Emergent Technologies for Early Abortions

Dr Narwadkar Mangesh

Safe Abortions - Earlier the Better

Complication Rate % 16 12 8 4 4 8 12 16 20

Weeks of Amenorrhea

Four fold rise in complications with late abortions

* WHO, Tech Report., 1997

Safe emerging technologies for early abortions

1.

Manual Vacuum Aspiration Medical Methods of Abortion

2.

Manual Vacuum Aspiration

MVA Kit (Aspirator & Cannula)

MVA Kit (Aspirator & Cannula)

Manual Vacuum Aspiration

Evacuation of uterine contents through a cannula, attached to a hand-held vacuum aspirator. The pre created vacuum evacuates the contents of the uterus without damaging the lining of the uterus.

Indications for MVA

Threatened abortion Inevitable/ Incomplete abortion Septic abortion Missed abortion Blighted ovum Hydatidiform mole Retained placental products Endometrial sampling

contraindications
Ut > 12 weeks Acute cervicitis/PID Multiple fibroids h/o bleeding disorder Suspected uterine perforation

FIGO/WHO Endorsement of MVA

Properly equipped hospitals should abandon

curettage and adopt the aspiration methods, selecting Manual Vacuum Evacuation and or Electric Aspiration MVA is an essential basic procedure at First Referral Unit level.

Vacuum Aspiration and D&C

Lesser incidence of haemorrhage, cervical injury, lacerations, uterine perforation Less dilatation required and hence less painful and lesser chances of vagal reactions Less pain medication and anaesthesia Less hospital stay No major O.T. set up required

MVA and EVA

Equivalent high levels of effectiveness and low complication rates. Pressure created is EQUAL in both But with MVA No electricity required Safe in accidental perforations Intact gestation sac in early pregnancy termination

MVA Procedure

Cx ripening
Commnly used agent Tab misoprost 400 microgram 3-4 hours prior,vaginally Prostodine 45 min prior I/M

Evacuating uterine contents

15

Dilate the cervix with cannulae of increasing sizes till appropriate number is reached, after taking appropriate pain control measures

Connect the cannula to the aspirator Move the cannula back and forth gently and slowly, rotating the cannula and the syringe at the same time

Cannula selection
Depends upon uterine size, period of gestation, amount of dilatation required to aspirate poc Important to have appropriate cannula (retained products or loss of suction) 4-6 weeks LMP-----4-7mm cannula 7-9 weeks LMP------5-10mm cannula 9-12 weeks LMP-----8-12 mm cannula

Pain management
The three major sources of discomfort and pain during uterine evacuation with MVA are anxiety, cervical dilation and uterine cramping. Verbal reassurance and respectful, supportive care by staff throughout the procedure helps to reduce anxiety and decrease pain, and should be a standard part of abortion care. Pain and discomfort during an MVA procedure ca be reduced using a combination of verbal support oral medications, Para cervical block and gentle clinical technique.

Signs that the uterus is empty

Red or pink foam without tissue passing through cannula. Gritty sensation over surface of uterus. Cervix gripping over the cannula. Uterus contracting around cannula. Increased uterine cramping.

Inspecting the tissue

19

Strain and Inspect the evacuated tissue

No visible POC, a lower quantity of tissue than expected or an inconclusive tissue sample may indicate incomplete abortion, completed spontaneous abortion, failed abortion, suspected ectopic pregnancy or anatomical anomaly. Technical problems that can occur with the instrument during an MVA procedure include a full aspirator, a cannula that is clogged or withdrawn prematurely, or a loss of vacuum due to incorrect assembly.

Post procedure care/follow up care

Physical monitoring: Emotional support: Contraceptive counseling: Addressing other health issues: anemia, reproductive-tract infections (RTIs, HIV, violence, , cancer screening.

Post procedure care/follow up care

Providing discharge instructions. Pain management: Analgesics, NSAID. Provision of antibiotics: Research has shown that routinely providing antibiotics to women undergoing MVA reduces infection. Scheduling follow-up care within one week.

Sterilization / High Level Disinfection

MVA Plus Aspirator and Easy Grip Cannulae can be: stetrilized by Autoclaving (121 C for 30 minutes) or soaking in Gluteraldehyde for 10 hrs OR High level disinfected by boiling for 20 mins or soaking in Gluteraldehyde or chlorine solution for 20 mins.

