Information for Referring Doctors and Nurses on
Early Medical Abortion

To be read in conjunction with the Patient Information Leaflet from AMAC on Early Medical Abortion and the data sheet on Mifegyne®

 

MEDICAL ABORTION: INTRODUCTION

In the last decade, physicians in many countries have been studying new methods of terminating pregnancy with the use of medications. The method that is now available in New Zealand uses the antiprogestin mifepristone or Mifegyne® formerly known as RU486, in combination with misoprostol or Cytotec®, a prostaglandin. There are now multiple protocols for medical abortion and these will continue to evolve over time. You will notice that the medical protocol to be used at AMAC for early abortions differs from the one in the data sheet on Mifegyne® because more recent clinical trials have found this regimen to be more effective. The efficacy depends on the dose of the two drugs, and the site of administration of the Cytotec® (vaginal or oral) and on the stage of the pregnancy.

Used within 49 days of the first day of the last menstrual period, the combination of oral Mifegyne® followed by vaginal Cytotec® now has a reported efficacy of 96 to 98%. About 3-5% of these abortions occur before the administration of the Cytotec® and 70 to 99% of the women will abort within six hours after the administration of Cytotec®.

Not all women who are eligible for medical abortion will choose this method, in fact the majority may still chose surgery. Medical abortion takes longer and there is usually more bleeding and cramping. Many women may not wish to be active participants, preferring that someone perform the abortion for them. On the other hand, medical abortion offers a number of advantages over suction curettage.

One major advantage is that it can be performed as soon as pregnancy is confirmed and the earlier in the pregnancy the more successful it is. Early diagnosis of pregnancy and efficient procedures are therefore mandatory.

Medical abortion makes the experience more private and more proactive for the woman. It avoids the complications such as perforation, specific to the surgical method. There are no anaesthetic risks and there is less risk of infection. However, surgical facilities must be available for use when the medical method is unsuccessful in about 5% of cases. Women must be prepared to accept this outcome.

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THE LEGAL SITUATION IN NEW ZEALAND

All abortions must comply with the New Zealand law. Medical abortion is legal in New Zealand under the same restrictions as apply to surgical abortion.

Approval by two certifying consultants is required and all abortions must be performed in licensed premises. The law requires that both drugs be given on licensed premises.

Because we at AMAC have no first hand experience with Medical TOP, we require that initially women agree to stay on the premises until they have passed products or 6 hours (whichever is sooner). If, after observation for 6 hours they have not completed the abortion, they will be given the choice of going home or having a surgical procedure at the time. If they chose to go home, they must return to AMAC for another check-up one week later.

 

THE INITIAL SCREENING by referring doctors’ Receptionist/Nurse

When a woman rings for a pregnancy test, it is important to find out the date of her last period. If she indicates she is considering an abortion and her last period was 6 weeks ago or less, she may be eligible for a medical abortion. She will need an urgent appointment within a day or two to confirm the pregnancy. The reason for this is because if she is eligible and chooses to have a medical abortion, the treatment must be commenced within 7 weeks (49 days) of her last menstrual period and it will take about a week to organise.

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THE FIRST VISIT TO REFERRER

If the pregnancy test is positive then pregnancy counselling options must be offered in the usual way. If there is no ambivalence and if the pregnancy is definitely unplanned and unwanted, then the medical abortion option can be presented to eligible women. To determine eligibility, go through the following lists:

Social contraindications:
Absolute medical contraindications:

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Relative medical contraindications requiring consultation with doctor and if necessary specialist advice:
If there is limited time at the first visit the following are essential:

Smear, swabs and blood tests can be done at a subsequent visit. Contraception may require another consultation.

