2 Emergent Techniologies for Early Abortions1

7/31/2019 2 Emergent Techniologies for Early Abortions1

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Emergent Technologiesfor

Early Abortions

Dr Narwadkar MangeshDr Narwadkar Mangesh


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Safe Abortions - Earlier the Better

Four fold rise in complications with late abortionsFour fold rise in complications with late abortions

* WHO,* WHO, Tech Report., 1997 Tech Report., 1997

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4 8 12 16 20

C o m p l

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R a

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Weeks of Amenorrhea


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Safe emerging technologies forearly abortions

1.1. Manual Vacuum AspirationManual Vacuum Aspiration

2.2. Medical Methods of AbortionMedical Methods of Abortion


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Manual Vacuum Aspiration


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MVA Kit (Aspirator & Cannula)


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MVA Kit (Aspirator & Cannula)


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Manual Vacuum Aspiration

Evacuation of uterine contents through aEvacuation of uterine contents through acannula, attached to a hand-held vacuumcannula, attached to a hand-held vacuum

aspirator.aspirator.The pre created vacuum evacuates theThe pre created vacuum evacuates thecontents of the uterus without damaging thecontents of the uterus without damaging thelining of the uterus.lining of the uterus.


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Indications for MVA

Threatened abortionThreatened abortionInevitable/ Incomplete abortionInevitable/ Incomplete abortionSeptic abortionSeptic abortionMissed abortionMissed abortionBlighted ovumBlighted ovumHydatidiform moleHydatidiform moleRetained placental productsRetained placental products

Endometrial samplingEndometrial sampling

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contraindications

Ut > 12 weeksUt > 12 weeks

Acute cervicitis/PIDAcute cervicitis/PID

Multiple fibroidsMultiple fibroidsh/o bleeding disorder h/o bleeding disorder

Suspected uterine perforationSuspected uterine perforation


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FIGO/WHO Endorsement of MVA

Properly equipped hospitals should abandonProperly equipped hospitals should abandoncurettage and adopt the aspiration methods,curettage and adopt the aspiration methods,selecting Manual Vacuum Evacuation and or selecting Manual Vacuum Evacuation and or Electric AspirationElectric Aspiration

MVA is an essential basic procedure at FirstMVA is an essential basic procedure at FirstReferral Unit level.Referral Unit level.


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Vacuum Aspiration and D&C

Lesser incidence of haemorrhage, cervicalLesser incidence of haemorrhage, cervicalinjury, lacerations, uterine perforationinjury, lacerations, uterine perforation

Less dilatation required and hence less painfulLess dilatation required and hence less painful

and lesser chances of vagal reactionsand lesser chances of vagal reactionsLess pain medication and anaesthesiaLess pain medication and anaesthesia

Less hospital stayLess hospital stay

No major O.T. set up required No major O.T. set up required


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MVA and EVA

Equivalent high levels of effectiveness and lowEquivalent high levels of effectiveness and lowcomplication rates.complication rates.Pressure created is EQUAL in bothPressure created is EQUAL in both

But with MVA But with MVA No electricity required No electricity requiredSafe in accidental perforationsSafe in accidental perforationsIntact gestation sac in early pregnancyIntact gestation sac in early pregnancyterminationtermination


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MVA ProcedureMVA Procedure


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Cx ripening

Commnly used agentCommnly used agent

Tab misoprost 400 microgram 3-4 hoursTab misoprost 400 microgram 3-4 hours

prior,vaginally prior,vaginallyProstodine 45 min prior I/MProstodine 45 min prior I/M


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Evacuating uterine contents

Dilate the cervix withcannulae of increasing sizes tillappropriate number is reached,after taking appropriate paincontrol measures

Connect the cannula to theaspirator

Move the cannula back and

forth gently and slowly, rotatingthe cannula and the syringe atthe same time

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Cannula selection

Depends upon uterine size, period of gestation,Depends upon uterine size, period of gestation,amount of dilatation required to aspirate pocamount of dilatation required to aspirate poc

Important to have appropriate cannula (retainedImportant to have appropriate cannula (retained products or loss of suction) products or loss of suction)

4-6 weeks LMP-----4-7mm cannula4-6 weeks LMP-----4-7mm cannula

7-9 weeks LMP------5-10mm cannula7-9 weeks LMP------5-10mm cannula

9-12 weeks LMP-----8-12 mm cannula9-12 weeks LMP-----8-12 mm cannula


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Pain managementThe three major sources of discomfort and pain

during uterine evacuation with MVA are anxiety,cervical dilation and uterine cramping.Verbal reassurance and respectful, supportive care by

staff throughout the procedure helps to reduce anxietyand decrease pain, and should be a standard part of abortion care.Pain and discomfort during an MVA procedure ca be

reduced using a combination of verbal support oralmedications, Para cervical block and gentle clinicaltechnique.