Sterilizing Agent

To sum up - MVA

MVA is an effective surgical method for termination of pregnancy up to 12 weeks. Increases access and decreases costs as it is OPD procedure Reduces complication risks and time of procedure as it is done under local anaesthesia Easy to process and handle Improves patient provider rapport Allows immediate identification of POC Excellent backup for failed medical abortion

Medical Methods of Abortion

What is Medical Methods of Abortion?

Medical abortion is a non surgical, non invasive method of termination of pregnancy by combination of drugs.

Medical Methods of Abortion

Approved in 30 countries Available for early pregnancy up to 63 days High success rate 93-95% It takes 8-12 days for the complete process Requires minimum 3 visits Requires follow up to ensure completion of abortion

Why women like Medical Methods of Abortion ?

No admission required No fear of surgery The method is convenient It enables the woman to look after her home or job without a break

(Population Council, KEM Hospital Pune 1990-1993)

Commonly used drugs

Mifepristone (RU 486) invented in 1980 initials of pharmaceutical company Roussel-Uclaf 486 is a random laboratory serial number. Misoprostol Combinations of the two drugs has a high success rate Both the drugs have been approved for use in early pregnancy termination in India

Mifepristone RU486

Antiprogesterone compound that blocks Progesterone receptor sites in endometrium, decidua and dislodges the fertilized egg. Available as 200 mg Tab more effective in early pregnancy when progesterone is present in lower concentrations due to limited production by corpus luteum. When used alone complete abortion rate is 75% When used with Misoprostol complete abortion rate is 93-95% Now available in India since April 2002 (Mifegest, Mifeprin, MTPill, Mifyron etc)

Side Effects of Mifepristone

Serious S/E are rare, however the woman may experience Nausea Vomiting Fatigue Diarrhoea

Misoprostol

PGE1 analogue Most commonly used drug for medical methods of abortion FDA Approved for prevention of gastric ulcer Effective route are oral/vaginal/sublingual/buccal Available as 200 micrograms tablet Available as Cytotec, Zitotec, Cytolog, Misogon etc

Advantages of Misoprostol

Low cost Stable at room temperature Effective by different routes

Side effects of Misoprostol

Nausea Vomiting Associated with congenital anomalies, if pregnancy continues

Medical Methods of Abortion & MTP Act

It can be provided only by MTP certified providers and comes under the purview of MTP Act. MMA upto 7 weeks of gestation can be provided from approved sites as well as non-approved clinics with referral linkage to approved MTP site. The law requires that a certificate of access to a registered place (i.e. showing that a referral link has been established) from the owner of the approved site must be displayed in the clinic where MMA is being provided. MMA upto 63 days (9 weeks) can be provided only from the approved sites.

Eligibility of the woman

Option of medical methods of abortion should be given to all women coming to a health facility seeking termination of pregnancy up to 9 weeks of gestation No medical contraindication. Frame of mind of the woman, i.e. Acceptability of minimum three visits Ability to understand the instructions Agrees for vacuum aspiration procedure, if failure or excessive bleeding occurs.

Eligibility of the woman

Support from family or others. Permission of guardian in case of minor as per MTP Act 1971. Easy access to appropriate health care facility during emergency.

Contraindications for Medical Methods of Abortion

Undiagnosed adnexal mass Confirmed or suspected ectopic pregnancy IUCD in situ Chronic Adrenal failure Concurrent long term corticosteroid therapy Inherited Porphyrias No access to medical facilities in case of emergency uncontrolled high blood pressure, diabetes, certain heart or blood vessel diseases, severe liver, kidney or lung disease, or an uncontrolled seizure disorder

SCARRED UTERUS

a uterine scar is not a contraindication for first trimester misoprostol induction, but that the risk may increase with increasing gestational age, particularly in the late second trimester

Investigations (Recommended) Haemoglobin. Routine Urine Examination. ABO Rh. Investigations (Optional) Ultrasound if: She is unsure of LMP. She has irregular periods. Uterine size and menstrual dates do not match. There is suspicion of ectopic / fibroid during P/V examination.

