occurred in electric
group.”
Goldberg AB et al.
Obstet Gynecol, 2004
Goldberg AB, et al. Obstet Gynecol. 2004.
Safety and Efficacy:
Family Practice Office
Methods
• Abortion using MVA, <12 weeks LMP
• Retrospective chart review, N = 1,677
• 60% performed by residents under
supervision
• 40% performed by attendings
more…
Westfall JM, et al. Arch Fam Med. 1998.
Safety and Efficacy:
Family Practice Office (continued)
Results
• 99.5% effective
• 1.3% minor complications
• No hospitalizations
Westfall JM, et al. Arch Fam Med. 1998.
Patient Satisfaction
• Both EVA and MVA groups were highly
satisfied
• No differences in:
▪
▪
▪
▪
▪
Pain
Anxiety
Bleeding
Acceptability
Satisfaction
• More EVA patients were bothered by noise
Bird ST, et al. Contraception. 2003.; Dean G, et al. Contraception.
2003.; Edelman A, et al. Am J Obstet Gynecol. 2001.
MVA Safety and Efficacy: Summary
• MVA is simple
▪
Easily incorporated into office setting
• Training/Practice Issues
▪
▪
▪
▪
▪
▪
Expanding pain management options
Ultrasound as needed
No sharp curettage
Patient-provider interaction
Identifying products of conception
Instrument processing for multiple use
MVA in Office Settings
• Safety and efficacy equivalent to EVA
• Portable
• Simple
• Low cost
• Small and quiet
Beneficial to incorporate MVA services
into the office setting.
Goldberg AB, et al. Obstet Gynecol. 2004.
Module 2:
MVA Procedure
MVA Steps
After counseling and support …
Gather required supplies
Charge aspirator
Stabilize and anesthetize cervix
Insert cannula
Empty uterus
MVA Instruments
Steps for Performing MVA
A step-by-step, onepage poster is
available from the
manufacturer to
guide clinicians
through the
procedure
MVA and Pain
Pain is made worse by:
• Fearfulness
• Anxiety
• Depression
Belanger E, et al. Pain. 1989.; Smith GM, et al. Am J Obstet Gynecol. 1979.
Hansen GR, Streltzer J. Emerg Med Clin N Am. 2005.
Effective Pain Management
• Respectful, informed, and supportive staff
• Warm, friendly environment
• Gentle operative technique
• Women’s involvement
• Effective pain medications
Pain Management Philosophies
• Minimize risk/maximize benefit
• Take away all pain/all feeling
• Get through it
Pain Management Techniques
With addition of:
• Focused breathing: 76%
• Visualization: 31%
• Localized massage: 14%
General or nitrous
10%
32%
Local
+ IV
58%
Local
Lichtengerg ES, et al. Contraception. 2001.
Good M, et al. Pain Manag Nurs. 2002.
Paracervical Block
Regular Injection
Castleman L, Mann C. 2002.
Maltzer DS, et al. 1999.
Deep Injection
Efficacy of Ancillary Anesthesia
• Importance of psychological preparation and
support
• Music as analgesia for abortion patients
receiving paracervical block
▪
85% who wore headphones rated pain as “0,”
compared with 52% of controls
• Verbicaine (“Vocal Local”)/Distraction
Therapy
Shapiro AG, Cohen H. Contraception. 1975.
Stubblefield PG.Suppl Int J Gynecol Obstet. 1989.
Sharp Curettage and Pain
• Often requires
increased dilatation
• Often painful
• More difficult to
reduce anesthesia
Forna F, Gulmezoglu AM. Cochrane Library. 2002.
Sharp Curettage and MVA
• Generally not indicated
• Not routinely recommended after MVA
more…
WHO. 2003
Sharp Curettage and MVA (continued)
“…Health managers and policy
makers should make all possible
efforts to replace sharp curettage
(D&C) with vacuum aspiration.”
WHO, 2003
WHO, Safe Abortion: Technical and Policy Guidance for Health Systems. 2003.