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Signs that the uterus is empty

Red or pink foam without tissue passingthrough cannula.

Gritty sensation over surface of uterus.Cervix gripping over the cannula.Uterus contracting around cannula. Increased

uterine cramping.


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Inspecting the tissue 19

Strain and Inspectthe evacuated

tissue


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No visible POC, a lower quantity of tissue thanexpected or an inconclusive tissue sample may

indicate incomplete abortion, completedspontaneous abortion, failed abortion, suspectedectopic pregnancy or anatomical anomaly.Technical problems that can occur with the

instrument during an MVA procedure include a fullaspirator, a cannula that is clogged or withdrawn

prematurely, or a loss of vacuum due to incorrect

assembly.


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Post procedure care/follow up care

Physical monitoring:Emotional support:

Contraceptive counseling:Addressing other health issues: anemia,reproductive-tract infections (RTIs, HIV, violence, ,cancer screening.


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Post procedure care/follow up care

Providing discharge instructions.Pain management: Analgesics, NSAID.

Provision of antibiotics: Research has shown thatroutinely providing antibiotics to womenundergoing MVA reduces infection.Scheduling follow-up care within one week.


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Sterilizing

Agent

MVA Plus Aspirator and Easy Grip

Cannulae can be: stetrilized by Autoclaving (121Autoclaving (121

C for 30 minutes) or soaking inC for 30 minutes) or soaking inGluteraldehyde for 10 hrsGluteraldehyde for 10 hrs

OR OR High level disinfected by boilingHigh level disinfected by boiling

for 20 minsfor 20 mins or soaking inor soaking inGluteraldehyde or chlorineGluteraldehyde or chlorinesolution for 20 mins.solution for 20 mins.

Sterilization / High Level Disinfection


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To sum up - MVA

MVA is an effective surgical method for terminationMVA is an effective surgical method for terminationof pregnancy up to 12 weeks.of pregnancy up to 12 weeks.

Increases access and decreases costs as it is OPDIncreases access and decreases costs as it is OPD procedure procedure

Reduces complication risks and time of procedure asReduces complication risks and time of procedure asit is done under local anaesthesiait is done under local anaesthesia

Easy to process and handleEasy to process and handle

Improves patient provider rapportImproves patient provider rapportAllows immediate identification of POCAllows immediate identification of POC

Excellent backup for failed medical abortionExcellent backup for failed medical abortion


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Medical Methods of Abortion


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What is Medical Methods of Abortion?

Medical abortion is a non surgical, non invasiveMedical abortion is a non surgical, non invasivemethod of termination of pregnancy bymethod of termination of pregnancy bycombination of drugs.combination of drugs.


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Medical Methods of Abortion

Approved in 30 countriesApproved in 30 countries

Available for early pregnancy up to 63 daysAvailable for early pregnancy up to 63 days

High success rate 93-95%High success rate 93-95%

It takes 8-12 days for the complete processIt takes 8-12 days for the complete process

Requires minimum 3 visitsRequires minimum 3 visits

Requires follow up to ensure completion of abortionRequires follow up to ensure completion of abortion


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Why women like Medical Methods of Abortion ?

No admission required No admission required

No fear of surgery No fear of surgery

The method is convenientThe method is convenient

It enables the woman to look after her home or jobIt enables the woman to look after her home or jobwithout a break without a break

(Population Council, KEM Hospital Pune 1990-1993)

C l d d


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Commonly used drugs

Mifepristone (RU 486)Mifepristone (RU 486)

invented in 1980initials of pharmaceutical company Roussel-Uclaf 486 is a random laboratory serial number.

MisoprostolMisoprostol

Combinations of the two drugs has a high success rateCombinations of the two drugs has a high success rate

Both the drugs have been approved for use in early Both the drugs have been approved for use in early

pregnancy termination in India pregnancy termination in India


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Mifepristone RU486Antiprogesterone compound that blocks Progesterone receptor Antiprogesterone compound that blocks Progesterone receptor sites in endometrium, decidua and dislodges the fertilized egg.sites in endometrium, decidua and dislodges the fertilized egg.

