Medical Abort

8/3/2019 Medical Abort

1/41

Frequently asked clinical questionsabout medical abortion

Wo r ld Hea lthOrgan iza t ion


2/41

W HO Lib ra ry Ca ta logu in g -in -Pub lica tion Da taF re que ntly a ske d c lin ic al que stio ns a bo ut m ed ica l a bo rt io n.

"O n 1-5 N ovem be r 2004 , in B ellag io , Ita ly , the U ND P/U NFP AlW H O lW orld B ank S pec ia lP rog ram m e o f R esea rch , D eve lopm en t and R esea rch T ra in ing in H um an R eprod uction (H RP ),o rg an ize d a m ee tin g e ntitle d In te rn atio na l C on se nsus C on fe re nce o n N on -su rg ica l (M ed ica l) A bo rtio nin E arly F irs tT rim este r on Issues R ela te d to R eg im ens and S erv ice D elive ry (A nnex 1). Th is docum en tis the resu lt o f the de libe ra tions o f the pa rtic ipan ts in tha t m ee ting , w ho in cluded h igh ly expe riencedre se arc he rs a nd c lin ic ia ns in th e a re a o f m e dic al a bo rtio n."--B ac kg ro un d.

1 .A bo rtio n, In d uc ed - m e th od s. 2 .A b ortifa cie nt a ge nts . 3 .M ife pris to ne . 4 .P ro sta g la nd in s. 5 .F am ilyp la nn in g s erv ic es . I.In te rn atio na l C on se ns us C on fe re nc e o n N on -s urg ic al (M e dic al) A bo rtio n inE arly F irs t T rim este r o n Issue s R ela te d to R eg im en s a nd S erv ice D elive ry (200 4 : B ella gio , Ita ly )II.U NDP /U N FP AlWHO lW o rld B an k S pe cia l P ro gra mme o f R e se arc h, D ev elo pm e nt a nd R es ea rc hT ra in in g in H um an R e pro du ctio n .III.W o rld H e alth O rg a niz atio n.IV T itle : M e dic al a bo rtio n.ISBN 92 4 159484 5ISBN 978 92 4 159484 4

(N LM c la ss ific atio n: WQ 4 40 )

F requen tl y asked cl in ica l q ue stio ns a bo u t med ic al a bo rtio n Wo rld H e alth O rg an iz atio n 2 00 6A ll r igh ts re se rved . P ub lica tions o f the W orld H ea lth O rgan iza tio n can be ob ta ined from W H O P ress,W o rld H ea lth O rgan iza tio n, 20 A ven ue A pp ia , 1211 G eneva 27 , S witze rlan d (te l.: +41 22791 3264 ;fax : +41 22791 4857 ; e -m ail: booko rde rs@ w ho .in t). R equests fo r pe rm iss ion to re produce o r trans-la te W H O pub lica tions - w he the r fo r sa le o r fo r noncom merc ia l d is tr ibu tion - sh ou ld be add ressed toW H O P re ss, a t the above add ress (fax : +41 22 791 4806 ; e -m ail: pe rm iss ions@ w ho .in t).The des igna tions em ployed and the presen ta tio n o f the m ate ria l in th is pub lica tion do no t im ply theexpress io n o f any op in ion w ha tsoeve r on the pa rt o f the W orld H ea lth O rgan iza tio n conce rn ing thelega l s ta tus o f any coun try , te rrito ry , c ity o r a rea o r o f its au th oritie s , o r conce rn ing the de lim ita tiono f its fro ntie rs o r b ou nd arie s.The m en tio n o f spec ific com pan ies o r o f ce rta in m anu fac tu re rs ' p ro ducts does no t im ply tha t theya re endo rsed o r re com mended by the W orld H ea lth O rgan iza tion in p re fe rence to o the rs o f a s im ila rna tu re tha t a re no t m en tion ed . E rro rs a nd om iss ions exce pted , the nam es o f p rop rie ta ry p roductsa re d is tin gu is he d b y in itia l c ap ita l le tte rs .A ll reasonab le p recau tions have been taken by the W orld H ea lth O rgan iza tion to ve rify the in fo rm a-tion con ta ined in th is pub lica tio n. H ow eve r, the pub lished m ate ria l is be ing d is tr ibu ted w itho ut w ar-ran ty o f any k ind , e ithe r expressed o r im plied . The re spons ib ility fo r the in te rp re ta tion an d use o f them ate ria l lie s w ith the reade r. In no even t sh all the W o rld H ea lth O rgan iza tion be liab le fo r dam agesa ris ing from its use .Th is pub lica tion con ta ins th e co lle c tive v iew s o f an in te rna tiona l g roup o f expe rts and does no t ne c-e ssa rily re pre se nt th e d ec is io ns o r th e sta te d po licy o f th e W o rld H ea lth O rg an iza tio n.P rin te d in


3/41

A C K N O W L E D G E M E N T SWHO is g ra te fu l to th e R o ck efe lle r F ou nd atio n a nd its B ella gio C o nfe re nc e C e nte rfo r p ro vid in g sp ace a nd a cco mm od atio n fo r th e m ee tin g, a nd to Ip as fo r itsfin an cia l c on trib utio n to w ard s th e e ditin g a nd p rin tin g o f th is p ub lic atio n.


4/41


5/41

C O N T E N T SB ackg ro und _In tro duc tio n _P re -a b or tio n c are

1 . W h at co un se llin g is n eed ed by a w om an w ith a n un wan te d p re gna ncyw ho is con tem p la tin g abo rt io n? _2 . W h a t fa cto rs sh ou ld be ta ke n in to a cco un t w he n co un se llin g a w om an

a bou t h e r ch o ice be tw ee n m ed ica l a n d s u rg ica l a bo rt io n? _3 . W ha t a re th e con tra in d ica tio n s to m e d ica l a b o rt io n? _4 . D o a n y o th er ch ara cte ris t ic s o f th e w om an n ee d t o be ta ke n in to a cco un t

in p ro v id in g m ed ica l a bo r tio n ? 105 . H ow sho u ld p re g nan cy be c o n firm ed and ge s ta tio n e s tim a te d ? 116 . W h a t c lin ic al a ss es sm e n t a n d la b ora to ry in ve stig a tio n s a re re q uire d

p rio r to m ed ica l a bo rt io n ? _7 . W h a t s te ps a re n ece ssa ry to m in im ize th e ris k o f un dia gn ose d

e c to p ic p re gn an cy? _R eg im e n fo r m e dica l a bo rtio n

8 . W ha t is th e re comm ende d re g im e n fo r m ed ica l a b o rt io n? 179 . A re o th e r d o se s o f m ife p ris to n e po ss ib le ? 171 0. A re o th e r d o se s o r ro ute s o f a d m in is tra tio n o f th e p ro sta g la nd in

po ss ib le ? 191 1. W h a t a re th e a d va n ta g es a n d d isa d va n ta ge s o f m iso pro sto l v ers usgem ep ro s t? 2012 . Ca n o th e r p ro s ta g la n d in s be used? 201 3. Is th e in te rv al b etw e en a dm in is tra tio n o f m ife pris to ne a n d

p ro s ta g la n d in c ru c ia l? 2114 . C a n a bo r tio n b e in du ce d us in g pro s ta g la n d in a lo n e? 2115 . W ha t pa in re lie f sh ou ld be a va ila b le to w om en du r in g m ed ica l a b o rt io n? __ 22

P o sta b ort io n c are1 6. If a w om a n h as a n in co m ple te a bo rt io n, is it n ece ssa ry to e va cu ate

th e u te rus su rg ica lly? _17 . H ow sho u ld p e lv ic in fe c tio n be d ia g n o se d and tre a te d a fte r a bo rt io n? _18 . H ow s ho u ld t h e succe ss o f m ed ica l a bo rt io n be co n firm ed? _19 . H ow sho u ld e c to p ic p re gnan cy be id e n tif ie d a fte r m ed ica l a bo rt io n ? 2820 . Is t h e re a ris k o f fe ta l a bno rm a lity a fte r a n un succe ss fu l m ed ica l a b o rt io n? __ 2921 . W h ich m eth o d s o f co n tra ce p tio n can a w om an use a fte r m ed ica l a bo rt io n? __ 30

Issu es re la te d to p ro vis io n o f m e dica l a bo rt io n se rv ice sLega l a n d re gu la to ry is su e s _S e tt in g up a m ed ica l a bo rt io n se rv ice _O b ta in in g th e n e ce ssa ry m ed ic in e s _

An nex1 _

3

789

1213

272728

32323334


6/41


7/41

Background

B A C K G R O U N D

O n 1-5 No vem b er 2 00 4, in B e lla g io , Ita ly , t he UNDP /UNFPAlWHO lWo r ldB a nkS pe cia l P ro gramm e o f R e se arc h, D e ve lo pm e nt a nd R e se arc h T ra in in g in H uma nRep ro d u ctio n (HRP ) ,o rg a n iz e d a mee tin g e n title d In te rn a tio n a l C o n s en s usC o n fe re n ce o n N o n -s urg ic al (M e d ic al) A b ortio n in E a rly F irs t T r im e ste r o n Is su es R e la te d toR e gim e ns a nd S erv ic e D e liv ery (A nn ex 1 ). T h is d oc um e nt is th e re su lt o f th e d elib era tio nso f th e p artic ip an ts in th at m e etin g, w h o in clu de d h ig hly e xp erie nc ed re se arc he rs a ndc lin ic ia ns in th e a re a o f m e dic al a bo rtio n.P rio r to th e m e e tin g h e alth -c are p ers on n el p ro vid in g a bo rtio n s erv ic es in v ario us c ou ntrie sw ere a ske d to pro vid e a lis t o f th e m ost fre qu en tly a ske d qu estio ns a bo ut m ed ica l a bo rtio n.T he m ee tin g pa rtic ipa nts re vie we d th ose q ue stio ns a nd co mp ile d a nsw ers to th em ba se do n th e s cie ntific lite ra tu re a nd th eir o w n c lin ic al e xp erie nc e. T he a ns we rs a re p re se nte d int h is pub l i ca t io n .


8/41


9/41

Introduction

I N T R O D U C T I O N

P ro vis io n o f sa fe a bo rtion to th e fu ll e xten t o f the law is a n im po rta nt com pon en t o fre p ro d uc tiv e h e alth s erv ic es . T h e d e ve lo pm e n t o f m e th o ds o f in d uc in g a bo rtio nm e d ic ally (n o n-s urg ic ally ) h a s c re a te d a lte rn a tiv e o ptio n s to m a k e a bo rtio n a va ila bleto w om en in a va rie ty o f h ea lth -ca re se ttin gs . T he to pic h as b ee n re vie we d e xte ns ive ly inth e p ast five ye ars a nd a n um be r o f e vid en ce -ba se d g uid elin es h ave be en p ub lish ed (1-6).It is n ot th e in te ntio n h ere to re pe at th ese g uid elin es , b ut ra th er to p ro vid e a nsw ers tofre qu en tly a sk ed q ue stio ns , b as ed o n a re vie w o f a va ila ble e vid en ce . B y fo cu sin g o np ra ctic al is su es , th e a ns we rs s ho uld b e p artic ula rly h elp fu l to h ea lth -c are p ers on ne l w h oa re c on sid erin g e sta blis hin g, o r a lre ad y p ro vid in g, a s erv ic e fo r m e dic al a bo rtio n in th eea r ly f ir st tr imes t e r.Id ea lly , a n y m e th od o f m e dic al a bo rtio n s ho uld h av e a n o ve ra ll e ffic ac y c om p ara ble to th ato f va cuum a sp ira tio n, i.e . a ra te o f co mp le te a bo rtion o f m ore th an 95% a nd a n on go ingp re gn ancy ra te o f le ss th an 1% .O th er d es ira ble c ha ra cte ris tic s o f a m e th od o f m e dic al a bo rtio n fo r th e e arly firs t tr im e ste ra re th e fo llow in g : it shou ld be e ffe c tive up to 63 days o f ges ta tio n ; it shou ld be easy to adm in is te r; it sho uld be sa fe , an d h ave a cce pta ble s ide -e ffec ts ; b loo d loss sh ou ld be s im ila r to , o r le ss th an , tha t asso cia te d w ith va cuum a sp ira tio n; it shou ld be a ffo rdab le ; it shou ld be w ide ly ava ilab le .T he o nly re gim en th at m ee ts th e e ffica cy cr ite ria is a c om bin atio n o f m ife pris to ne a nd ap ro sta gla nd in - e ith er m is op ro sto l o r g em e pro st. U se o f m ife pris to ne o r a p ro sta gla nd ina lo ne d oe s n ot m ee t th em . U se o f m eth otre xa te in co mb in atio n w ith pro sta gla nd in ca na pp ro ac h th e re qu ire d e ffic ac y, b ut is n ot re comm en de d b ec au se it is te ra to ge nic .T he re comm en da tio ns o n m e dic al a bo rtio n g iv en h ere a re re str ic te d to e ar ly firs ttr im este r (up to 63 da ys s in ce th e firs t da y o f th e la st m en strua l pe rio d - LM P). Alth oug ha dm in is tra tio n o f m ife pris to ne fo llo w ed b y a p ro sta gla nd in w ill te rm in ate p re gn an cy a ta ny s ta ge (a nd in so me co un trie s is lice nse d fo r a bo rtio n u p to 2 4 w ee ks), te rm in atio n o fp re gn an cy w he n g esta tio na l a ge is > 63 d ays is le ss co mm o n, re qu ire s a n in pa tie nt se ttin g,a nd ra is es s ep ara te m e dic al, le ga l a nd s erv ic e is su es .

