medical abortion

Question 1

medical abortion is achieved by a combination of

Answer 1

oral mifepristone (a progesterone receptor blocker) and buccal misoprostol (a prostaglandin analogue), available as a composite pack (mifepristone and misoprostol [MS-2 Step]

Question 2

this regimen induces the miscarriage of an intrauterine pregnancy by

Answer 2

preventing progesterone from supporting the pregnancy
softening and dilating the cervix
increasing uterine contractility

Question 3

In the primary care setting, medical abortion is only approved by the Australian Therapeutic Goods Administration (TGA) for intrauterine pregnancies of up to

Answer 3

63 days (9weeks) gestation

Question 4

very early medical abortion

Answer 4

medical abortion when an ultrasound has not shown definite evidence of an intrauterine pregnancy. The drug regimens used are the same as for gestations of up to 63 days (9 weeks)

Question 5

why is very early medical abortion risky

Answer 5

Very early medical abortion should only be offered by experienced practitioners, because of the increased risk of an undiagnosed ectopic pregnancy. Alternatively, abortion can be deferred until ultrasound confirms that the pregnancy is intrauterine.

Question 6

benefits of medical abortion

Answer 6

usually avoids invasive procedure and surgical complications (eg. uterine perforation, anaesthetic risk)
may be safer in obesity or distortion of the uterine cavity
may be more widely accessible
usually less costly
usually allows abortion to take place at home

Question 7

benefits of surgical option

Answer 7

less likely to require subsequent evacuation of retained products
requires only one appointment and is usually performed under sedation
causes less pain, bleeding resolves after a few days
less risk of severe bleeding
avoids potential distress of seeing the gestational sac

Question 8

contraindications to medical abortion iin general practice

Answer 8

travel time >2 hours to nearest hospital emergency
suspected ectopic
IUD in place
uncertainty about gestational age
haemorrhagic disorders or anticoagulants
porphyria
hypersensitivity to mifepristone, misoprostol or any prostaglandin
long term use of oral corticosteroid

Question 9

why is current IUD a contraindication for medical abortion

Answer 9

mifepristone and misoprostol cause strong uterine contractions, which can cause injury if IUD is in place.
other risk factors for uterine rupture (including previous c/s and other uterine surgery) are not contraindications for medical abortion `

Question 10

precautions for medical abortion

Answer 10

poorly controlled asthma
well controlled asthma (increase inhaled corticosteroids because mifepristone has antiglucocoticoid affects)
severe anaemia
epilepsy
IHD, heart disease of hepatic, kidney orr resp disease
diabetes on insulin (additional glucose monitoring and nausea prevention required)

Question 11

investigations before medical abortion

Answer 11

US scan (transvaginal or transabdominal)
qHCG
haemoglobin if risk factors for anaemia
screening for STIs

Question 12

monitoring qHCG

Answer 12

before medical abortion, provider should perform baseline gHCG (ifeally day before mife is taken)
compare to gHCG 7 days after mife is taken
drop to below 20% of baseline confirms no continuing pregnancy

Question 13

rhesus testing before medical abortion

Answer 13

evidence is insufficient to recommend routine use of rhesus D immunoglobulin for medical abortion before 10 weeks gestation

Question 14

U/S scan before medical abortion

Answer 14

routinely recommended to determine gestataion and viability and confirm pregnancy is intrauterine

Question 15

heterotopic pregnancy define

Answer 15

simultaneous ectopic and intrauterine pregnancies can occur
very rare
confirmation of intrauterine pregnancy via U/S does not technically rule out ectopic

Question 16

empty gestational sac

Answer 16

an intrauterine sac without a yolk sac or fetal pole as seen on ultrasound

Question 17

causes of empty gestational sac

Answer 17

• very early intrauterine pregnancy (yolk sac and fetal pole are not seen before 5 weeks)
• ectopic pregnancy, which can cause a collection of fluid in the uterus (psuedosac)
• nonviiable pregnancy

Question 18

VEMA

Answer 18

very early medical abortion
can be performed by experienced providers, bearing in mind that pregnancy could be ectopic or non viable

Question 19

serum gHCG is also useful for

Answer 19

for very early gestations, to guide timing of US scan (if the HCG is <1500, US sould be delayed unless suspicion of ectopic or non viable pregnancy

Question 20

what to do depending on qHCG

Answer 20

if <1500, delay US unless suspicion of ectopic or nonviable pregnancy
if >1500, can usually detect a intrauterine gestational sac
if around 5400 - 90% likleihood that high quality transvaginal US will detect a yolk sac

Question 21

premedication and supportive treatment

Answer 21

analgesia, consider oral opoiod
NSAID unless contraindicated
antiemetic - ondansetron or metaclopramide

Question 22

action of mifepristone

Answer 22

blocks progesterone, the hormone necessary for continuing a pregnancy
also softens and dilates the cervix, and increases uterine activity (by increasing prostaglandin concentrations and uterine sensitivity to prostaglandins)

Question 23

action of misoprostol

Answer 23

synthetic prostaglandin E1 analogue that increases uterine contractility and softens the cervix
effects are enhanced by the preceding dose of mifepristone

Question 24

how is misoprostol given

Answer 24

given buccaly
oral dosing is less effective and causes more GI adverse effects (eg. nausea and vomiting)

Question 25

to induce medical abortion, use

Answer 25

mifepristone 200 mg orally
FOLLOWED BY

misoprostol 800 micrograms buccally, 36 to 48 hours after taking mifepristone.
Moisten the mouth, then place 2 tablets (400 micrograms) on each side between the teeth and the gums and hold in place for 30 minutes. Remaining tablet fragments may be swallowed with a glass of water.

