1. Caring for the Woman with an Unintended Pregnancy
A slide presentation for
Advanced Practice Clinicians and students
Kristina Chamberlain, CNM, IBCLC
Prepared by the Reproductive Options Education Consortium for Nursing
This slide presentation takes hours to deliver in its entirety. Users may choose to omit individual slides or entire sections based on the learning needs of their audience or time constraints.
Alternative uses of the presentation include having advanced practice nurses/students review the presentation on their own (as a course assignment).
The presenter’s notes provide additional background information related to the slide. They are particularly intended to assist those who are preparing to present the slide presentation. They may be used or not as desired.
A brief reference list is included at the end, and may also be used to provide additional background information. In addition, for more resources on Caring for Women with Unintended Pregnancies, users of this slide presentation may want to look at the guide: Teaching Reproductive Options: A Guide for Nurse Educators also located on this website.
Please contact us if you have any questions or feedback about the slide show!

2. Overview of this presentation
Unintended pregnancy
Background
Prevention
Pregnancy diagnosis
Options counseling
Abortion
Types
Aftercare
1st point: Many women will turn to their primary care provider for assistance when they have questions or concerns about their reproductive health, including when they are faced with an unplanned pregnancy.
For this reason, it is important for advanced practice clinicians to be knowledgeable and up-to-date in their understanding of available options for women seeking to prevent or faced with unintended pregnancies.
(Advanced practice clinicians includes nurse midwives, nurse practitioners and physician assistants).
Final note: You may choose to add: For some of you the issues we discuss today may be difficult. If you feel the need to talk with me privately after the class, please feel free to do so.
Before next slide comes up:
Solicit from class—How many women become pregnant each year in the United States? (answer: ~6.3 million)
How many of those pregnancies are unplanned? (see following slide)
What do women do when they are faced with an unplanned pregnancy? (see following slide)
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3. Unintended Pregnancy: Background
Each year in the United States:
48% of pregnancies are unintended
Of those unintended pregnancies:
Approximately half are carried to term or end in miscarriage
Other half are terminated
(Henshaw, 1998)
Women with unintended pregnancies are from all races, ethnicities, classes, and religions
1st point: The United States has a significantly higher rate of unintended pregnancy compared to other industrialized countries.
2nd point: Though we will be focusing on the care of women in this talk, this does not negate the role of men or the need to involve them in comprehensive reproductive health care as well.
Before next slide comes up:
Solicit from class/brainstorm--
So why do women experience unplanned pregnancies?
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4. Why do women experience unintended pregnancies?
Contraceptive failures
Contraceptives unavailable/hard to get/expensive
Lack of understanding of reproduction/fertility
Sexual assault/abuse/coercion
Religion and/or partner forbid use of contraception
Emotional/psychological reasons
Don’t know about or can’t get Emergency Contraception
Contraceptive failures--No method is perfect. For example, even after surgical sterilization, one woman out of every 200 becomes pregnant. Contraceptives are not easy to use exactly right--pregnancies happen when condoms break, or pills stay in their package.
Contraceptives are unavailable, difficult to obtain or too expensive—For ex. a woman may run out of birth control pills or not be able to get refill promptly; insurance may not cover her birth control or she may be uninsured.
Lack of understanding of reproduction/fertility –Many women do not understand when risk of pregnancy is greatest.
Sexual assault/abuse/coercion
A woman’ s religion or her partner may forbid her to use contraception (so even though a woman may not want to have another pregnancy, she may not feel she can use or be able to obtain contraceptives)
Emotional/psychological reasons: Denial about the possibility of getting pregnant, ambivalence about having a child or the desire to be sure she is fertile sometimes lead women to have unplanned pregnancies.
Finally: Many women still don’t know about or aren’t able to get emergency contraception! which we’ll talk about more in a few minutes
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5. Caring for the Woman with an Unintended Pregnancy: Roles of the APC
Performing pregnancy tests and delivering results
Providing options counseling
Providing prenatal or abortion care, or referrals
Assisting with selecting an acceptable contraceptive method
Prevention
1st point: As an advanced practice clinician, even if you are not planning to work in an Ob/Gyn or women’s health setting, if you are going to be providing care to women of reproductive age in any setting, it is likely that you will be involved in caring for women with unintended pregnancies. (Remember, almost half of all pregnancies are unintended).
