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Medication Abortion

Medication Abortion. Dr. Sasan Zaeri (PharmD, PhD) Department of Pharmacology. What is medication abortion?. Medication abortion, also known as non-aspiration or non-surgical abortion, refers to a family of safe and effective methods for terminating an early unwanted pregnancy.

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Medication Abortion

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  1. Medication Abortion Dr. Sasan Zaeri (PharmD, PhD) Department of Pharmacology

  2. What is medication abortion? Medication abortion, also known as non-aspiration or non-surgical abortion, refers to a family of safe and effective methods for terminating an early unwanted pregnancy. Through the use of a drug or combination of drugs that are administered orally, vaginally, and/or intramuscularly, medication abortion first causes the pregnancy to terminate and then causes the uterus to expel the products of conception

  3. Why “medication abortion”? Non-aspiration or non-surgical abortion is commonly referred to as “medical abortion”. However, this phrase has led to confusion among both providers and the public, as the term “medical” is often associated with physician-based practices and/or medical necessity. “Medication abortion” more accurately represents the family of safe and effective drug-based methods that can terminate an unwanted pregnancy and will be used throughout this presentation.

  4. Methods of medication abortion • Mifepristone and misoprostol • Methotrexate (MTX) and misoprostol • Misoprostol alone Medication abortion methods can be used throughout early pregnancy (≤63 days’ gestation)

  5. Medication abortionMechanisms of action of the medications • Mifepristone • Anti-progestin that blocks the action of progesterone • Alters the uteral lining • Methotrexate • Anti-metabolite • Interferes with DNA synthesis and cell growth • Misoprostol • Prostaglandin E1 analog • Stimulates uterine contractions and induces cervical softening

  6. Medication abortion Additional uses of the medications • Mifepristone • Labor induction (under investigation) • Infertility treatment (under investigation) • Methotrexate • Treatment of neoplastic diseases • Treatment of rheumatoid arthritis • Misoprostol • Prevention of NSAID-induced gastric ulcers

  7. Medication abortionDosage forms of the medications • Mifepristone • Tablet 200 mg (Mifeprex) and 300 mg (Korlym) • Methotrexate • Tablet 2.5, 5, 7.5, 10, 15 mg • Injection solution 5 mg/mL • Powder for injection 1 g/vial • Misoprostol • Tablet 100 and 200 µg (Cytotec)

  8. Mifepristone/misoprostol regimen

  9. Mifepristone/misoprostol regimenGeneral protocol • Day 1 (Clinic) • Mifepristone (100-600 mg) is orally administered • Day 1-4 (Home or clinic) • Misoprostol is administered • 200-600 µg (oral) or 400-800 µg (vaginal, buccal or sublingual) • Day 7-14 (Clinic) • Patient returns to the clinic for follow-up • Clinician assesses for the completion of the abortion

  10. Mifepristone/misoprostol regimenEfficacy and safety • Approximately 95% of women will have a successful abortion when using mifepristone/misoprostol within 49 days’ gestation • Completion rates appear to decline slightly with increasing durations of pregnancy after 56 days’ gestation

  11. Mifepristone/misoprostol regimenEfficacy and safety • Approximately 67% of women will have a complete abortion within four hours of using misoprostol. • Approximately 90% of women will have a complete abortion within 24 hours of using misoprostol.

  12. Mifepristone/misoprostol regimenEligibility for use • Non-ectopic pregnancy of ≤63 days’ gestation • Absence of contraindications • Willingness to undergo vacuum aspiration or dilation and curettage (D&C), if indicated

  13. Mifepristone/misoprostol regimenContraindications to use • Confirmed or suspected ectopic (extra-uterine) pregnancy • Allergy to either mifepristone or misoprostol • Presence of an intrauterine device (IUD) • Chronic systemic use of corticosteroids • Chronic adrenal failure • Coagulopathy or current therapy with anticoagulants

  14. Effects of abortion process Cramping Often described as similar to menstrual cramps Vaginal bleeding Median bleeding time 9-13 days Often described as similar to a heavy period or spontaneous miscarriage Common side effects Nausea Vomiting Diarrhea Headache Dizziness Fever, chills, hot flashes, warmth Mifepristone/misoprostol regimenSide effects

  15. Mifepristone/misoprostol regimenComplications

  16. Mifepristone/misoprostol regimenSummary • Millions of women worldwide have safely used mifepristone/misoprostol • Mifepristone/misoprostol is more than 95% effective in terminating early pregnancies • Mifepristone/misoprostol is widely acceptable to both patients and providers

  17. Methotrexate/misoprostol regimen

  18. Methotrexate/misoprostol regimenEvidence-based protocol • Day 1 (Clinic) • Methotrexate is administered either orally (50 mg) or intramuscularly (50 mg/m2) • Day 3-7 (Home) • Misoprostol is self-administered vaginally (800 µg) at home. • Day 8 (Clinic) • Clinician performs a vaginal ultrasound to determine if the abortion is complete. • If abortion is complete (75% of women) no further visits are required. • If the abortion is incomplete additional misoprostol is given and patient returns • On Day 15 if cardiac activity is detected • On Day 28-45 if no cardiac activity is detected on ultrasound

  19. Methotrexate/misoprostol regimenEvidence-based protocol continued • Day 15 (Clinic, if necessary) • Patient is assessed for continued pregnancy. • If cardiac activity is detected, a aspiration termination is performed. • If no cardiac activity is detected, patient returns in three weeks. • Day 28-45 (Clinic, if necessary) • The patient is assessed for continued pregnancy. • If the abortion is incomplete (5% of cases), a aspiration termination is performed.

