Transcript 30-Min Crash Couse in UA Dopppler

Pregnancy Options
Julie Moldenhauer, MD
Reproductive Genetics
Maternal Fetal Medicine
Obstetrics and Gynecology
Objectives
 Review background information relating to
pregnancy options
 Discuss management options for pregnancy
 Review timing, benefits and risks of various
options
 Review options in multiple gestations
In the U.S. 47% of pregnancies are
unplanned.
• Pregnancy intendedness is associated
with adverse obstetric, neonatal and
parenting outcomes
Finer 2006, Perspectives on Sexual and Reproductive Health
Henshaw SK: Family Planning Perspectives 1998;30:24-29.
Every woman who is diagnosed with an
unplanned pregnancy should be made
aware of all of her options.
• Continuation of pregnancy
 Termination
 Adoption
Hacker, Moore and Gambone. Essentials of Obstetrics and Gynecology, 4th Ed.
Background
• 1973 Roe v. Wade Supreme Court
decision legalized abortion in the U.S.
• Abortion laws vary state by state
• Gestational age limits
• 24 hour wait time prior to procedure
• Teens and parental notification
Pregnancy Termination
• Language:
• Indications
• Termination
• Personal choice
• Abortion
• Medical recommendation
• Elective abortion
• Anomalous fetus
• Therapeutic abortion
• Intrauterine infection or
• Interruption of pregnancy
• Definition: The removal of
a fetus or embryo from the
uterus before the stage of
viability
Septic abortion
• Methods
• Dependent upon
gestational age and
provider abilities
Medications Used in Medical Abortions
• Medical abortions are performed early in gestation – typically < 9
weeks (63 days) from LMP (Last Menstrual Period)
• Mifepristone – progestin analogue that binds to the progesterone receptor and
acts as an antiprogestin. Results in separation of the trophoblast from the
endometrial wall, increases endogenous prostaglandin release, sensitizes the
myometrium to exogenous prostaglandins, and softens the cervix. Administered
orally. Side effects: abdominal pain, nausea, vomiting, diarrhea, dizziness, fatigue,
and fever.
• Misoprostol – prostaglandin E1 analogue that causes uterine contractions
resulting in cervical softening and dilation. Administered orally and vaginally. Side
effects: nausea, vomiting, fevers, chills.
• Methotrexate – antimetabolite that inhibits the enzyme dihydrofolate reductase
interfering with DNA production. It targets rapidly dividing cells and interferes with
implantation. Contraindicated in women with kidney disease, liver dysfunction or
anemia. Administered orally or intramuscularly. Side effects: nausea, vomiting,
diarrhea, fever, chills, headache, dizziness, and oral ulcers.
Termination in Early Gestation:
Medical Abortion
•
< 49 days from LMP
•
Mifepristone followed 2 days later by misoprostol orally
•
FDA approved: 600 mg mifepristone/400micrograms misoprostol
•
92-99% complete abortion
•
Most effective method of termination < 49 days from LMP
•
Variation on dosing and route
•
Studies validate this regimen up to 63 days from LMP
•
Performed as outpatient, readily available and pain managed with
NSAIDS
•
Proportion of women will require surgical procedure to evacuate
contents of uterus if incomplete. Recommend follow-up visit to check
for negative pregnancy test or ultrasound.
•
Bleeding occurs for about 14 days after procedure
Termination in Early Gestation:
Medical Abortion
• Methotrexate followed by misoprostol
• < 49 days from LMP
• ~ 95% complete abortion
• Misoprostol alone
• Typically used <63 days from LMP
• Varying doses and routes of administration
• > 85% effective
Termination in Early Gestation:
Surgical – Vacuum Aspiration
• Up to 12 completed weeks
• Suction procedure
• Manual vacuum aspiration
• Electric vacuum aspiration
• 95-100% effective
• < 0.1% complication rate
http://www.who.int/reproductive-health/impac/Procedures/Manual
• Inexpensive
• Typically done as outpatient with local
anesthesia or premedication
• When performed <6 weeks more
• likelihood of retained products
www.ipas.org/Library/News/News
World Health Organization.
Safe abortion : technical and policy guidance for health systems. 2003.