In this role you may provide pregnancy testing, options counseling, referrals, contraception, and other prevention efforts to women.
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6. Diagnosing pregnancy: Types of tests
Immunometric tests
Detects human chorionic gonadotropin (HCG) in urine
Highly sensitive; positive within 7-10 days after conception
Qualitative measure (“yes” or “no”)
Quick, simple, low-cost
Radioimmunoassay tests
Detects HCG in blood
Highly sensitive
Quantitative or qualitative measure
Used primarily for clinical management of pregnancies that are problematic or concerning
First point: There are several types of pregnancy tests. Immunometric tests, also known as ELISA or monoclonal antibody tests, have become the most common type of test, both at home and in clinical settings, because they are easy to use, non-invasive, highly sensitive and inexpensive.
2nd point: Radioimmunoassay tests, also known as RIA or quantitative beta-HCG tests, are more commonly used when there is a clinical indication. They require more sophisticated laboratory equipment, and are more expensive than urine tests.
3rd point: With either of these types of tests, women can know they are pregnant before they miss a period
4th point: An older type of test--agglutination tests--are no longer common because immunometric and RIA tests provide positive results much earlier and at comparable cost.
5th point: For our discussion of basic, primary care, we’ll focus on urine pregnancy testing. Use of blood tests is only indicated for women with symptoms of a problem pregnancy including pain, bleeding, or irregular menses. (In depth discussion of these clinical conditions and HCG testing as part of the management is beyond the scope of this lecture).
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7. Pregnancy testing: Roles of the APC
Order and/or perform tests appropriately
Interpret test results
Inform patient of result using neutral language
Provide options counseling or prevention measures
1st point: As an APC, your responsibilities may include performing pregnancy tests, interpreting the results, and informing patients about the results.
2nd point: If a qualitative test is negative, it is important to understand the implications of this (for example, it may simply be too early to be positive). It is rare to have false negatives, and even rarer to have false positive tests. If the result of the urine test is different than was expected, it is generally advised to repeat it in 1-2 weeks.
3rd point: When delivering the test results, it is important to deliver pregnancy test results in a neutral and clear way. For example rather than saying “Congratulations, your test is positive”, it is better to say: “Your test result is positive, which means that you are pregnant.” Don’t make assumptions about what the patient wants the result to be.
Before next slide comes up: QUESTION TO CLASS: Imagine a client comes in requesting a pregnancy test. What are some things you might want to know before doing a pregnancy test?
Solicit/Brainstorm responses. Be sure the following are included: (see following slide)
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8. Suggested steps in pregnancy testing
Before test discuss with client:
Why does she think she may be pregnant?
When was her LMP?
Has she thought about what she will do if the test is + ?
After test:
If – : provide contraception, educate/advance Rx for EC and safer sex counseling
If + : estimate gestational age by last menstrual period and/or clinical exam (and/or ultrasound), and provide pregnancy options counseling
1st point: Asking these questions before the test is important to help you determine why a woman suspects she is pregnant, and whether it is even appropriate to be doing a pregnancy test at this time.
It is also helpful to know whether a woman has thought about what she will do if the test is positive before giving the results in order to anticipate what the patient’s reaction might be.
2nd point: For the woman who does not want to be pregnant, a negative result provides a “teachable” moment --following a negative test she may be highly motivated to use a reliable method of birth control and to learn about safer sex practices and emergency contraception.
3rd point: If the test is positive, go on to provide options counseling. Estimating the gestational age of the patient is important as it may impact the choices a woman has and the type of referral she may need. There are varying upper limits for abortion depending on the state.
Transition statement: So, following a positive pregnancy test, what are a woman’s options?
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9. Pregnancy Options Counseling
Following a positive pregnancy test result what are a woman’s options?  
Continue pregnancy and:
parent
make an adoption plan
place infant in temporary foster care
Terminate pregnancy through:
medical abortion
surgical abortion
1st point: Women with unintended pregnancies have two primary options—to continue or to end their pregnancies. Within each of these options, there are additional options.
