Basics of Medical Abortion MARY STARK, DNP, FNP NURSE PRACTITIONERS OF OREGON CONFERENCE FALL 2018
AGENDA Legal context for providing abortion Ordering medication for medical abortion Billing and coding for medical abortion services Resources available for providers and patients about medical abortion Discussing abortion options with women Medication protocols for medical abortion Common side effects of medication Recognizing and managing complications Follow-up after medical abortion
DISCLOSURES I have no disclosures.
Definitions Medical Abortion = Medication Abortion = MAB = Abortion Pill = RU486 Medical Abortion ≠ Emergency contraception (EC, morning-after pill, Plan B)
History 2000 FDA first approved Mifeprex (mifepristone) Evidence-based regimen used for a long time 2016 FDA approved updated labeling to Mifeprex (mifepristone)
NP Scope of Practice No abortion provision allowed by NPs Medication abortion provision allowed by NPs Medication and aspiration abortion allowed by NPs
Mifeprex (mifepristone) Must be provided to the patient via a provider/ health center/ clinic NPs may be prescribing provider
Guttmacher Institute State-specific info http://www.guttmacher.org
Ordering Mifeprex (mifepristone) http://www.earlyoptionpill.com/wp- content/uploads/2016/02/Prescriber-Agreement- Form-March2016-2.pdf They can get you meds very quickly They also offer pre-packaged misoprostol
Billing and Coding ICD-10 Encounter for termination of pregnancy Z33.2 Recommend for initial visit and for follow-up Add in any additional codes for contraception There’s no CPT code for MAB, there’s a HCPCS code though E&M code by time, plus any U/S, in clinic labs S0199 – includes all services EXCEPT medications S codes S0190 = mifepristone S0191 = misoprostol
Oregon Health Plan Reimbursement S0190 Mifepristone, oral, 200 mg $90.00 S0191 Misoprostol, oral, 200 mcg $1.20 S0199 Med abortion including all services except drugs $176.39
Resources www.earlyoptionpill.com www.prochoice.org www.reproductiveaccess.org
Pregnancy Options Abortion Adoption Parenting
Medication Abortion CONS PROS Happens at home Happens at home Private Must follow up in some way to confirm completion “More natural” Pain/bleeding can be prolonged Might be able to avoid a procedure Might end up needing a procedure Might have more flexibility in scheduling Slightly less effective than in clinic procedure
Aspiration Abortion PROS CONS Typically very short Not private procedure Must be done in clinic/office No follow-up required Crampy/painful Very effective
Eligibility for MAB LMP ≤ 70 days ago Able to give consent and comply with follow-up Access to phone and transportation to emergency care Willing to have aspiration procedure if medication fails
HISTORY LMP ROS – experiencing any bleeding or pain Past Med Surg History – previous pregnancies Sexual history – using contraception, wants to use BC, new partner?
Contraindications/Special Conditions Bleeding/hemorrhagic disorder or current anticoagulant therapy Chronic adrenal failure Current long-term system corticosteroid therapy Confirmed or suspected ectopic pregnancy Inherited porphyrias IUD in place (must remove before treatment) Allergy to mifepristone, misoprostol, or other prostaglandin Current anemia (Hemoglobin < 10)
EXAM Bimanual exam Help dating pregnancy…??? No adnexal masses/pain
LABS/DIAGNOSTICS Rh(o) factor Hemoglobin Quant hCG (formerly “beta hCG” or “beta”) Transvaginal U/S
STOP! Did you get a pregnancy test? If a urine pregnancy test is negative, she isn’t pregnant.
Question for the group How many of you have transvaginal (or transabdominal) U/S available in your health center?