Protocol for Medical Methods of Abortion

First visit ( Day 1) Mifepristone - 200mg given

orally, after ruling out contraindications.

Second visit ( Day 3) Misoprostol 400/800 microgms vaginally/orally and kept at the clinic for 4 hours
Third visit (Day 15) Follow up to determine if

complete abortion has occurred

Mifepristone-Misoprostol Protocol
200 mg mifepristone 400 /800 g misoprostol

Visit 1 1 2

Visit 2 3

Visit 3 15

Protocol Day
Pain relief 1-3 hours of misoprost

Recent research studies have shown that allowing women to take misoprostol either vaginally or orally at home is safe, effective and acceptable to women. However Government of India recommends that misoprostol be administered at the clinic and the woman observed for at least four hours.

Outcome of Medical Methods of Abortion

Parity is not a major factor affecting the outcome Lesser the period of gestation, better the results

CabezasE,IntJGynaecolObstet1999;63(suppl1):S.:1416.

Most women abort within 4 hrs of Misoprostol administration Of the rest:

30% abort within next 24 hrs 65% abort within next 5 days

Heaviest bleeding lasts 1 4 hours that coincides with the expulsion of POC. Mean period for bleeding is 8 13 days) The incidence of endometritis following medical abortion is lower than after surgical abortion

Day 3-15 She should preferably avoid going out of station till the third visit. She should report if there is no bleeding even 24 hrs. after taking misoprostol. This may be rare, but the doctor should consider following possibilities: Rule out ectopic pregnancy and confirm an intrauterine pregnancy. The drug may not have worked and / or more tie is needed; repeating the dose may be an option.

Third visit (Day 15) What to do Pelvic examination to confirm completion of abortion USG if examination does not confirm Debris in the uterus without a gestational sac, pain, fever, or excessive vaginal bleeding does not usually require intervention Antibiotics: These are not generally prescribed routinely but should be given to a woman showing / susceptible to infection. She should report back if there are no periods within 6 weeks of completion of the abortion

Failure of the method requiring surgical intervention

Incomplete abortion 3 - 5% Continuation of pregnancy - 1 -2%

Excessive bleeding - 0.2 2% (soaking 2 or more maxi pads per hour for 2 hours continuously.)

Contraception after abortion. Oral pills can be started on 3rd or 15th day of the protocol on confirmation of completion of abortion process. IUCD can be inserted on day 15 provided the presence of infection is ruled out. Condom can be used as soon as she resumes sexual activity after abortion.(It is advised to abstain from sex until the
abortion process is complete.. If there is sexual activity after taking the drugs and before the abortion, it is advised that condom / barrier be used to prevent infection.)

Contraception after abortion.. Tubal ligation can be done after first cycle. However if desirous of concurrent tubal ligation, surgical method of abortion is preferred. Injectables can be given on the 3rd or 15th day, after confirming the completion of the process. Vasectomy, if chosen, can be done independent of the procedure.

An acceptability . If a future abortion was required, 42 percent of patients who underwent a surgical abortion would opt for a medical abortion; in contrast, only 9 percent of women who received medical abortion would prefer a surgical abortion . However, others have reported greater satisfaction with surgical abortion. Medical abortion becomes more painful and less effective in women with gestations over 50 days, particularly in those using oral misoprostol. Therefore, these women are likely to find vacuum extraction more acceptable

Medical Abortion and the Risk of Subsequent Adverse Pregnancy Outcomes

No evidence that a previous medical abortion, as compared with a previous surgical abortion, increases the risk of spontaneous abortion, ectopic pregnancy, pre- term birth, or low birth weight.
Jasveer Virk, M.S., M.P.H., Jun Zhang, Ph.D., M.D., and Jrn Olsen, M.D., Ph.D. N Engl J Med 2007;357:648-53

Teratogenic effects on fetus in c/o failure of medical abortion e.g. Mobius syndrome congenital facial paralysis with or without limb defect, cranial nerve defect. Because of a potential teratogenic risk, surgical abortion is recommended in cases of failed pregnancy termination

To sum up Medical Methods of Abortion

Medical methods of termination of pregnancy have increased the choices for women and doctors Effective counseling increases the chances of success of medical methods of abortion Medical methods of abortion can go a long way in increasing access to Safe Abortions