3


10/41

F requen tly a sk ed questio ns about medic al a bo rtio n

References1 . M e dic al m e th od s fo r te rm in atio n o f p re gn an cy . Gen e va ,Wo r ld He a lth O r g an iz a tio n ,

1 99 7 (WHOTe ch nic al R e po rt S e rie s, N o . 8 71 ).2 . N a tio na l e vid en ce -b as ed c lin ic al g uid elin e: th e c are o f w omen re qu es tin g

induced abor tion. Up da te d g uid elin e s. L on do n, R o ya l C o lle ge o f O b ste tr ic ia n s a n dGynae colo g is ts , 2 0 04.

3 . S a fe a bo rtio n: te ch nic al a nd p olic y g uid an ce fo r h ea lth s ys tem s. Gen e va ,Wo r ld He a lthO rg an iz a tio n , 2 003 .

4 . P ro vid in g medic al a bo rtio n in d ev elo pin g c ou ntrie s: a n in tro du cto ry g uid eb oo k.New Y o rk , G y nu ity H e a lth P ro je cts , 2 00 4.

5 . P ris e e n c ha rg e d e I'in te rru ptio n v olo nta ire d e g ro ss es se ju sq u'a 14 semaines. Paris ,L 'A g e nc e Na tio n ale d 'A c cr ed ita tlo n e t d 'E v alu a tio n e n S a n te (ANAES ),2 0 01 ; a v aila b lea t: < http ://w ww .a na es.fr l> ; a cc ess ed o n 2 2 F eb ru ary 2 00 6.

6 . G uid elin es fo r th e u se o f m ife pris to ne a nd pro sta gla nd in in te rm in atio n o f e arlyp re g na n cy . In : Gu ide line f or fam i ly p lann ing techno logy B e ijin g, S ta te M in is try o f H e a ltha nd F am ily P la nn in g C ommitte e, 2 00 3 [D oc um e nt N o (2 00 3)3 2].

4


11/41


12/41


13/41

Pre -abort ion ca re

1 . W ha t counse llin g is needed by a w om an w ith an unw an tedp re gn an cy w h o is c on tem p la tin g a bo rtio n?

E ve ry w om a n w ith a n u nw an te d p re gn an cy w ho is co nte m pla tin g a bo rtio n sh ou ld re ce iv ec ou ns ellin g fro m a tra in ed h ea lth -c are p ro fe ss io n al w ith c om p re he n siv e k no w le d ge a nde xp erie n ce o f d iffe re n t m e th od s o f a bo rtio n. In fo rm a tio n m u st b e p ro vid ed to e ac h w om an ,re ga rd le ss o f h er a ge o r c ircu msta nce s, in a w ay th at sh e ca n un de rs ta nd , to a llo w h er tom ake h er o wn d ec is io ns a bo ut w he th er to h ave a n a bo rtio n a nd w ha t m eth od to ch oo se .B o th c ou ns ellin g a nd a bo rtio n p ro ce du re s s ho uld b e p ro vid ed a s p rom ptly a s p os sib lew ith o ut u nd ue d e la y. N e ve rth e le ss , c lin ic ia ns s ho uld b e s en sitiv e in re co gn iz in g th at s om ew om en re qu ire a dd itio na l tim e a n d s up po rt in re ac hin g th e ir d ec is io n .A bo rtio n c ou ns ellin g c an ta ke p la ce in a n y h ea lth -c are s ettin g; id ea lly , it s ho uld b e g iv enw h ere th e a bo rtio n p ro ce du re c an b e in itia te d. P riv ate in te rv ie w fa cilit ie s a re e ss en tia l a ndeach w om an shou ld be fre e to choose to be in te rv iew ed a lone o r w ith th e suppo rt o f ap a rtn e r, p a re n t, o r fr ie n d .H e a lth -c a re p ro fe s sio n als p ro v id in g a b ortio n c o un s ellin g m u s t b e fam ilia r w ith th e ir lo c alle ga l fra m ew ork re ga rd in g c on se nt b y w om e n b elo w th e le ga l a ge o f c on se nt. E ac h w om a nsh ou ld re ach h er o wn d ec is io n a nd sh ou ld n ot be co erce d in to in vo lv in g h er pa re nts o rpa rtn er w he re th ere is n o le ga l re qu ire me nt to d o so .I de a lly , p re -a b o rtio n c o u ns e llin g s h o u ld in c lu d e d is c us s io n a b o u t fu tu re c o n tra c e pt iv en ee ds. In h elp in g th e w om a n ch oo se th e m o st a pp ro pria te co ntra ce ptiv e m e th od fo r th efu tu re , it m a y b e u se fu l to e xp lo re th e c irc um sta nc es in w h ich th e u nw an te d p re gn an cyo cc urre d . T he g o al o f c on tra ce ptiv e c ou ns ellin g a nd p ro vis io n in th e c on te xt o f a bo rtio nca re is to b eg in th e c ho se n m e th od im m e dia te ly a fte r a bo rtio n.Fu rthe r r ead ing1 . H ad da d M e t a l. P atie nt su ppo rt a nd e duca tio n fo r p ro mo tin g a dh ere nce to h ig hly

a c tiv e a n tire tro v ira l th e ra p y fo r H I V/A IDS .Cochrane Da tabase Systema tic Rev iews,2000, 3 :CD001442 .

2 . John J. Im p ro v in g q ua lity th ro u gh p a tie n t - p ro v id e r c ommu n ic at io n . J ou rn al o f H ealthCare Marketing, 1991,1 1 :5 1 -6 0 .

3 . L ew in S A e t a l. In te rve ntio ns fo r p ro vid ers to p ro m ote a p atie nt-c en te re d a pp ro ach inc l in i ca l consu l ta t ions . Cochrane Da tabase Systema tic Rev iews, 2001, 4 :CD003267 .

4 . T he P icke r In stitu te . F rom th e patie nt's p ers pe ctiv e: q ua lity o f a bo rtio n c are .Was h in g to n , DC , K a is e r F am ily F o un d atio n , 1 99 9 .

5 . Z ap ka JG e t a l. T he s ile nt c on su me r: w o me n's re po rts a nd ra tin gs o f a bo rtio n se rv ic es .Medic al C a re , 2001 , 3 9 :5 0 -6 0 .

7


14/41

F re qu en tly a ske d clin ic al q ue stio ns a bo ut m ed ic al a bo rtio n

2 . W ha t fac to rs shou ld be taken in to accoun t w hen counse lling aw om an abou t he r cho ice be tw een m ed ica l and su rg ica l abo rtion?

T he re is litt le , if a ny , d iffe re nc e b etw ee n m e dica l a nd s urg ic al a bo rt io n in te rm s o f s afe tya nd e ffica cy . T h us, bo th m e th od s a re s im ila r fro m a m ed ica l p oin t o f v ie w a nd th ere a reo nly ve ry fe w s itua tio ns w he re a re co mm en da tio n fo r o ne o r th e o th er m e th od fo r m ed ica lre aso ns c an b e g iv en .Two s tu d ie s (1 , 2 ) h ave fo un d th at w om en a re m ore like ly to fin d a m e th od o f a bo rtio na cc ep ta ble if th ey h ave ch ose n it th em se lv es . B e in g p ro vid ed w ith a c ho ic e o f m e th od sis se en a s e xtre m ely im p orta nt b y th e m a jo rity o f w om e n u nd erg oin g a bo rtio n (2). Man ys tu die s s ug ge st th at w om e n w ho c ho ose m e dica l a bo rt io n fin d it m o re a cc ep ta ble a t e ar lie rth a n la te r g e sta tio n s (1, 3-5).Medic al a bo rtio n m a y b e p re fe rre d: if it is th e w om an 's p re fe rence ; in ve ry ea rly g es ta tio n ; up to 49 d ay s o f g e sta tio n, m e dic al a bo rtio n is c on sid ere d to b e

m o re e ffe ctiv e th a n s urg ic al a bo rtio n , e sp ec ia lly w h en c lin ic al p ra ctic e d o es n ot in clu ded e ta ile d in s pe c tio n o f a s pira te d tis su e (6);

if th e w om an is se ve re ly obe se (body m ass in dex g re a te r th an 30) b ut d oe s n ot h aveo th er c ard io va sc ula r r is k fa cto rs (s ee q ue stio n 3 ), a s s urg ic al tre atm e n t m a y b ete c h n ic a lly mo r e d iff ic u lt;

if th e w om an has u te rin e m alfo rm atio n s o r a fib ro id u te rus , o r has p re v ious ly h adc e rv ic a l s urg e ry (w h ic h m a y m a k e s urg ic a l a b ortio n te c hn ic ally m o re d iffic ult);

if th e w om an w an ts to a vo id a su rg ica l in te rven tio n.Su rg ic al a bo rtio n ma y b e p re fe rre d: if it is th e w om an 's p re fe re nce , o r if sh e re que sts co ncu rre nt s te riliz atio n; if sh e h as co ntra in dica tio ns to m ed ica l a bo rtio n (se e q ue stio n 3 ); if t im e o r g eo gra ph ica l co ns tra in ts p re clu de th e fo llo w-u p n ee de d to co nfirm th at

a b ortio n is c om ple te .Refe rences1 . H e nsh aw R C e t a l. C om p aris on o f m e dic al a bo rtio n w ith s urg ic al va cu um a sp ira tio n:

w om e n 's p re fe re n ce s a n d a c ce p ta b ility o f tre a tm e n t. B ritis h Medic al J ou rn al, 1 9 93 ,307:714-717.

2 . S la de P e t a l. A co mp ariso n o f m ed ica l a nd su rg ica l te rm in atio n o f p re gn an cy : ch oice ,e m o tio na l im p ac t a n d s atis fa ctio n w ith c are . Br itis h Jour na l o f Obs te tric sand Gynaecology, 1998, 105:1288-1295.

8


15/41

P re -a bo rtio n c are

3 . H o nka ne n H , v on H e rtz en H . U s ers ' p ers pe ctiv es o n m e dic al a bo rtio n in F in la nd .Contracept ion, 2002, 65:419-423.

4 . W in ik off B e t a l. S a fe ty , e ffic ac y a nd a cc ep ta bility o f m e dic al a bo rtio n in C h in a, C ub a,a n d In d ia : a c om pa ra tiv e tr ia l o f m ife p ris to n e im is op ro s to l v e rs us s urg ic al a b ort io n .Ame ric an J ou rn al o f Ob ste tric s a nd Gyne co lo gy , 1997, 176:431-437.

5 . H o nka ne n H e t a l. W H O m ultin atio na l s tu dy o f th re e m iso pro sto l re gim e ns a fte rm ife p ris to n e fo r e a rly m e d ic a l a b ortio n . II: S id e e ffe cts a n d w ome n 's p e rc e ptio n s.BJOG ,2004, 111:1-11.

6 . N atio na l e vid en ce -b as ed c lin ic al g uid elin e: th e c are o f w ome n re qu es tin ginduced abo rt ion . Up d ate d g u id e lin e s. L o nd o n , R o y al C o lle g e o f O b s te tric ia n s a n dGynaeco log i s t s , 2004.

