Medical Abortion: Options in an Outpatient Setting

Objectives

• Pharmacology• Eligibility for medical abortion• Describe the process of consent, counseling,

administration, complications, and follow-up of medication abortions.

• Understand the role of medical abortions in the context of Family Practice Clinics

• Describe the process taking place to increase access to medical abortions within CCRMC

Data from US Abortion Surveillance, 2005

• Induced abortion rate peaked during the ’80’s, 23-24/1000, was 20-21/1000 in the ’90’s and in ’05, 15/1000.

• 2% decline from 2004• 61% were less than 8 weeks EGA• 87% were less than 12 weeks EGA• 81% were known D&C/D&E• 10% were MABs (increased from 1% in 2000)• 94% of MABs were less than 8 weeks EGA• There has been a steady increase in ABs <6

weeks, with a decrease in ABs 7-10 weeks.

MMWR, 2008

Pharmacology

Mifepristone– A progesterone blocker– Interferes with placental attachment– Causes uterus lining to thin– Stops growth of embryo

Misoprostol – Also called Cytotec– A prostoglandin E1 analog– Stimulates uterine contractions– Causes cervical ripening

Mifepristone Regimens

$270 for mifepristone$2.00 for misoprostol

$90 for mifepristone$4.00 for misoprostol

Cost of medications

32Minimum office visits

Day 10-15Day 4-10Office follow-up visit

400 mcg. oralOffice administration48 hours later

800 mcg. vaginalHome self-administration

6 - 72 hours later

Misoprostol dosing

600 mg. oral200 mg. oralMifepristone dose

49 days63 daysGestational Age Limit

FDA Product LabelingEvidence-Based Protocol

Contraindications to Mifepristone + Misoprostol

• Confirmed or suspected ectopic pregnancy• IUD in place (must be removed before

treatment)• Adrenal failure• Current long-term systemic corticosteroid

therapy• Allergy to mifepristone• Hemorrhagic disorder or current anticoagulation• Inherited porphyria• Allergy to misoprostol

Additional Screening

• The decision is uncoerced

• EGA is less than 63 days

• Patient has the time and resources for reliable follow-up

• Able to understand the instructions

Comparison of medical vs surgical abortion

• Offered up to 63 days EGA

• Approx. 2 office visits• 95-99% effective

• Depending on facility, offered up to 12 weeks, or later

• Approx. 1 office visit• 98% effective

Safety and cost are similar between the two

Comparison of medical vs surgical abortion: Advantages

• May feel more natural• No shots, anesthesia,

instruments, or machines

• Can end pregnancy earlier

• Privacy of home• Initiated by the

woman

• Quick and over in a few minutes

• Slightly higher success rate

• Less bleeding• Medical staff present

The Access Project

Comparison of medical vs surgical abortion: Disadvantages

• Takes several days• Not as predictable• Heavier bleeding• More severe

cramping• Slightly lower success

rate• Side effects of meds• May need surgical

follow-up

• Invasive• Side effects of

anesthesia• Woman has less

control over procedures

• Cannot be done as early

The Access Project

Logistics of Administration

• Confirm pregnancy– Urine HCG and/or sonogram

• Confirm gestational age– LMP history

– bimanual exam• Lemon 5-6 weeks

• Orange 7-8 weeks

• Grapefruit 9-10 weeks

– sonogram

• Rule out ectopic pregnancy

Counseling: What to Expect

• Preparation is the key to a successful outcome• Pain• Bleeding• Side effects of medications• Support

• There must be surgical back-up, readily available.

Follow Up Visit

• Schedule 1-2 weeks after initial visit

• Confirm completed abortion– Criteria #1:

• History• Pelvic exam• Falling HCG

– Criteria #2 • History• Repeat ultrasonography

Indications for Aspiration

• Approximately 2-5% of patients treated with mifepristone+misoprostol will need a follow up aspiration.

• Aspiration is most often done to– Resolve an incomplete abortion– Terminate a continuing pregnancy– Control bleeding

The two key elements for successful outcomes are:

1) Appropriate screening

2) Thorough counseling

Satisfaction depends on an informed choice

NAF abortion textbook

Advantages of Primary Care Providers doing MABs

• Continuity• Increase access to abortion, especially in

underserved areas• Expand options• Safe and efficacious

– In a retrospective case series, of 236 MABs performed in 4 community health centers (majority managed by family physicians) only 1 pt. required aspiration, a failure rate of .4%. (Prine et al.)

• MABs require key PCP skills: assessing a patient’s support system, emotional state and understanding of the process (Prine et al., 2005).

Integration of MABs in to FPC: Patient Support

• A survey of 148 urban women were surveyed– 70% agreed their clinic should provide MABs– 73% (of those who would consider abortion)

would prefer to have it done by their family physician.

Rubin et al, 2008

Integration of MABs in to FPC: Patient Choice

• What might women choose if they receive options counseling in a clinical setting that offers on-site MABs and referrals for off-site surgical TABs?– A retrospective, cohort study of 204 women, in a

university setting, found 85% of eligible women chose medication abortion. The earlier the gestational age, the more likely a MAB.

– Reasons: convenience if both options are acceptable, bias in physician counseling, self-selection of patients

Leeman et al., 2007

MABs within the Contra Costa County Health Services

• Current Services

• Goals:– Increase number of providers who offer MABs– Establish an infrastructure and protocol to

support providers– Model integration of MABs into FPC as part of

resident training– Accomplish goals in a manner that is

respectful of differences in values

Establish Support: Non-resident physicians/NP’s

• Identify interested providers, preceptors– Qualifications

• FDA: must be able to reliably determine gestational age.

• Need to be approved by OB/GYN to use US• In-service training

Establish Support

1) Residents: 11 of 22 eligible residents would like to incorporate MABs into their FPCs.

2) Nursing: Organize values clarification workshops to discuss concerns, if needed.

3) Social Work: Entry way into the system

Clear, Accessible Protocol • On-site info packets: medication guide,

mifeprex patient agreement, CCRMC consent, provider note template, charting template

• Dictate a procedure note• Notify back-up OB-Gyns• On call responsibility• Follow-up visits* Additional counseling resources available

for provider reference.

References

• Comparison of the Two types of First Trimester Abortion. The Access Project.

• Chapter 3: Informed Consent, Counseling, and Patient Preparation. NAF Abortion Textbook.

• Gamble et al. “Abortion Surveillance --- United States, 2005.” MMWR. 2008; 57: 1-32.

• Leeman et al. “Can Mifepristone Medication Abortion Be Successfully Integrated into Medical Practices That Do Not Offer Surgical Abortion?” Contraception. 2007; 76: 96-100.

• Prine et al. “Medication Abortion and Family Physicians’ Scope.” Journal of American Board of Family Medicine. 2005; 18: 304-306.

• Prine et al. “Medical Abortion in Family Practice: A Case Series.” Journal of American Board of Family Medicine. 2003; 16: 290-295.

• Rubin et al. “Patient Attitudes Toward Early Abortion Services in the Family Medicine Clinic.” Journal of American Board of Family Medicine. 2008; 21: 162-164.