Surgical Procedures: D&C and D&E
• Require accurate determination of gestational age
• Involve manual dilation of cervix and removal of intrauterine contents
• Require anesthesia and typically more expensive
• Destructive procedures requiring both aspiration and sharp curettage
• D&C: Dilation and Curettage – “Sharp curettage”
• Up to 12 weeks
• Can typically be done with minimal anesthesia as outpatient
• D&E: Dilation and Evacuation
• 12+ weeks
• Typically done in an OR setting using heavy sedation/anesthesia
• Requires more operator skill
World Health Organization.
Safe abortion : technical and policy guidance for health systems. 2003.
Laminaria
Dilipan
www.berkeleymedevices.com/dispbles.html
Barcointernational.se
Cervical Dilators
Curettes
Cookmedical.com
thomasmedical.com
Second Trimester Medical Management
•
Typically used > 14 weeks
•
Similar to an induction of labor – many options for management
•
Cervical ripening
• Misoprostol
• Foley bulb
• Laminaria
•
Multiple agents
• Pitocin
• Misoprostol**
•
Inpatient procedure – expensive
•
Pain management
•
Most women will deliver within 24 hours
•
Fetus delivered intact – autopsy available
•
Risk of failure/retained products of conception and the need for D&C or D&E
World Health Organization Recommendations
World Health Organization. Safe abortion : technical and policy guidance for health systems. 2003.
Maternal Mortality in the United States:
12.1 deaths per 100,000 live births
Hoyert DL. Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 3(33). 2007.
Safety
According to WHO an unsafe abortion is defined as:
A procedure for terminating an unintended pregnancy carried out either by persons lacking the
necessary skills or in an environment that does not conform to minimal medical standards, or both.
Grimes DA et al. Lancet 2006;368:1908-1919
Safety
• Morbidities associated
with unsafe abortion:
• Bleeding
• Infection
• Poisoning
• Damage to vagina,
cervix, uterus, and
other abdominal
organs
Grimes DA et al. Lancet 2006;368:1908-1919
• Death
Safety
• Approximately 20 million unsafe abortions take
place annually worldwide
– 97% of these occur in developing nations
– 68,000 women die
– Case-fatality rate 367 deaths/100,000 unsafe abortions
• In the United States the case-fatality rate is < 1
death per 100,000 procedures
• Overall complication rate:
– 0.7/1000 procedures requiring hospitalization
– 8/1000 procedures less serious complications
Grimes DA et al. Lancet 2006;368:1908-1919
Grimes DA and Creinin MD. Ann Int Med 2004;140:620-626.
Hakim-Elahi et al. Obstet Gynecol 1990;76:129-135.
Special Consideration: Multiples
• Higher order multiples – triplets, quads,etc
• High risk pregnancy category with
outcomes dependent upon gestational age
at delivery
• Option of MultiFetal Pregnancy Reduction
(MFPR)
• Ultrasound guided needle technique to
deliver cardiotoxic agent to fetus(es) to
reduce the overall number
Special Consideration: Multiples
•
Selective Reduction of an
abnormal co-twin to optimize
survival or outcome for normal
twin
•
Procedure dependent upon
placentation, clinical picture and
practitioner skill
http://fetus.ucsfmedicalcenter.org/twin/trap_sequence.asp
•
Cardiotoxic agents cannot be
used in monochorionic cases
•
Options for monochorionic:
• Umbilical cord ligation
• Radiofrequency Ablation
• Alcohol/Sclerosing Agents
http://www.chop.edu/consumer/jsp/division/generic.
Adoption
• Open Adoption
• Birth parent(s) choose adoptive parents and are involved
after adoption completed.
• Semi-Open Adoption
• Birth parent(s) choose adoptive parents, but are not involved
after birth/adoption completed.
• Closed Adoption
• No identifying information is known on either side of the
adoption. Typically medical history is shared.
Adoption
• Birth records can also be “sealed”
• Legal agreements between adoptive adults
are void once the child reaches the age of
majority, typically 18
• Laws vary state by state
• Adoptions can be arranged privately or
through governmental programs
Summary
• Options are available to women/couples diagnosed with
unplanned pregnancies and they should be counseled about
these options.
• Pregnancy prevention is preferred.
• Routine prenatal care should occur in continuing
pregnancies.
• Termination of pregnancy is a safe option.
• Method is dependent upon gestational age and patient preference.
• Laws vary state by state.
• Adoptions can be set up to meet the expectations of both the
biological and adoptive parents.