Guidelines 2016 – Medical Abortion
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
A medical abortion terminates a pregnancy as early as pregnancy can be confirmed, but no later than 63 days from the last menstrual period, with the use of misoprostol and mifepristone. The shorter the time a woman has been pregnant, the better the medications work (National Abortion Federation [NAP], http://prochoice.org).
A. Mifepristone (Mifeprex): a derivative of norenthindrome with a strong affinity for progesterone receptors. The progestin antagonist effect of mifepristone interferes with the maintenance of early pregnancy. Mifepristone acts on the deciduas to break down the capillary epithe- lial cells, causing the trophoblast to separate from the decidua. This leads to the disruption of the integrity of the pregnancy, bleeding, and a decrease in maternal human chorionic gonadotropin (hCG).
B. Misoprostol (Cytotec; also known as RU-486): a synthetic prostaglandin analogue. Misoprostol efficiently ripens the cervix and induces uter- ine contractility. Misoprostol tablets are taken within a few days of taking mifepristone (Mifeprex) and may be taken orally, placed into the vagina, or tucked between the cheek and gum.
II. ETIOLOGY
A. Therapeutic abortion: patient presents with desire to terminate early pregnancy by nonsurgical means
III. HISTORY
A. Medical guidelines for eligibility
1. Amenorrhea with positive pregnancy test
2. Pelvic or transvaginal ultrasound documenting intrauterine preg- nancy up to 63 days gestation
3. Full medical and surgical information, including, but not limited to, the following areas:
a. Diabetes
b. Cardiovascular conditions
c. Infectious disease (including sexually transmitted infections [STIs], hepatitis, HIV, tuberculosis [TB])
d. Thyroid
e. Lung
f. Autoimmune conditions
g. Metabolic conditions
h. Psychiatric illness (especially eating disorders if currently active)
i. Surgeries (especially gynecologic)
j. Kidney
k. Epilepsy
l. Allergies
4. Full psychosocial history, including, but not limited to, the following:
a. Drug and alcohol use/abuse/dependence (including prescrip- tives, nonprescriptives, street drugs, and herbal preparations)
b. Tobacco use/dependence
c. Domestic violence (with regard to safety of woman)
d. High-risk behaviors
e. Patient’s support system, especially with regard to knowledge of her pregnancy and decision to terminate, at home and avail- able support person(s)
f. Cultural beliefs (especially with regard to pregnancy and abortion)
5. Full gynecologic/obstetrical history, including, but not limited to, the following:
a. Menstrual history
b. Gynecologic history
c. Pap smear history (especially with regard to abnormal Pap smears and treatment, including ablations, cryocautery, cone biopsies, etc.)
d. High-risk behaviors (especially STIs and number of sexual part- ners, prostitution)
e. Pregnancy history, including number of pregnancies, deliveries, miscarriages, previous abortions (medical and surgical), ecto- pic pregnancies, stillbirths, and other neonatal losses or infant/ child deaths (e.g., sudden infant death syndrome [SIDS])
f. Contraceptive history and desire for contraception after abor- tion is complete
g. Past or current history of attempt to end current pregnancies with prescriptive, nonprescriptive, or herbal preparations or street drugs
IV. CONTRAINDICATIONS AND INELIGIBILITY
A. Greater than 63 days amenorrhea or beyond last menstrual period
B. Intrauterine device (IUD) in situ (IUD must be removed prior to taking Mifeprex)
C. Inconclusive pelvic or transvaginal ultrasound for intrauterine preg- nancy or documented/suspected extrauterine (ectopic) pregnancy or documentation of placenta developing abnormally
D. History of severe adrenal failure, severe cardiovascular issues, liver disease, or diabetes
E. History of current anticoagulant therapy or blood-clotting disorder
F. Taking any medication(s) that interfere with or cannot be combined with either misoprostol or mifepristone
G. Documented allergy to Cytotec or Arthrotec
H. Certain steroidal medication therapies
I. Undiagnosed adnexal mass
J. If breastfeeding, a woman must understand that medications can cross into breast milk and cause diarrhea in the infant.