2nd point: Separating parenting from placing a child for adoption or in temporary foster care are important distinctions. Women who are considering adoption should be referred to a professional, such as a social worker, who can offer accurate information and counseling. Adoption is a very complex decision, and anyone considering it needs strong support and accurate information.
3rd point: No matter what her ultimate plan, a woman who chooses to continue her pregnancy should be assisted to begin early prenatal care.
4th point: Abortion is legal in the US, however, restrictions exist that limit a woman’s ability to have one. Restrictions vary from state to state but may include 24 hour waiting periods, prohibitions on Medicaid funding, and parental consent laws that require a young woman to get permission from one or both of her parents or a judge. It is important to be familiar with the laws that affect abortion in the state where you are practicing.
Final point: Those who choose abortion may have the option of choosing between a medical and a surgical termination, which we will discuss further later.
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10. Options counseling: Roles of the APC
Inform and educate self and clients
Provide non-judgmental, non-directive counseling
Ensure confidentiality
Provide resources for desired services, including referrals to quality providers
1st point: Many women with unintended pregnancies have questions or are misinformed about their options, therefore it is important for clinicians to know what each of the options are and what they involve in order to dispel patient myths, clarify misinformation and accurately answer questions.
2nd point: It is also essential that pregnancy options counseling be non-judgmental, sensitive and non-directive. Though we may have opinions about what a woman should do when faced with an unintended pregnancy, it is ultimately her decision, and she deserves respect and compassion as she makes that decision and acts upon it.
It is also essential to reassure the woman, even if she is a minor, that everything you discuss is confidential. During at least part of the encounter, you should be alone with her as she may not feel comfortable or be able to tell you all of her feelings if a parent, boyfriend, or other person is present. It is important to be sure the patient is free from coercion around this important decision.
Final point: No matter what her ultimate decision is, every woman deserves good care. Many APCs provide prenatal care and/or work in settings where abortions are performed. If you are not able or interested in providing the full range of reproductive health services to your patients, it is important to refer them to a reputable agency for the care they need.
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11. Suggested steps in pregnancy options counseling
Explore how the woman is feeling about the positive test result
If she is unsure of her plans, help her to consider her alternatives
Help her to identify support systems
Help her to reach a decision; or if she is not ready, discuss timetable for decision-making
Refer or provide her with appropriate service
Before reviewing points: Remind students that many different techniques are useful for counseling patients; encourage them to use the same techniques—i.e. reflecting feelings, paraphrasing, using open-ended questions, etc.—that they have learned about in other classes when doing pregnancy options counseling.
1st point: This is a suggested framework and some suggestions to keep in mind when you are providing pregnancy options counseling. When a woman presents with a positive pregnancy test, some possible opening questions to ask are: How are you feeling about being pregnant? Did you expect this result, or are you surprised?
2nd point: In helping a woman consider her alternatives, you might ask her: Do you know what your choices are? Or What are your thoughts about adoption/becoming a parent/abortion?
3rd point: Encourage her to talk with her friends, family, or partner. It can be a red-flag if a patient tells you she has no one she can tell/talk to, as it may indicate a lack of social support/isolation. These patients may need more intensive follow up.
4th point: The decision to have an abortion is time-sensitive. Abortion is possible until ~24 weeks, but it is safest if done by 12 weeks. Also, cost increases with gestational age, and many settings that provide abortions are not able to perform them after the first trimester. Follow up may include returning for additional visits for continued help with decision-making.
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12. Summary: Caring for women with unintended pregnancies
Important points to keep in mind:
There are many reasons women experience unintended pregnancies
An unintended pregnancy is a crisis for most women
Sensitive, non-judgmental, non-directive counseling and care is essential
1st point: So before we move on to the next section, I just want to make a few concluding remarks about caring for women with unintended pregnancies. As we discussed earlier, women become pregnant without intending to for many reasons.
2nd point: For some, an unplanned pregnancy may be a particularly difficult life experience. Even if a woman winds up deciding to continue a pregnancy and is happy about it, if it was not planned it usually creates a lot of upheaval in her life. For example, for the teenage woman who has gotten pregnant and doesn’t want her parents to know, or the perimenopausal woman who thought she could no longer become pregnant, or the sexual assault victim who has gotten pregnant as a result of her trauma, this can be a particularly difficult life experience.
