Download the lecture by Dr Ezeanochie

Safe abortion- medical methods
of termination, post abortion care
and referral, pre and post
abortion counseling
27/06/2014
Learning Objectives

Definition of Abortion

Comprehensive abortion care

Concept of unsafe/safe abortion

Protocols for medical termination

Components and principles of Post abortion
care
Introduction

The termination of a human pregnancy
before the age of viability

Unsafe abortion is defined by the World
Health Organization (WHO) as a procedure
for terminating an unintended pregnancy,
carried out either by persons lacking the
necessary skills or in an environment that does
not conform to minimal medical standards, or
both.
Comprehensive abortion care
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Provide safe, high-quality services, including abortion,
postabortion care and family planning;
Decentralize services so they are closer to women;
Be affordable and acceptable to women;
Understand each woman’s particular social
circumstances and individual needs and tailor her
care accordingly;
Address the needs of young women;
Reduce the number of unintended pregnancies and
abortions;
Identify and serve women with other sexual or
reproductive health needs;
Be affordable and sustainable to health systems.
Pre-abortion encounter

Information, counselling and decision-making

Medical history

Physical examination

Laboratory and other investigations
(if necessary and available)

Discussing contraceptive options
Objectives of Pre-abortion
encounter
 Provide
information and offer counselling in a way
that a woman can understand to allow her to make
her own informed decisions
 Confirm pregnancy status and determine location
and duration.
 Evaluate for any medical conditions that require
management or may influence the choice of
abortion procedure.
 Provide an opportunity to discuss future use of
contraception.
Medical Termination
 Use
of pharmacological drugs to
terminate pregnancy.
 Sometimes the terms “non-surgical
abortion” or “medication abortion” are
also used.
 Medical abortion is a multistep process
involving two medications (mifepristone
and misoprostol) and/or multiple doses of
one medication (misoprostol alone).
Peculiarities
Avoids surgery
 Mimics the process of miscarriage
 Controlled by the woman and may take place at
home
 Takes time (hours to days) to complete abortion,
and the timing may not be predictable
 Women experience bleeding and cramping, and
potentially some other side-effects (nausea and
vomiting)
 May require more clinic visits than MVA

Protocols for Medical
Termination
 Up
to 9weeks (63 days), preferred option
 Mifepristone 200mg oral stat, then
 Misoprostol 800ug stat (oral, vaginal or
sublingual) 24-48 hours after mifepristone
 If less than 7weeks, may use 400ug
misoprostol stat
 Alternative
option (up to 63 days ie
9weeks) when mifepristone isn't available
 Misoprostol 800 μg
 Vaginal or sublingual
 Every 3-12 hours up to 3 doses
 Stop when patient stats bleeding
 9–12
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weeks (63–84 days, preferred option)
Mifepristone 200mg stat orally, then
Misoprostol 800 μg, then 400 μg
subsequently
(Vaginal, then vaginal or sublingual)
Every 3 hours up to 5 doses
Start 36–48 hours after taking mifepristone
 Alternative
option (9-12weeks), when
mifepristone is not available
 Misoprostol 800 μg
 Vaginal or sublingual
 Every 3-12 hours up to 3 doses
 Stop when patient stats bleeding
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12 – 16 weeks
Misoprostol 800 μg, then 400 μg
Vaginal, then vaginal or sublingual
OR
Misoprostol 400 μg, then 400 μg
Oral, then vaginal or sublingual
Every 3 hours up to 5 doses
Start use 36–48 hours after taking mifepristone
 Alternative
Misoprostol 400 μg
 Vaginal or sublingual
 Every 3 hours up to 5 doses

 Buccal
misoprostol
 Sublingual
Follow-up
 Usually
seen 1 – 2 weeks after intake of
drugs
 Confirm complete abortion by clinical
examination, negative PT or ultrasound if
indicated
 Suspect ectopic pregnancy if no
response or features of rupture
Pain management
 Respectful,
non-judgmental
communication
 Verbal support and reassurance
 Thorough explanation of what to expect
 The presence of a support person who
can remain with her during the process (if
the woman desires it)
 Hot water bottle or heating pad
Pain mgt contd
 Analgesia
(NSAIDs, e.g. ibuprofen 400–800
mg and opiod analgesia e.g tramadol)
 Anxiolytics / sedatives (e.g. diazepam 5–
10 mg)
 Adjuvant medications may also be
provided, if indicated, for side-effects of
misoprostol (e.g. loperamide for
diarrhoea)
Pain mgt contd
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>12 weeks’ gestation
In addition to NSAIDs, offer at least one or more of
the following:
oral opioids;
intramuscular (IM) or intravenous (IV) opioids;
Paracetamol is usually ineffective for pain
management during an abortion and is not
recommended
Give oral analgesics 30-45 minutes before drugs to
ensure maximal pain relief
Caution
 It
is essential that the woman knows to
seek medical attention for:
 prolonged or heavy bleeding (soaking
more than two large pads per hour for
two consecutive hours)
 fever lasting more than 24 hours
 Malodourous vaginal discharge
 or feeling generally unwell more than 24
hours after misoprostol administration
Post abortion care
 Post
abortion care is a strategy to address
this problem by treating women with
complications, providing family planning
services to prevent future abortions,
counseling and referring women for other
needed services, and engaging
communities.
PAC
Postabortion care is an approach for
reducing deaths and injuries from
incomplete and unsafe abortions and their
related complications.
Postabortion care is an integral component
of comprehensive abortion care
Post abortion encounter
 Follows
principles of PAC
 Counselling
on family planning and
linkage to other reproductive health
services
 Counselling
should be non-judgemental
and woman centred
Components

Treatment of incomplete and unsafe abortion
and complications

Counselling to identify and respond to
women’s emotional and physical health
needs

Contraceptive and family-planning services
to help women prevent future unwanted
pregnancies and abortions
Components of PAC
 Reproductive
and other health services
that are preferably provided on-site or via
referrals to other accessible facilities
 Community and service-provider
partnerships to prevent unwanted
pregnancies and unsafe abortions, to
mobilize resources to ensure timely care
for abortion complications, and to make
sure health services meet community
expectations and needs.
Conclusion
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Unsafe abortion remains a serious public
health problem and a leading cause of
maternal morbidity and mortality
Delivery of safe abortion services especially
medical abortion can help reduce
complications associated with unsafe
abortion
Family planning services and linkage to other
reproductive health services are essential
components of comprehensive Post abortion
care