Disclosures I have no financial disclosures I present off-label - PDF document

Time for Action: Managing Early Pregnancy Loss and Medication Abortion in Primary Care CME Medical Care of Vulnerable and Underserved Populations Jessica Beaman, MD MPH Assistant Professor of Medicine Division of General Internal Medicine at ZSFG Zuckerberg San Francisco General Disclosures  I have no financial disclosures  I present off-label indications for mifepristone and misoprostol Zuckerberg San Francisco General 1 | [footer text here]

“We acknowledge our awareness of the sensitive and emotional nature of the abortion controversy; of the vigorous opposing views, even among physicians.” -- From Justice Harry A. Blackmun’s majority opinion in Roe v. Wade (January 22, 1973) Zuckerberg San Francisco General Learning Objectives Describe early pregnancy loss and abortion trends in the 1. United States Analyze current evidence for medical management of early 2. pregnancy loss and medication abortion Effectively counsel your patients about medical management 3. of early pregnancy loss and medication abortion List key clinical and legal considerations for integration of 4. mifepristone in to practice Zuckerberg San Francisco General 2 | [footer text here]

Learning Objectives Describe early pregnancy loss and abortion trends in the 1. United States Analyze current evidence for medical management of early 2. pregnancy loss and medication abortion Effectively counsel your patients about medical management 3. of early pregnancy loss and medication abortion List key clinical and legal considerations for integration of 4. mifepristone in to practice Zuckerberg San Francisco General Overview Zuckerberg San Francisco General 3 | [footer text here]

Terminology  Distinct clinical conditions  Early pregnancy loss (EPL) = nonviable, intrauterine pregnancy before 13 weeks gestation - Commonly referred to as miscarriage  Elective abortion = when a medication is taken or a procedure is performed to end a pregnancy - Also called an induced abortion, pregnancy termination, or abortion ACOG 2018 Zuckerberg San Francisco General Reproductive age women in primary care  61 million US women of reproductive age (15-44) - 10% become pregnant annually  Half of all US women will seek primary care in an internal medicine or family medicine clinic each year CDC NCHS 2010 Pregnancy Rates Amongst U.S. Women (most recent data available) Daniels et al. Natl Health Stat Report 2015 Petterson et al. JWH 2014 Zuckerberg San Francisco General 4 | [footer text here]

Prenatal Care Zuckerberg San Francisco General “ “On average, U.S. women want to have two children. To accomplish that goal, a woman will spend close to three years pregnant, postpartum, or attempting to become pregnant, and about three decades… trying to avoid an unintended pregnancy.” Sonfield et al. From in “Moving Forward: Family Planning in the Era of Health Reform” (2014) Zuckerberg San Francisco General 5 | [footer text here]

Lifetime Prevalence of Common Medical Conditions Perce Breast Cancer nt 50 47 Breast Cancer Cervical Cancer 45 Cervical Lifetime Prevalence (%) 39 Depression Cancer 40 Depression Diabetes 33 35 Diabetes Hypertension 30 27 Hypertension 25 20 15 12 10 5 1 0 Guttmacher Institute National Cancer Institute Surveillance, Epidemiology, and End Results Program National Center for Health Statistics Zuckerberg San Francisco General Unintended Pregnancy is Common 50 47 45 Lifetime Prevalence (%) 39 Unintended Pregnancy 40 Depression 33 Cervical Cancer 35 30 27 Hypertension Diabetes 25 20 Breast Cancer 15 12 10 5 1 0 Guttmacher Institute National Cancer Institute Surveillance, Epidemiology, and End Results Program National Center for Health Statistics Zuckerberg San Francisco General 6 | [footer text here]

Unintended Pregnancy Pregnancy Intentions  45% of all pregnancies are Uninteded - unintended unwanted 18%  Mistimed = wants to become pregnant in the future but not at Intended Unintended - the time she became pregnant 55% mistimed 27%  Unwanted = did not want to become pregnant then or at any time in the future Finer and Zolna, NEJM 2016 Zuckerberg San Francisco General Outcomes of Pregnancy Early Pregnancy Loss (EPL) Abortion  Estimated that 10-20% of  Half of all unintended all pregnancies end in EPL pregnancies end in abortion - 80% of all pregnancy loss is EPL - 1 in 4 women will have an abortion by age 45 (20% by age 30) Over 1/3 of all pregnancies result in EPL or elective abortion ACOG 2018 Guttmacher Institute 2018 Zuckerberg San Francisco General 7 | [footer text here]

