Pregnancy Termination Flashcards
1
Q
epidemiology of pregnancy termination
A
- 45% of pregnancies in the US were unintended
- Of these, 19% resulted in pregnancy termination
- Highest rates of abortions in women ages 20-24
- Most pregnancy terminations performed in first trimester, 63% at < 8 weeks, 91% at < 13 weeks.
- 89% of all US counties lacked an abortion provider in 2011.
- 38% of all women in live in those counties
- Abortion laws vary by state, although most states restrict abortion after viability. However, the definition of viability varies by state.
2
Q
Public health and policy
A
- In the 1973 Roe v. Wade decision, the Court established that:
- In the first trimester (up to 14 weeks), state laws cannot interfere with a woman’s right to end a pregnancy; decisions are left to a woman and her medical provider.
- During second trimester (14 to 24 weeks), state laws may regulate abortion procedures only in
- order to protect the woman’s health.
- During third trimester (after 24 weeks), state laws may prohibit abortion except when it is necessary
- In the 1992 Planned Parenthood of SE Pennsylvania v. Casey decision, the Court established that: States can restrict abortions, even in the first trimester, as long as restrictions do not place “undue burden” on women.
- Many state laws requiring waiting periods, mandatory counseling, and parental consent or notification have been implemented. Record numbers of restrictive state laws have been passed since 2010
- Hyde amendment forbids the use of federal funds for abortions except in cases of life endangerment or incest
- Many states have laws in effect restricting even private insurance coverage of abortion.
3
Q
Guttmacher institute
A
- Leading research and policy organization committed to advancing sexual and reproductive health and rights in the US and globally
- Summarizes state policy updates surrounding reproductive health including funding, mandatory counseling, waiting periods and parental consent laws
- State-Mandated Counseling: 18 states mandate that women be give counseling before an abortion that includes information on at least one of the following: the purported link between abortion and breast cancer (5 states), the ability of a fetus to feel pain (13 states) or long-term mental health consequences for the woman (8 states).
- Waiting Periods: 27 states require a woman seeking an abortion to wait a specified period of time, usually 24 hours, between when she receives counseling and the procedure is performed. 14 of these states have laws that effectively require the woman make two separate trips to the clinic to obtain the procedure.
- Parental Involvement: 37 states require some type of parental involvement in a minor’s decision to have an abortion. 26 states require one or both parents to consent to the procedure, while 11 require that one or both parents be notified.
4
Q
access to abortion
A
- Access to safe abortion hinges upon the availability of trained abortion providers. ( According to November 2014 and reaffirmed 2017 ACOG Committee Opinion)
- The number of abortion providers has not met the level of need.
- According to 1 survey only 32% of medical schools offered at least one abortion related lecture
- A survey of residency program directors revealed that only 51% of OBGyn residency offered routine abortion training.
5
Q
health workforce pilot
A
- Multisite study (6 years 2007-2013) led to passage of law AB-154 which allows NP, CNMs, PAs to provide 1st trimester aspiration abortion in California.
- 25 site study that provided concrete evidence that 1st trimester abortion is safe whether provided by an NP, CNM, PA or Physician
- Numerous studies of abortions provided by NPs, CNMs, and PAs worldwide show that they are as safe as abortions provided by physicians trained in abortion care.
- In the HWPP #171 study, women reported high satisfaction ratings (9.4/10) with abortion services whether they were provided by NPs, CNMs, PAs, or MD/DOs.
6
Q
abortion safety - advancing new standards in reproductive health - a collaborative research group at the UCSF
A
- Retrospective study 55,000 abortions using Medi-Cal data from 2009-2010 (UCSF ANSRH)
- Major complications, defined as hospitalizations, surgeries, transfusions were rare at a rate of less than a quarter of one percent (0.23%) of all abortions
- Less than one percent of abortions result in a complication that is diagnosed and treated in an emergency room
- The overall abortion complication rate is lower than those for wisdom tooth removal
7
Q
intentional vs unintentional pregnancy
A
- Planned vs Unplanned pregnancy is multifactorial
- Ambivalence, partner influence, and cultural perspective all inform how patients feel about pregnancy intention
- Even with this variation, the significant political and emotional dissonance surrounding reproduction and sexuality has limited funding, research, and guidelines for unintended pregnancy prevention
- This in turn poses a significant burden on patients, their families, and the medical system at large
8
Q
pregnancy options counseling
A
- When providing pregnancy test results, some patients will be surprised while others will have taken a test at home and only seek confirmation. In either case, the patient may or may not require support in their decision making process
- Our role is to listen and provide patients with the appropriate level of support to come to a decision about this pregnancy, if they have not already
- When providing positive results: Be clear what the result means: “Your pregnancy test came back positive, which means you are pregnant.”