When will you see a pregnancy on U/S? 5 weeks gestational age (35 days) or Quant hCG about 2000
To ultrasound or not to ultrasound… Not mandatory, fairly common though Studies support safety/efficacy of initiating MAB without U/S Might consider limitations: clear on LMP, not > 56 days
PUL Pregnancy of Unknown Location Positive pregnancy test without a pregnancy visible on U/S
Regimens National Abortion Federation Medication Abortion Protocol https://5aa1b2xfmfh2e2mk03kk8rsx- wpengine.netdna-ssl.com/wp- content/uploads/NAF_Mife-miso- _rotocol_2016.pdf
Mife + Miso Buccal Regimen Mifeprex (mifepristone) 200 mg tablet – 1 tablet taken in clinic Misoprostol 200 mcg tablets – 4 tablets placed between cheeks and gums 24-48 hours after Mifeprex. Hold tablets for 30 minutes
Medications for comfort Antiemetic: pick your favorite! Zofran (ondansetron) 4 mg/8 mg Promethazine 25 mg Meclizine 25 mg Ibuprofen – 600 or 800 mg TID Tiny amount of narcotic (?)
Medication Abortion Rx Prescriptions Ibuprofen 800 mg #30 Directions: 1 PO every 8 hours as needed for cramps Promethazine 25 mg #4 Directions: 1 PO q 6 hours PRN nausea A small amount of narcotics (?) Rh immune globulin for Rh negative patients
Rh Negative Patients Need Rh(o) immune globulin (IM injection) Less than 14 weeks gestational age = mini-dose of Rh immune globulin Rh immune globulin lasts more than 21 days OK to use full dose in 1 st trimester if mini-dose is not readily available
Contraception Start right away after MAB OK to give DMPA on day of mife OK to insert implant on day of mife Hormonal methods: start within 7 days of mifepristone OK to place IUC at 2 weeks if U/S OK Recognize that it can be too much to discuss in one visit for some patients
How much bleeding? At least as much as a period Expect clots Pads = Clots Tampons OK, but harder to evaluate Usually starts 2-24 hours after miso Stops and starts, and stops and starts
TOO MUCH Bleeding 2 full size pads per hour for 2 or more hours in a row or Anytime you feel dizzy/lightheaded or Bleeding > 4 weeks
Cramping/Pain is Expected Take ibuprofen regularly Rest, put your feet up Heat to abdomen (heating pad, hot shower/bath) Sit on the toilet for a while
Cheek time Very common to have N/V after misoprostol Tabs aren’t designed to completely dissolve
Follow-Up After Medication Abortion Repeat transvaginal U/S in 10-14 days No ongoing pregnancy or distinct gestational sac Repeat quant hCG levels in 3-14 days Expect at least a 50% drop in hCG level Check low-sensitivity pregnancy test (urine) in 2 weeks and phone follow-up Negative LSPT, no concerning symptoms when discussed by phone Any patient who still feels pregnant needs to follow up!!
Urine Pregnancy Tests Don’t check an HSPT for 4-6 weeks, it will be positive
Calls About Bleeding Dizzy/lightheaded, SOB? How often changing tampon/pad? How long has it been this heavy? Place a brand new pad in right now, call back in 2 hours to see
Managing Heavy Bleeding Misoprostol 800 mcg buccally Methergine 0.2 mg PO TID x 3 days Suction procedure
Managing Pain U/S can be useful tool – retained POC/clots vs infection Speculum exam: cervical discharge, wet mount Bimanual exam Treat endometritis with same regimen as pelvic inflammatory disease (PID) Ceftriaxone 250 mg IM x 1 dose Doxycycline 100 mg PO BID x 14 days With/without metronidazole 500 mg PO BID x 14 days
Intrauterine Debris vs Retained POC If you scanned every single uterus at 7 days post-mife, ALL of them would look like they have retained POC I think I’ve seen 1-2 radiology reports that didn’t claim “retained POC” post-MAB Treat the symptoms, not the U/S images Do nothing, repeat U/S in 1-2 weeks Repeat miso Suction procedure
Ongoing Pregnancy Repeat miso Suction procedure Misoprostol possibly teratogenic
Abnormal hCG Pattern Expect serum hCG to drop > 50% within 3 days after mife Rises or doesn’t drop > 50%... Ultrasound Ectopic work-up Suction procedure
Follow-up Visit or Call Did pt have bleeding? Passed tissue/clots? Feels like the pregnancy ended? Still having bleeding? What is the pattern? Still having pain/cramping? Things to watch out for after follow-up visit/call: same things as before
THANK YOU! Even after today if you only feel more prepared to discuss medication abortion as an option with patients, you are helping your patients make informed decisions!
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