Medication Abortion In Early Pregnancy

Induced termination

of early intrauterine pregnancy

using medications

6.4 Million Pregnancies/Year in the U.S.

51% Intended

24% Unintended

Used Contraception

25 % Unintended

Used No Contraception

Finer, 2006 (2002 data)

Unintended pregnancy rate: by race/ethnicity/income

0

20

40

60

80

100

120

140

160

180

Below povertylevel

Above povertylevel

allwhitelatinablack

Unintended pregnancies per 1,000 women

Finer, 2006

Outcomes of Unintended Pregnancies

(Approximately 3.1 Million Annually)

14%

42% 44%

0%

20%

40%

60%

80%

100%

Abortions Births Miscarriages

Finer, 2006 (2002 data)

% of unintended pregnancies

89% of abortions occur in the first 12 weeks of pregnancy

62.5%17.3%

9.4%

6.5%

3.3%1.0%

<9 weeks

9 to 10

11 to 12

13 to 15

16 to 20

21 or more

Under 9 weeks

9-10 weeks

11-12 weeks

Guttmacher Institute, 2004 data

Abortion Access

• 87% of counties have no abortion provider

• 35% of women live in these counties

• 25% of women travel > 50 miles to find provider

Source: Jones et al., 2008; Kaiser Family Foundation

% of Women in Counties with No Abortion Provider

Primary care shortage areas:

with

and

without family physicians

Graham Center, 2000

Abortion in Family Medicine:Training Issues

0

50

100

150

200

250

300

350

400

450

1997 2007

abortion training

no abortiontraining

Could training family physicians in medication

abortion make a difference?

Abortion in Family Medicine:

Implementation Issues

Wanted versus unwanted pregnancy:consequences

Medication & Aspiration Abortion:both safe and effective

Safety of Abortion

First trimester abortions DO NOT increase risk of:

• Infertility• Ectopic pregnancy• Miscarriage• Birth defect• Preterm or low-birth-weight delivery

Sources: Boonstra, 2006Virk, J et al, NEJM, 2007

Medication Abortion Regimens:Three Choices

Mifepristone + Misoprostol

Methotrexate + Misoprostol

Misoprostol alone

Most common med abortion regimen in US:

Mifepristone/Misoprostol

Medication Abortion: Advantages

• 95-99% effective• Avoids surgical and

anesthetic risk• Greater patient

autonomy & privacy• Less invasive• More “natural”

Aspiration Abortion: Advantages

Slightly more effective (about 99%)Shorter time to completionShorter bleeding duration

Can be performed later in gestation

Mifepristone-Misoprostol RegimensFDA Protocol Alternate Protocol

Gestational age limit 49 days 63 days

Mifepristone dose 600 mg. oral 200 mg. oral

Misoprostol dose, route, and timing

400 mcg. oralOffice administration

48 hours later

800 mcg. vaginal or buccalHome self-administration

6 - 72 hours later (vaginal)

24 - 36 hours later (buccal)

Office follow-up visit 10-15 days after mifepristone

4-10 days after mifepristone

Minimum office visits

3 2

Cost of medications $270 for mifepristone$2.00 for misoprostol

$90 for mifepristone$4.00 for misoprostol

CervicalRipening

MIFEPRISTONECauses

progesterone blockade

Decidual Necrosis

Detachment

MISOPROSTOLCauses uterine cramping & expulsion

Misoprostol

Yolanda

22 years old

Requests a pregnancy test

Counseling issues

Review all options

Assure that decision is hers

Establish gestational age

Rule out contraindications

• Allergy to meds• Adrenal insufficiency • Current steroid use• Coagulopathy or

anticoagulant use• IUD in place• No access to follow-up

Indications for sonography

Yolanda

Gestational age: 6 weeks

Patient agreement

Yolanda takes mifepristonein your office

At home:Yolanda takes pain medication, then misoprostol

Follow-up visit

•4 - 14 days later

•Assure completion

•Process experience

•Review contraceptive choice

Phone calls after medication abortion

Clostridium sordellii

• 6 deaths in North America due to toxic shock with Clostridium following medication abortion

• Similar deaths, however, also seen following miscarriage, childbirth, trauma, & surgery

• CDC: no causal link between medications and these incidents

Source: CDC 2006, FDA 2006

Methotrexate + Misoprostol medication abortion

Misoprostol-only medication abortion

800 mcg vaginally

> 1 dose may be needed

Conclusion

From pregnancy diagnosis through week nine,

medication abortion is safe and effective. As its

success depends on accessibility and

counseling, medication abortion is well suited

to the family medicine home.