3 . W h at a re th e co ntra ind ica tio ns to m ed ica l ab ortion ?T he re a re v ery fe w a bs olu te c on tra in dic atio ns to m e dic al a bo rtio n. T he y in clu de : p re vio us a lle rg ic re ac tio n to o ne o f th e d rug s in vo lve d; in he rite d po rphy ria ; ch ro nic a drena l fa ilu re ; kn ow n o r suspec ted ec top ic p reg nancy.C au tio n is re qu ire d in a ra ng e o f c irc um s ta nc es in clu din g: if th e w om an is o n lo ng -te rm co rtico ste ro id th era py (in clud in g th ose w ith se ve re ,

uncon tr o lle d as thma ) ; if she has a haem orrhag ic d iso rde r; if she has seve re anaem ia ; if s he h as p re -e xis tin g h ea rt d is ea se o r ca rd io va sc ula r r is k fa cto rs (e .g . h yp erte ns io n

a n d sm o kin g ).

Fu rther r ead ing1 . H ill N CW e t a l. T he p la ce nta l tra ns fe r o f m ife pr is to ne d urin g th e se co nd trim e ste r

a n d its in flu en ce u po n m a te rn a l a nd fe ta l s te ro id c on ce ntra tio ns . B ritis h J ou rn al o fObs te tric s and Gynaecology, 1990, 97:406-411.

2 . L eig h to n B e t a l. P h ys io lo g ic al g lu co co rt ic oid le ve ls re g ula te g lu ta m in e a nd in su lin -m e dia te d g lu co se m e ta bo lism in s ke le ta l m us cle o f th e ra t. S tu die s w ith R U 486(m i fepr is tone) . Biochemis tr y Jou rna l, 1991,274:187-192.

9


16/41

F requen tly a sk ed c lin ic al questio ns about medic al a bo rtio n

4 . D o any o th e r ch a rac te ris tics o f th e w om an need to be taken in toa cc ou nt in p ro vid in g m e d ic al a bo rtio n?

~ Ag e . N eith er a do le sce nce n or o ld er a ge (e .g . o ve r 3 5 ye ars) sh ou ld b e re ga rd ed a s ac o ntra in d ic a tio n to med ic a l a b o rtio n .~ An aem ia . T his n ee d n ot b e re ga rd ed a s a c on tra in dic atio n. H o we ve r, a na em ia d ete cte da t th e tim e o f a bo rtio n sh ou ld be tre ate d. A ve ra ge b lo od lo ss in m ed ica l a bo rtio n m a y bem o re th an th at in s urg ic al a bo rtio n (1), a nd th e in cid en ce o f h ea vy b le ed in g m ay be h ig he r.~ B reas tfe ed in g. It is lik ely th at m ife pris to ne p as se s in to b re as t m ilk . S tu die sin ve stig atin g th e e nd oc rin e e ffe cts o f m ife pr is to ne o n th e fe tu s h av e fo un d in cre as ed le ve lso f a d re n oc ortic otro p ic h o rm o n e a n d c ortis ol (2). T he c lin ic al im p lic atio ns o f th es e c ha ng esa re u n cle a r.S m all a mo un ts o f m iso pro sto l a lso e nte r b re as t m ilk so on a fte r a dm in is tra tio n, b ut it isn ot kn ow n w he th er th is co uld h ave a ny e ffe ct o n th e in fa nt. A s m iso pro sto lle ve ls d ec lin era pid ly , it h as b ee n re co mm e nd ed th at m iso pro sto l sh ou ld b e ta ke n im m ed ia te ly a fte r afe ed a nd th e n ext fe ed g ive n a fte r fo ur h ou rs in ca se o f o ra l a dm in is tra tio n (3). A fte r v a gin a la dm in is tra tio n, m is op ro sto lle ve ls s ta y h ig h fo r lo ng er, a nd th e fe ed s ho uld p re fe ra bly b eg iv en m o re th an s ix h ou rs la te r. U n fo rtu na te ly , th e a va ila ble d ata d o n ot a llo w a p re cis ere comm en da tio n o n o ptim um tim in g.~ In su lin -d ep en den t d ia be te s o r th yro id d is ord er. T he re is n o e vid en ce th at m ed ica la b ortio n c au se s p artic ula r p ro b lem s in w om e n w ith th e se d is ord e rs . H ow e ve r, m ife pris to n eh as b ee n s ho wn to a lte r in su lin s en sitiv ity i n v it r o (4 ) and these e ffe c ts m ayo r m ay no t bere fle cte d in b lo od s ug ar a nd in su lin le ve ls .~ M ultip le p reg nan cy (cu rren t g es ta tio n). Th ere is no e vid en ce tha t the fa ilu re ra te o fm ed ica l a bo rtio n is in cre ase d o r th at a d iffe re nt d osa ge re gim en is re qu ire d in th e ca se o fmu l tip le p regnancy .~ O bes ity . T he re is n o e vid en ce th at th e fa ilu re ra te o f m ed ica l a bo rtio n is in cre ase d o rth at a d iffe re nt d osa ge re gim en is re qu ire d in o be se w om en .~ P rev io us C aesa re an sec tio n . Th ere is e vid en ce from o ne s tud y th at th e sa fe ty a nde ffic ac y o f e ar ly m e dic al a bo rtio n a re u na ffe cte d b y p re vio us C a es are an s ec tio n (5).~ Sm o k in g . T he re is n o e vid en ce o f in te ra ctio n b etw ee n th e risks o f sm ok in g a ndm e d ic al a b ortio n . H ow e ve r, sm o kin g c on trib ute s to c ard io va sc ula r ris k a n d th is fa cto rs ho uld b e c on sid ere d w h en a ss es sin g a w om an 's o ve ra ll s uita bility fo r m e dic al a bo rtio n.~ U te rin e m a lfo rm a tio ns , c on ge nita l a nd a cqu ire d; p re vio us c erv ic al s urg ery . The reis n o e vid e nc e th a t th e se re pre se n t c on tra in d ic atio n s.

10


17/41

P re- abo rtion care

References1 . C ha n Y F, Ho P C, M a H K. B lo od lo ss in te rm in ation o f e ar ly p reg nan cy by va cuum

a sp ira tio n a nd b y c om b in atio n o f m ife pris to ne a nd g em e pro st. Cont racep tion , 1993 ,47:85-95.

2 . H ill N CW e t a l. T he p la ce nta l tra ns fe r o f m ife pris to ne d urin g th e se co nd tr im este ra nd its in flu en ce u po n m a te rn al a nd fe ta l s te ro id c on ce ntra tio ns . B ritis h J ournal o fObs te tr ic s and Gynaecology, 1990, 97:406-411.

3 . V og el 0 e t a l. M iso pro sto l ve rsus m e th yle rg om etrin e: ph arm aco kin etic s in h um an m ilk .Ame ric an Journal o f Obs te tric s and Gyneco lo g y, 2004, 191 :2168-2173.

4 . L eig hto n B et a l. P h ys io lo gic al g lu co co rtic oid le ve ls re gu la te g lu ta m in e a nd in su lin -m e dia te d g lu co se m eta bo lism in ske le ta l m usc le o f th e ra t. S tu die s w ith R U 486(mifepr is tone). B iochem ist ry Journa l, 1991,274:187-192.

5 . Xu J e t a l. T erm in atio n o f e ar ly p re gn an cy in th e s ca rre d u te ru s w ith m ife pr is to ne a ndmisopros to l . I nte rna tional Jou rna l o f Gynaecology and Obs te tr ic s , 2001,72:245-251.

5 . H ow shou ld p regnancy be con firm ed and ges ta tio n es tim a ted?In m ost ca ses , p re gn ancy ca n be co nfirm ed a nd its le ng th es tim ate d o n th e bas is o f thew oma n's h is to ry a nd a p hy sic al e xam in atio n. O c ca sio na lly , la bo ra to ry te sts m a y b e n ee de dw he n th e typ ica l s ig ns o f p re gn an cy a re n ot c le arly p re se nt a nd th e h ea lth -ca re p ro vid er isu nsu re w he th er th e w om an is p re gn an t.U ltra so un d s ca nn in g is n ot n ec es sa ry fo r th e p ro vis io n o f e ar ly a bo rtio n. W h e re u ltra so un de qu ip me nt is a va ila ble , a sca n ca n h elp id en tify a n in tra ute rin e p re gn an cy a nd e xc lud e a ne cto pic o ne a fte r a bo ut s ix w ee ks. It a lso h elps d ete rm in e g esta tio na l a ge a nd d ia gn os ep ath o lo g ie s o r n o n-v ia bility o f a p re g na n cy .

Fu rthe r r ead ing1 . S afe a bo rtio n: te ch nic al a nd p olic y g uid an ce fo r h ea lth s ys tem s. Geneva ,Wo r ld H e a lth O r g a niz a tio n , 2003.

2 . N atio na l e vid en ce -b as ed c lin ic al g uid elin e: th e c are o f w omen re qu es tin ginduced abort ion . Up da te d g uid e lin e s. L on d on , R o ya l C o lle g e o f O b ste tric ia n s a n dGynaeco log is ts , 2004.

11


18/41


6 . W h at c lin ic al as se ss m en t a nd la bo ra to ry in ves tiga tion s a re requ iredp rio r to m e d ic al a bo rtio n?

A s fo r a ny m e th od o f a bo rtio n, c lin ic al h is to ry -ta kin g s ho uld s erv e to id en tifyc on tra in d ic atio n s (s ee q ue stio n 3 ) a n d to id e ntify r is k fa cto rs fo r c om p lic atio n s.H is to ry -ta kin g s ho uld in clu d e: p ers on a l a n d fam ily h is to ry o f re le va n t d is ea se s; c urre n t u seo f m e d ic atio n s a n d k now n a lle rg ie s; o bs te tric a n d g yn a ec olo g ic al h is to ry , in clu d in g e cto picp re g na n cie s; a n y b le e din g te n de n cie s; a n d h is to ry o f s ex ua lly tra n sm itte d in fe ctio n s(S Tls ). S o cia l h is to ry s ho uld in clu de ris k a ss es sm e nt fo r S Tls , t ak in g in to a cc ou nt lo ca l S TIp re va le nc e ra te s. T he c lin ic ia n m u st b e a le rt to th e p os sib ility o f v io le nc e o r c oe rc io n in th ec on te xt o f th e u nw a nte d p re gn an cy .B a sic ro utin e o bs erv atio ns (p uls e, b lo od p re ss ure , a nd tem pe ra tu re ) a re u se fu l a s abase l ine .T he re a re n o la bo ra to ry te sts th at a re e ss en tia l b efo re m e dic al a bo rtio n. H o we ve r, t es tss uc h a s h aem og lo bin le ve l, b lo od g ro up a nd rh es us (R h ) ty pin g, a nd s cre en in g fo r h ep atitis ,h um a n imm un od efic ie nc y v iru s (H IV ),a nd S Tls , m a y b e o ffe re d o n th e b as is o f in d iv id ua lris k fa cto rs o r a va ila ble re so urc es . Id ea lly , s erv ic es s ho uld o ffe r te stin g fo r p ath og en s in th elo w er g en ita l tra ct, a nd tre at w om en fo un d p os itiv e.Rhesus s ta tus . T he p re va le nc e o f R h -n eg ativ e s ta tu s v arie s m a rk ed ly w ith e th nic ity , b ein gh ig he st am on g C a uc as ia ns . F or p re gn an cie s u p to 6 3 d ay s g es ta tio n, th e th eo re tic al ris ko f m ate rn al R h se ns itiz atio n is ve ry lo w; th ere is n o e vid en ce th at se ns itiz atio n o ccurs a tth is s ta ge o f p re gn an cy. T hu s, d ete rm in atio n o f b lo od g ro up a nd R h sta tu s a nd th e o ffe ro f a nti-D p ro ph yla xis to R h -n eg ativ e w ome n a re n ot c on sid ere d p re re qu is ite s fo r e ar lym e dic al a bo rtio n. In s ettin gs w h ere th e p re va le nc e o f R h -n eg ativ e s ta tu s is h ig h, a ndw h ere re so urc es p erm it, th e o ffe r o f R h ty pin g a nd a nti-D p ro ph yla xis c ou ld b e w o rth w hilea s p re ca utio na ry c om p on en ts o f m e dic al a bo rtio n c are .

