Re: mifepristone -What are the risks of medical abortion? doctors pls answer

• Messages sorted by: [ date ][ thread ][ subject ][ author ]
• Next message: Harvey S. Marchbein, M.D.: "Guidelines for posting to the PREGNANCY-BIRTH forum"
• Previous message: Tina: "luteal phase discharge"
• In reply to: tanda: "Re: mifepristone -What are the risks of medical abortion? doctors pls answer"
• Next in thread: Richard Chudacoff, MD: "Re: mifepristone -What are the risks of medical abortion? doctors pls answer"

Medical abortion agents include (1) mifepristone and misoprostol, (2) methotrexate and misoprostol, and (3) misoprostol.

Mifepristone is a progesterone antagonist that blocks the effects of progesterone by competing with endogenous progesterone for receptor binding. The primary effect is on the uterus, where it blocks the effect of progesterone on the endometrium and decidua. The endometrium degenerates and is shed, disrupting the implanted embryo/fetus. The endometrial lining and its contents are expelled. The normal suppression of uterine activity induced in the pregnant uterus by progesterone is lost. The cervix is dilated and softened by mechanisms that are not understood clearly.

Methotrexate is a folic acid antagonist that works by inhibiting dihydrofolate reductase, an enzyme needed to make DNA. In its role as an antimetabolite, methotrexate is toxic to the rapidly dividing cells of the trophoblast.

Misoprostol is a prostaglandin analog that acts by causing uterine contractions, which evacuate the uterine contents.

Medical abortion using mifepristone and misoprostol up to 49 days' gestation has been approved by the FDA.

The procedure requires 3 visits, as follows: Medical abortion using methotrexate and misoprostol: See mifepristone and misoprostol for patient selection criteria. Patients may be up to 63 days from LMP. The procedure requires a minimum of 3 visits, as follows:

* Day 1

o See mifepristone and misoprostol, day 1.

o Administer methotrexate 50 mg/m2 intramuscularly instead of mifepristone.

* Days 3-5: RhoGAM is administered, if needed. * Day 1

o Counseling is performed, and consent is obtained.

o History is obtained, and physical examination is performed.

o Pregnancy is dated by dates, sizing, and ultrasound.

o Hemoglobin (Hgb) and blood type are checked.

o Mifepristone 600 mg is given orally (if patient vomits15 min or more after administration, absorption probably is adequate).

* Day 3

o RhoGAM is administered, if needed.

o Misoprostol 400 mg is given orally.

o Patients are monitored for 4 hours (50-75% will abort within 4 h of misoprostol administration).

o Give Tylenol, Tylenol with codeine, or a nonsteroidal anti-inflammatory drug (NSAID) for pain relief. Avoid aspirin and other medications with anticoagulant properties.

* Day 15

o Assess completion of abortion by physical examination and ultrasound.

The following variations on this protocol have been reported in the literature, with low occurrence of adverse effects, good patient acceptance, and comparable effectiveness:

* Use up to 56 days

* Home use of misoprostol 800 mg per vagina on day 3

--
* Repeated dose of misoprostol on day 7 if needed
    * Days 5-7

          o Misoprostol 800 mg per vagina is administered at home by the patient.

    o Alternatively, repeat misoprostol in 24 hours if no vaginal bleeding occurs.

    * Day 8: Assess for completion of abortion using ultrasound.

          o If ultrasound reveals that abortion is not complete, repeat misoprostol.

          o If fetal cardiac activity is present, follow up on day 15.

    o If fetal cardiac activity is absent, follow up on day 36.

    * Day 15: Assess for completion of abortion using ultrasound.

          o If ultrasound reveals that abortion is not complete, repeat misoprostol.

    o If fetal cardiac activity is present, obtain a surgical abortion.

    * Days 29-45: Assess for completion of abortion using ultrasound.

          o If gestational sac is still observed, obtain a surgical abortion.

o If fetal cardiac activity is absent, follow up on day 36.

• Next message: Harvey S. Marchbein, M.D.: "Guidelines for posting to the PREGNANCY-BIRTH forum"
• Previous message: Tina: "luteal phase discharge"
• In reply to: tanda: "Re: mifepristone -What are the risks of medical abortion? doctors pls answer"
• Next in thread: Richard Chudacoff, MD: "Re: mifepristone -What are the risks of medical abortion? doctors pls answer"