Pain Management Tips
Affirm patient’s viewpoint
Provide medical information
Avoid glib reassurances
Tell patient her fears are common
Help patient differentiate pain
Pain Management Options:
Summary
• More to pain management than avoiding pain
• No pain panacea
• Women should be involved
• Curette check increases pain; usually not
needed
• Pre-procedure preparation and psychological
support can reduce anxiety and improve
overall experience
Who Can Provide MVA in the United
States?
• All physicians
• All mid-level providers including:
▪
▪
▪
Physician assistants
Nurse practitioners
Nurse midwives
• Research your state’s individual laws,
rulings, and professional scopes of practice
more…
Who Can Provide MVA in the United
States? (continued)
Legal use may depend upon specific
diagnosis of patient:
• Incomplete abortion
• Prolonged uterine bleeding
• Endometrial biopsy
• Elective abortion where legal
MVA Training Organizations
• Association of Reproductive Health Professionals
(ARHP)
• Clinician Training Initiative (CTI)—Planned
Parenthood of New York City (PPNYC)
• National Abortion Federation (NAF)
• Planned Parenthood® Federation of America (PPFA)
• Ipas
• Physicians for Reproductive Choice and Health
(PRCH)
Facilities Needed for MVA
• Privacy for counseling
• Procedure room
▪
▪
Exam table
Space for supplies,
processing instruments,
and examining products
of conception
Medications and Supplies Needed
for MVA
• Analgesia
• Anesthetic
• Silver nitrate or ferric subsulfate
• Uterotonic agent
• Rhogam
more…
Medications and Supplies Needed
for MVA (continued)
• Urine pregnancy tests
• Emergency cart
• Pharmacologic agents for cervical ripening
(optional)
Equipment Needed for MVA
Procedure
• Aspirators
• Cannulae
• Speculae
• Sharp-toothed and/or atraumatic tenaculae
more…
Equipment Needed for MVA (continued)
Procedure
• Antiseptic solution
• Mechanical dilators
• 20-cc syringe for local anesthesia
more…
Equipment Needed for MVA (continued)
Equipment for POC Exam after MVA
Tissue examination
• Basin for POC
• Fine-mesh kitchen strainer
• Back light or enhanced light
• Tools to grasp tissue and POC
• Specimen containers
Hyman AG, Castleman L. Ipas. 2005
Ultrasound and MVA
• Not required for
MVA
• Used by some
providers routinely
• Use contingent on
provider preference
and experience
Word Health Organization. 2003.
Women’s Access to Care
Leonard A, Winkler J. Adv Abortion Care. 1991.
Incorporating MVA Into Practice
What does it take to
incorporate the MVA
procedure into a
clinical practice?
MVA Staffing and Facilities
Requirements: Summary
• All physicians and advanced practice
clinicians in many states can provide MVA
• Facilities requirements include medication,
supplies, equipment, and instruments
• Use of ultrasound is not required
MVA Patient Intake and Counseling
Contraindications to MVA
• First-trimester induced abortion—NONE
• First-trimester spontaneous abortion—NONE
• Completion of incomplete abortion—NONE
• Suspected pregnancy—endometrial biopsy
should NOT be performed
Ipas. 2007.
Use Caution in Women with…
• Uterine anomalies
• Coagulation problems
• Active pelvic infection
• Extreme anxiety
• Any condition causing the patient to be
medically unstable
Ipas. 2007.
Patient Intake Steps for MVA
• Medical history
• Lab work, including -hCG
• Determine gestational age
• Educate about procedure
and pain management
• Informed consent
• Discuss contraception
MacIsaac L, Darney P. Am J Obstet Gynecol. 2000.
World Health Organization. 2003.
Counseling for MVA
Effective counseling occurs
before, during, and after the
procedure
• Woman-centered
• Structured completely
around the women’s
needs and concerns
more…
Breitbart V, Repass DC. J Am Med Womens Assoc. 2000.; Hogue
CJ, et al. Epidemiol Rev. 1982; Steward FH, et al. 2004. Hyman
AG, Castleman L. 2005
Counseling for MVA (continued)
• Prepare women for
procedure-related effects
• Address women’s concerns
about future desired
pregnancies
more…
Breitbart V, Repass DC. J Am Med Womens Assoc. 2000.; Hogue
CJ, et al. Epidemiol Rev. 1982; Steward FH, et al. 2004. Hyman
AG, Castleman L. 2005
Counseling for MVA (continued)
Quality of
counseling
Picker Institute. 1999.