Fu rthe r r ead ing1 . T ho ng K J, N orm an JE , B aird O T .C ha ng es in th e c on ce ntra tio n o f a lph a-fe to pro te in a nd

p la ce nta l h orm o ne s fo llo w in g tw o m e th od s o f m e dic al a bo rtio n in e ar ly p re gn an cy .B ritis h J ou rn al o f Ob ste tric s a nd Gynaecolo gy , 1993, 100: 1111-1114.

2 . N aik K e t a l. T he in cid en ce o f fe to ma te rn al h ae mo rrh ag e fo llo win g e le ctive te rm in atio no f firs t-tr im e s te r p re g n an c y. Eu ropean Journa l o f Obs te tric s, Gyneco logy andReproduc tive B iology, 1988, 27:355-357.

3 . F ia la C , F ux M, Gemze ll-Oa n ie ls so n K . Rh -p ro p h yla x is in e a rly a b o rtio n . Ac ta Obs te tr icae t Gyneco log ica Scand inavica , 2003, 82:892-903.

12


19/41

Pre -abort ion ca re

4 . Ja ba ra S , B arn ha rt K T. Is R h im m un e g lo bu lin n ee de d in e ar ly firs t-tr im e ste r a bo rtio n?A re vie w . Ame ric an J ou rn al o f Ob ste tric s a nd Gyne co lo gy , 2003 , 1 8 8 :6 2 3- 62 7 .

5 . S te venson MM , Rad c liffe KW .P re v e n tin g p e lv ic in fe c tio n a fte r a b o rtio n . InternationalJourna lo fSTDandAIDS, 1995,6 :305-312.

6 . P e nn e yGC . P re ve n tin g in fe ctiv e s eq ue la e o f a bo rtio n. Human Rep ro du ctio n, 1 9 97 ,1 2 (1 1 S u pp l): 1 07 -1 12 .

7 . S tu bb le fie ld PG ,G rim e s D A . C u rre nt c on ce pts : s ep tic a bo rtio n. New E nglan d J ou rn al o fMedic ine, 1994 , 331 :310 -314 .

8 . B la ckw ell A L e t a l. H ea lth g ain s fro m scre en in g fo r in fe ctio n o f th e lo we r g en ita l tra ct inw om en a tte n din g fo r te rm in a tio n o f p re gn a nc y. TheLance t , 1993 , 342 :206 -210 .

7 . W ha t s tep s a re necessa ry to m in im ize the ris k o f und iagnosedec to p ic p re g n an cy?

M ife pris to n e a nd m is op ro sto l a re n o t tre a tm e nts fo r e cto pic p re gn a nc y, w h ic h, if p re se nt,w ill c on tin ue to g ro w . If m e d ic al a bo rtio n is c on tem pla te d v ery e a rly in g es ta tio n , i.e . b efo rea n in tra ute rin e p re g na n cy c an b e d ia g no se d w ith u ltra so un d , c lin ic ia n s m u st b e p artic ula rlya le rt to th e p os sib ility o f e cto pic p re gn a nc y. T h e y s ho uld c he ck w h eth er th e u te ru s fe e lss ma lle r th an e xp ec te d a cc ord in g to th e d ate o f th e w om a n's la st m e ns tru al p er io d. W om e ns ho uld b e to ld to s ee k m e dica l a dv ice p ro m ptly if th ey e xp erie nc e s ym p to m s a nd s ig nsth at m a y in dic ate e cto pic p re gn a nc y, s uc h a s a bd om in a l p ain o n o ne s id e . V e rific atio no f e xp uls io n in th ese ve ry e arly c ase s c an b e d on e o nly b y co m pa rin g h um a n ch orio nicg on a do tro ph in (h CG )le ve ls p rio r to th e tre atm e n t a n d a t fo llo w -u p (s ee q ue stio n 1 9).Wh e r e c lin ic a l fe a tu re s (e .g . h is to ry o f e c to p ic p re g n an c y o r S T I, d is cre p an c y b e tw e e nm e n stru al d ate s a n d u ltra so un d a pp ea ra nc e, v ag in a l b le ed in g, o r p elv ic p ain ) ra is es us pic io n o f a n e cto pic p re gn a nc y, a pp ro pr ia te te sts s ho uld b e d on e . If e cto pic p re gn a nc yis d ia g no se d o r s tro n gly s us pe cte d, th e w om an s ho uld b e tra ns fe rre d to a n a pp ro pr ia teg y na e co lo g y s erv ic e fo r c o ntin u in g c a re .

Fu rthe r r ead ing1 . K en ig sb erg D e t a l. M e dica l tre atm e nt o f re sid ua l e cto pic p re gn an cy: R U 48 6 a nd

me tho t r exa te . Fer ti li ty and Steri li ty , 1987,47 :2-3 .2 . U lm a n n A , D u bo is C . A nti-p ro ge ste ro n es in o bs te tr ic s, e cto pic p re gn an cie s a nd

gynaeco lo g ic a l ma l ig nanc ie s . Ba illie re 's C l in ic a l Obs te tric s and Gynaeco logy, 1988,2:631-638.

3 . L iu F e t a l. M ife pris to ne in th e tre atm en t o f 47 e cto pic p re gn an cy pa tie nts .H unan Y iK e D a Zue Zue B ao, 1998, 2 3 :2 6 5- 26 8 .

13


20/41


4 . G azavan i M R e t a l. M ife pr is to ne in c om b in a tio n w ith m e th otre xa te fo r th e m e d ic altre a tm e n t o f tu b al p re g na n cy : a ra n d om is e d c o ntro lle d tr ia l. Human Reproduc tion ,1998, 1 3 :1 9 8 7- 19 9 0 .

5 . F ia la C e t a l. V er ify in g th e e ffe ctive ne ss o f m e dic al a bo rtio n; u ltra so un d v ersu s h CGtes t ing . Eu ropean Journal o f Obs te tric s, Gyneco logy and Rep roductiv e B io logy, 2003 ,109 :190 -195 .

6 . E dw ard s J, C arso n S A. N ew te ch no lo gie s pe rm it sa fe a bo rt io n a t le ss th an 6 w ee ks 'g es ta tio n a n d p ro vid e tim e ly d ete ctio n o f e cto pic g e sta tio n . Americ al J ou rn al o fObs te tr ics and Gyneco logy, 1997 , 176 :1101 -1106 .

7 . K elly A J, S ow te r M C ,T rin de r J. The managemen t o f tu ba l p re gnan cy . L o nd o n , R o y alC o lle g e o f O b s te tr ic ia n s a n d G y n ae c olo g is ts , 2 00 4 (RCOGGu id e lin e N o . 2 1).

14


21/41


22/41


23/41

R egim en for m edical abortion

8 . W h at is th e recom m en ded reg im en fo r m ed ic a l abo rt io n?T he re co mm en de d re gim en fo r m ed ica l a bo rtio n is 200 mg o f m ife pr is to ne g iv en o ra lly ,fo l lowed 36-48 h ours la te r by a pro sta gla nd in - e ith er 0.8 m g o f m iso pro sto l o r 1 mg o fg em ep ro st - g ive n va gin ally (1 , 2 ). T his co mb in atio n re su lts in co mp le te a bo rtio n in m oretha n 96% o f ca ses ; th e ra te o f con tin uing p re gna nc ie s is le ss th an 1% in ge sta tion s up to63 d a ys ' ameno rrh o e a (3-5).M iso pro sto l ca n a lso be g iven o ra lly a t a d ose o f 0.4 m g, bu t o win g to th e h ig he r fa ilu rera te w ith d os e, it is re co mm en de d th at o ra l m iso pro sto l u se a t th is d osa ge b e re str ic te d tove ry e arly p re gn an cy - i.e . < 50 days .

References1 . S afe a bo rtio n: te ch nic al a nd p olic y g uid an ce fo r h ea lth s ys tem s. Geneva ,Wo r ld H e a lth O r g a niz a tio n , 2003.

2 . N atio na l e vid en ce -b as ed c lin ic al g uid elin e: th e c are o f w omen re qu es tin g in du ce dabort ion. L o n do n , Ro y al C o lle g e o f Ob s te tric ia n s a n d Gyna ec o lo g is ts , 2004.

3 . A sho k PW e t a l. Fa cto rs a ffe ctin g th e o utcom e o f e ar ly m ed ica l abo rtio n: a re vie w o f4132 c o ns e cu tiv e c a se s . 8JOG, 2002, 109:1281-1289.

4 . S ch aff E A , F ie ld in g S L,W e sth off C . R a nd om iz ed tr ia l o f o ra l v ers us v ag in al m is op ro sto l2 d a ys a fte r m i fe p ris to n e 200 m g fo r a bo rtio n up to 63 d a ys o f p re g na n cy .Contracept ion, 2002, 66:247-250.

5 . S ch aff E A e t a l. Lo w-d ose m ife pris to ne fo llo we d by va gin al m iso pro sto l a t 48 h o u rs fo ra bo rtio n u p to 63 days . Contracept ion, 2000, 61:41-46.

9 . A re o th e r d o ses o f m ifep r is to n e po ss ib le?B o th m ife pr is to ne a nd p ro sta gla nd in s, g iv en a lo ne , m a y le ad to a bo rtio n; h ow e ve r, th eyh ave e ith er a lo w e ffe ctive ne ss o r a h ig h ra te o f s id e-e ffe cts . In co mb in atio n, th ey a cts yn erg is tic ally . T he c ha lle ng e, th ere fo re , is to fin d a re gim e n c om b in in g th e lo w es t d os esfo r b oth d ru gs th at is h ig hly e ffe ctive a nd h as fe w s id e-e ffe cts . In a dd itio n, in m an y pa rts o fth e w o rld , c os t c on sid e ra tio n s a re im p orta n t.In m an y co un trie s, m ife pr is to ne is lice nse d fo r use a s a s in gle o ra l d os e o f 600 mg.H ow eve r, t he re is n o e vid en ce th at a d ose o f g re ate r th an 200 m g is n ece ssa ry fo r o ptim a le ffe ct w h en fo llo w ed b y a s uita ble p ro sta gla nd in (1 -4 ). S om e s tu die s h av e in dic ate d th atm ife pr is to ne ca n b e g ive n a s five o r s ix d iv id ed d ose s o f 25 m g o ve r th re e d ays, fo r a to ta ld ose o f 125-150 mg (5). Th is reg im en is w ide ly used in C hina and has been show n to

17


24/41

Frequently asked questions about m edical abortion

be h ig hly e ffe ctive u p to 49 d ays o f g es ta tio n w he n use d in c om bin atio n w ith a su ita blep ro sta gla nd in . H o we ve r, f or s erv ic e d eliv ery a nd p atie nt c on ve nie nc e, th e s in gle d os e o fm ife p ris to n e is p re fe rre d .A 50 m g do se o f m ife pris to ne h as bee n sh ow n to be less e ffe ctive tha n a 200 m g d ose ,w h en g iv en in c om b in atio n w ith g em e pro st v ag in ally (6 ). S tu die s a re c on tin uin g toin ve stig a te th e m in im um e ffe ctiv e d o se o f m ife pr is to n e.

References1 . W o rld H e alth O rg an iz atio n T as k F orc e o n P o st-o vu la to ry M e th od s fo r F ertility

R e g ula tio n . T e rm in a tio n o f p re g na n cy w ith re d uc ed d o se s o f m ife pr is to n e.Britis h Med ical J ournal, 1993, 307:532-537.2 . W o rld H e alth O rg an iz atio n T as k F orc e o n P o st-o vu la to ry M e th od s fo r F ertilityR e gu la tio n. C omp aris on o f tw o d os es o f m ife pr is to ne in c om b in atio n w ith m is op ro sto lfo r e ar ly m e dic al a bo rtio n: a ra nd om iz ed tr ia l. BJOG,2000, 107:524-530.

3 . W o rld H e alth O rg an iz atio n T as k F orc e o n P o st-o vu la to ry M e th od s fo r F ertilityR e g ula tio n . M e d ic al a bo rtio n a t 57 to 63 d ays g esta tio n w ith a lo we r d ose o fm ife pr is to n e a n d g em ep ro st. A ra n dom iz e d c on tro lle d tria l. Ac ta Obste tric a e tGyneco log ica Scand inav ica , 2001, 80:447-451.