3rd point: And finally, as clinicians it is important to provide sensitive, non-judgmental care. In order to do so, it is important for you to clarify your beliefs and to be sure that they will not conflict with your ability to provide such care.
Transition statement: Now we will go on to talk about women who choose to have abortions.
NOTE: Several values clarification exercises are included on the CD. This may be a time to have students break into small groups to talk through these exercises. Alternatively, suggest that students do them on their own to help them think through their beliefs/values about providing care to women with unintended pregnancies.
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13. Who has abortions? In the United States:
In 2000, 1.31 million abortions were performed (Jones et al., 2003)
35% of women will have at least one abortion by the age of 45 (AGI, 2003)
52% of women are under the age of 25 (Jones et al., 2003)
Abortion is one of the most frequently performed surgical procedures (Finer and Henshaw, 2003)
During the remaining 20 (or so) minutes of this class, I’ll go over
-Basic information about who has abortions;
-Types of abortion;
-Post abortion care;
And the role that advanced practice clinicians can play in abortion care.
So, who has abortions in the United States?
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14. “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
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15. Surgical abortion Methods and timing: Vacuum aspiration
Up to weeks
Dilation and evacuation
15-23 weeks
Induction or instillation
Rarely used (<1%), usually between weeks
1st point: All surgical abortion procedures involve first dilating the cervix with dilators that are either tapered metal rods of increasing size, or an absorbent material which is placed in the cervix, where it swells as it draws moisture from the surrounding cervical tissue, causing the cervix to open. The cervix is opened so that a plastic tube, called a cannula, can be passed into the uterus.
The cannula is connected to a suction source which applies gentle pressure inside the uterus, causing the products of conception (or POC) to separate from the uterine wall and be removed. The source of suction is either an electric pump, or with early abortions, it can be from a hand-held vacuum syringe.
Some clinicians combine aspiration with curettage, which involves passing a sharp instrument over the inner walls of the uterus after the use of suction to be sure all of the pregnancy tissue has been removed. This is called dilation and curettage (or a D &C).
2nd point: Dilation and evacuation (or D&E) involves the additional use of forceps to remove the pregnancy. Dilation and Extraction (or D&X)--which has been erroneously called “partial birth abortion” by groups opposed to abortion--is a subtype of this method.
3rd point: Induction/instillation involves inducing labor through administration of medications. Fewer than 2% of all abortions are now performed this way in the U.S. Though it is technically not surgery, for the purposes of this lecture we are categorizing it with the other surgical methods to distinguish it from other forms of medical abortion which are used only in early terminations.
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16. A few important facts about surgical abortion in the first trimester
88% are done in the first 12 weeks of pregnancy
(Elam-Evans et al., 2002)
95% performed in outpatient setting (NAF, 2000)
Actual procedure takes less than 5-10 minutes in most cases
Local anesthesia used; may opt for additional anesthesia, including general
In outpatient settings, cost ranges widely: average cost $372 (Henshaw and Finer, 2003)
1st point: Vacuum aspiration is the most common type of procedure used in abortion.
2nd point: Pain during the procedure varies from person to person. It is usually compared to strong menstrual cramps. At a minimum, all women receive local anesthesia (usually lidocaine) which is injected directly into the cervix. Additional anesthesia may be available including IV sedation, and in some settings, general anesthesia may be available.
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17. Facts about abortion procedures after the first trimester:
Less than 12% take place after 12 weeks
Less than 2% after 20 weeks
(Elam-Evans et al, 2002)
Time to complete depends on procedure:
D & E: minutes
Instillation/induction: ranges from hours to days
Pain medication always used
Cost increases with gestational age
1st point: Some of the main reasons for later abortions include:
-Fetal anomalies discovered by genetic testing or ultrasound that are performed after 15 weeks gestation;
-Maternal medical problems that would worsen with full term pregnancy, such as heart disease.