To make an informed decision, women need to know the advantages and disadvantages of both methods. The following lists may be helpful:

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ADVANTAGES OF MEDICAL ABORTION

ADVANTAGES OF SURGICAL ABORTION

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CONCERNS ABOUT ELIGIBILITY

Extra sensitivity may be in order if either the clinician or the woman decides that there are any medical, psychological, or social contraindications. Some women may be disappointed or angry if they are “ruled out” or found to be ineligible for the procedure. Patients need to know that even if they “opt out” at any point in the procedure and request a surgical abortion, they have not “failed”. Some may fear that their care will be jeopardised if they do not choose a particular method. The woman can be reassured that she will receive the same high quality care whatever method is used, and that she will be cared for until the desired outcome of a complete abortion is achieved.

REQUIREMENTS FOR REFERRING TO AMAC

WHAT HAPPENS AT AMAC?

Initially it is planned to offer Mifegyne® on Mondays (Day 1) with admission on Wednesdays (Day 2) for the insertion of the Cytotec®. As the demand increases this may be extended to having Day 1 on Monday, Tuesday or Wednesday.

Day 1

The first visit to AMAC includes further counselling, decision-making, assessment for legal requirement, the signing of two certificates by the certifying consultants, and the signing of the patient consent forms. If there are no contraindications and no need for further counselling, the tablet of Mifegyne® will be given.

Contraception This is the joint responsibility of the referring doctor and AMAC. Because there is a risk with both Mifegyne® and Cytotec® of foetal abnormalities, it is recommended that women do not get pregnant in the first month following the abortion. For women starting on oral contraceptive pills, the advice is to start on the day after the abortion is complete.

For women requesting Depo-Provera or an IUCD, it is recommended that this be commenced / inserted at the follow-up visit with their own doctor 10-14 days after the abortion.

Day 2

At the second visit to AMAC, 36-48 hours later, the vaginal tablets of Cytotec® are inserted and the woman will be kept under observation until it is confirmed that the abortion is complete or 6 hours has passed.

THE MEDICAL TOP PROCEDURE

The treatment will usually consist of one Mifegyne® oral tablet containing 200mg of Mifepristone. Mifegyne® acts by blocking the action of progesterone at the site of the progesterone receptors. This is followed in 36-48 hours by the insertion into the posterior fornix of the vagina, of four tablets each containing 200ug of Cytotec® i.e. a total of 800ug of misoprostol, by either a nurse or doctor at AMAC. Cytotec® is a prostaglandin which stimulates contractions of the uterus to expel the pregnancy. This is the standard regimen that will be used at AMAC but in some cases the doses of both drugs may be varied by the doctor in charge of the case.

After taking Mifegyne® the woman is kept under observation at AMAC for about an hour to ensure that the tablet is retained and that there are no side effects. Usually there are none. After 12 hours, bleeding may start in some women. It may be quite heavy and women are advised to have maxi-pads available for use at home and later at AMAC. A few women, about 3-5% will abort within the first 48 hours and will not require Cytotec®. They must still return to AMAC for assessment on Day 2 as arranged.

When to call. Women will be given the telephone numbers to contact AMAC should they need advice.
A clear explanation of when the woman should seek assistance can reduce the patient’s anxiety, give her a greater sense of control, and limit the number of calls to the provider. For instance: You can expect heavy bleeding, but if it lasts more than 12 hours or you soak more than two maxi-pads an hour for two hours, you should ring AMAC.

Women who are Rh negative will be given an injection of Anti-D immunoglobulin at the time of the insertion of the vaginal tablets of Cytotec®.

On day 2 women will have to remain at AMAC until the abortion is complete or 6 hours has passed.

They will be kept under observation and provided with nursing support during this time. Those who are not already bleeding will usually start bleeding now. The bleeding may be quite heavy and is likely to include some large clots. Cramping pain is more likely in nulliparous women and in women who suffer from dysmenorrhoea.

Pain relief will be provided if needed. Paracetamol with or without codeine is the preferred analgesic and is usually sufficient. In a small proportion, fentanyl may be required.