- Allow some time for the patient to process the information
- Avoid assuming how a patient will react to the result
- Avoid making assumptions especially whether or not a patient will be sad or happy about the news of a pregnancy
- For many patients the decision to have an abortion or parent is clear. They won’t need options counseling
- For patients who are less sure, provide basic information in a non-directive manner. Have referrals handy for pre-natal, adoption and abortion resources. If patient’s plan to continue pregnancy advise or prescribe pre-natal vitamins
9
Q
pregnancy and confirmation of intrauterine pregnancy (IUP)
A
- Last Menstrual Period (LMP)
- Urine HCG Blood Quant HCG
- Bimanual Exam comparison to fruit :Lemon 5-6 weeks, medium 7-8 weeks grapefruit 9-10 weeks or fungal height after 12 weeks uterus rises out of pelvis at 20 weeks reaches umbilicus.
- Ultrasound evaluation
10
Q
locating an intrauterine pregnancy
A
11
Q
early pregnancy confirmation
A
- A normal early GS can be characterized by the FEEDS mnemonic, although meeting all criteria does not exclude the possibility of ectopic pregnancy
- F - Fundal - in mid or upper uterus
- E - Ellpitical or round shape in 2 views
- E - Eccentric to the endometrial stripe
- D - Decidual reaction (surrounded by a thickened choriodecidual reaction; appears like a fluffy white cloud or ring surrounding the sac
- S - Size > 4 mm (soft criteria)
12
Q
features of an IUP
A
- The embryo and cardiac activity
- The embryo follows a predictable path of development and therefore can be used to date a pregnancy based on its size. The embryo appears at approximately 6 weeks and grows 1mm per day thereafter until 12-14 weeks. After 12 weeks, fetal flexion and extension make measuring length more challenging and using the fetal biparietal diameter (BPD) is preferred. Cardiac activity appears around 6 ½ weeks.
13
Q
first trimester abortion
A
- Medication abortion (MAB)
- An option for up to 10 weeks 0 days gestation
- Surgical Abortion
- An option for less than 13 weeks 6 days gestation
14
Q
first trimester abortion: medication abortion
A
- Also known as a medical abortion
- It is the termination of pregnancy using medications alone, rather than surgery.
- First introduced in the US in 2000
- In 2009, the CDC reported that 16.2% of abortions at _<_8 weeks and 0.9% at >8 weeks were performed via medication alone
- We will review the combination of mifepristone and misoprostol; other medications and combinations do exist.
15
Q
benefits and risks of MAB
A
- Benefits of MAB
- Privacy, can be performed partially at home in a non-clinical setting
- A sense of control over the process
- A safe and effective way to terminate a pregnancy up to 70 days gestation
- Risks of MAB
- Similar to a first trimester surgical abortion, particularly:
- Endometritis, infection, hemorrhage
- No risk of cervical injury or uterine perforation
- Increase in teratogenic risk to an ongoing pregnancy
- May still need surgical aspiration to complete the termination
- Similar to a first trimester surgical abortion, particularly:
16
Q
indications and contraindications for MAB
A
- Indications
- The US Food and Drug Administration (FDA) has approved mifepristone for the termination of an intrauterine pregnancy up to 49d gestation.
- Beyond this 49d gestation is considered off-label
- Contraindications
- Ectopic pregnancy
- Intrauterine device in place
- Patients with chronic adrenal failure or who are on concurrent long-term corticosteroid therapy
- History of hemorrhagic disorders, are on anticoagulant therapy, or on any medications that interfere with hemostasis
- History of porphyrias
- Lack of ability to comply with the regimen or access care in case of complication
- No data for women with chronic medical conditions (HTN, DM, cardiovascular, hepatic or renal disease) or cigarette smokers – labeling of mifepristone advises caution in women with these conditions
17
Q
drug interactions for MAB
A
- Drug Interactions
- Mifepristone is metabolized by cytochrome P450 3A4 (CYP3A4) and can theoretically interact with agents that impact CYP3A4 function.
- No specific food or drug interactions with a single dose of mifepristone have been reported.
