Basics of Medical Abortion MARY STARK, DNP, FNP NURSE PRACTITIONERS [PDF]

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Basics of Medical Abortion

MARY STARK, DNP, FNP NURSE PRACTITIONERS OF OREGON CONFERENCE FALL 2018

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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

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DISCLOSURES

 I have no disclosures.

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Definitions

 Medical Abortion = Medication Abortion = MAB

= Abortion Pill = RU486

 Medical Abortion ≠ Emergency contraception

(EC, morning-after pill, Plan B)

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History

 2000 FDA first approved Mifeprex (mifepristone)  Evidence-based regimen used for a long time  2016 FDA approved updated labeling to

Mifeprex (mifepristone)

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NP Scope of Practice

No abortion provision allowed by NPs Medication abortion provision allowed by NPs Medication and aspiration abortion allowed by NPs

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Mifeprex (mifepristone)

 Must be provided to the patient via a provider/

health center/ clinic

 NPs may be prescribing provider

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Guttmacher Institute

 State-specific info  http://www.guttmacher.org

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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

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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

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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

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Resources

www.earlyoptionpill.com www.prochoice.org www.reproductiveaccess.org

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Pregnancy Options

 Abortion  Adoption  Parenting

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Medication Abortion

PROS

 Happens at home  Private  “More natural”  Might be able to avoid a

procedure

 Might have more flexibility in

scheduling CONS

 Happens at home  Must follow up in some way to

confirm completion

 Pain/bleeding can be prolonged  Might end up needing a

procedure

 Slightly less effective than in clinic

procedure

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Aspiration Abortion

PROS

 Typically very short

procedure

 No follow-up required  Very effective

CONS

 Not private  Must be done in clinic/office  Crampy/painful

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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

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HISTORY

LMP ROS – experiencing any bleeding or pain Past Med Surg History – previous pregnancies Sexual history – using contraception, wants to use

BC, new partner?

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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)

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EXAM

 Bimanual exam

 Help dating pregnancy…???  No adnexal masses/pain

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LABS/DIAGNOSTICS

 Rh(o) factor  Hemoglobin  Quant hCG (formerly “beta hCG” or “beta”)  Transvaginal U/S

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STOP! Did you get a pregnancy test?

If a urine pregnancy test is negative, she isn’t pregnant.

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Question for the group

How many of you have transvaginal

(or transabdominal) U/S available in your health center?

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When will you see a pregnancy on U/S? 5 weeks gestational age (35 days)

r

Quant hCG about 2000

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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

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PUL

 Pregnancy of Unknown Location

 Positive pregnancy test without a pregnancy visible on

U/S

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Regimens

National Abortion Federation Medication Abortion Protocol https://5aa1b2xfmfh2e2mk03kk8rsx- wpengine.netdna-ssl.com/wp- content/uploads/NAF_Mife-miso- _rotocol_2016.pdf

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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

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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 (?)

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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

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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 1st trimester if mini-dose is not readily

available

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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

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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

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TOO MUCH Bleeding

 2 full size pads per hour for 2 or more hours in a

row

r

 Anytime you feel dizzy/lightheaded

r

 Bleeding > 4 weeks

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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

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Cheek time

 Very common to have N/V after misoprostol  Tabs aren’t designed to completely dissolve

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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!!

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Urine Pregnancy Tests

 Don’t check an HSPT for 4-6 weeks, it will be positive

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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

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Managing Heavy Bleeding

 Misoprostol 800 mcg buccally  Methergine 0.2 mg PO TID x 3 days  Suction procedure

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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

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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

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Ongoing Pregnancy

 Repeat miso  Suction procedure  Misoprostol possibly teratogenic

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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

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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

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THANK YOU!

Even after today if you only feel more