Available as 200 mg TabAvailable as 200 mg Tabmore effective in early pregnancy when progesterone is

present in lower concentrations due to limited production by

corpus luteum.When used alone complete abortion rate is 75%When used alone complete abortion rate is 75%

When used with Misoprostol complete abortion rate is 93-95%When used with Misoprostol complete abortion rate is 93-95%

Now available in India since April 2002 (Mifegest, Mifeprin, Now available in India since April 2002 (Mifegest, Mifeprin,MTPill, Mifyron etc)MTPill, Mifyron etc)


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Side Effects of Mifepristone

Serious S/E are rare, however the woman may experienceSerious S/E are rare, however the woman may experience

Nausea Nausea

VomitingVomiting

FatigueFatigue

DiarrhoeaDiarrhoea


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Misoprostol

PGE1 analoguePGE1 analogue

Most commonly used drug for medical methods of Most commonly used drug for medical methods of abortionabortion

FDA Approved for prevention of gastric ulcer FDA Approved for prevention of gastric ulcer Effective route are oral/vaginal/sublingual/buccalEffective route are oral/vaginal/sublingual/buccal

Available as 200 micrograms tabletAvailable as 200 micrograms tablet

Available as Cytotec, Zitotec, Cytolog, Misogon etcAvailable as Cytotec, Zitotec, Cytolog, Misogon etc


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Advantages of Misoprostol

Low costLow cost

Stable at room temperatureStable at room temperature

Effective by different routesEffective by different routes


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Side effects of Misoprostol

Nausea Nausea

VomitingVomiting

Associated with congenital anomalies, if pregnancyAssociated with congenital anomalies, if pregnancycontinuescontinues


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Medical Methods of Abortion& MTP Act

It can be provided only by MTP certified providers and comesIt can be provided only by MTP certified providers and comesunder the purview of MTP Act.under the purview of MTP Act.MMA upto 7 weeks of gestation can be provided from approvedsites as well as non-approved clinics with referral linkage to

approved MTP site. The law requires that a certificate of accessto a registered place (i.e. showing that a referral link has beenestablished) from the owner of the approved site must bedisplayed in the clinic where MMA is being provided.

MMA upto 63 days (9 weeks) can be provided only from theapproved sites.

Eligibility of the woman


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g yOption of medical methods of abortion should begiven to all women coming to a health facilityseeking termination of pregnancy up to 9 weeks of gestation

No medical contraindication.

Frame of mind of the woman, i.e.Acceptability of minimum three visitsAbility to understand the instructions

Agrees for vacuum aspiration procedure, if failure or excessive bleeding occurs.

Eligibility of the woman


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g y

Support from family or others.

Permission of guardian in case of minor as per MTPAct 1971.Easy access to appropriate health care facility during

emergency.

Contraindications


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Contraindicationsfor Medical Methods of Abortion

Undiagnosed adnexal massUndiagnosed adnexal massConfirmed or suspected ectopic pregnancyConfirmed or suspected ectopic pregnancyIUCD in situIUCD in situChronic Adrenal failureChronic Adrenal failure

Concurrent long term corticosteroid therapyConcurrent long term corticosteroid therapyInherited PorphyriasInherited Porphyrias

No access to medical facilities in case of emergency No access to medical facilities in case of emergencyuncontrolled high blood pressure, diabetes, certain heart or uncontrolled high blood pressure, diabetes, certain heart or

blood vessel diseases, severe liver, kidney or lung disease, or blood vessel diseases, severe liver, kidney or lung disease, or an uncontrolled seizure disorder an uncontrolled seizure disorder


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SCARRED UTERUS

a uterine scar is not a contraindicationfor first trimester misoprostol induction,

but that the risk may increase withincreasing gestational age, particularly inthe late second trimester


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Investigations (Recommended)Haemoglobin.Routine Urine Examination.ABO Rh.

Investigations (Optional) Ultrasound if:She is unsure of LMP.She has irregular periods.Uterine size and menstrual dates do not match.There is suspicion of ectopic / fibroid during P/Vexamination.


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Protocol for Medical Methods of Abortion

First visit ( Day 1) Mifepristone -First visit ( Day 1) Mifepristone - 200mg given200mg givenorally, after ruling out contraindications.orally, after ruling out contraindications.

Second visit ( Day 3) Misoprostol 400/800Second visit ( Day 3) Misoprostol 400/800microgms vaginally/orally and kept at the clinicmicrogms vaginally/orally and kept at the clinicfor 4 hoursfor 4 hours

Third visit (Day 15) Follow up Third visit (Day 15) Follow up to determine if to determine if complete abortion has occurredcomplete abortion has occurred


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h d h h


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Recent research studies have shownthat allowing women to takemisoprostol either vaginally or orallyat home is safe, effective andacceptable to women. However Government of India recommends thatmisoprostol be administered at theclinic and the woman observed for atleast four hours.

f f


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Outcome of Medical Methods of AbortionParity is not a major factor affecting the outcomeParity is not a major factor affecting the outcome

Lesser the period of gestation, better the resultsLesser the period of gestation, better the resultsCabezas E, Int J Gynaecol Obstet 1999;63 (suppl 1):S.:1416.Cabezas E, Int J Gynaecol Obstet 1999;63 (suppl 1):S.:1416.