4. M cK in le y C ,Th ong K J, B aird O T.Th e e ffec t o f do se o f m ife pris to ne a nd g esta tio n o n thee ffic ac y o f m e d ic al a b ortio n w ith m ife pr is to n e a n d m is op ro sto l. Human Reproduct ion ,1993, 8:1502-1505.

5 . W o rld H e alth O rg an iz atio n T as k F orc e o n P o st-o vu la to ry M e th od s fo r F ertilityR e g ula tio n . P re g na n cy te rm in a tio n w ith m ife p ris to n e a n d g em ep ro st: a m u ltic en te rc om p aris on b etw e en re pe ate d d os es a nd a s in gle d os e o f m ife pris to ne . Fertilit y andSterility, 1991,56:32-40.

6 . Wo r ld H e a lth O r ga n iz atio n T a sk F o rc e o n P o st-o vu la to ry Me th o ds fo r F e rtilityR e gu la tio n. L ow e rin g th e d os es o f m ife pr is to ne a nd g em e pro st fo r e ar ly a bo rtio n: ara n d om is e d c o ntr olle d tr ia l. BJOG, 2001, 108:738-742.

18


25/41


10 . Are o th er doses o r rou tes o f adm in is tra tion o f the p ros tag lan dinposs ib le?

V ag in al a dm in is tra tio n o f m is op ro sto l is m o re e ffe ctiv e a nd a ss oc ia te d w ith fe w ers id e-e ffe cts th an o ra l a dm in is tra tio n o f th e s am e d os e (1-4). H owe ve r, if th e w oma np re fe rs to ta ke th e d ru g o ra lly , a nd th e g esta tio na l a ge is le ss th an 50 d a ys LMP ,tw ota ble ts o f 0.2 m g o f m iso pro sto l ca n b e ta ke n o ra lly 36-48 h o urs a fte r th e m ife p ris to n edose (5). If th e g esta tio na l a ge is 50 d ay s o r m o re LMP,o ra l a dm in is tra tio n o f m is op ro sto l isn ot re comm en de d b ec au se o f its h ig he r fa ilu re ra te .In s om e s tu die s, re pe ate d d os es o f m is op ro sto l h av e b ee n u se d, e ith er ro utin ely fo r a llw om en o r in th ose w ith e vid en ce o f in co mp le te a bo rtio n (1 , 6 , 7 ). R e pe ate d d os es a rea ss oc ia te d w ith a n in cre a se d in cid e nc e o f p ro sta g la n din -re la te d s id e -e ffe cts . T h ere isin su ffic ie nt e vid en ce a t th e m om en t th at th e o ve ra ll e ffic ac y is in cre as ed b y u sin g re pe ate ddoses o f p ro s tag la nd in '.L ow e r v ag in al d os es a nd d iffe re nt ro ute s o f a dm in is tra tio n, e .g . b uc ca l a nd s ub lin gu al, o fm i so p ro s to l a re c u rr en tly u n d er in v es tig a tio n .References1 . vo n H ertz en H e t a l. W H O m ultin atio na l s tu dy o f th re e m iso pro sto l re gim en s a fte r

m ife pr is to n e fo r e a rly m e d ic al a bo rtio n . I: E ffic ac y. 8JOG, 2003, 110:808-818.2. E I-R e fa ey H e t a l. In du ctio n o f a bo rtio n w ith m ife pr is to ne (R U 486) a nd o ra l o r va gin al

m isopros to l . New Engla nd J ou rn al o f M edic in e, 1995,332:983-987.3 . H on ka ne n H e t a l. W H O m ultin atio na l s tu dy o f th re e m iso pro sto l re gim en s a fte r

m ife pr is to n e fo r e a rly m e d ic al a bo rtio n . II: S id e e ffe cts a n d w ome n's p erc ep tio n s.8JOG, 2004, 111 :715-725.

4 . S ch aff E A , F ie ld in g S L,W e sth off C . R a nd om iz ed tr ia l o f o ra l v ers us v ag in al m is op ro sto l2 d a ys a fte r m i fe p ris to n e 200 m g fo r a bo rtio n up to 63 d a ys o f p re g na n cy .Contracept ion, 2002, 66:247-250.

5 . S afe a bo rtio n: te ch nic al a nd p olic y g uid an ce fo r h ea lth s ys tem s. Gene va ,Wo r ld H e a lthOrgan iza t ion , 2003.

6 . C ah ill S , G allo M , C astle ma n L . M o re th an o ne d ose o f m iso pro sto l in m ed ica l a bo rtio na t less th an te n w ee ks o f g es ta tio n Contracept ion, 2006, 74:36-41.

7 . A sho k PW e t a l. Fa cto rs a ffe ctin g th e o utcom e o f e ar ly m ed ica l abo rtio n: a re vie w o f4132 c o ns e cu tiv e c a se s . 8JOG, 2002, 109:1281-1289.

, A lthough no t cove red in these gu ide line s, abo rtion in la te first tr im este r and in the second trim es te ro f p re gn an cy u su ally re qu ire s re pe at a dm in istra tio n o f p ro sta gla nd in s.

19


26/41


11 . W h at a re the advan tages and d isadvan tages o f m isop ros to lv e rsu s gemep ro st?

M is op ro sto l is ch ea pe r th an g em e pro st a nd is s ta ble a t ro om te m pe ra tu re . G e me pro st isfo rm ula te d fo r use a s 1 m g va gin al p essa rie s a nd n ee ds to be ke pt fro ze n un til a bo ut h alfa n h ou r b efo re u se . S o m e s tu die s re po rt th at se ve re p ain is m o re co mm on a fte r g em e pro stc om pa re d to m is o pro sto l (1,2). A lth ou gh m iso pro sto l is fo rm u la te d fo r o ra l u se , it is m o ree ffe c tiv e if g iv e n v ag in a lly o r s ub lin g ua lly (3-5).References1 . S ve nd se n P F e t a l. C o mp aris on o f g em e pro st a nd v ag in al m iso pro sto l in firs t tr im e ste r

m i fe p r is to ne - in duced abo r tio n . Contraception, 2005 , 7 2 :2 8 -3 2 .2 . C e le nta no C e t a l. O r al m is op ro sto l v s. v ag in a l g em ep ro st p rio r to s urg ic al te rm in atio no f p re g na n cy in n u llip a ra e . Ac ta Obs te tric a e t Gyneco logica Scand inav ica, 2004 ,83:764-768.

3 . E I-R efa ey H e t a l. In du ctio n o f a bo rtio n w ith m ife pris to ne (R U 4 86 ) a nd o ra l o r v ag in alm isopros to l . New Engla nd J ou rn al o f Medic in e, 1995,332:983-987.

4 . Ta ng a s e t a l. A p ro sp ec tiv e, ra nd om iz ed , p la ce bo -c on tro lle d tr ia l o n th e u se o fm ife pris to n e w ith s ub lin gu al o r v ag in a l m is op ro sto l fo r m e d ic al a bo rtio n s o f le ss th an9 w e ek s g es ta tio n . Human Reproduct ion , 2003, 1 8 :2 3 15 -2 3 1 8.

5 . Ta ng a s e t a l. A p ro sp ec tiv e ra n dom iz ed c om p aris on o f s ub lin gu al a n d o ra l m is op ro sto lw he n co m bin ed w ith m ife pr is to ne fo r m e dica l a bo rtio n a t 1 2-2 0 w ee ks ' g es ta tio n.Human Reproduc tion , 2005 , 20 :3062 -3066 .

12 . Can o ther p ros tag land ins be used?A n um be r o f p ro sta gla nd in s th at w ere u se d in th e p as t, s uc h a s s ulp ro sto ne a nd 1 5-m e th ylp ro sta g la n d in F2a, a re n o lo ng er u se d b eca use o f th eir a dv erse s id e-e ffe cts o r re la tive la cko f e ff i c a cy (1).Reference1 . S an g G e t a l. A la rg e-sca le in tro duc to ry tr ia l o n te rm in atio n o f e arly p re gn an cy b y

m ife p ris to n e in c om bin a tio n w ith d iffe re n t p ro s ta g la n d in s . Ch inese Journa l o f C l in ic alPharmacology, 1999, 1 5 :3 2 3 -3 2 9 .

20


27/41


13 . Is th e in te rv al b etw een a dm in is tra tio n o f m ifep ris to ne a ndp ro s ta g la n d in c ru c ia l?

Th e lice nse d a nd m ost co mm on ly use d in te rva l, o f 36 -4 8 h ou rs (1 , 2 ), c o rre s po n d s to th etim e w h en th e u te ru s is m o st s en sit iv e to p ro sta gla nd in a fte r p rim in g w ith m ife pris to ne ;h en ce th e th era pe utic d os e c an b e re du ce d to th e m in im um. T his in te rv al w as a lso fo un dto b e th e m o st e ffe ctiv e in in itia l s tu die s w he n u te rin e co ntra ctility w as m e as ure d a td iffe re n t tim e s b e tw e e n a dm in is tra tio n o f m ife p ris to n e a n d o f p ro sta g la n d in (3). It h as b ee ns ho wn re ce ntly , h ow eve r, th at th e in te rv al c an b e sh orte ne d to 2 4 h ou rs o r le ng th en ed to72 h ou rs , w ith ou t lo ss o f e ffica cy , w he n m ife pr is to ne is use d in co mb in atio n w ith 0 .8 m g o fv a g in a lly a dm in is te re d m i so p ro s to l (4 , 5 ). I f m iso pro sto l is g ive n a s a n o ra l d ose o f 0 .4 m g,th e in te rv al o f 3 6-4 8 h ou rs sh ou ld b e a dh ere d to . O th er tim e in te rva ls a re cu rre ntly b ein gs tud ied (6).References1 . v on H e rtz en H e t a l. W H O m ultin atio na l s tu dy o f th re e m is op ro sto l re gim e ns a fte r

m ife p ris to n e fo r e a rly m e d ic a l a b ortio n . I: E ffic a cy . BJOG, 2003, 1 1 0:8 0 8 -8 1 8.2 . M IF E PREX (m ife pr is to n e) T ab le ts , 2 00 m g ; fo r o ra l a dm in is tra tio n o nly . A va ila ble a t:

< h ttp ://www . e a rly o p tio n p ill.c om /p d fs /p re s cr ib in g 0 7 19 0 5 .p d f> ; a c ce s s ed o n1 7 F eb ru ary 2 00 6.

3 . S wa hn M L , B yg de ma n M . T he e ffe ct o f th e a ntip ro ge stin R U 4 86 o n u te rin e co ntra ctilitya n d s e ns itiv ity to p ro sta g la n d in a n d o x yto c in . B ritis h J ou rn al o f O b ste trics a ndGynaecology, 1988 , 9 5 : 1 2 6 -1 3 4 .

4 . S ch aff E A e t a l. V ag in al m is op ro sto l a dm in is te re d 1 , 2 , o r 3 d ays a fte r m ife pris to ne fo re a rly m e d ic a l a b ortio n : a ra n dom iz e d tr ia l. J AMA , 2000, 2 8 4:1 9 4 8- 19 5 3 .

5 . S ch a ff E A , F ie ld in g S L ,W e sth o ff C . R a nd om iz ed tr ia l o f o ra l v ers us v ag in a l m is op ro sto la t o n e d a y a fte r m ife pris to n e fo r e ar ly m e d ic al a bo rtio n. Contracept ion, 2001 ,64 :81-85 .

6 . C re in in M D e t a l. A ran dom ized com pa rison o f m isop ro s to l 6 to 8 h ou rs ve rsus 24h o urs a fte r m ife p ris to n e fo r a b ortio n . Obs te tr ic s and Gyneco logy, 2004, 1 0 3 :8 5 1 -8 5 9 .

14 . C an ab ortio n b e in du ced u sin g p ro stag la nd in a lo ne?I t is p os sib le to in du ce a bo rtio n in e a rly p re gn a nc y u sin g p ro sta gla nd in s a lo n e. H o w ev er,e ve n th e m o st e ffe ctiv e re g im e n s, in vo lv in g re pe ate d re la tiv ely la rg e d o se s o f m is op ro sto l(0 .8 m g ) o r g em e pro st (1 m g ) va gin ally , a re le ss e ffe ctive a nd h av e m o re s id e-e ffe cts th anth e c om bin a tio n re g im e n s w ith m ife p ris to n e p re tre a tm e n t.