  20. Methotrexate/misoprostol regimenEfficacy and safety • Approximately 95% of women will have a complete abortion when using methotrexate/misoprostol up to 49 days’ gestation. • Medication abortion completion rates decline with increasing gestational age

  21. Methotrexate/misoprostol regimenEligibility for use • Pregnancy of ≤49 days’ gestation • Methotrexate/misoprostol is preferable for women with ectopic pregnancies • Absence of contraindications • Willingness to undergo vacuum aspiration or dilation and curettage (D&C), if indicated

  22. Methotrexate/misoprostol regimenContraindications to use • Allergy to either methotrexate or misoprostol • Presence of an intrauterine device (IUD) • Coagulopathy or current severe anemia • Acute or chronic renal or hepatic disease • Acute inflammatory bowel disease • Uncontrolled seizure disorders.

  23. Effects of abortion process Cramping Often described as similar to menstrual cramps Vaginal bleeding Median bleeding time 2-3 weeks Often described as similar to a heavy period or spontaneous miscarriage Common side effects Nausea Vomiting Diarrhea Headache Dizziness Fever, chills, hot flashes, warmth Oral ulcers Fetal malformations Methotrexate/misoprostol regimenSide Effects

  24. Methotrexate/misoprostol regimenComplications (≤49 days’ gestation)

  25. Methotrexate/misoprostol regimenSummary • Methotrexate/misoprostol is approximately 95% effective in terminating pregnancies ≤49 days’ gestation • Methotrexate/misoprostol is the preferred medication abortion method for confirmed or suspected ectopic pregnancies

  26. Misoprostol-only regimen

  27. Misoprostol-only regimenEvidence-based protocols • No consensus exists on optimal protocol • Various regimens, dosing schedules and routes of administration are currently under investigation • Most commonly used protocol • Vaginal administration of 800 µg of misoprostol • If abortion fails, misoprostol dose is repeated every 24 hours, up to three doses

  28. Misoprostol-only regimenEfficacy and Safety • Efficacy varies widely (65%-93%) • Efficacy varies by route of administration, dose, dosing schedule, and gestational age • Misoprostol-only regimens are not as effective as either mifepristone/misoprostol or methotrexate/misoprostol regimens

  29. Misoprostol-only regimenEligibility for use • Non-ectopic pregnancy of ≤63 days’ gestation • Absence of contraindications • Willingness to undergo vacuum aspiration or dilation and curettage (D&C), if indicated • Lack of access to either mifepristone or methotrexate

  30. Misoprostol-only regimenContraindications for use • Confirmed or suspected ectopic pregnancy • Allergy to misoprostol • Presence of an intrauterine device (IUD) • Uncontrolled seizure disorder • Inflammatory bowel disease

  31. Effects of abortion process Cramping Often described as similar to menstrual cramps Often described as more severe than the cramping of either mifepristone/misoprostol or methotrexate/misoprostol regimens Vaginal bleeding Median bleeding time 2 weeks Often described as similar to a heavy period or spontaneous miscarriage Common side effects Nausea Vomiting Diarrhea Headache Dizziness Fever and chills Rashes Pelvic pain Misoprostol-only regimenSide effects

  32. Misoprostol-only regimenComplications • Approximately 10%-35% of women will require an aspiration intervention • Misoprostol-only regimen is less effective in terminating early pregnancy than when used in combination with either mifepristone or methotrexate

  33. Misoprostol-only regimenSummary • Misoprostol used in conjunction with either mifepristone or methotrexate is more effective at terminating early pregnancy than misoprostol alone • Efficacy varies widely • Optimal regimen has yet to be determined • Misoprostol-only regimen is an important alternative for women who do not have access to other medical or aspiration abortion methods

  34. Medication abortionComparing the three regimens

  35. Medication Abortion in the 2th trimester • Medication abortion vs. aspiration abortion: • similar advantages and disadvantages as in early gestational age • Main medication regimen: High-dose IV oxytocin • 50-300 unit oxytocin in 500 mL NS in 3h followed by 1 h diuresis without oxytocin • Success rate: 80-90%

  36. Medication Abortion in the 2th trimester-Other medications used • Dinoprostone (Prostin E2 ) (PG E2) • One vaginal suppository (20 mg) (high in vagina) • More adverse effects than oxytocin • Nausea, vomiting, fever, diarrhea

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