OPTIONS COUNSELING Management of Unintended Pregnancy Learning Objectives

OPTIONS COUNSELING Management of Unintended Pregnancy

Learning Objectives • Learners will be able to • Describe the epidemiology of unintended pregnancy in the United States • Discuss positive pregnancy results in a patient-centered and unbiased manner and demonstrate appropriate options counseling. • Understand explain standard protocols for adoption, medication and procedure abortion

45% of pregnancies in the US are unintended, and of those 42% end in abortion Intended 55% Unintended – Mistimed 27% Unintended- Unwanted 18%

Unintended pregnancy by consistency of contraception use Consistent use 5% Inconsistent use 41% Nonuse 54%

Abortion Facts • 59% of abortions are obtained by women with children • 49% of abortion patients live below the federal poverty level • 60% of abortions are obtained by women in their 20 s, and 25% in their 30 s.

Empathy Exercises • Everyone should stand up • Now sit down if … • You have ever smoked cigarettes • You ever overeat • You work too hard or too many hours • Stand up again • Now Sit down if… • You’ve ever been judged by your skin color, gender, sexual orientation, accent

Learning points • A positive pregnancy test may not be “good news” for a patient • Results should be discussed neutrally and without judgement • Patients have multiple options when addressing an unintended pregnancy* • Options counseling (including abortion) is an ACGME requirement.

Suggested steps in Pregnancy Options Counseling • 1) Explore the patient’s feelings after giving the positive test result • 2) If unsure of plans, help patient to consider their options • 3) Identify social supports • 4) Help to reach a decision, or discuss a time table if still undecided • 5) Refer or provide the appropriate service

What are the options? Continue pregnancy Terminate pregnancy • Parent • Place in adoption • Medication abortion • Aspiration abortion

Language tips • Pay attention to both verbal and non-verbal cues • Avoid referring to the pregnancy as “baby”. Embryo and fetus are better alternates • Demonstrate empathy by using patient’s terms, following their cues

Adoption • Can be arranged through any of the following: • Adoption agency • Attorney who specializes in adoption • “Exchange” or “consultant” who works with a specific population • Becoming an adoption expert

Types of Adoption • 1) Open • Birth mother and adoptive parents have direct contact with each other • 2) Semi-Closed • Contact between birth mother and adoptive family is through an agency or agent • 3) Closed • There is no contact between families Of note, about 30% of Americans have considered adoption when surveyed, however 2% have actually done so.

Abortion options Medication Abortion Procedure

Abortion Safety • One of the safest and most common medical procedures • First trimester abortions DO NOT increase the risk of: • Infertility • Ectopic pregnancy • Miscarriage • Birth defects • Preterm or low birth weight delivery • Breast cancer • Mental health disorders

Medication and Aspiration Abortion: Both safe and effective

Medication Abortion Advantages: 98 – 99% effective Up to 10 weeks from LMP Greater autonomy and privacy Less invasive, more “natural” Disadvantages Takes 1 -2 days to complete, follow up with provider recommended Bleeding and cramping can be heavier and more intense May need an Ultrasound or blood test

Manual Vacuum Aspiration Advantages - 99% effective - Takes minutes to complete, no follow up needed - Multiple anesthesia options (including local) - shorter bleeding duration - Can be performed later in pregnancy Disadvantages: - Requires pelvic instrumentation - Less patient control over a procedure - Potential medication side effects (anesthesia and analgesia)

Medication Abortion: How it works

Medication Abortion: Office Visit #1 • Estimate gestational age • Options counseling • Rule out contraindications • Counsel on Med Ab process • Labs • Hemoglobin/Hematocrit • Rh Status • Obtain ultrasound vs β-h. CG quantitative (+pelvic exam) • Discuss contraception options

Medication Abortion process • Administer mifepristone • Patient NOT REQUIRED to take medication in front of a provider • Give misoprostol for patient to take 6 -72 hours post- mifepristone • Misoprostol may be buccal or vaginal • Provide pain medications • Patient should expect cramping and bleeding within 4 -24 hours of misoprostol placement • Provide contact information if questions/concerns

Medication Abortion: Office Visit #2 • Should occur 1 -2 weeks post med ab • Obtain history for abortion completion • Repeat ultrasound or β-h. CG quantitative to compare to initial visit • Discuss and provide contraception if desired

Manual Vacuum Aspiration

MVA from the Patient Perspective • Analgesia and anxiolytic options: • NSAIDs • Anesthesia options: Local (cervical block with lidocaine), moderate or deep sedation • heat packs, music • using patient centered language vs triggering language • Support persons and/or doulas present • Procedure lasts about 5 -10 minutes

Key points • Unintended pregnancy is common, and so is abortion • Patients should be counseled on all options for unintended pregnancy, including abortion • Some patients are certain of their plan for unintended pregnancy, while others may be less clear. Individualizing counseling is key. • If a patient chooses abortion, options for medication versus procedure abortion should be discussed. • Access to abortion is variable, knowing state laws is important.