Patient
satisfaction
with care
Post-Procedure Care
• Observe for complications
▪
▪
Bleeding
Pain
• Monitor pain and treat accordingly
• Monitor vital signs
• Check bleeding and pain
more…
Post-Procedure Care (continued)
• Give instructions for aftercare/follow-up
• Discuss contraception, if appropriate
• Discharge patient
▪
▪
▪
Tolerates oral intake (general anesthesia only)
Vital signs are normal
Bleeding is minimal
Lichtenberg ES, Shott S. Obstet Gynecol. 2003.
Instructions for Aftercare
• Warning signs to call a
clinician
• Pain management options
• Prophylactic antibiotics
▪
Many regimens effective
• When to return to normal
activities
Lichtenberg ES, Shott S. Obstet Gynecol. 2003.
When Women Should Contact
Clinician
• Heavy bleeding with dizziness,
lightheadedness
• Worsening pain not relieved with medication
• Flu-like symptoms lasting >24 hours
• Fever or chills
• Syncope
• Any questions
Contraception After MVA
Ovulation may occur within 7–10 days postMVA
• Dispense EC with instructions for use
• Can start hormonal contraceptives
immediately
• Can insert IUD immediately post-procedure
more…
Contraception After MVA (continued)
• Tubal ligation can be performed postprocedure or scheduled; develop interim
contraception plan
• Use barrier contraceptive with first and
subsequent intercourse
Module 3:
Medication Abortion
Medication Abortion
Jones RK, Henshaw SK. Perspet Sex Reprod Health. 2002.
Medication Abortion Regimens
• FDA-approved regimen
▪
Mifepristone 600 mg PO followed by misoprostol
400 µg orally 48 hours later
• Evidence-based regimens
▪
▪
Mifepristone 200 mg followed by 600 µg of oral
misoprostol
Mifepristone 200 mg followed by 800 µg of
vaginal misoprostol
WHO Task Force. BJOG. 2000; Peyron R, et al. N Engl J Med. 1993.; Spitz
IM, et al. N Eng J Med. 1998.; Aubény E, et al. Int J Fertil Menopausal Stud.
1995; Kahn JG, et al. Contraception. 2000.
Protocols – Medication Abortion
FDA Approved Regimen
(Based on evidence up to 1996)
Alternative Evidence-Based Regimen
(Based on current evidence)
Gestational age:
Up to 49 days after first day
of last period
Gestational age:
Up to 56 days after first day
of last period
Gestational age:
Up to 63 days after first day
of last period
Mifepristone 600 mg.
(swallowed in the office)
Mifepristone 200 mg.
(swallowed in the office)
Mifepristone 200 mg.
(swallowed in the office)
Misoprostol 400 mcg.
Oral use
Swallowed in the office
48 hours after taking
mifepristone
Misoprostol 800 mcg.
Buccal use
Used at home 24-48 hours
after taking mifepristone
Put in the cheek to melt
Misoprostol 800 mcg.
Vaginal use
Used at home 6–72 hours
after taking mifepristone
Put in the vagina
Office follow-up 10–15 days
after taking mifepristone
Office follow-up 4–14 days
after taking mifepristone
Office follow-up 4–14 days
after taking mifepristone
3 office visits
2 office visits
2 office visits
RHEDI. Montifiore Medical Center.
www.rhedi.org
Evidence-Based Regimens
• 200-mg dose of mifepristone
• Buccal or vaginal administration of
misoprostol
• Home use of misoprostol
• Flexibility in day of vaginal misoprostol use
• Flexibility in initial follow-up evaluation
Kahn JG. Contraception. 2000.; Middleton T. Contraception. 2005.; El-Rafaey H. N Engl J Med.