18
Q
clinician requirements for MAB
A
- Clinician requirements: The FDA requires mifepristone by prescribed* only by physicians (not NPs, PAs, or nurse midwives) who can:
- Make an accurate assessment of gestational age
- Diagnose ectopic pregnancy
- Provide surgical intervention in cases of severe bleeding or incomplete abortion OR make provisions to provide care through another provider
- Assure patient access to medical facilities equipped to perform blood transfusions and resuscitation
- *a physician may delegate another health professional to administer the drug
- Clinician requirements continued:
- These physicians:
- Must sign a prescriber’s agreement with the manufacturer of mifepristone
- Require that patients read the manufacturer’s Medication Guide and sign the Patient Agreement form
- Report any ongoing pregnancy or serious events (eg hospitalization, infection, blood transfusion).
- These physicians:
19
Q
two regimens of MAB
A
- Two regimens to choose from:
- FDA approved/manufacturer recommended regimen
- Mifepristone 600mg orally, followed 48 hours later by misoprostol 400mcg orally. Both administered by a clinician
- This is not as effective as the regimen below
- Mifepristone 600mg orally, followed 48 hours later by misoprostol 400mcg orally. Both administered by a clinician
- Alternative regimen, referred to as the evidenced-based regimen
- Mifepristone 200mg orally administered by a clinician, followed 24-72 hours later by misoprostol 800mcg buccal, administered by a healthcare provider or self-administered in a non-clinical setting
- Miso works by stimulating the uterus to cramp
- FDA approved/manufacturer recommended regimen
- Which regimen to choose?
- Differences in mifepristone dose, misoprostol route of administration, dose, and timing, and whether the drug is given in a clinic setting by a clinician or in a nonclinical setting by patient
- Most providers/clinics prefer the evidenced-based regimen
- In general it results in fewer ongoing pregnancies
- Lower frequency of side effects
- Lower cost
- Greater convenience
- Greater efficacy at gestations between 50-63 days
20
Q
how does mifepristone work?
A
- It is a derivative of norethindrone (a synthetic progestin) that acts as an antiprogestin.
- It binds to the progesterone receptor with greater affinity than progesterone itself.
- However, the receptor does not activate, thus blocking the action of progesterone which is needed to establish and maintain placental attachment.
21
Q
MAB protocol
A
- Protocol typically includes the following steps:
- Initial visit and mifepristone administration
- Misoprostol administration
- Follow-up visit
22
Q
initial vist and mifepristone administration in MAB
A
- Initial visit and mifepristone administration
- Pregnancy confirmation and gestational age
- Pregnancy confirmed by urinary or serum hCG measurement or transvaginal ultrasound
- Gestational age must be determined using menstrual history, pelvic examination, and transvaginal ultrasound
- Ultrasound evaluation also allows for exclusion of ectopic pregnancy
- Counseling about options and informed consent
- Review options and details of procedure
- Each step of the procedure should be reviewed and patient should confirm that she is willing able to complete each step
- Comprehensive counseling about expected experience, symptoms, and recovery is very important
- Specific counseling should be done that a surgical procedure will be required to complete the procedure if unsuccessful and any ongoing pregnancy carries the risk of fetal abnormalities
- STI testing if risk factors present or infection suspected – this is a great time to get these people in case you never see them again
- Blood typing/verification and administration of Rh immune globuline if needed (mini rhogam)
- Pregnancy confirmation and gestational age
- Prophylactic antibiotics administered – to prevent endometritis
- Use is controversial, as the rate of infection MAB is low.
- No randomized trials regarding use of prophylactic antibiotics and first trimester MAB
- Most commonly Azithromycin 500mg x 1 or Doxycycline 100mg BID x 7d
- History of serious infection, particularly clostridial sepsis, in MABs using misoprostol vaginally. No further cases identified after practices modified to use one or more of the following interventions:
- Prophylactic antibiotics, non-vaginal route of administration, counseling on when to seek medical attention for signs of infection
- Single dose of mifepristone administered
- If no contraindications and woman consents to procedure
- Some women will experience bleeding or cramping after mifepristone dose, although most women only have symptoms after misoprostol (especially if given within 24-36 hours after mifepristone).
- Even if bleeding and cramping occurs after mifepristone, unless expulsion of gestation confirmed, patients should take misoprostol as indicated.
- About 1-5% of patients will expel conceptus after mifepristone only.
