Plan A Parenthood - Abortions under General Anesthesia in an ASF certified facility


EARLY MEDICAL ABORTION

Policy Statement:  Medical induction is an effective method for early abortion. Adequate counseling and follow-up care will enhance its and acceptability.

Standard 1:  Patient history must be obtained and documented.

Standerd2:   Intrauterine pregnancy must be Confirmed and sonogram picture taken.

Standard 3:   The patient must be informed about the about the efficacy , side effects, and risks, especially excessive bleeding and infections.

Standard 4: The patient must be informed of the need to ensure that she is no longer pregnant and of the teratogenicity associated with the medications to be used.

Standard 5: Patient instructions must include written and oral information about use of medications at home and symptoms of abortion complications.

Standard 6:  The patient must be informed that a surgical abortion will be recommended if medical abortion fails and this must be documented.

Standard 7:  The facility must provide an emergency contact service on a 24-hour basis and must offer or assure referral for uterine aspiration if indicated.

Standard 8:  Gestational age must be verified and documented.

Recommendation 8.1: Ultrasonography, using a consistent and published table of fetal measurements, should be used to confirm and document gestational age when physical exam and LMP are substantially discordant.

Option 8.01.  Ultrasonography may be used routinely and relied upon.

Standard 9: In case of strong urine pregnancy test and If intrauterine gestation has not been confirmed by ultrasound, ectopic pregnancy must be considered. At a minimum, evaluation will include history and physical exam and may also require serology, sonography, and examination of uterine aspirate, as well ad documented follow-up through either clinical resolution or transfer of care.

 

Standard 10 :   Combination regimens are more effective ingestationsless than 6 weeks than prostaglandin alone.    In less than 6 weeks of gestation where waiting is not a choice and mifepristone is available, an evidence-based mifepristone/misoprostol regimen must be used.

Recommendation 10.1: When mifepristone and vaginal, buccal, or sublingual misoprostol are used, the regimen is recommended for gestations up to  70 days.

Recommendation 10.2:  When mifepristone and oral misoprostol are used, the regimen is recommended for gestations up to 56 days.

Recommendation 10.3:  Where mifepristone is not available and methotrexate and misoprostol are used, a regimen using vaginal, buccal, or sublingual misoprostol is recommended for gestations up to 63 days.

Recommendation 10.4:  Where neither mifepristone or methotrexate  are available and misoprostol alone is used, a regimen using vaginal, buccal, or sublingual misoprostol is recommended for gestations up to 77 days.

Standard 11:  Patient comfort level during the abortion procedure must be considered.

Option 11.01: Analgesia or other comfort measures may be used as needed unless there are contraindications.

Standard 12:   Complication of the abortion must be documented by ultrasonography, Hcg TESTING, OR BY CLINICAL MEANS. If the patient has failed to follow-up as planned, clinical staff must document attempts to reach the patient to ensure the abortion is complete. All attempts to contact the patient ( phone calls and letters) must be documented in patient’s medical record.

        Recommendation 12.1:  Ultrasonography should be used to evaluate complication of the abortion when expected bleeding does not occur after medications.

         Option 12.01: Ultrasonography may be used routinely.

Standard 13:   Rh immune globulin must be offered in accordance with Rh Guidelines.

Standard 14:    Clinical Policy Guidelines Standards 6, 7, 8  for post-procedure Care must be followed

Recommendation 01:  Either hematocrit or hemoglobin screening should be obtained in women with history of significant anemia or specific indication.

Recommendation 02.  A complete blood count (CBC) should be considered for women receiving methotrexate.

Recommendation 03:  Vital signs (e.g. , blood pressure, pulse, and temperature) and physical exan may be done as indicated by medical history and patient symptoms.

 

 

  Discussion:  Many patients prefer Pharmacological methods of terminating early pregnancies rather than suction curettage. Medical abortion has several advantages for patients. It avoids surgery and anesthesia and offers woman more active participation and control over the abortion process.  Medical abortions are   little (less than 1%) less effective than surgical abortion but carries no risks associated with surgical abortions. less complications than surgical abortions. It can take same office visits or in some cases few more office visits to confirm the completion of procedure.

Extensive research has established the safety and efficacy of medical abortions for early pregnancy termination.  Methotrexate and misoprostol have also been found to be effective and are used in some services where mifepristone is not available. While misoprostol alone is inferior to combined methods for termination of pregnancy, in areas where mifepristone or methotrexate are not available, it may be an acceptable alternative.

Mifepristone is administered orally: Original trials involved a 600 md dose, but an abundance of research indicated that 200 md provided comparable efficacy. The best studied methotrexate regimen involved 50 mg/m2 (body surface area) given intramuscularly, the same dose used in treating early unruptured ectopic pregnancy. Research also indicated acceptable efficacy when methotrexate is administered orally in dose of 25-50 mg.

Information has also evolved on the types, doses, and routines of administration of the prostaglandin agents used in medical abortion regimens. Currently, misoprostol  is the favored agent because it is efficacious, inexpensive, stable without refrigeration, and already FDA-approved for other indications.

Buccal administration of misoprostol has a similar physiological effect on the uterus as vaginal administration and is similarly highly effective for medical abortions. Sublingual administration of misoprostol is also highly effective for medical abortion with mifepristone, but is associated with a higher frequency of chills. One large retrospective study suggests that a change of routine from vaginal to buccal administration of misoprostol after mifepristone was associated with a reduced incidence of serious infection, although absolute risk is extremely low. The effectiveness of medical abortion declines very gradually with advancing gestational age. This decline is more evident with oral administration of misoprostol.

 

 

 

The above mentioned guidelines are by NAF (National Abortion Federation 2013) but at Women’s Choice LI, De Joel Cooper a board certified OB/GYN has seen success of medical abortion following his own protocol:

a)     Patient detailed medical history.

b)    Patient prior pregnancy history.

c)     Patient Rh blood type ( positive or Negative)

d)    Patient hemoglobin screening ( must be over 10)

e)     Patient vaginal or abdominal sonogram to confirm IUP/Age.

f)      Discussion of the findings by Clinical staff with Dr. Cooper.

g)     Counseling about procedure and choices available. Risks and benefits of medical abortions.

h)    Starting the procedure upon approval of the clinician as follows:

1)    Gestation under 6 weeks, recommendation to wait till age 6+ or use of combination of Mifepristone/Misoprostol.

2)    Gestation of 42day to 77 days, recommendation to start the medical abortion procedure using , 400 mcg of Misoprostol by mouth and 600 mcg of misoprostol vaginally. Waiting in the office on stretcher for 20 to 25 minutes and then discharged.

3)    Discussion about post procedure guidelines and setting up a post procedure date to return for medical examination to confirm the pregnancy has ended.

 

 

 

 

 

 

 

 


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