Most women abort within 4 hrs of Misoprostol administrationMost women abort within 4 hrs of Misoprostol administration

Of the rest:Of the rest:30% abort within next 24 hrs30% abort within next 24 hrs

65% abort within next 5 days65% abort within next 5 daysHeaviest bleeding lasts 1 4 hours that coincides with the expulsion

of POC. Mean period for bleeding is 8 13 days)The incidence of endometritis following medical abortion is lower

than after surgical abortion

Day 3-15


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Day 3 15She should preferably avoid going out of station

till the third visit.She should report if there is no bleeding even 24

hrs. after taking misoprostol. This may be rare, butthe doctor should consider following possibilities:Rule out ectopic pregnancy and confirm anintrauterine pregnancy.The drug may not have worked and / or more tie is

needed; repeating the dose may be an option.

Third visit (Day 15)


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( y )What to do

Pelvic examination to confirm completion of abortionUSG if examination does not confirmDebris in the uterus without a gestational sac, pain,

fever, or excessive vaginal bleeding does notusually require interventionAntibiotics: These are not generally prescribedroutinely but should be given to a woman showing /

susceptible to infection.She should report back if there are no periodswithin 6 weeks of completion of the abortion


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Failure of the method requiring surgicalintervention

Incomplete abortion 3 - 5%Incomplete abortion 3 - 5%

Continuation of pregnancy - 1 -2%Continuation of pregnancy - 1 -2%

Excessive bleeding - 0.2 2%Excessive bleeding - 0.2 2%(soaking 2 or more maxi pads per hour for 2 hours

continuously.)

Contraception after abortion.d h


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Oral pills can be started on 3 rd or 15 th day of the protocol on confirmation of completion of abortion

process.IUCD can be inserted on day 15 provided the

presence of infection is ruled out.

Condom can be used as soon as she resumes sexualactivity after abortion.( It is advised to abstain from sex until theabortion process is complete.. If there is sexual activity after taking thedrugs and before the abortion, it is advised that condom / barrier be used to

prevent infection.)

Contraception after abortion..b l l b d f f l


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Tubal ligation can be done after first cycle. However if desirous of concurrent tubal ligation, surgical method

of abortion is preferred.Injectables can be given on the 3 rd or 15 th day, after

confirming the completion of the process.

Vasectomy, if chosen, can be done independent of the procedure.

An acceptability .If f b i i d 42 f i


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If a future abortion was required, 42 percent of patientswho underwent a surgical abortion would opt for a

medical abortion; in contrast, only 9 percent of womenwho received medical abortion would prefer a surgicalabortion . However, others have reported greater satisfaction with surgical abortion.

Medical abortion becomes more painful and lesseffective in women with gestations over 50 days,particularly in those using oral misoprostol . Therefore,

these women are likely to find vacuum extraction moreacceptable

Medical Abortion and the Risk of Subsequent
http://www.uptodate.com/contents/misoprostol-drug-information?source=see_linkhttp://www.uptodate.com/contents/misoprostol-drug-information?source=see_link


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Adverse Pregnancy Outcomes

No evidence that a previous medical abortion,as compared with a previous surgical abortion,increases the risk of spontaneous abortion,ectopic pregnancy, pre- term birth, or low birthweight.

Jasveer Virk, M.S., M.P.H., Jun Zhang, Ph.D., M.D., and Jrn Olsen, M.D., Ph.D. N Engl JMed 2007;357:648-53


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Teratogenic effects on fetus in c/o failure of Teratogenic effects on fetus in c/o failure of medical abortion e.g. Mobius syndrome -medical abortion e.g. Mobius syndrome -congenital facial paralysis with or without limbcongenital facial paralysis with or without limbdefect, cranial nerve defect.defect, cranial nerve defect.

Because of a potential teratogenic risk, surgicalabortion is recommended in cases of failed

pregnancy termination


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To sum up Medical Methods of Abortion

Medical methods of termination of pregnancy haveMedical methods of termination of pregnancy haveincreased the choices for women and doctorsincreased the choices for women and doctors

Effective counseling increases the chances of success of Effective counseling increases the chances of success of medical methods of abortionmedical methods of abortion

Medical methods of abortion can go a long way inMedical methods of abortion can go a long way in

increasing access to Safe Abortionsincreasing access to Safe Abortions


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Documents

2 Emergent Techniologies for Early Abortions1