Trends in Early Pregnancy Loss  Self-reported early pregnancy loss rate is increasing in US - 22,000 births - Risk of EPL increased by 2% annually - Exception = women 20-24 years old Rossen et al Paediatr Perinatal Epidemiol 2018 (data from National Survey of Family Growth) Zuckerberg San Francisco General Early Pregnancy Loss  50% of all cases of early pregnancy loss are due to fetal chromosomal abnormalities  Risk Factors - Advanced maternal age  9-17% from 20-30 years  80% at 45 years - Prior early pregnancy loss - Substances (alcohol, caffeine, cigarette (> 10/day), cocaine) - Comorbidities (e.g., APLS, DM, thyroid disease) Stephenson et al. Hum Reprod 2002 American Society for Reproductive Medicine Fertil Steril 2012 Zuckerberg San Francisco General 8 | [footer text here]

Trends in Abortion Guttmacher Institute 2018 Zuckerberg San Francisco General Zuckerberg San Francisco General 9 | [footer text here]

Zuckerberg San Francisco General Zuckerberg San Francisco General 10 | [footer text here]

Zuckerberg San Francisco General Access to Care 90% of women live in US county without an abortion clinic Guttmacher Institute 2018 Zuckerberg San Francisco General 11 | [footer text here]

Impact on Patients 42 clinics 19 clinics Zuckerberg San Francisco General Impact on Patients - Dark blue = no facility, > 100 miles traveled - Mean distance Δ = 51 miles - Decrease in abortions Grossman et al. JAMA 2017 Zuckerberg San Francisco General 12 | [footer text here]

Turnaway Study (UCSF, 2018 and ongoing) ANSIRH (Advancing New Standards in Reproductive Health) Large, longitudinal study (N=1000)  - 8000 interviews Women turned away based on GA  Lasting impacts  - Unemployment/living below FPL - In relationship w/ abusive partner - Less likely to have aspirational plans No increased likelihood for:  - Depression - Anxiety - Suicidal ideation Foster et al. ANSIRH 2018 Zuckerberg San Francisco General Incorporating Abortion into Primary Care • 2005 by Schwarz and Luetkemeyer • 212 Residents, 11 residencies • 42% IM residents willing to prescribe medication abortion • 2010 by Godfrey et al • 299 Patients in NYC and Chicago • 58% would choose primary care clinic (PCC) for abortion • 2012 by Page et al • 90 Patients in academic PCC • 67% felt PCC should offer medical abortions • 87% would want PCP to perform Zuckerberg San Francisco General 13 | [footer text here]

Support Policies for Comprehensive Reproductive 2018 Health Zuckerberg San Francisco General Support Policies for Comprehensive Reproductive 2018 Health Well-suited to provide high-quality  women’s health care Should receive appropriate training  Essential for women to have access to  comprehensive, nondiscriminatory health coverage Oppose legislations or regulations that  limit access, including abortion Zuckerberg San Francisco General 14 | [footer text here]

Overview Summary  PCPs care for reproductive-age women who have a high likelihood of experiencing: - Early pregnancy loss - Unintended pregnancy - Abortion  Rates of early pregnancy loss are increasing  Health disparities exist in who experiences abortion and has access to care  Patients and providers have shown interest in integrating abortion care into primary care Zuckerberg San Francisco General Learning Objectives Describe early pregnancy loss and abortion trends in the 1. United States Analyze current evidence for medical management of early 2. pregnancy loss and medication abortion Effectively counsel your patients about medical management 3. of early pregnancy loss and medication abortion List key clinical and legal considerations for integration of 4. mifepristone in to practice Zuckerberg San Francisco General 15 | [footer text here]

Evidence Zuckerberg San Francisco General Early Pregnancy Loss Management  EPL management has traditionally been one of the following: - Expectant management (days to weeks)  Day 7 – 50%  Day 46 = 90% - Medications - D&C procedure Medication protocols  - Misoprostol alone - Mifepristone and misoprostol Nanda et al. Cochrane Database Syst Rev 2012 Zuckerberg San Francisco General 16 | [footer text here]