medication abortion in early pregnancy induced termination of early intrauterine pregnancy using...
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Medication Abortion In Early Pregnancy
Induced termination
of early intrauterine pregnancy
using medications
6.4 Million Pregnancies/Year in the U.S.
51% Intended
24% Unintended
Used Contraception
25 % Unintended
Used No Contraception
Finer, 2006 (2002 data)
Unintended pregnancy rate: by race/ethnicity/income
0
20
40
60
80
100
120
140
160
180
Below povertylevel
Above povertylevel
allwhitelatinablack
Unintended pregnancies per 1,000 women
Finer, 2006
Outcomes of Unintended Pregnancies
(Approximately 3.1 Million Annually)
14%
42% 44%
0%
20%
40%
60%
80%
100%
Abortions Births Miscarriages
Finer, 2006 (2002 data)
% of unintended pregnancies
89% of abortions occur in the first 12 weeks of pregnancy
62.5%17.3%
9.4%
6.5%
3.3%1.0%
<9 weeks
9 to 10
11 to 12
13 to 15
16 to 20
21 or more
Under 9 weeks
9-10 weeks
11-12 weeks
Guttmacher Institute, 2004 data
Abortion Access
• 87% of counties have no abortion provider
• 35% of women live in these counties
• 25% of women travel > 50 miles to find provider
Source: Jones et al., 2008; Kaiser Family Foundation
% of Women in Counties with No Abortion Provider
Primary care shortage areas:
with
and
without family physicians
Graham Center, 2000
Abortion in Family Medicine:Training Issues
0
50
100
150
200
250
300
350
400
450
1997 2007
abortion training
no abortiontraining
Could training family physicians in medication
abortion make a difference?
Abortion in Family Medicine:
Implementation Issues
Wanted versus unwanted pregnancy:consequences
Medication & Aspiration Abortion:both safe and effective
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, 2006Virk, J et al, NEJM, 2007
Medication Abortion Regimens:Three Choices
Mifepristone + Misoprostol
Methotrexate + Misoprostol
Misoprostol alone
Most common med abortion regimen in US:
Mifepristone/Misoprostol
Medication Abortion: Advantages
• 95-99% effective• Avoids surgical and
anesthetic risk• Greater patient
autonomy & privacy• Less invasive• More “natural”
Aspiration Abortion: Advantages
Slightly more effective (about 99%)Shorter time to completionShorter bleeding duration
Can be performed later in gestation
Mifepristone-Misoprostol RegimensFDA 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. oralOffice administration
48 hours later
800 mcg. vaginal or buccalHome 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
CervicalRipening
MIFEPRISTONECauses
progesterone blockade
Decidual Necrosis
Detachment
MISOPROSTOLCauses uterine cramping & expulsion
Misoprostol
Yolanda
22 years old
Requests a pregnancy test
Counseling issues
Review all options
Assure that decision is hers
Establish gestational age
Rule out contraindications
• Allergy to meds• Adrenal insufficiency • Current steroid use• Coagulopathy or
anticoagulant use• IUD in place• No access to follow-up
Indications for sonography
Yolanda
Gestational age: 6 weeks
Patient agreement
Yolanda takes mifepristonein your office
At home:Yolanda takes pain medication, then misoprostol
Follow-up visit
•4 - 14 days later
•Assure completion
•Process experience
•Review contraceptive choice
Phone calls after medication abortion
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
Methotrexate + Misoprostol medication abortion
Misoprostol-only medication abortion
800 mcg vaginally
> 1 dose may be needed
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.