21


28/41


T he re is in su ffic ie nt e vid e nc e to s up po rt re comm e nd a tio n s o n th e d o se , ro ute o fa dm in is tra tio n a nd tim in g o f re g im e n s u sin g p ro sta gla n din s a lo ne . R e po rte d c as e s er ie ss ug ge st th at re pe ate d a dm in is tra tio n o f 0 .8 m g o f va gin al m is op ro sto l is n ee de d. T h e o nlyra n dom iz ed s tu dy (y et u np ub lis he d), th a t c om p are d a s ho rt (3 -h ou r) a nd a lo n g (1 2-h ou r)in te rv al b etw e en v ag in al a nd s ub lin g ua l d os es , d em o n stra te d th at if m is op ro sto l is g iv ens ub lin g ua lly , it h as to b e a dm in is te re d a t th e s ho rte r in te rv al to h av e a s im ila r e ffe ctiv en es sa s v a g in a l a dm in is tr atio n .Fu rthe r r ead ing1 . J ain J K e t a l. A p ro sp ec tiv e ra n dom iz ed , d ou ble -b lin de d , p la ce bo -c on tro lle d tr ia l

c om p arin g m ife pr is to ne a n d v ag in al m is op ro sto l to v ag in a l m is op ro sto l a lo ne fo re le ctiv e te rm in a tio n o f e a rly p re g na n cy . Human Reproduc tion , 2002, 1 7 :1 4 7 7- 14 8 2 .2 . M e c ks tro th KR ,D a rn e y PD . P ro s ta g la n d in s fo r f irs t-tr im e s te r te rm in a tio n . BestP ra ctic es in Re searc h in C lin ic al Ob ste tric s a nd Gynaecolo gy , 2003, 1 7 :7 4 5- 76 3 .

3 . C arbone ll JL e t a l. O ra l a n d vag in al m isop ro s to l 800 m ic ro g eve ry 8 h fo r e ar lyabor t ion . Contraception, 2003, 6 7 :4 5 7- 46 2 .

4 . N orm an JE e t a l. M ed ica l abo rtio n in w om en o f le ss than o r equa l to 56 daysam e no rrh oe a : a c om p aris on b etw e en g em e pro st (a PG E 1a na lo gu e) a lo ne a ndm ife p ris to n e a n d g em e pro s t. B ritis h J ou rn al o f Ob ste tric s a nd Gynaecolo gy , 1 992,99:601-606.

15 . W h at p ain re lie f sh ou ld b e ava ila b le to w o m en d urin g m e dic a labo r t i on?

P ain is c au se d b oth b y th e a bo rtio n p ro ce ss a nd a s a s id e-e ffe ct o f th e p ro sta gla nd in . Itis m o st lik ely to b e fe lt in th e fe w h ou rs a fte r a dm in is tra tio n o f th e p ro sta gla nd in , w h enth e g esta tio na l s ac /e m bryo is b ein g e xp elle d fro m th e u te ru s. S tu die s h ave s ho wn th atw om en fe el le ss pa in if th ey a re o ld er, h ave be en p re gn an t b efo re o r a re in th e e arly s ta ge so f p re gn a nc y. H o w ev er, n on e o f th es e fa cto rs is s uffic ie n tly p re d ic tiv e to b e u se fu l in th em a n ag em en t o f in d iv id ua l c as es .T he p erce ptio n o f p ain a nd re qu est fo r re lie f va ry g re atly fro m o ne in div id ua l to a no th er a ndam o ng c ultu re s. In a n y c as e, h ea lth -c are p ro vid ers s ho uld m a ke a d eq ua te a na lg e sia e as ilya va ila ble to a ll w om e n w ho re qu est it d urin g m e dic al a bo rtio n. E xa m ple s o f co mm on lyu se d p re pa ra tio ns a re : p ara ce tam o l 5 00 -1 00 0 m g o r n o ns te ro id a l a nti- in fla mm a to ry d ru gs(N SA ID s),su ch a s ibup ro fe n 2 00 m g. In ca se s o f se ve re p ain , co de in e 30 -4 0 m g m ay bea d de d to e ith er o f th e a bo ve -m e ntio ne d tre atm e n ts .

22


29/41

Regimen fo r medic al a bo rtion

Fu rthe r r ead ing1 . A sh ok PW e t a l. F ac to rs a ffe ctin g th e o utco me o f e ar ly m ed ica l a bo rtio n: a re vie w o f

4132 c o n se c u tiv e c a se s . 8JOG, 2002, 109:1281-1289.2 . W e sth off C e t a l. P re dic to rs o f a na lg es ia u se d urin g s up erv is ed m e dica l a bo rt io n.

Contraception, 2000, 61 :225-229.3 . W e sth off C , D as ma ha pa tra R , S ch aff E .A na lg es ia d ur in g a t-h om e u se o f m iso pro sto l a s

p art o f a m e dica l a bo rtio n re gim e n. Contraception, 2000, 62:311-314.

23


30/41


31/41


32/41


33/41

Postabort ion care

16 . If a w om an has an incom ple te abo rtion , is it necessa ry to evacuateth e u te ru s su rg ic a lly ?

O n a ve ra ge , va gin al b le ed in g g ra du ally d im in ish es o ve r a bo ut tw o w ee ks a fte r a m ed ica la bo rtio n, b ut in in div id ua l ca se s spo ttin g ca n la st up to 45 d a y s. G en e ra lly , b le e d in g a fte rm e dic al a bo rtio n la sts lo ng er th an a fte r v ac uum a sp ira tio n. If th e w oma n is w e ll, n e ith erp ro lo ng ed b le ed in g n or th e p re se nce o f tissu e in th e u te ru s (a s d ete cte d b y u ltra so un d) isa n in dic atio n fo r s urg ic al in te rv en tio n. R em ain in g p ro du cts o f c on ce ptio n w ill b e e xp elle dd urin g s ub se qu en t v ag in al b le ed in g. S urg ic al e va cu atio n o f th e u te ru s m a y b e c arr ie d o uto n th e w om an 's re que st o r if the b le ed in g is he avy o r p ro lo nge d, o r ca uses a na em ia , o r ifth ere is e vid en ce o f in fe ctio n. In th e la tte r c as e, a ntib io tic tre atm e nt s ho uld b e in itia te d( see ques tio n 17).Fu rthe r r ead ing1 . F ia la C e t a l. V er ify in g th e e ffe ctive ne ss o f m ed ica l a bo rtio n; u ltra so un d v ersus h CG

test ing. Eu ro pean J ou rn al o f Ob ste tric s a nd Gyne co lo gy and Repro du ctiv e B io lo gy ,2003, 109:190-195.

2 . A cha rya G e t a l. R ole o f ro utin e u ltraso nog ra phy in m on ito r in g the o utco me o f m ed ica la b ortio n in a c lin ic al s ettin g . Ac ta Obste tric a e t Gyneco log ica Scandinavica, 2004 ,83:390-394.

3 . C ow ett A A e t a l. U ltra so un d e va lu atio n o f th e e nd om etriu m a fte r m ed ica l te rm in atio n o fp r egnancy . Obs te tr ics and Gyneco logy, 2004, 103:871-875.

17 . H ow shou ld pe lv ic in fec tion be d iagnosed and trea ted a fte rabort ion?

T he g en ita l tra ct is m ore susce ptib le to a sce nd in g in fe ctio n w he n th e ce rv ix is d ila te d a fte ra bo rtio n o r c hild birth . T he re a re fe w d ata o n th e in cid en ce o f c lin ic ally s ig nific an t p elv icin fe ctio n a fte r m ed ica l a bo rtio n, b ut it se em s to b e ra re a nd pro ba bly o ccurs le ss o fte nth an a fte r v acu um a sp ira tio n. M a ny o f th e sym pto ms o f pe lv ic in fe ctio n, suc h a s p ain , a rera th er n on sp ec ific a nd h en ce p re cis e d ia gn os is is d iffic ult. W om e n w ith c lin ic al s ig ns s uc ha s p elv ic p ain , a bd om in al o r a dn ex al te nd ern es s, v ag in al d is ch arg e a nd fe ve r s ho uld b etre a te d w ith b ro a d -s p ec tr um an tib io tic s.R are ca se s o f a na ero bic in fe ctio n w ith ou t fe ve r h av e be en re po rte d fro m C an ad a (o nec as e) a nd th e U SA ( fo ur c as es ) fo llo w in g m e dic al te rm in atio n o f p re gn an cy . N o s uc hca ses h ave be en re po rted fro m C hin a o r fro m E uro pe . In th e re po rte d ca ses w om en ha dlitt le o r n o fe ve r; v ar ia ble n au se a, v om itin g, w ea kn es s a nd s om e a bd om in al p ain ; ra pidd e te rio ra tio n w ith in h o urs o r d a ys ; ta ch yc ard ia a n d re fra cto ry h yp o te n sio n ; m u ltip lee ffu sio n s; e le va te d h a em a to crit a n d e le va te d le uk oc yte c ou n t, n e utro ph ilia . A ll fiv e o f th ew om en had Clostrid ium sordell ii -re lated to x ic s h oc k.

27


34/41


Refe rences1 . FDA Pub lic h ea lth a dv is ory ; s ep sis a nd medic al a bo rtio n. U S Fo od a nd D rug

Adm in is t ra t ion . Ava i lab le a t ;a cc es se d o n 20 February 2006.

Fu rther r ead ing1 . S ha nn on C e t a l. In fe ctio n a fte r m ed ica l a bo rtio n: a re vie w o f th e lite ra tu re .

Contracept ion, 2004, 70: 183-190.2 . S itruk-W a re R , Sp itz 1 M . Pha rma co lo g ic a l p ro p e rtie s o f m i fe p ris to n e : to x ic o lo g y a n d

sa fe ty in a nim a l a nd h um an stud ie s. Contracept ion, 2003, 68:409-420.

18 . H ow sh ou ld th e su ccess o f m e dic a l ab ort io n b e co nfirm e d?F or a ll w om en w ho u nd erg o m ed ica l a bo rtio n, it is im po rta nt to co nfirm th at th e p re gn an cyh as in de ed b ee n te rm in ate d. If e xp uls io n o f th e pro du cts o f co nce ptio n w as co nfirm ed b y aq ua lifie d p ers on in th e h ou rs a fte r a dm in is tra tio n o f th e p ro sta gla nd in , fu rth er fo llo w -u p isn ot a bs olu te ly n ec es sa ry . O th erw is e, a fo llo w -u p v is it s ho uld b e a rra ng ed a bo ut tw o w e ek sa fte r th e a dm in is tra tio n o f m ife pris to ne , a t th e c on ve nie nc e o f th e p atie nt.

A t th e fo llo w -u p v is it, c om p le te a bo rtio n s ho uld b e c on firm e d c lin ic ally , e ith er b y b im a nu alp elv ic e xam in a tio n o r, if a va ila b le , p elv ic u ltra so un d . If s er ia l m e a su rem e nts o f h um a nch orio nic g on ad otro ph in (h CG ) in b lo od o r u rin e a re use d, it sh ou ld be re membe re d th atin so me ca ses lo w h CG leve ls can be de te ctab le fo r up to fo ur w ee ks a fte r succe ssfu le xpu ls io n. W om en w ho co ntin ue to h ave sym pto ms o f pre gn an cy o r w ho h ave m in im a lb le ed in g a re m o st lik ely to b e s till p re gn an t.1 9. H o w s ho uld ec to pic p re gn an cy b e id en tif ie d a fte r m e d ica l a bo rtio n?E cto pic p re gn an cy is a life -th re ate nin g c on ditio n a nd a s ig nific an t c au se o f m a te rn alm orta lity . S ee q ue stio n 7 fo r th e s te ps th at sh ou ld be ta ke n b efo re m ed ica l a bo rtio n tod e te c t e c to p ic p re g n a nc y.E ve n w h ere th ese s te ps h ave b ee n ta ke n, h ea lth -ca re p ro vid ers sh ou ld be a wa re o fth e p os sib ility o f e cto pic p re gn an cy a nd o f th e fa ct th at m ed ica l a bo rtio n m ay m ask itss ym p tom s. V e ry o cc as io n ally , a n e cto p ic p re g na n cy m a y c o-e xis t w ith a n in tra u te rin ep regnancy .If a n e cto pic p re gn an cy is c lin ica lly su sp ecte d (e .g . th e w om an h as co ntin uin g sym pto ms o fp re g na n cy o r a b dom in a l p a in ), fu rth e r in ve stig a tio n s, s uc h a s p elv ic u ltra so un d a n d s eria lm ea su re me nt o f h CG , sh ou ld be pe rfo rm ed . If th is is n ot p os sib le , th e w om an sh ou ld bere fe rre d to a s pe cia lis t c en tre .28


35/41

Postabort ion care

Fu rther r ead ing1 . K elly A J, S ow te r M C ,T rin de r J. The managemen t o f tu ba l p re gnan cy . L o nd o n , R o ya l

C o lle g e o f O b s te tr ic ia n s a n d G y n ae c olo g is ts , 2 0 04 (RCOGGu id e lin e N o .2 1).2 . S ha nn on C e t a l. E cto pic p re gn an cy a nd m ed ica l a bo rtio n. Obs te tr ics and Gyneco logy,

2004 ,104 :161 -167 .