-Late detection of pregnancy
-Restrictive laws, including parental consent laws
-Difficulty getting money to pay for service
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18. Surgical abortion: vacuum aspiration
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
+/- curettage
Before undergoing an abortion procedure, all women are counseled. Counseling may include options counseling (for those who are not yet decided about their decision), and abortion-specific counseling (for those who are sure they want to terminate the pregnancy, but may not know about the different options for termination). In addition, specific considerations and risks associated with the type of procedure they are having are reviewed. Informed consent is obtained. Any patient who is not able to give full consent (either because of ambivalence, coercion or other limitations, such as age or mental capacity) will not be able to have the procedure.
A medical and social history are performed to identify patients who are at high risk or ineligible for a procedure.
Labs are performed to ensure that the woman is pregnant, that she is not anemic and that there is no infection present that could predispose her to post-abortion endometritis. In addition, women who are Rh negative are identified so that they can be given Rhogam.
A clinical (pelvic) exam and/or ultrasound is performed to be sure that the EGA correlates to the uterine size.
5) For pain control, in most settings the woman is given a paracervical block routinely prior to the procedure. In addition, in many facilities women are offered additional analgesia (and/or anti-anxiety) options, including agents that are administered orally or via IV. General anesthesia is offered in some settings, however because it increases the risk of the procedure, it’s use is generally limited to special clinical situations.
5) After confirming the EGA and providing desired analgesia, the provider dilates the cervix by inserting consecutively larger dilating rods, until the desired cervical opening is achieved. (The size of the cervical opening needed increases with advancing gestational age). In some settings or in more advanced pregnancies, dilation may be achieved through the use of osmotic dilators (such as laminaria) which are placed in the cervical os several hours-a day prior to the procedure. One advantage of osmotic dilators is that they can decrease the risk of cervical perforation. In some settings, providers use misoprostol to promote cervical ripening prior to dilating the cervix.
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19. Surgical abortion: D & E, D & X
Same as with vacuum aspiration +
D & E: Suction + forceps
D &X: Suction + forceps and reduction of fetal cranium
Takes longer, more involved procedure
Requires more advanced training on part of providers
Dilation usually achieved through osmotic dilators (v. mechanical)
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20. Abortion through labor induction
Labor-Induction Techniques:
Intra-amniotic instillation
Intramuscular prostaglandin
Intravenous oxytocin
Usually used in pregnancies of >20 weeks gestation
Less commonly used now in US because less safe and more emotionally difficult for patients than D&E
However, D & E requires skilled provider (not always available)
(Paul et al, 1999)
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21. Risks/Complications of surgical abortion
First trimester procedure is very safe:
Hemorrhage (<1%) 
Infection (<3%)
Missed abortion (<1/2 of 1%)
Retained tissue (<1%)
Perforation/cervical tear (<1%) (NAF, 2003)
After first trimester:
Same as with 1st trimester, but risk increases with advancing gestational age
 The risks associated with carrying a pregnancy to term are 10 x greater than with a surgical abortion (Ibid)
1st point: 1st trimester surgical abortion is extremely safe (if properly performed). The biggest threat to safety is illegality: in places where it is illegal, it remains a leading cause of maternal death.
2nd point: Among women undergoing first trimester abortion, fewer than 3% report complications, and less than 0.5% experience a serious complication. This makes it safer than tonsillectomy, appendectomy or childbearing.
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22. Medical 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
Used only for terminations up to days gestation
Side effects/complications:
Common: nausea, diarrhea,vomiting, headaches
Rare: excessive bleeding, infection
1st point: The term medical abortion has been used to describe an abortion which is carried out through the use of medications, rather than through surgery.
2nd point: Specific protocols for using each of the two main drugs used for medical abortion vary. As a result, ranges are given for the effectiveness, dosages and gestational age limits for use. At present both drugs can be used reliably for terminations of up to 49 days from LMP; some protocols allow use up to 63 days from LMP.
3rd point: All women will bleed during the course of a medical abortion (this is part of its normal effect). Cramping is also considered a normal effect of the drugs as they cause an abortion. 80% of women report some abdominal pain and cramping when they have a medical abortion, which they usually describe as “like an intense menstrual period.” Many also report nausea, or diarrhea. These side effects are generally mild and do not require treatment.
4th point: Excessive bleeding is not common and usually results when there is retained tissue.
