Medication Abortion in Early Pregnancy Induced termination of

Medication Abortion in Early Pregnancy Induced termination of early intrauterine pregnancy using medications

• Describe the baseline unintended pregnancy rates in the US which lead to the need for abortion care. Objectives • Explain the tenets of nonjudgmental options counseling • Access resources for the updated protocol for medication abortion so that it can be integrated into primary care practice.

6. 1 million pregnancies/year in the U. S. Unwanted 18% Intended 55% Mistimed 27% Guttmacher Institute, 2018 (2011 data)

Unintended pregnancy rate by race, ethnicity, and income Finer and Zolna, 2016 (2011 data)

Outcomes of unintended pregnancies (Approximately 2. 8 million annually) Abortion 40% Births 51% Miscarriage 9% Guttmacher, 2018 (2014 data)

89% of abortions occur in the first 12 weeks of pregnancy >21 weeks 16 -20 weeks 1, 3% 3, 8% 13 -15 weeks 6, 2% 11 -12 weeks 8, 3% 9 -10 weeks 14, 5% <8 weeks 65, 9% Guttmacher Institute, 2018

Wanted vs. unwanted pregnancy: consequences

Abortion access Guttmacher Institute, 2017 (2014 data)

Primary care shortage areas Impact of family physicians on PCHPSAs With family physicians: Graham Center, 2000 Without family physicians:

Abortion in family medicine: training issues 600 564 446 450 432 300 150 36 25 11 0 1997 Abortion Training 2007 No Abortion Training 2018

Could training family physicians in medication abortion make a difference?

Abortion in Implementation issues family medicine

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-birthweight delivery National Academies of Sciences, Engineering, and Medicine. 2018

Medication abortion regimens: three choices Mifepristone + Misoprostol Methotrexate + Misoprostol alone

Mifepristone + Misoprostol The most common regimen in the U. S.

Medication abortion: advantages • 98 -99% effective • Avoids surgical and anesthetic risk • Greater patient autonomy and privacy • Less invasive • More “natural”

Aspiration abortion: advantages • Slightly more effective (99%) • Shorter time to completion • Shorter bleeding duration • Can be performed later in gestation

Misoprostol Route and Timing Misoprostol Route Buccal Vaginal Misoprostol dose 800 mcg Misoprostol timing 24 - 48 hours after Mifepristone 6 -72 hours after Mifepristone

Mifepristone Causes progesterone blockade Decidual necrosis Cervical ripening Detachment Misoprostol Causes uterine cramping and expulsion

• 22 years old • Requests a pregnancy test Case study: Yolanda

• Review all options • Ensure the decision is hers Case study: Yolanda – counseling issues

• Establish gestational age • Rule out contraindications Next steps • Allergy to meds • Chronic adrenal failure • Long-term systemic corticosteroid therapy • Coagulotherapy or anti-coagulant use (excluding aspirin) • IUD in place • No access to follow-up • Ectopic pregnancy • Indications for sonography

• Gestational age: 6 weeks • Patient agreement Case study: Yolanda

What happens next? Yolanda takes mifepristone in your office, or later at home At home, Yolanda takes pain meds, then misoprostol

Follow Up: In office or by phone • 7 -14 days later • Assure completion • Process experience • Review contraceptive choice

Phone Triage Call – Bleeding with Medication Abortion

Phone calls after medication abortion “There wasn’t much blood. ” Was there some bleeding? Any cramping? Did you take the misoprostol? “I’m bleeding and cramping a lot. ” That’s normal unless you’re soaking two heavy pads an hour for two consecutive hours. “Am I still pregnant? ” Ask if pregnancy symptoms have disappeared. “I’m still bleeding after 2 weeks. ” That’s normal unless you’re soaking two heavy pads an hour for two consecutive hours. Offer follow-up appointment.

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 and misoprostol medication abortion

• 800 mcg vaginally • More than one dose might be needed Misoprostol alone medication abortion

What barriers do you anticipate if you were to try to provide medication abortions in your office?

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.