23
Q
misoprostol administration - MAB
A
- Review of misoprostol administration very important
- Patient should be given further instructions on how to take misoprostol dose
- Written and verbal instructions should be given regarding symptoms, adverse effects, and what to do in case of significant pain, bleeding, or other reactions.
- Review of NSAID and/or oral narcotic analgesia use for pain.
- Emergency phone number should be given
24
Q
follow-up visit MAB
A
- Follow-up visit in approximately 2 weeks to confirm pregnancy was expelled – usually via history and pelvic exam or transvaginal ultrasound
- Provide contraception – can be morning after pill, condoms, IUD, implant, nuvaring, etc.
25
side effects of regimen - MAB
* Side effects of the regimen
* Gastrointestinal discomfort: nausea, vomiting, diarrhea
* Abdominal pain
* Abdominal pain and cramps experienced by nearly all women undergoing MAB
* Pain is usually self-limited and most severe shortly after misoprostol is taken, lasting until expulsion of pregnancy
* Usually predose with ibuprofen 30 mins before the miso
* Excessive vaginal bleeding
* Bleeding is common and typically heavier than a period
* Mean duration of bleeding ranges from 8-17 days
* Some women experience headaches, dizziness, or fatigue.
26
complications of MAB
* Hemorrhage
* Infection
* Incomplete abortion
* Incomplete expulsion
* Ongoing pregnancy
* Unrecognized ectopic pregnancy
* Hemorrhage
* Can be related to uterine atony or retained products of conception
* For patients with excessive or prolonged bleeding, incomplete abortion should be excluded.
* Generally, blood loss is not severe enough to require therapy.
* In a large study, blood transfusion was required in only 0.05% of procedures.
* Infection: an uncommon complication of MAB
* Fever, even in the absence of infection, is a common effect of misoprostol. Women with fever should be evaluated for any signs of local infection, primarily endometritis.
* Since there is no uterine instrumentation with an MAB, there is a lower incidence of infection compared to surgical AB.
* In a large retrospective study, incidence of infection was 0.016% and rate of IV antibiotic treatment was 0.02%
* Women with following symptoms should be evaluated for infection: fever, chills, body aches, excessive or prolonged vaginal bleeding, moderate to severe pelvic pain persisting for a day or more after expulsion of pregnancy, purulent vaginal discharge.
* Incomplete abortion in 2-8% of procedures
* Incomplete expulsion: If the pregnancy has not been expelled, patients can be given an additional dose of misoprostol or surgical evacuation
* Rate of expulsion with second dose of misoprostol is much lower than the first dose
* Ongoing pregnancy: Rarely, women choose to continue a pregnancy after a failed MAB or a continuing pregnancy is not recognized. Surgical abortion should be performed in cases of failed termination due to potential teratogenic risk.
* Unrecognized ectopic pregnancy
* Rarely, diagnosed after receiving mifepristone/misoprostol dose.
* Occurs in approximately 7-20 per 100k procedures
* Ectopic pregnancy should be excluded during initial evaluation of patient.
27
outcomes of MAB
* Outcomes: First trimester mifepristone/misoprostol abortion is successful in 92-98% of procedures
* Efficacy varies with several factors:
* Gestational duration
* Up to 49 days gestation, successful completion in 91-98%
* Up to 63 days gestation, successful completion in 94-97%
* 64 to 70 days gestation, a randomized trial showed success rate of 93%
* Route of administration and dose of misoprostol
* Parity: Rate of successful abortion is lower with increasing parity and in women who have had a previous abortion
* No evidence that MAB is associated with any increased risk of adverse outcomes in subsequent pregnancies
28
first trimester abortion: surgical abortion
* Surgical abortion is the most commonly used method of pregnancy termination in the US.
* Also known as therapeutic abortion (TAB),
* Available techniques include suction curettage, sharp curettage, and dilation & evacuation (D&E)
* Usually performed between the 7w and 12w6d gestation
* According to the CDC, over 96% of abortion in the US in 2001 were performed by suction curettage
29
benefits and risks of SAB
* Benefits of Surgical Abortion:
* Considered safe and effective in terminating first trimester pregnancies.