5th point: Infection is extremely rare following medical abortion, less than 1%.
Final point: Because the medications used in medical abortion are known teratogens, if a woman does not successfully abort after receiving the medications, she must undergo a surgical abortion to complete the procedure.
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23. Medical Abortion: Mifepristone
Mechanism of action:
“Anti-progestin”blocks progestin
Takes 2-4 days for completion of abortion
~95% effective (NAF, 2001)
Requires at least 2 visits to provider
Approved by the FDA for use in abortion
Potential for numerous other medical uses including endometriosis, brain cancers, post-coital contraception, other
1st point: Mifepristone is also known as RU-486 or the “French abortion pill”. The commercial name in the US is “mifeprex”
2nd point: Mifepristone is given orally, and then several days later, as with methotrexate, misoprostol is given to cause the uterus to contract and expel the pregnancy tissue. Unlike methotrexate, however, women generally pass the pregnancy tissue 4-6 hours after the administration of misoprostol, which for many, makes it a preferable method.
3rd point: Mifepristone was approved by the FDA in Fall 2000, so it’s use in the US is still limited but is expected to increase over the coming years. Studies of women who have used the medication report high levels of satisfaction.
4th point: Efficacy of mifepristone/misoprostol ranges from 85-97% (variables include length of gestation,
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24. Medical Abortion: Misoprostol
Mechanism of action: Prostaglandin analogcauses uterine contractions
Used in conjunction with mifepristone or methotrexate to cause expulsion of pregnancy tissue
Causes cramping/bleeding (desired); may cause other GI upset
Oral v. vaginal administration
Under study for use alone as medical abortion method
FDA approved for use for treatment of ulcers; off label use for abortion, labor induction, etc.
Known teratogen (NAF, 2001)
1st point: Misoprostol is a type of synthetic prostaglandin which is used for a wide variety of purposes including treatment of ulcers and labor induction.
2nd point: In conjunction with either mifepristone or methotrexate, misoprostol is given to stimulate the uterus to expel the pregnancy. If the woman does not pass the pregnancy tissue within 2 days, she may be given a second, or even several additional doses of misoprostol.
3rd point: There are some studies underway that are looking at the use of misoprostol alone to induce abortion. In some developing countries it is already being widely used by women attempting to self-abort.
4th point: Misoprostol’s side effects are generally self-limiting and do not pose a major threat to a woman’s health.
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25. Medical 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 medical abortion
Very rare side effects include alopecia, leukopenia, interstitial pneumonitis (NAF, 2001)
1st point: Methotrexate has been in use for cancer and arthritis treatment, as well as for the treatment of ectopic pregnancies for a number of years in the US. In recent years it has become more widely used for early pregnancy terminations. Since the FDA approval of mifepristone in 2000, methotrexate has become less common as a method for medical abortion. This is largely due to the fact that it is slightly less effective, and does not offer the same reliability in the timing of passage of pregnancy tissue. (It can take up to 45 days for bleeding and passage of pregnancy tissue to occur following use of misoprostol)
2nd point: When it is used to induce an abortion, methotrexate is given as a one-time IM injection. The dose depends on a woman’s bodyweight. The medication works by inhibiting DNA synthesis, which stops the division of cells that divide rapidly, such as those of a developing pregnancy days after the methotrexate injection is given, misoprostol (800 micrograms) is administered vaginally, which causes the uterus to expel the POC at some point from hours to weeks later.
Final point: One benefit of a methotrexate abortion is that it is effective in ending ectopic as well as uterine pregnancies, thus if a woman has a known or undetected ectopic, a methotrexate abortion can prevent complications that are associated with with this condition.