Question 26

if vomiting occurs within 1 hour of mifepristone administration

Answer 26

provide a repeat prescription for mifepristone and misoprostol, with an antiemetic administered beforehand.

Question 27

if products of conception are expelled in the time between taking mifepristone and misoprostol

Answer 27

in 5% of patients, products of conception are expelled in the time between taking the mifepristone and misoprostol
miso should be taken regardless to minimise the risk of retained products of conception

Question 28

can normal activities continue while taking medical abortion

Answer 28

normal activities can continue after taking mifepristone, but the inidivdual should be at home with access to a toilet one miso is taken.
they may need an additional 1-2 days off work
a support person is recommended once the miso is taken until the heaviest bleeding has been settled, to help access emergency treatment if required.
for 14 days after taking mife, the individual should be within 2 hours of emergency services

Question 29

effects after taking mifepristone

Answer 29

a small portion of individuals experience cramping and light bleeding
in 5% of users, products of conception are expelled before taking miso

Question 30

expected effects after taking misoprostol

Answer 30

central lower abdominal craping begins within 2-4 hours
pain generally decreases once the products have passed
if pain persists or worsens a weeks or more after taking miso, consider infection

Question 31

adverse effects of medical abortion

Answer 31

can cause short term nausea and vomiting (as well as transient fevers, chills, and diarrhoea)
vomiting does not significantly reduce effectiveness because the medication is absorbed buccally, provided the tablets dont fall out during vomiting

Question 32

advice to give to patients

Answer 32

written outline of symptoms they may experience
list of symptoms that reuire urgent medical review
24 hour helpline number (included in the MS 2 step after information)
access to hospital emergency services within 2 hours travel time for 14 days after mife
advise that once medical abortion is started, it must be completed
provide path request for folllow up qHCG for 7 days after mife
advise presence of bleeding does not always imply success

Question 33

is medical abortion safe during breastfeeding

Answer 33

yes
no need to express and discard

Question 34

what should patient avoid after misoprostol

Answer 34

for 7 days after taking misoprostol, to reduce the risk of infection, avoid
- sexual intercourse
- use of tampons or menstrual cups
- swimming
- taking a bath or using a spa

Question 35

when to go to an emergency department

Answer 35

if very heavy bleeding ie. filling more than 2 large pads in an hour for more than 2 hours in a row, passing clots the size of a small lemon, feeling faint
any sympoms suggestive of ectopic: severe abdo pain, pain in pelvis on one side, pain in tips of shoulders

Question 36

things that indicate the medical abortion has failed

Answer 36

at 24 hours there is little to no bleeding (less than a normal period), or no clots larger than a small grape
at 48 hours you still have nausea
bleeding stopped within 4 days
at 14 days you still have breast tenderness

Question 37

symptoms implying retained tissue

Answer 37

at 7 days after miso you are still passing clots, still have cramping pain, still have bleeding heavier than a period, bleeding that has stopped and restarted
at 14 days bleeding is as heavy as when it started
at 4 to 5 weeks you have not returned to normal menstrual cycle

Question 38

symptoms indicating infection of the uterus

Answer 38

pelvic pain
pain during sex
unusual vaginal discharge
fever > 38
tenderness on touching abdomen
nausea or vomiting or feeling unwell

Question 39

if serum qHCG is more than 20% baseline at folllow up

Answer 39

pelvic US to assess possible causes which may include
- continuing pregnancy
- retained products
- rarer causes: heterotopic, trophoblastic disease, placenta accreta

Question 40

complications of medical abortion

Answer 40

retained products of conception
continuing pregnancy
haemorrhage
upper genital tract infection

Question 41

medical management of retained products of conception

Answer 41

repeat dosing of buccal misoprostol with analgesia and premedication
(combination mife and miso not required or advised)

Question 42

surgical evacuation for retained products

Answer 42

for line for people with
- haemorrhage
- significant retained products confirmed on US with moderate bleeding, mild anaemia or concurrent infection
- heavy ongoing bleeding even if retained products are not visible on US
- moderate to severe anaemia
- prefers surgery

Question 43

nonviable pregnancy

Answer 43

suggested or confirmed by US in conjunction with date of LMP and qHCG
management options are expectant, medical or surgical

Question 44

VEMA should not be done if there is

Answer 44

risk factors for ectopic e.g previous ectopic, IUD in place, hx of PID, tubal surgery
signs or symptoms of ectopc pregnancy
gestation is incompatiible with qHCG and furst US
individual is unable to given informed consent or comply with follow up