20 . Is th e re a ris k o f fe ta l abno rm a lity a fte r an unsuccess fu l m ed ica labor t ion?

O n ly o ne a no m aly h as b ee n re po rte d a fte r th e u se o f m ife pr is to ne a lo ne . T h is ca se ,d es cr ib ed a s a s ire no m elia (1 ), co uld n ot b e re la te d to th e d ru g in ta ke . In de ed , th is ty peo f an om aly o ccu rs a t a ve ry ea r ly s ta ge o f p regna ncy - a t a bou t fo ur w eeks o f em bryod ev elo pm e nt - w h ile th e tre atm e nt w as ta ke n in th e fifth w ee k o f p re gn an cy . Th ir te eno th er c as es o f m a lfo rm a tio n h a ve b ee n re po rte d : a ll o cc urre d in p re gn a nc ie s in w h ic hm ife pris to ne w as a dm in is te re d a t 7 -9 w e eks o f a m en orrh oe a, fo llo w ed in e ig ht c ase sb y g em e pro st a nd in five c ase s b y m is op ro sto l. N on e o f th e e ve nts co uld b e c on clu siv elyre la te d to th e tre a tm e n t (2).I t is n ot p oss ib le to d ete rm in e w he th er th e re po rte d a no m alie s w ere c au se d b y th etre atm e nt, s in ce th e in cid en ce o f b irth d efe cts in a n orm a l p op ula tio n is a ro un d 2 p er1 0 0 b ir th s (3 ). S om e p ro sta g la n d in s h a ve b e en c la s sifie d a s te ra to g e nic , a lth o ug hm is op ro sto l d id n ot in d uc e s uc h e ffe cts in em bry oto xic olo g y s tu die s (4 ). M ife pris to n e isn ot a te ra to ge nic a ge nt b ut, w he n u se d in co m bin atio n w ith a p ro sta gla nd in , m a y in du ceu te rin e c on tra ctio n, w h ic h c ou ld a cc ou nt fo r s om e o f th e o bs erv ed d e fe cts (5).S in ce th e a va ila ble d ata a re lim ite d a nd in co nc lu siv e, th ere is n o n ee d to in sis t o nte rm in atio n o f a n e xp ose d p re gn an cy if th e w om a n w ish es to co ntin ue it. W om e n s ho uld ,n ev erth ele ss , b e in fo rm e d th at, b ec au se o f th e u nk no wn ris k o f a bo rt ifa cie nt d ru gs to th efe tu s, fo llo w -u p is im p o rta n t.Refe rences1 . P on s J -C e t a l. D ev elo pm e nt a fte r e xp osu re to m ife pr is to ne in e ar ly p re gn an cy.

The Lance t, 1991, 3 3 8 :7 6 3 .2 . E xe lg yn . Perio dic s afe ty u pdate No . 16 ,31 M a y 2005 .3 . S itru k-W a re R , D a ve y A , S ak iz E . F e ta l m a lfo rm a tio n a nd fa ile d m e dic al te rm in atio n o f

p r egnancy . The Lance t, 1998 , 3 5 2 :3 2 3 .4 . K o ts on is F N e t a t. P re clin ic al to xic olo gy p ro file o f m is op ro sto l. D iges tive D iseases

Sciences, 1 98 5, 3 0 (1 1 S up pl.) 1 42 S -1 46 S .

29


36/41


5 . Jo st A . N ew d ata o n the h orm on al requ ire me nts o f th e preg nan t rabb it: pa rtia lp re gn an cie s a nd fe ta l a bn orm a litie s a fte r tre atm e nt w ith a h orm o na l a nta go nis t a tsubabo r tif a cie n t doses . Compte s R e nd ue s d e l'A cu iem le d es S cie nc es , 1986, 303(s e rie s III, N o . 7):281-284.

21 . W h ich m ethods o f con tracep tion can a w om an use afte r m ed ica labort ion?

M os t w om en w ho ha ve an ind uced a bo rtion fo r a n un wa nte d preg nan cy d o n ot w an tto g et p reg nan t ag ain im m ed ia te ly . In a fe w ca ses, th ere m ay be m ed ica l re aso ns fo ra vo id in g imm e dia te p re gn an cy . P os ta bo rtio n fa m ily p la nn in g is th ere fo re a n in te gra l p art o fc omp re h e n siv e a b o rtio n c a re (1 , 2 ).W o me n w ho h ave ha d a n ea rly abo rtio n a re a lm os t im m ed ia te ly a t risk o f be co min gp re gn an t a ga in . O v ula tio n m a y o cc ur a s e arly a s d ay 1 0 (3 ) a fte r a firs t-tr im e ste r a bo rtio n;up to 78% o f w om en in o ne stud y ha d o vu la ted by th e tim e o f th e s ix -w ee k fo llo w-up (4).W ome n w ho h ave ha d a m ed ica l a bo rtion ca n use a ny m od ern m eth od o f con tra ce ptio na fte rw ard s. W h en th e w om an is co un se lle d a bo ut th e a bo rtio n, th e o pp ortun ity sh ou ld b eta ke n to re vie w h er c on tra ce ptiv e n ee ds . Id ea lly , s he s ho uld b e p ro vid ed w ith a n e ffe ctiv ec on tra ce p tiv e m e th o d imme d ia te ly a fte r th e a b ortio n .C om bin ed o ra l co ntra ce ptive p ills ca n b e sta rte d o n th e d ay th at m iso pro sto l isa dm in is te re d , w h en e xp uls io n u su ally o cc urs . T w o p ro sp ec tiv e ra n dom iz e d c on tro lle ds tu die s e va lu ate d th e e ffe cts o f imm e dia te u se o f c om b in ed o ra l c on tra ce ptiv e p ills v ers usp la ce bo fo llo w in g m e dic al a bo rtio n a nd fo un d n o d iffe re nc e in c om p le te a bo rtio n ra te s,s id e -e ffe cts a n d d ura tio n o f b le e din g (5 , 6 ). P ro g es to g en -o n ly m e th o ds a re c ommo n lya ss oc ia te d w ith b re ak th ro ug h b le ed in g, w h ic h m a y b e c on fu se d w ith a n in com ple teabor t ion .D e po t-m e d ro xy pro g es te ro n e in je ctio n s a n d im p la n ts a re o fte n a ss oc ia te d w itham en orrh oe a, o r ir re gu la r b le ed in g, w h ic h m a y m a ke it d iffic ult to d ete rm in e w h eth erp re gn an cy h as b ee n te rm in ate d. It m a y th ere fo re b e p re fe ra ble to s ta rt u sin g th es em eth od s o nly a fte r it h as be en co nfirm ed th at th e p re gn an cy h as b ee n te rm in ate d.S te riliz atio n a n d in se rtio n o f a n in tra ute rin e d e vic e s ho u ld b e d e fe rre d u ntil c on firm a tio nth at th e a bo rtio n is c om p le te .W om en w ho ch oo se a co ntra ce ptive m eth od th at ca nn ot be s ta rte d im m ed ia te ly sh ou ldbe e nco ura ge d to use co nd om s in th e m ea ntim e. O th er m eth od s, suc h a s ca ps, sp on ge s,d ia ph ra gm , s pe rm ic id al fo am s , je llie s a nd v ag in al ta ble ts , c an b e u se d a s s oo n a s s ex ua lin te rc ou rs e is re sum ed , p re fe ra bly w h en b le ed in g h as s to pp ed . M e th od s o f n atu ra l fa m ilyp la nn in g ca n be re su me d o nly a fte r th e re tu rn o f re gu la r cyc le s.

30


37/41

Pos ta bo rtio n c are

References1 . Jo hn so n B R e t a l. R ed uc in g u np la nn ed p re gn an cy a nd a bo rtio n in Z im b ab we th ro ug h

pos tabo r ti o n con tr a cept io n . Studie s in Fam ily P lann ing , 2002, 3 3 :1 9 5 -2 0 2 .2 . P an de y ON e t a l. C on tra ce ptiv e c ov era ge a fte r m e dic al te rm in atio n o f p re gn an cy. Indian

Journal o f Hospita l Pharmaco logy , 1989,26 :154-157.3 . B o yd E F ,H o lm s tro m EG .O v ula tio n fo llo w in g th era pe utic a bo rt io n. America n J ou rn al o f

Obs te tr ics and Gyneco logy, 1972 , 1 1 3 :4 6 9- 47 3 .4 . ta hte en rn ak l P e t a l. R etu rn o f o vu la tio n a fte r a bo rtio n a nd a fte r d is co ntin ua tio n o f o ra l

con t racep t ives . Fer ti li ty and Steri li ty , 1980, 3 4 :2 4 6 -2 4 9.5 . M a rtin C W ,B ro wn A H, B aird O T .A p ilo t s tud y o f th e e ffe ct o f m eth otre xa te o r co mb in ed

o ra l c on tra ce ptiv e o n b le ed in g p atte rn s a fte r in du ctio n o f a bo rtio n w ith m ife pr is to n ea n d a p ro sta g la nd in p es sa ry . Contraception, 1998,58 :99-103.6 . T an g O S e t a l. T he e ffe ct o f co ntra ce ptive p ills o n th e m ea su re d b lo od lo ss in m ed ica l

te rm in a tio n o f p re g na nc y b y m ife pr is to ne a nd m is op ro sto l: a ra n dom iz ed p la ce bocon t r o ll ed t ri a l. Human Reproduc tion , 2002, 1 7 :9 9 -1 0 2 .