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26. Typical mifepristone medical abortion process
Varies from site to site + from FDA protocol
Day 1:
Counseling and informed consent, including consent for surgery if method fails
Medical and social hx
Labwork including: pregnancy test, H&H, Rh factor, tests for vaginal/cervical tests prn
Ultrasound to confirm IUP/EGA, +/- clinical exam
Mifepristone ( mg) given on site
Misoprostol + Rx’s for pain and nausea relief given for at home administration
1st point: Medical abortion protocols vary from site to site. The FDA approved protocol is largely based on clinical trials that were conducted prior to Since that time many studies have been conducted to investigate alternative methods of administration and protocols. These alternative or “evidence-based” options often differ from the FDA-approved protocol with regard to medication doses, administration and timing, use of ultrasound, gestational limits and required follow up visits. Currently in most settings in the US, patients are given mifepristone pill(s) ( mg) on site following clinical exam and/or ultrasound to verify gestational age. One to three days later the woman administers misoprostol vaginally (or orally) at home. In the majority of women, bleeding and passage of the pregnancy ensues several hours after misoprostol administration, but may take up to 24 hours or longer. A follow up visit is required several days to weeks later to ensure that the pregnancy has been successfully terminated.
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27. Typical mifepristone medical abortion process (continued)
Day 2-4:
Vaginal (or oral) administration of miso 800 mcg
Vaginal bleeding, cramps begin 2-4 hours after administration of miso
Bleeding/cramping most intense during passage of pregnancy tissue, then subsides
May take up to 24 hours (or longer) to pass pregnancy
Bleeding may continue for 2-4 weeks
Follow up appointment 3 days – 2 weeks later:
U/S +/- clinical eval to confirm passage of pregnancy
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28. Medical vs. surgical abortion
Advantages:
May offer more privacy
Avoid surgery
Considerations:
Requires at least 2 visits and takes daysweeks to complete
If unsuccessful, requires surgical intervention
Only for early abortions
Surgical
Advantages:
Usually requires only 1 visit
Procedure complete within minutes
High success rate
Considerations:
Involves invasive surgical procedure
First point: In helping a woman to decide between a medical and a surgical abortion, it can be helpful to review some of the advantages and particular considerations that each method entails.
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29. Post-abortion evaluation at 2-3 weeks
Subjective:
Bleeding
Pain
S/s infection
Pregnancy symptoms
Emotional state
Sexual function
Satisfaction with/need for contraception
1st point: Women who have abortions are advised to return for routine post-operative evaluations 2-3 weeks after their procedure. In addition, some will contact their primary care provider if they have questions or concerns before that visit. In providing such care, it is important to assess the patient for the following:
Bleeding: Bleeding following a surgical abortion can range from no bleeding to bleeding like a period for some days after the procedure. If a patient reports twice her normal menstrual flow, saturating a sanitary pad in <1 hour, or passing multiple large clots, she may require evaluation. Many women note that their bleeding increases if they increase their physical activity. For women undergoing a medical abortion, after the pregnancy passes, bleeding should slow, and then generally follow the same pattern as after a surgical abortion. It can be normal for women to continue to spot or bleed lightly for 4 weeks or more after an abortion. Menses usually returns 4-6 weeks after an abortion.
Pain: Following a surgical or medical abortion, some women will experience cramping for a few days that is generally relieved with over-the-counter analgesics or other non-pharmacologic pain relief measures. Pain that increases or persists should be evaluated. By the routine 2 week check, a woman should no longer be experiencing pain.
Symptoms of pregnancy normally resolve quickly after an abortion is complete. Nausea generally resolves within 24 hours. Breast tenderness can last up to a week and if there is nipple discharge, it may last several weeks. If a patient reports still feeling pregnant at her 2 week evaluation, this warrants further evaluation.
Emotional responses: Most of the research on abortion has found that women feel positively about their decision, and commonly report feelings of relief. (NAF, 1999) These feelings may be mixed with other transient feelings of sadness, loss or guilt. In rare cases women may experience severe depression or guilt. It is important to assess how a woman is coping with her emotions in order to identify those who may need more intensive follow up (i.e. referral to a counselor)
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30. Post-abortion evaluation at 2-3 weeks
Objective:
Vital signs
Pelvic exam
HCG (if indicated)
Ultrasound (if indicated)
Assessment/Plan:
Complications
Contraception
Access to ongoing care
1st point: Unless there is concern about the possibility of a continued pregnancy, it is not necessary to perform a pregnancy test. A sensitive HCG will still be positive up to 4-8 weeks after an abortion, however, a non-sensitive test should not be positive and serial quantitative HCGs should be decreasing.