There is a difference of medical opinion concerning the giving of non–steroidal anti-flammatory drugs (NSAIDs) for pain relief. Some assert that they act primarily on the production of new prostaglandin and have little effect on the circulating prostaglandin which has been ingested and this is supported by clinical experience, at least for some NSAID’s. Different NSAID’s may work by different metabolic pathways. However, it is the manufacturer’s recommendation that they not be used because of their potential anti-prostaglandin activity.

Side effects of medications. Apart from bleeding and pain, women may experience other side effects. After the Mifegyne® some women may experience nausea. After the Cytotec® there may be more side effects which include nausea, vomiting, diarrhoea, dizziness, less commonly headaches or warm/hot flashes and in rare instances, oral ulcers or a skin rash. In some cases (about 1 in 300) the bleeding will be so heavy that a blood transfusion and/or curettage may be necessary to stop the bleeding.

Women will be advised to avoid alcohol and smoking during the treatment and for at least two days after the insertion of the vaginal Cytotec®. They will be advised to avoid illicit drugs.

Complete abortion will usually occur in the 6-8 hours following the administration of Cytotec®. Bedpans will be used to collect the loss and inspected for products of conception, which may be sent for histology. Once the sac is identified and the woman is comfortable, she will be discharged home with instructions for aftercare.

To prevent infection, she will be advised to abstain from sexual intercourse until the abortion is complete and the bleeding has stopped. That could take as long as four weeks so check whether this will create difficulties for her. She will also be advised not to use internal sanitary protection and not to bathe or swim.

FAILURE TO COMPLETE ABORTION WITHIN 6 HOURS

In about 5-10% of cases, the abortion will not be completed within 6 hours. The woman will then be given a choice of having a surgical procedure at this time or going home to complete the TOP over the next few days or even weeks. If she goes home, she must agree to return to AMAC the following week for a check-up.

If a woman chooses to go to theatre, it will usually be a quick procedure because the cervix is already softened and dilated.

REFERRING DOCTORS RESPONSIBLE FOR THE FOLLOW-UP VISIT

The woman must return to her referring doctor for a check up in about 10-14 days. Some women may still be bleeding and this may be within the range of normality. However, if an incomplete abortion or a continuing pregnancy is suspected, case management should be discussed with AMAC.

A transvaginal ultrasound examination may be requested but is not always diagnostic, as intrauterine heterogeneous echoic material is normal and expected after medical abortion. Treat the patient and not the scan. Serial Beta HCG levels may assist in the evaluation of a missed ectopic, and these will be ordered by AMAC if no products are seen. Indications for surgical aspiration include one or more of the following:

At the follow-up visit, contraceptive requirements will be checked. This is also a useful time to find out how the experience has been for the woman and how she is feeling emotionally now. Feedback to AMAC will help improve the service for women.

THE IMPORTANCE OF COUNSELLING

A patient’s satisfaction with medical abortion will depend greatly on factors that go beyond medical eligibility. The factors, which are considered essential for success are; careful screening, good counselling and a supportive environment. While thorough and sensitive counselling is important for all abortion patients, medical abortion makes additional counselling demands on health professionals, largely because of the more active involvement required of the patient. Clinical experience with medical abortion also teaches that patients who are well informed are more likely to have a positive experience.

Staff involved in referrals will already be familiar with the general principles of patient-centred counselling:

Asking open-ended questions e.g. What makes you choose a medical abortion? This open-ended question is far more likely to initiate real dialogue than a yes-or-no question like, “Are you sure you want to have a medical abortion?”

Validating emotions, not minimising them e.g. What is hardest about this for you? Important issues that may be raised include: the woman’s support systems, fears of pain, bleeding, side effects, confidentiality issues, and anxiety about others knowing of her abortion.

Encouraging a patient’s questions e.g. If she has specifically asked for a medical abortion:
How did you hear about medical abortion? Or What interests you about this choice? Responses to these questions can provide valuable information that can guide the clinician’s next steps.

There may be misconceptions to be cleared up, particular anxieties to be allayed, or a positive interest in certain elements of the medical abortion procedure to be explored.