V. ADDITIONAL CONSIDERATIONS
A. Must be certain in decision to terminate pregnancy
B. Must agree to participate in her own abortion and take responsibility for her own care
C. Must agree to return for follow-up visit if required by caregiving clinic/facility
D. Must be able to understand and follow instructions for medical abor- tion, as well as the risks, benefits, and side effects of medications used
E. Must not have comprehension or language barriers
F. Must agree to have a surgical abortion should the medical abortion fail
G. Must have access to telephone in case of emergency
H. Must have access to transportation to an emergency facility if one is needed
I. Must agree not to take any herbal medications or supplements or pre- scription medication without asking the clinician during the medical abortion
J. Must agree not to use any of the following medications/foods/herbs during the abortion procedure
1. Ketoconazole
2. Itraconazole
3. Erythromycin
4. Grapefruit juice
5. Klonopin
6. Rifampin
7. Dexamethasone
8. St. John’s wort
9. Carbamazepine
10. Corticosteroids
VI. PHYSICAL EXAMINATION
A. Vital signs: blood pressure, pulse, temperature, respirations
B. Pelvic examination: unnecessary unless patient has complaints or there is need to assess uterine size
C. Pelvic or transvaginal ultrasound (depending on office protocol)
D. Urine or serum pregnancy test (if ultrasound is inconclusive for intra- uterine pregnancy)
E. Laboratory values: hemoglobin and Rh testing
F. Height and weight
VII. COUNSELING AND CONSENT SIGNING
A. Patient should be counseled on options for current pregnancy to include delivery, adoption, and abortion.
B. Patient will be required to read material provided by office on medical abortion.
C. Discussion with patient regarding the dosage of misoprostol and mife- pristone approved by the U.S. Food and Drug Administration (FDA).
D. Patient should be counseled regarding instructions for medication use—to include taking mifepristone in the office and when to insert misoprostol at home.
E. Patient should be given oral and written instructions to aid her in what to expect and how to identify a complication.
F. Patient should be counseled on what she might experience once she takes each medication, including possible bleeding following mifepristone. These include passing tissue (including a grayish sac) and cramping and the possibility of nausea, vomiting, fever, head- ache, diarrhea, chills, and fatigue. Patient should also be counseled to expect bleeding to last 1 to 2 weeks.
G. Patient should be counseled on what to do if abortion does not occur.
H. Patient should be counseled on what to do in case of emergency, including heavy or uncontrolled bleeding, pain that does not respond to medication, or fever greater than 101°F. Patient should be given an information sheet about medical abortion to hand to emergency room personnel in case of emergency.
I. Patient should be counseled on when to begin contraception and that the first period may be heavier than usual.
J. Patient will be required to read Mifeprex medication guide and to sign a patient agreement.
K. Patient will be given written instructions and information on after- care that include pain medications, heating pad use, antiemetics, and comfort care; discussion about diet, exercise, heavy lifting, return to sexual activity, and other restrictions postabortion.
L. Patient will be counseled about the importance of attending follow-up visits if they are scheduled.
VIII. MEDICATION REGIMEN (BASED ON INDIVIDUAL CARE FACILITY PROTOCOL)
A. Mifepristone 600 mg orally and 400 mcg misoprostol to be used 48 hours after mifepristone dosing orally, vaginally, or bucally
IX. OTHER MEDICATIONS TO CONSIDER
A. RhoGAM (D) 1 mL must be given after oral dose of mifepristone to all women who test Rh negative.
B. Antiemetic (i.e., Zofran ODT, Compazine, ginger, B6)
C. Pain medication (i.e., ibuprofen 800 mg every 8 hours; narcotic pain medications per care facility protocol)
X. COMPLICATIONS WITH MEDICAL ABORTION
A. Patient to be instructed to seek emergency treatment if
1. Bleeding (soaking through two thick, full-size sanitary pads per hour for 2 consecutive hours)
2. Pelvic pain uncontrolled with medication regimens recommended
3. Fever greater than 100.4°F or higher that lasts more than 4 hours
4. Severe abdominal pain
5. Weakness, nausea, vomiting, and/or diarrhea more than 24 hours after taking misoprostol
XI. CONSULTATION/REFERRAL FOR SIGNS OF INCOMPLETE ABORTION OR INFECTION
A. Uncontrolled bleeding
B. Continued pregnancy symptoms (i.e., nausea/vomiting or breast ten- derness) 1 week after medical abortion
C. Unexplained fever
D. Failure to return to prepregnancy baseline
XII. FOLLOW-UP
A. Follow-up visit should occur 2 to 3 weeks postabortion and should include
1. Vital signs
2. Pregnancy test
3. Medical and psychosocial history since medical abortion, including bleeding pattern, pain or cramping, fever, pregnancy symptoms, support network, signs and symptoms of depression, or anxiety caused by the decision to terminate and signs and symptoms of continued pregnancy
4. Pelvic exam to assess
a. Involution of uterus
b. Vulvovaginal infection postabortion
c. Resolution of bleeding
d. Pelvic pain or pelvic inflammatory disease (PID)
5. Review of birth control management or plan, including
a. Current method used, evaluate
i. Effective versus ineffective
ii. User friendliness
iii. Side effect profile
iv. Need for sample, refill, or new prescription
b. If no current method used, evaluate
i. Need for method—review options
ii. Review risks, benefits, side effects, and instructions for use
iii. Give sample, new prescription, or referral (as for IUD)
See Bibliographies.
Website: www.fwhc.org/abortion/medical-ab.htm