2nd point: Speculum and bimanual examinations should be performed at the 2 week post ab check to assess for cervical closure and uterine involution, which should be complete by that time. Foul-smelling or mucopurulent discharge is not a normal finding. If the uterus is enlarged, tender or boggy, this is not a normal finding.
3rd point: Abnormal findings or complications following an abortion are not common. Management depends on the finding and generally requires consultation or referral to a physician or the site where the abortion was performed.
4th point: If the client has not already established a reliable method of birth control following her abortion, it should be addressed during the post-ab check. Virtually all methods can be started immediately after an abortion, or at any point before the woman has resumed sexual activity.
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31. Abortion care: Roles of the APC
Provide method specific counseling and screening
Assist with procedure or provision of medications
In a number of states may provide medical abortion; surgical in some
Provide post-abortion care, including evaluation for potential complications
Prevention
1st point: In summary, as a primary (or specialty) care provider to women, it is likely that you will provide pregnancy options counseling, which includes providing accurate, up-to-date information about abortion options. For women who are electing to terminate a pregnancy, in some settings, APCs provide counseling and screening. APCs may also insert laminara, perform ultrasounds and otherwise assist with abortion procedures.
2nd point: In some states, it is legal for advanced practice clinicians to provide medical and surgical abortions. In the majority of states, however, only physicians are permitted to provide abortions, including the administration or prescribing of medical abortifacients. In Vermont, where there is no physician-only law, APCs have been performing 1st trimester surgical abortions for more than 20 years. Two studies that compared abortion care given by physician assistants and physicians found no difference in the complication rates between the two. (Freedman, 1986; Goldman)
Because of a significant decline in the number of physicians who are trained and willing to provide abortion services over the past decade, the need to expand the pool of providers is very acute. With proper training, APCs have great potential to help solve this growing problem.
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32. Resources for more information
The Alan Guttmacher Institute (
Clinicians for Choice (
Earlyoptions (
Ferre Institute (
The Hope Clinic (
IPAS (
Kaiser Family Foundation (
National Abortion Foundation (
The ROE Consortium (Abortion Access Project) (
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33. References
Alan Guttmacher Institute. State Facts about Abortion
Elam-Evans, L. D., Strauss, L. T., Herndon, J., Parker, W. Y., Whitehead, S., & Berg, C. J. (2002). Abortion surveillance—United States, MMWR Surveillance Summaries, 51(9), 1-28.
Ellertson, C., Evans, M., Ferden, S., Leadbetter, C., Spears, A., Johnstone, K., et al. (2003). Extending the time limit for starting the Yuzpe regimen of emergency contraception to 120 hours. Obstetrics & Gynecology, 101,
Finer, LB and Henshaw, SK. Abortion incidence and services in the United States in Perspectives on Sexual and Reproductive Health, 2003; 35:6-15.
Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med 1998;339:1-4.
Grimes, D. A. (2002). Switching emergency contraception over-the-counter status. New England Journal of Medicine, 347,
Henshaw, S. K. (1998). Unintended pregnancy in the United States. Family Planning Perspectives, 30, 24-29, 46
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34. References (continued)
Henshaw SK and Finer LB, The accessibility of abortion services in the United States, 2001, Perspectives on Sexual and Reproductive Health, 2003, 35(1):16-24.
Jones RK, Darroch JE and Henshaw SK, Patterns in the socioeconomic characteristics of women obtaining abortions in , Perspectives on Sexual and Reproductive Health, 2002, 34(5):
National Abortion Federation, 2003; Fact Sheet: Access to abortion;
National Abortion Federation, Fact Sheet: Safety of Surgical Abortion;
National Abortion Federation, Early Options Training and Resource Binder: A Provider’s Guide to Medical Abortion. Washington, DC: National Abortion Federation, 2001.
Paul, M., Lichtenberg, ES, Borgatta, L, Grimes, D, and Stubblefield, P. A Clinicians Guide to Medical and Surgical Abortion. (1999) New York: Churchill Livingstone.
Raine T, Harper C, Leon K, Darney P. Emergency contraception: advance provision in a young, high-risk clinic population. Obstet Gynecol 2000;96:1-7
WHO Task Force on Postovulatory Methods of Fertility Regulation. Randomized controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352:
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