* Complication rate of 0-3% and efficacy rate of 98-99%
* Usually completed in one visit
* Risks of Surgical Abortion
* Similar to MABs
* Endometritis
* Life threatening infections are rare, but have occurred more often with surgical abortion
* Hemorrhage occurs at similar rates to MABs, but cause is usually related to cervical laceration or uterine injury due to instrumentation
30
indications for SAB
* Very Early Abortion (VEA): from the time of positive pregnancy test up to 6 weeks
* Can be performed without visualization of gestational sac if ectopic pregnancy unlikely
* Manual vacuum aspiration or electric aspiration used
* Tissue examined while pt remains in room; serial hCG testing done if not confirmed
* First trimester abortion
* Up to 13 weeks 6 days gestation
* Manual vacuum aspiration or electromechanical suction
31
protocol for SAB
* Protocol typically includes the following steps:
* One Visit
* Pregnancy confirmation and gestational age
* Pregnancy confirmed by urinary or serum hCG measurement or ultrasound
* Gestational age must be determined using menstrual history, pelvic examination, and ultrasound
* Pelvic exam should also note uterine size and position
* Ultrasound evaluation also allows for exclusion of ectopic pregnancy
* Counseling about options and informed consent
* Review options and details of procedure
* Informed consent must be obtained in writing
* STI testing if risk factors present or infection suspected
* Contraception counseling for post-procedure
* Blood typing/verification and administration of Rh immune globulin if needed
* Premedicated most commonly with NSAID and anxiolytic (eg ibuprofen and Ativan) and prophylactic antibiotics
* Sterile technique
* Cervix cleansed with povidone-iodine, anesthetic cervical block given
* Cervix dilated (if needed, may be performed with osmotic dilators or prostaglandins)
* Aspiration, manual or electric
* Products of conception verified while pt remains in room
* Postoperative monitoring for at least 30 minutes
* Discharge with medications (NSAIDs, methergine, doxycycline, contraception)
* Routine follow-up recommended in 2-4 weeks
32
post-procedure expectations
* Post-procedure expectations
* Most women experience mild lower abdominal cramping for 2-4 days post-procedure
* Women should be informed that vaginal passage of small amounts of tissue and blood can be expected post-procedure
* Emergency number should be given and used if heavy bleeding, fever, or severe abdominal pain develop
* Most complications develop within one week post-procedure
* Return to clinic if pregnancy symptoms have not resolved within one week of procedure or if normal menses has not returned by 6 weeks post-procedure.
Abstain from vaginal intercourse or tampon use x 2 weeks
33
compications of SAB
* Hemorrhage
* May result from cervical or vaginal lacerations
* Uterine perforation
* Retained tissue
* Uterine atony
* Infection
* Incomplete abortion
* \*Generally, suction curettage procedures performed in an outpatient setting have low rates of morbidity and mortality, comparable to procedures performed within a hospital setting.
34
outcomes of SAB
* Outcomes
* First trimester surgical abortion is effective in terminating pregnancy in 98-99% of procedures and has a complication rate of 0-3%
35
second trimester abortion
* Second trimester (14 to \<28 weeks gestation) pregnancy terminations make up 10-15% of the approximately 42 million abortions worldwide.
* The CDC reported that 7% of abortions were performed between 14-20 weeks and 1.3% at or after 21 weeks.
* Second trimester abortion associated with increased morbidity and mortality, and for some women, more social or emotional challenges compared with a first trimester abortion.
* Rarely associated with death, but the mortality risk increases by 38% for each successive gestational week after eight weeks.
36
indications and contraindications for second trimester abortion
* Indications and Contraindications
* Various reasons for second trimester terminations
* Elective pregnancy termination
* Delay in diagnosis of pregnancy
* Delay in obtaining an abortion
* Fetal anomaly
* Maternal illness (eg early severe preeclampsia)
* Preterm premature rupture of membranes
* No contraindications
* Some women with medical comorbidities have an increased risk of complications
37
protocol for second trimester abortion
* Protocol typically includes:
* Pregnancy confirmation and gestational age
* Pregnancy confirmed by urinary or serum hCG measurement or transvaginal ultrasound
* Gestational age must be determined using menstrual history, pelvic examination, and ultrasound
* Counseling about options and informed consent
* Review options and details of procedure
* STI testing if risk factors present or infection suspected
* Blood typing/verification and administration of Rh immune globulin if needed
* Preoperative evaluation
* Informed consent
* Comprehensive counseling about expected experience, symptoms, and recovery is very important
* Preprocedure preparation
* Cervical dilation: using osmotic dilators (laminaria) and/or prostaglandins
* Anesthesia and antibiotics
* Usually using paracervical block and IV conscious sedation
* Paracervical block = lidocaine at 12, 3, 6, and 9 oclock
* Single dose of prophylactic antibiotics
* Procedure (focusing on D&E)
* Cervical dilation: using surgical dilators
* Uterine evacuation (via a combination of suction, forceps extraction, and curettage).