31


38/41


I S S U E S R E L A T E D T O P R O V IS IO N O F M E D IC A L A B O R T IO N S E R V IC E SL eg al a nd reg ula to ry issu esT he pra ctice o f a bo rtio n is g ove rn ed by re gu la tio ns o pe ra tin g w ith in th e le ga l fra me wo rk o fth e s pe cific c ou ntry a nd /o r lo ca lity . In m o st c ou ntr ie s, te rm in atio n o f p re gn an cy is le ga llype rm itte d fo r a t le as t o ne in dica tio n, e .g . a fte r ra pe o r to p ro te ct th e life o f th e p re gn an tw oma n. L eg is la tio n in s om e c ou ntrie s p erm its a bo rtio n fo r a b ro ad ra ng e o f in dic atio ns .O fte n, th e le ga l fra m ew o rk w a s e sta blis he d lo ng b efo re m e dic al a bo rtio n b ec am e a va ila ble .T he d eve lo pm e nt o f m eth od s fo r m ed ica l a bo rtio n ca n ra ise so me un ce rta in ty in th ein te rp re ta tio n o f e xis tin g la w s o r re gu la tio ns , a s th es e w e re g en era lly fo rm u la te d o n th eb as is o f s urg ic al a bo rtio n a s th e p re va ilin g m e th od . F or e xam ple , in s om e c ou ntr ie s, th ela w re qu ire s th at a bo rtio ns ta ke p la ce in a c lin ic re gis te re d fo r th e p urp os e. W i th s urg ic alm eth ods th ere is n o d oub t a s to w he re the a bo rtion is pe rfo rm ed . B ut w he n a bo rtion isin du ce d b y m ed ica tio n, is th e a bo rtio n p erfo rm ed w he re th e d ru gs a re p re scrib ed o r w he reth ey a re a dm in is te re d? O r is it w he re th e p ro ducts o f co nce ptio n a re e xp elle d?Settin g u p a m ed ica l ab ortio n se rv iceH ea lth -ca re m an ag ers w ho a re co nte mp la tin g se ttin g up a se rv ice to pro vid e m ed ica la bo rtio n w ill firs t n ee d to fin d o ut w ha t is th e re le va nt le ga l fra me wo rk in th eir co un try w ithre ga rd to m e dic al a bo rtio n. In m a ny c ou ntrie s, th ere a re n o s pe cific re gu la tio ns d ea lin gw ith m e dic al a bo rtio n; in th is c as e, m e dic al a bo rtio n is g ov ern ed b y th e g en era l a bo rtio nre gu la tio ns . O th er c ou ntrie s m a y h av e s pe cific re gu la tio ns re la tin g to th e p ro vis io n o fmed i ca l abo rt io n .T he re m a y b e re gu la tio ns g ov ern in g w h ic h fa cilit ie s c an p ro vid e a bo rtio n s erv ic es . In s om ec ou ntrie s, th e n a tio n al g o ve rnm e nt m a y s tip ula te s ta n da rd s th ro u gh le g is la tio n o r th ro u ghh ea lth sys te m n orm s a nd re gu la tio ns . E lse wh ere , su ch re gu la tio ns m a y b e d ra wn up a t th ep ro vin ce , s ta te o r lo ca l le ve l.M e dica l a bo rtio n m a y b e p ro vid ed in h ea lth -ca re se ttin gs th at d o n ot a lre ad y p ro vid ea b ortio n s erv ic es . Id e ally , it s ho uld b e in te g ra te d in to b ro a de r re pro d uc tiv e h e alth s erv ic es .Th is w ou ld a llo w w om en w ho h ave ha d a m ed ica l a bo rtion e asy a cce ss to o th er se rv ice s- such a s fa mily p la nn in g - a s a n im po rta nt e lem en t o f co mpreh ens ive a bo rtion ca re .Em erg en cy c are a nd fa cilit ie s fo r s urg ic al in te rv en tio n s ho uld b e a va ila ble lo ca lly o rth ro ug h a re fe rra l m e ch an is m w ith e sta blis he d lin ka ge s. B ac k-u p s erv ic es s ho uld in clu deu te rin e e va cu a tio n , flu id re pla cem e nt a n d b lo o d tra n sfu sio n .

32


39/41

Ob ta in in g th e n ec es sa ry m e d ic in esWh e re m ife pr is to ne is a lre ad y lic en se d fo r u se in m e dic al a bo rt io n, th e lic en ce w ill u su allys pe cify th at it s ho uld b e u se d w ith a s pe cific p ro sta gla nd in (u su ally m is op ro sto l), o r s im p lyth at a "s uita ble p ro sta gla nd in " sh ou ld b e u se d. In co un tr ie s w he re m e dic al a bo rt io n isp erm itte d, m ife pr is to ne is a va ila ble fro m th e p hy sic ia n o r c lin ic . H o w ev er, it is p os sib leth at n o p ro sta gla nd in a pp ro pria te fo r u se in e ar ly m e dic al a bo rtio n is lic en se d. W h e n n olic en se d p ro sta g la n din is a va ila b le , m is op ro sto l is g en e ra lly u se d s in ce it is a va ila ble inm a n y c ou ntrie s, a lth o ug h it is n o t s pe cific ally lic en se d fo r u se in a bo rtio n.In m a ny p la ce s, lic en se d m e dic in es ca n b e u se d fo r c lin ic al in dica tio ns th at a re n otc ov ere d b y th e o rig in a l p ro d uc t re gis tra tio n. O fte n , p hy sic ia ns h av e th e fre e dom to u sem e dic in es fo r u nlic en se d p urp ose s w he n th ere is m e dic al e vid en ce to s up po rt s uc h u se .If a ph ys ic ia n u se s a d rug fo r pu rpo se s o th er th an fo r w hich th e d rug is lice nse d, th ep hy sic ia n m u st in fo rm th e p atie nt a bo ut th is . M a n ag e rs c on sid e rin g th e in tro d uc tio n o fm e dica l a bo rtio n sh ou ld ch eck th e s itu atio n in th eir c ou ntry w ith re ga rd to th is iss ue . Ins om e re im b urs em e n t s ys te m s, d o cto rs m a y p re sc rib e o ff- la be l u se , b ut p atie nts m a y n otb e a ble to c la im re im bu rs em e nt fo r th e tre atm e nt.A cc ord in g to th e U n ite d S ta te s F oo d a n d D ru g A dm in is tra tio n , "G o od m e dic al p ra ctic ea n d th e b es t in te re sts o f th e p atie n t re qu ire th at p hy sic ia ns u se le ga lly a va ila ble d ru gs ,b io lo g ic s a nd d e vic es a cc ord in g to th eir b es t k no w le d ge a nd ju dgm e nt. If p hy sic ia ns u sea p ro du ct fo r a n in dic atio n n ot in th e a pp ro ve d la be llin g, th ey h ave th e re sp on sib ility to b ew e ll in fo rm e d a bo ut th e p ro du ct, to b ase its u se o n firm s cie ntific ra tio na le a nd o n s ou ndm e d ic al e vid e nc e, a nd to m a in ta in re co rd s o f th e p ro d uc t's u se a nd e ffe cts ."Fu rthe r r ead ing1 . M IF E PREX (m ife pr is to n e) T ab le ts , 2 00 m g ; fo r o ra l a dm in is tra tio n o nly . A va ila ble a t:

< h ttp ://www . e a rly o p tio n p ill.c om /p d fs /p re s cr ib in g 0 7 19 0 5 .p d f> ; a c ce s s ed o n2 3 F eb ru ary 2 00 6.

2 . M is op ro sto l. M a jo r la be llin g c ha ng e s. WHO Pha rm ace utica ls N ew sle tte r, 2 00 2 , 3 :5 .3 . W e eks A D, F ia la C , Sa fa r P . M is op ro sto l a n d th e d eb ate o ve r o ff- la be l d ru g u se . 8JOG,

2005, 1 1 2:2 6 9 -2 7 2.

33


40/41

F req uently as ked qu estion s a bo ut m ed ical ab ortio n

A nnex 1IN T E R N A T IO N A L C O N S E N S U S C O N F E R E N C E O N N O N -S U R G IC A L(M E D IC A L ) A B O R T IO N IN E A R L Y F IR S T T R IM E S T E R O N IS S U E S

R E L A T E D T O R E G IM E N S A N D S E R V IC E D E L IV E R YBe llag io Conf erence Cente r, Be llag io , Ita ly

1-5 N ovember 2004Part icipants

D r D av id B a ird , P ro fe ss or , Co n tr ac ep tiv e De ve lo pme n t Ne two rk , Un iv ers ity o f E d in bu rg h ,Ed inbu rgh , Sco tlandD r L au ra C a stleman , Me dic al D ire cto r, Ip as , C h ap el H ill, NC , USAD r U nan C heng , D ir ec to r, S h an g ha i In stitu te o f F am ily P la n nin g T e ch n ic al In str uc tio n ,S ha ng ha i, P eo ple 's R e pu blic o f C h in aD r Ku ru s Co ya ji, D ire cto r a nd H o n. P ro fe ss or, D e pa rtm e nt o f O b ste tr ic s a nd G y na ec olo gy ,K .E .M . Hosp ita l, P u ne, In d iaMs A nge la D avey, Bu sin e ss a n d Me d ic al S e rv ic es D ir ec to r, E x elg yn , O x fo rd sh ire ,Un ite d K in g domDr Ch ris tia n F ia la , Cha ir o f F IAPAC ,V ie n na, Au s tr iaDr Kr is ti na Gemze ll-Dan ie lsson, D ire cto r, WHO Co lla bo ra tin g C e ntre in H umanR epro du ctio n, D epa rtm en t o f W om an a nd C hild H e alth , D iv is io n fo r O bste trics a ndGy na e co lo g y, K a ro lin sk a Un iv er sity Ho sp ita l, S to ck ho lm , Swe de nD r S elm a H ajri, Con su lta n t in Re pro d uc tiv e He a lth , T un is , T u nis iaD r H ele na v on H ertze n, Med ic al O ffic er , M a n ag e r, Re se a rc h G r ou p o n Po st-o vu la to ryM e th od s fo r F ertility R e gu la tio n, UNDP /UNFPA lWHO lW o rld B an k S pe cia l P ro gramme o fR e se arc h, D e ve lo pm e nt a nd R e se arc h T ra in in g in H uman Re pro du ctio n (HRP ),Wo r ld He a lth O r ga n iz atio n , Ge n ev a, Sw itz er la n dD r P ak C hung Ho , P ro fe ss or a nd C h air in O b ste tr ic s a nd G yn ae co lo gy , D e pa rtm e nt o fO b ste tr ic s a nd G y na ec olo gy , U n iv ers ity o f H o ng K on g, S pe cia l A dm in is tra tiv e R e gio no f C hin a

34


41/41

D r L en a Ma rio ns , S en io r C o ns ulta nt, WHO Co lla bo ra tin g C e ntre in H uman Re pro du ctio n,D ep artm e nt o f W om an a nd C hild H ea lth , D iv is io n fo r O bste tr ics a nd G yn ae co lo gy,K a ro lin sk a Un iv er sity Ho sp ita l, S to ck ho lm , Swe de nD r Sun ee ta M itta l, P ro fe sso r a nd H e ad , D epa rtm en t o f O bste tr ics a nd G yn ae co lo gy a ndD ire cto r in C h arg e, WHO Co lla bo ra tin g C e ntre in H uman Re pro du ctio n, A ll In dia In stitu te o fM e dic al S cie nc es , N ew De lh i, In diaD r N guyen th i N hu N goc, Con su lta n t in Re se a rc h a n d In te rn a tio n al Co lla bo ra tio n , M e d ic alA bo rtio n U n it, WHO Co lla bo ra tin g C e ntre in H uman Re pro du ctio n, H u ng vu on g H o sp ita l,H o C hi M inh C ity , V ie t N amD r J oa ch im Oeh le r, Ch ie f E xe cu tiv e O f fic er, T h e Co n ce pt F o un d atio n , P a th um th a ni,Tha i landDr G illia n Penney , C lin ic al S en io r L ec tu re r a t th e U n iv ers itie s o f E din bu rg h a nd A be rd ee n,SPCERH ,A b er de e n Ma te rn ity Ho sp ita l, A b er de e n, S c otla n dDr G ild a P ia gg io , S ta tis tic ia n , S ta tis tic s a n d In fo rma tic s S u pp o rt T e am , UNDP /UNFPA IWHO lW o rld B an k S pe cia l P ro gra mm e o f R ese arch , D eve lo pm en t a nd R ese arch T ra in in g inHuman Re pr od uc tio n (HRP ),Wo r ld He a lth O r ga n iz a tio n , Ge n ev a, Sw itz e rla n dD r E ric A . S ch aff, P ro fe sso r o f F am ily M e dic in e, o f P ed ia trics a nd o f O bste trics a ndG yn ec olo gy a nd D ire cto r, R e pro du ctiv e H e alth P ro gram F ello w sh ip , D e pa rtm e nt o f F am ilyM e dic in e, U n iv ers ity o f R o ch es te r, S ch oo l o f M e dic in e, R o ch es te r, NY ,USADr Reg in e S itru k-Wa re , Ad ju nc t P ro fe ss or , Ro ck efe lle r Un iv er sity a n d E x ec utiv e D ir ec to rC o ntra ce ptiv e D e ve lo pm e nt, C e nte r fo r B iom ed ic al R e se arc h, P op ula tio n C o un cil, N e w Y ork ,NY ,USAD r O i S h an Tang, A ss oc ia te C o ns ulta nt, D e pa rtm e nt o f O b ste tric s a nd G y na ec olo gy ,Q ue en M a ry H o sp ita l, H o ng K on g, S pe cia l A dm in is tra tive R eg io n o f C hin aDr Beverly W inik of f, P re sid en t, G y nu ity H e alth P ro je cts , N ew Y ork , NY ,USA

Documents

Medical Abort