2. Medication Abortion In Early Pregnancy Induced termination of early intrauterine pregnancy using medications

3. 6.4 Million Pregnancies/Year in the U.S. 51% Intended 24% Unintended Used Contraception 25 % Unintended Used No Contraception Finer, 2006 (2002 data) 

4. Unintended pregnancy rate: by race/ethnicity/income Unintended pregnancies per 1,000 women Finer, 2006

5. Outcomes of Unintended Pregnancies (Approximately 3.1 Million Annually) Finer, 2006 (2002 data) % of unintended pregnancies

6. 89% of abortions occur in the first 12 weeks of pregnancy Under 9 weeks 9-10 weeks 11-12 weeks Guttmacher Institute, 2004 data

7. 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

8. Primary care shortage areas: with and without family physicians Graham Center, 2000

9. Abortion in Family Medicine: Training Issues

10. Could training family physicians in medication abortion make a difference?

11. Abortion in Family Medicine: Implementation Issues

12. Wanted versus unwanted pregnancy: consequences

13. Medication & Aspiration Abortion: both safe and effective

14. 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, 2006 Virk, J et al, NEJM, 2007

15. Medication Abortion Regimens: Three Choices Mifepristone + Misoprostol Methotrexate + Misoprostol Misoprostol alone

16. Most common med abortion regimen in US: Mifepristone/Misoprostol

17. Medication Abortion: Advantages 95-99% effective Avoids surgical and anesthetic risk Greater patient autonomy & privacy Less invasive More “natural”

18. Aspiration Abortion: Advantages Slightly more effective (about 99%) Shorter time to completion Shorter bleeding duration Can be performed later in gestation

19. Mifepristone-Misoprostol Regimens FDA ProtocolAlternate Protocol Gestational age limit49 days63 days Mifepristone dose600 mg. oral200 mg. oral Misoprostol dose, route, and timing 400 mcg. oral Office administration 48 hours later 800 mcg. vaginal or buccal Home self-administration 6 - 72 hours later (vaginal) 24 - 36 hours later (buccal) Office follow-up visit10-15 days after mifepristone 4-10 days after mifepristone Minimum office visits 32 Cost of medications$270 for mifepristone $2.00 for misoprostol $90 for mifepristone $4.00 for misoprostol

20. Cervical Ripening MIFEPRISTONE Causes progesterone blockade Decidual Necrosis Detachment MISOPROSTOL Causes uterine cramping & expulsion

21. Misoprostol

22. Yolanda 22 years old Requests a pregnancy test

23. Counseling issues Review all options Assure that decision is hers

24. Establish gestational age

25. Rule out contraindications Allergy to meds Adrenal insufficiency Current steroid use Coagulopathy or anticoagulant use IUD in place No access to follow-up

26. Indications for sonography

27. Yolanda Gestational age: 6 weeks

28. Patient agreement

29. Yolanda takes mifepristone in your office

30. At home: Yolanda takes pain medication, then misoprostol

31. Follow-up visit 4 - 14 days later Assure completion Process experience Review contraceptive choice

32. Phone calls after medication abortion

33. 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

34. Methotrexate + Misoprostol medication abortion

35. Misoprostol-only medication abortion 800 mcg vaginally > 1 dose may be needed

36. 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.