* Possible use of uterotonics
* Assessment for retained products of conception
* Evacuated contents are inventoried
* Pelvic ultrasound if needed
* Discharge when stable
* Follow up at two weeks, emergency number given.
38
complications of second trimester abortion
* Complications
* Retained products of conception
* Found in fewer than 1% of second trimester D&E procedures
* Cervical laceration
* Occurs in up to 3% of second trimester abortions, whether performed by D&E or medication. Surgeons can reduce frequency of cervical lacerations by using cervical preparation and appropriate technique with metal dilators.
* Uterine perforation
* Occurs in fewer than 1% of second trimester D&E procedures.
* In some cases, perforation results in hemorrhage or damage to bowel or bladder.
* Factors that increase risk of perforation include: increasing gestational age, cervical abnormalities, multiparity, and an inexperienced provider
* Infection
* Rates vary up to as high as 4%. The management of postabortal endometritis is similar to postpartum endometritis.
* Hemorrhage
* Can result from a variety of causes: uterine atony, retained POC, coagulopathy, abnormal placentation, and uterine or cervical injury.
* Uterine atony is the most common cause of hemorrhage following D&E and complicates ~2% of D&E procedures
39
outcome of second trimester abortion
* Outcome
* Second trimester surgical abortion is a safe and effective procedure. Uterine evacuation is completed in a single procedure in most women.
* In general, fewer than 5% of women have retained products of conception or a complication
40
early pregnancy loss: EPL
* Most common signs and symptoms: vaginal bleeding, abdominal cramping, pelvic or back pain, passing of tissue from the vagina, loss of pregnancy related symptoms, constitutional symptoms (fever, chills, muscle aches
* Diagnosis of EPL is confirmed by one of the following: 1) US confirmation of an embryonic gestation or fetal demise in the uterus in conjunction with falling serial HCGs, 2) absence of previously seen IUP on US 3) Tissue exam confirming expulsion from uterus
* EPL Management
* Expectant management (watch and wait) - need close follow up every 1-2 weeks
* Medical management (with MAB medications Mife/Miso or Miso alone or Methotrexate (in settings of EPL vs ectopic) - need follow up ultrasound
* Aspiration in out patient or OR setting - usually no follow up require
41
ectopic pregnancy
* In all patients presenting with first trimester bleeding, ectopic pregnancy should be considered. Ectopic pregnancies often present at 6-8 weeks gestation.
* Generally when a patient presents with a positive pregnancy without ultrasonographic evidence of an IUP clinical suspicion should be high for an ectopic
* Diagnosis is confirmed by serial HCGs and ultrasounds – in normal pregnancies, HCGs double every day, but in ectopic, the HCG stays pretty much the same
* Treatment is usually methotrexate followed by serial HCGs.
42
overall health effects and long-term concerns of aboriton
* The mortality associated with childbirth is 14 times that of legal abortion
* First trimester abortions pose no long-term risk of infertility,ectopic pregnancy, spontaneous abortion, or breast cancer
* Leading experts conclude that abortion does not pose a
* hazard to patient’s mental health. The most common emotional response following an abortion is a sense of relief
* Exhale After-Abortion talk-line. [www.exhaleprovoice.org](http://www.exhaleprovoice.org/) 1-866-4-EXHALE
* Future fertility: First trimester abortion is not associated with any measurable risk for infertility or miscarriage. Second trimester abortion with D&E may show an increased risk for miscarriage or preterm birth, in a few studies.
* Post abortion care / Contraception: Ovulation an possibility of another pregnancy may occur as soon as 10 days after an abortion. Pregnancy prevention is key!
43
pregnancy prevention
* Consider LMP a vital sign for any female patient ages 9-55
* U.S. Medical Eligibility Criteria (US MEC) for Contraceptive Use
* Family planning discussions are necessary and relevant in most medical encounters
* Discuss pregnancy prevention for all males with female partners
* As a provider, be non-judgmental and compassionate. Abortion is a difficult, complex, and deeply personal decision. Provide your patients with medically accurate and objective information.