1995.; Schaff EA. J Fam Pract. 1997.; Schaff EA. Contraception. 1999.; Schaff EA.
JAMA. 2000.; Schaff EA. Contraception. 2001.; Schaff EA. Contraception. 2000.
Medication Abortion Efficacy
600 mg oral mifepristone/400 mcg oral misoprostol
Gestational
age (weeks)
Complete
Time to expulsion
abortion rate (%) (after misoprostol)
< 49
91–97
< 56
83–95
< 63
88
49%–61%
within 4 hours
87%–88%
within 24 hours
WHO Task Force. BJOG. 2000.; Peyron R, et al. N Engl J Med. 1993.
Spitz IM, et al. N Engl J Med. 1998; Winikoff B, et al. Am J Obstet Gynecol. 1997.
Medication Abortion Efficacy
200 mg oral mifepristone/600 mcg oral misoprostol
Gestational
age (weeks)
Complete
Time to expulsion
abortion rate (%) (after misoprostol)
< 49
96–97
50–63
89–93
McKinley C, et al. Hum Reprod. 1993.
Baird DT, et al. Hum Reprod. 1995.
56%
within 4 hours
Plasma misoprostol concentration (pg/mL)
Plasma Concentration of Misoprostol
350
300
250
200
150
100
50
0
vaginal (n = 10)
oral (n = 10)
60 min
120 min
180 min
240 min
Wiehe E, et al. Obstet Gynecol. 2002.; el-Refaey H, et al. N Engl J Med. 1995.
Schaff EA, et al. Contraception. 2001; Zieman M, et al. Obstet Gynecol. 1997;
Fjerstad, 2006.
Medication Abortion Efficacy
600 mg oral mifepristone/800 mcg vaginal misoprostol
Gestational
Complete
age (weeks) abortion rate (%)
<56
98
<63
95
Schaff EA, et al. Contraception. 1999.
el-Refaey H, et al. N Engl J Med. 1995.
Time to expulsion
(after misoprostol)
93%
within 4 hours
Medication Abortion Efficacy
200 mg oral mifepristone/800 mcg vaginal misoprostol
Gestational
Complete
Time to expulsion
age (weeks) abortion rate (%) (after misoprostol)
94%
< 49
98
within 6 hours
< 56
97–98
< 63
98
Ashok PW, et al. Hum Reprod. 1998.
Schaff EA, et al. Contraception. 1999.
Medication Abortion Safety Issues
• Atypical presentation of infection and sepsis
• Prolonged heavy vaginal bleeding
Danco Laboratories. 2005.; FDA. 2006.
Green MF. N Engl J Med. 2005.
Do Not Use in Women with…
• Confirmed or suspected ectopic pregnancy
• IUD in place
• Long-term corticosteroid use
• Hemorrhagic disorders or inherited
porphyrias
more…
Danco Laboratories. 2005.
Do Not Use in Women with…(continued)
• Concurrent anticoagulant use
• Chronic adrenal failure
• Allergy to mifepristone, misoprostol, or other
prostaglandin
Danco Laboratories. 2005.
Patient Intake Exercise
Patient Intake Steps for Medication
Abortion
• Medical history
• Lab work
• Determine gestational age
• Educate about procedure and pain
management
• Informed consent and patient agreement
• Medication guide
• Discuss contraception
Danco Laboratories. 2005.
World Health Organization. 2003.
Pain Management
• Ibuprofen or acetaminophen initially
• Oral narcotics if necessary
Grimes DA, Creinin MD. Ann Intern Med. 2004.
When Women Should Contact
Clinician
• Heavy bleeding with dizziness,
lightheadedness
• Worsening pain not relieved with medication
• Flu-like symptoms lasting >24 hours
• Fever or chills
• Syncope
• Any questions
FDA. 2006.
Clostridium sordelli Infection
• Fever may not develop
• Consider other signs of infection:
▪
▪
▪
▪
Weakness
Nausea
Vomiting
Diarrhea
FDA. 2006.
