Caring for the Woman with an Unintended Pregnancy: Abortion as an option

1. Caring for the Woman with an Unintended Pregnancy:Abortion as an option A slide presentation for Advanced Practice Registered Nurses and students Prepared by

2. Overview of this presentation Women considering abortion Background Types of terminations Aftercare

3. Who has abortions? In the United States: Abortion is one of the most frequently performed procedures in women, ages 15-45. In 2005: 1.2 million abortions were performed 22 % of pregnancies ended in abortion

4. “There aren’t women who have abortions and women who have babies; they are the same women at different points in their lives” -Rachel Atkins, PA-C, Women’s Health Care Provider

5. A few important facts about first trimester aspiration abortion 88% are done in the first 12 weeks of pregnancy 95% performed in outpatient setting Actual procedure takes less than 5-10 minutes in most cases In outpatient settings, average cost $413 (2008)

6. First trimester aspiration abortion Pre-procedure work up Counseling and informed consent Medical and social history Labs: pregnancy test (unless already documented), Rh factor, hematocrit/hemoglobin, tests for vaginal/cervical infection prn Confirmation of EGA by clinical exam/ultrasound Pain relief Dilation: Mechanical v. osmotic v. chemical (misoprostol) Suction: EVA v. MVA

7. Risks/Complications of aspiration abortion First trimester procedure is very safe: Hemorrhage (<1%)  Infection (<2%) Missed abortion (<1/2 of 1%) Retained tissue (<1%) Perforation/cervical tear (<1%) After first trimester: Risk increases with advancing gestational age

8. Facts about abortion procedures after the first trimester Pain medication always used Cost increases with gestational age

9. Second trimester procedures Dilatation and Evacuation ( D & E) Involves cervical preparation prior to procedure Induction/instillation procedures Longer, more involved procedures Requires more advanced training on part of providers

10. Medication abortion Definition: Abortion caused through administration of medications currently including either: a) mifepristone and misoprostol or b) methotrexate and misoprostol Causes bleeding and uterine contractions that lead to expulsion of pregnancy tissue Currently used for terminations up to 63 days gestation Side effects/complications: Common: nausea, diarrhea, vomiting, headaches Rare: excessive bleeding, infection

11. Medication Abortion: Mifepristone Mechanism of action: “Anti-progestin”blocks progestin Average of 4-6 hours to completion of abortion 93-98% effective Requires at least 2 visits to provider Approved by the FDA for use in abortion Potential for numerous other medical

12. Medication Abortion: Methotrexate Mechanism of action: Anti-folate blocks division of rapidly dividing cells   Takes 3-45 days for completion of abortion ~90-95% effective Requires at least 2 visits to medical provider Used “off-label” for medication abortion Very rare side effects include alopecia, leukopenia, interstitial pneumonitis

13. Medication Abortion: Misoprostol Mechanism of action: Prostaglandin analog  causes uterine contractions Generally used in conjunction with mifepristone or methotrexate to cause expulsion of pregnancy tissue Few medical contraindications FDA approved for use for treatment of ulcers; off label use for abortion, labor induction, etc. Ongoing studies on the use of misoprostol alone for abortion

14. Misoprostol Alone for 1st trimester abortions Advantages of misoprostol alone: widely available low cost stable at room temperature Some evidence that use of misoprostol reduces complications where abortion is restricted Disadvantage: Less effective than other regimens, not FDA approved.

15. Typical mifepristone medication abortion process Varies from site to site + from FDA protocol Day 1: Counseling and informed consent, including consent for aspiration procedure if method fails Medical and social history Lab work: pregnancy test, H&H, Rh factor, tests for STIs tests prn Ultrasound to confirm IUP/EGA, +/- clinical exam Mifepristone 200mg given on site Misoprostol + script for pain / nausea relief given for home administration

16. Typical mifepristone medication abortion process(continued) Day 2-4: Self administration of misoprostol 800 mcg. vaginal or buccally Vaginal bleeding, cramping begins 2-4 hours after administration of miso Bleeding/cramping most intense during passage of pregnancy tissue, then subside Bleeding may continue for 2-4 weeks

17. Medication vs. aspiration abortion Medication Advantages: May offer more privacy Avoids “surgery” Considerations: Requires at least 2 visits and takes several hours to pass the pregnancy If unsuccessful, requires f/u aspiration procedure Currently only for abortions to 63 days Aspiration Advantages: Usually requires only 1 visit Procedure complete within minutes High success rate Considerations: Involves invasive procedure

18. Post-abortion evaluationat 1-3 weeks Subjective: Bleeding Pain S/s infection Pregnancy symptoms Emotional state Sexual function Satisfaction with/need for contraception

19. Post-abortion evaluationat 1-3 weeks Objective: Vital signs Pelvic exam HCG (if indicated) Ultrasound (if indicated) Assessment/Plan: Complications Contraception Access to ongoing care Cappiello et al. (2011) Clinical issues in post abortion care. The Nurse Practitioner. 36 (5), 35-40.

20. Abortion care: Role of the APRN Provide method specific counseling and screening Assist with procedure or provision of medications Depending on specific state regulations, APRNs may provide medication abortion and/or aspiration abortion. Provide post-abortion care, including evaluation for potential complications Provide contraception

21. Additional curriculum resources from the ROE Consortium • Review of Family Practice NP Textbooks for Reproductive/ Abortion Content (May 2008) • Teaching Reproductive Options Through the Use of Fiction: The Cider House Rules Project (October 2007) • For Nursing Students: Understanding abortion care in your future practice (August 2007) • Teaching Reproductive Choice Options: A Resource Guide (January 1997) • Providing Abortion Care: A professional toolkit for nurse-midwives, nurse practitioners and physician assistants.

22. Access curriculum resourcesat www.abortionaccess.org

23. Enhance prevention: Apply a public health model to unintended pregnancy • Primary Prevention • Preconception care • Contraception • Emergency contraception • Secondary Prevention • Pregnancy diagnostics • Early pregnancy loss, ectopic pregnancy screening • Pregnancy options counseling • Early abortion care, adoption, referral for prenatal care • Tertiary Prevention • Late term unintended pregnancy support • Pregnancy termination

24. Resources for more information The Guttmacher Institute (www.agi-usa.org) Clinicians for Choice (www.prochoice.org/cfc) Earlyoptions (www.earlyoptions.org) Facts about Abortion 2003 (http://www.agi-usa.org/pubs/sfaa.html) Association of Reproductive Health Professionals (www.arhp.org) The Hope Clinic (www.hopeclinic.org/PublicationsOrdering.htm) IPAS (http://www.ipas.org/Products.aspx) National Abortion Foundation (www.prochoice.org)