Abortion

Abortion - NRSG 835

Objectives:

Describe two new options for medical abortion- Mifepristone & Methotrexate
Discuss clinical issues: mechanism of action, dosing regimen, treatment regimen, efficacy rates, safety profiles
Compare and contrast the two technologies from a provider and a client perspective

Introduction:

In the US, 1/2 of the pregnancies are unplanned
1/2 of women with unplanned pregnancies choose to abort
In the US, 53% of abortions are performed within 8 weeks; 89% within the first trimester

Mifepristone (RU 486) plus Misoprostol (Cytotec) - Mechanism of action:

Misoprostol

Synthetic prostaglandin E1 analog
Approved in US for the treatment of gastric ulcers
Well absorbed from GI track and vagina
Softens the cervix and stimulates uterine contractions.
Most effective when used in combination with other drugs

Mifepristone

Antiprogestin
Antagonizes progesterone receptors in the endometrium
Causes decidual breakdown and detachment of the embryo
Increases myometrial response to exogenous prostaglandins and myometrial contractions are enhanced.

Treatment Plan

Must be within the first 49 days of the LMP
Day 1 600 mg mifepristone (#3 200’s)
36 hrs later, 400 mg misoprostol
Day 2 Examine. Dose of misoprostol
OR Dose of misoprostol in 3-4 days
Day 12-13, Follow up.
Surgical termination, if necessary.

Efficacy

When used in the first 7 weeks
95-98% effective in inducing abortion
3-4 % incomplete abortion
1% ongoing pregnancy

Timing of procedure completion

60% pass products of conception in 4 hours after prostaglandin
2/3 to 3/4 abort within 24 hours of either the first or second dose

Common side effects

1-20% require narcotic, Tylenol # 3
Avoid antiprostaglandin
Nausea 33%
Diarrhea 10%

Testing and progress in the US

FDA Advisory Panel Review
1996 found to be safe & efficacious

Methotrexate - Mechanism of action:

Dihydrofolate reductase inhibitor
Toxic to the trophoblast which probably loosens the connection to the endometrium and decreases trophoblast production of HCG.
Also used to treat ectopic pregnancy and choriocarcinoma

Dosing Regimen

Methotrexate 50 mg/m2 IM
Then, 3-7 days later, 800 ug Misoprostol vaginally
Lie down for 30 minutes
If no bleeding within 24 hours, insert another dose of misoprostol
Avoid folic acid as a vitamin

Efficacy

Depends upon gestational age
Up to 49 days gestation most efficacious
69% completed within 14 days

Common Side Effects

Nausea
Cramping
Diarrhea

Timing of Procedure

Within 49 days of LMP

Mifepristone and methotrexate: A Comparison:

Similarities

No surgery
Resembles a natural miscarriage
More private
Can be offered earlier than surgery
Does not effect future fertility

Clinic Facilities Needed:

Patient needs to stay for 4 hours after the prostaglandin
Need adequate # of bathrooms
Counseling. Need to initiate this procedure early in pregnancy
Protocols need to be written
Vaginal ultrasound, how often?

Sterilization:

This is the most popular and common form of contraception for persons in their 30's and 40's. They must be very sure they want no more children. Reversal is possible, but not easy or cheep!!