Follow-up After Medication Abortion
• Assess completion of abortion by
▪
▪
▪
Patient history
Serial HCGs or sonography
Speculum and/or bimanual exam as indicated
• Documentation of missed follow-up
• If procedure is incomplete or unsuccessful,
MVA can be used for retained POC
Contraception After Medication
Abortion
• Ovulation may occur within 7–10 days after
abortion
• Dispense EC with instructions for use
• Can start hormonal contraceptives before
follow-up
• Can insert IUD when abortion is confirmed
Stewart FH, et al. 2004.
Becoming a Medication Abortion
Provider
• Apply to distributor to obtain mifepristone:
www.earlyoptionpill.com
• Training available through National Abortion
Federation: www.prochoice.org
Grimes DA, Creinin MD. Ann Intern Med. 2004.
Module 4:
Counseling Women on MVA
Versus Medication Abortion
Factors to Consider
• Duration of pregnancy
• Efficacy
• Safety
• Side effects
• Use of anesthesia
• Location
• Time required
Options for Terminating Pregnancy
Electric Vacuum Aspiration
Manual Vacuum Aspiration
0
Dilation and Evacuation
24 Weeks LMP
12
Methotrexate/
Misoprostol
Amniocentesis/Amnioinfusion
Uterotonic/Hypertonic
Mifepristone/Misoprostol
Stewart FH, et al. 2004.
Efficacy of Abortion Options
Surgical and medication abortion are highly effective
Manual vacuum
aspiration 99%
0
1
2
3
4
5
6
7
8
9
10 Weeks LMP
Medication abortion (oral)
91%–97%
88%
98%
Medication abortion
(vaginal)
Edwards J, Creinin MD. Curr Probl Obstet Gynecol Fertil. 1997.
Goldberg AB, et al. Obstet Guynecol. 2004; WHO Task Force. BJOG. 2000.
Ashok PW, et al. Hum Reprod. 1998.
Safety of Abortion
Surgical and medication abortion are low risk
MVA
• Uterine or
cervical injury
• Infection
Medication
• Infection
• Heavy bleeding
Stewart FH, et al. 2004.; Danco Laboratories. 2005.
FDA. 2006.; Green MF. N Engl J Med. 2005.
Expectations
Usually subside quickly
MVA
• Cramping
• Bleeding
Grimes DA, Creinin MD. Ann Intern Med. 2004.
NAF. 2006.
Medication
• Cramping
• Bleeding
• Nausea/vomiting
• Diarrhea
• Fever/chills
• Fatigue
Location: Where Abortion Occurs
MVA
• Hospital or
office setting
NAF. 2006.
Medication
• Begins in
hospital/office
• Occurs at home
Time Required for Abortion
MVA
Medication
• Complete within
minutes
• 1 visit to provider
• Complete within
24–48 hours
• 2 visits to provider
(evidence-based)
NAF. 2006.
Advantages of Abortion Options
MVA
• Quicker
• Woman less
involved
• More certain
Stewart FH, et al. 2004.
NAF. 2006.
Medication
• More natural
• More private
• Usually avoids
surgery
Disadvantages of Abortion Options
MVA
Medication
• Invasive
• Less private
• Small risk of
injury or infection
• Waiting, uncertainty
• Longer bleeding,
cramping, nausea
• Additional clinic visit
Stewart FH, et al. 2004.
NAF. 2006.
Appendix
Expert Medical Advisory Committee
Herbert P. Brown, MD
Clinical Associate Professor of Ob/Gyn
University of Texas Health Science Center
San Antonio, TX
Michelle Forcier, MD, MPH
Adjunct Assistant Clinical Professor of Pediatrics
University of North Carolina School of Pediatrics and
Family Medicine and Duke University School of Pediatrics
Chapel Hill, NC
Emily Godfrey, MD, MPH
Assistant Professor, Department of Family Medicine
University of Illinois at Chicago
Chicago, IL
more…
Expert Medical Advisory Committee
(continued)
Marji Gold, MD
Professor of Family and Social Medicine
Albert Einstein College of Medicine
Bronx, NY
Jini Tanenhaus, PA, MA
Associate Vice President, Clinician Training Initiative
Planned Parenthood of New York City
New York, NY