Using if/then statements. e.g. If you have a medical abortion, you will need time away from other responsibilities. What will this mean in terms of your job, kids, partner, and for younger women, your school, your parents?

Providing factual information at an appropriate level. e.g. the pelvic examination or ultrasound examination, may raise anxieties or other emotional reactions from some women. If she appears anxious, offering information about the procedures can ease tensions.

Watching for non-verbal clues. A woman’s behaviour can say more than her words.

OTHER USEFUL QUESTIONS

 
What do you imagine the experience would be like for you?

Many women who have used both methods prefer having an abortion this way instead of by surgery because it feels more private and they feel more in control of the situation. Other women find it hard to deal with the bleeding and cramping.

How do you feel about the sight of blood or possibly pregnancy tissue?

The woman need not see any products of conception unless she requests this. The pregnancy tissue is sometimes hard to find amongst the blood clots. The sac and the placenta surrounding the embryo can sometimes be seen as pale tissue but the embryo itself is too small to be seen clearly. It is called an embryo because it is under 8 weeks. After 8 weeks it is called a foetus.

Have you had an abortion in the past?

Learning if the patient has had prior experience with abortion can be informative when exploring why she is choosing medical abortion. If she has had a surgical abortion, how did she feel about it? Does she express a desire for “more control” this time, or would she rather let someone else “do” the abortion for her?

Some women may seek a medical abortion because they believe it is “easier” than a surgical procedure. The provider can help assess the woman’s perception of medical abortion by asking: What do you expect this procedure to be like?

Are you concerned about pain?

It is important to point out that pain is not always a signal that something is wrong, and can signify that everything is proceeding properly. Explanation: You can expect that cramping will probably begin about one to seven hours after the vaginal tablets have been inserted into your vagina. This medication causes cramping as the pregnancy tissue is being expelled from your uterus (womb). The cramps and pain mean that the medicine is working the way it should.

Being honest about the level of pain is also important. Explanation: It’s the same kind of cramps that some women get with their period, but usually stronger. It varies for each individual. Very few require more pain medication than standard analgesics such as paracetamol/codeine. Some women find a heating pad helpful for the cramps. It is also important that women receive clear instructions about when they should call the clinic regarding pain e.g. unrelieved pain for more than 24 hours.

Will you be able to manage the bleeding?

It is important to adequately prepare women for the amount of bleeding caused by medical abortion. It is helpful to explain in detail what the woman should expect so she can be prepared. Explanation: The amount of bleeding will vary for every individual. Most likely it will be much heavier than a period so you will need a good supply of maxi-pads. The bleeding will most likely begin within 2 to 4 hours after the cramping begins, but can start as soon as half an hour or as long as 10 hours later. Heavy bleeding will most likely last up to four hours. You may see very large clots; this is normal. It is also normal for light bleeding to continue for a few weeks after the abortion is completed.

She needs to know how much bleeding is too much. Explanation: Heavy bleeding is expected, but if you soak more than two maxi-pads per hour for more than two hours in a row, call AMAC.

What do you expect it might be like for you if the medication doesn’t work completely? What would you like to know about surgical abortion before you make up your mind?

There must be a commitment to the possibility of having a surgical abortion. For approximately 5% of the women who try medical abortions, the medications do not work. All women should therefore be informed from the beginning of the process that they may need to have a surgical abortion. Many women choose a medical abortion because they want to avoid surgery. For these women, the need for surgical intervention will require a great deal of explanation and sensitivity on the part of the clinician. Explanation: There is a 95 percent chance that the medications will be successful in bringing on an abortion. But in the rare event that the drugs do not work for you, the embryo can be damaged and you will need to have a surgical abortion.

Because medical abortion is a new and unfamiliar procedure, many women will have additional questions or concerns. These may arise at any stage. Anticipating all questions is impossible. Some can be answered simply by giving factual information, while others will require the clinician’s listening and supportive skills.

FREQUENTLY ASKED QUESTIONS

It is a good idea to think about the response that you might give to some of the frequently asked questions, which include the following:

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