- 1.1 Abortion – A Global Perspective
- 1.2 Safe abortion - Definition and Methods
- 1.3 Approved Techniques and Methods of Safe Abortion
- 1.4 Role of Pharmacists in Safe Medical Abortion
- 2.1 Methods of Medical Abortion
- 2.2 Continuum of Safety in Medical Abortion
- 3.1 Importance of Screening
- 3.2 Goals of Screening Clients
- 4.1 Considerations
- 4.2 How To Use Abortion Pills: Mifepristone + Misoprostol
- 4.3 How To Use Abortion Pills: Misoprostol Only:
- 5.1 Managing Expected Effects
- 5.2 Managing Common Side Effects
- 6.1 Duration for Abortion
- 6.2 Warning Signs and How to Manage Them
- 6.3 Returning Clients – Common Scenarios and How to Manage Them
Lesson 1: An Overview Of Abortion
In this lesson, we will review abortion within a global context, define the various types of safe abortion, and explore the expanding role of pharmacists within safe abortion work. Upon completing this lesson successfully, you will be able to cite global rates of abortion and differentiate between safe and unsafe methods of abortion.
Abortion is defined as the expulsion of products of conception from the uterus before the fetus is viable. An abortion can occur spontaneously due to complications during pregnancy, or can be induced. The term abortion most commonly refers to the induced abortion of a human pregnancy, while spontaneous abortions are usually referred to as miscarriages.
1.1) Abortion in the Global Context
The Guttmacher Institute estimates that between 2010-2014, approximately 56 million induced abortions occurred worldwide each year. This represents the termination of roughly 25% of all pregnancies for that time period.1
Clearly, induced abortion is a common procedure throughout the world. Most women seek an abortion because they became pregnant when they did not intend to. While a large majority of these women have an unmet need for contraception, it is important to remember that all meth-ods of contraception can fail at some point, and that women may seek an abortion even while using contraception.
When trained providers perform abortions with appropriate equipment or drugs, correct tech-niques & doses, and in sanitary standards in early pregnancy, abortion is one of the safest known medical procedures. In fact, it carries less risk than a full term pregnancy. 2
However, abortions that do not maintain the above mentioned standards may lead to complica-tions that can result in death. Unsafe abortion is a significant contributor to high rates of maternal mortality in developing countries. Recent studies estimate that between 8–18% of maternal deaths worldwide are due to unsafe abortion. The number of abortion-related deaths in 2014 ranged from 22,500 to 44,000. 3 4 5
1Sedgh G et al., Abortion incidence between 1990 and 2014: global, regional, and subregion-al levels and trends, The Lancet, 2016.
2Raymond, Elizabeth G.; Grimes, David A. The Comparative Safety of Legal Induced Abortion and Childbirth in the United States. Obstetrics & Gynecology. 119(2, Part 1):215-219, February 2012.
3Singh S, Darroch JE and Ashford LS, Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014, New York: Guttmacher Institute, 2014.
1.2) Safe Abortion – definition and methods
A safe abortion is a medical process by a trained individual that limits risk of morbidity and mortality to the woman. Thus, it is important that abortion procedures adhere to specific safety requirements.
Contrary to safe abortion, the World Health Organization defines an unsafe abortion as a procedure for terminating an unintended pregnancy, carried out either by persons lacking the necessary skills and/or in an environment that does not conform to minimal medical standardsi.
The health consequences of unsafe abortion depend on the facilities where abortion is performed; the skills of the abortion provider; the method of abortion used; the health of the woman; and the gestational age of her pregnancy. Unsafe abortion procedures may involve any of the following practices:
- insertion of an object or substance into the uterus, such as roots, metallic objects, or traditional herbal concoctions;
- dilation and curettage performed incorrectly by an unskilled provider;
- ingestion of harmful substances;
- or the application of external force.
All of these can lead to a number of medical complications, and in many instances, may be life-threatening.
4Kassebaum NJ et al., Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013, The Lancet, 2014, 384(9947):980–1004.
5Say L et al., Global causes of maternal death: a WHO systematic analysis, The Lancet Global Health, 2014, 2(6):e323–e333
6Safe Abortion: Technical and Policy Guidance for Health Systems, Second edition page 18 (World Health Organization 2012):
1.3) Approved Techniques and Methods of Safe Abortion
The WHO, based on a systematic review of evidence, has recommended the following as safe methods for terminating a pregnancy:
- Vacuum Aspiration (manual or electric): This is a surgical method in which the products of conception are removed by aspiration using a plastic canula inserted into the uterus. A vacuum created either manually or through the use of an electric pump is used to achieve the aspiration. Since the material used is not metallic and the amount of vacuum used is limited, this procedure is safe and reduces the risk of damage to the organs when used correctly. This method is usually used to terminate pregnancies up to 12 -14 weeks.
- Medical Abortion (MA): In this method, a combination of two drugs or repeated doses of a single drug are given to terminate a pregnancy. This is a non-surgical, non-invasive way to terminate a pregnancy and remove the products of conception. The two commonly used drugs are Misoprostol either alone or in combination with Mifepristone. Based on a review of a number of clinical studies, the WHO and other international organizations have identified the most effective regimens and protocols for the use of these drugs for a safe abortion. The dose of the drugs used will vary with the duration of pregnancy to achieve best results and limit harm to the woman. This method can be used throughout the pregnancy, with variations in the dosage and timing of the drugs used to achieve an abortion.
- Dilation and Evacuation: Beyond 14 weeks of a pregnancy, the WHO recommends a procedure called Dilation and Evacuation, wherein drugs or metallic dilators are used to open the cervix and the fetus is removed using a forceps. This is an advanced and complex surgical procedure and should only be performed by trained and competent health care providers in an appropriate setting.
It is important to note that Dilation and Curettage (commonly referred to as "D&C" or “curettage”) is NOT considered to be a safe procedure based on the review of evidence, and thus the WHO does not recommend it as a safe procedure to terminate pregnancies.
1.4) Role of Pharmacists in Safe medical Abortion
Pharmacist and Pharmacy workers are a key group of allied health care providers who can play a pivotal role in expanding access to safe medical abortion. Current research from a number of countries indicates that women seek pharmacists’ guidance when they want to end unwanted pregnancies, regardless of the legal situation in their country. This presents a great opportunity for pharmacists and pharmacy workers to play a leadership role in expanding access to safe abortion services, especially safe medical abortion in the first trimester.
The WHO has explicitly acknowledged pharmacists and pharmacy workers as a discrete category of health care providers who have a role to play in expanding access to safe abortioni. The WHO has recommended, in the context of rigorous research, the following tasks as safe and effective for pharmacists during a medical abortion in the first trimester:
- Assessing eligibility for medical abortion
- Administering the medications and managing the process and common side-effects independently
- Assessing completion of the procedure and the need for further clinic-based follow-up
This is an area of great interest and growing research. This training course is an initiative to improve pharmacists’ ability to help women benefit from safe and effective medical abortions by providing accurate information and services for a medical abortion up to 11 weeks.
7Health worker roles in providing safe abortion care and post-abortion contraception, World Health Organization 2015
Lesson 2: Safe Medical Abortion
In this lesson, we will explore Mifepristone and Misoprostol, the two recommended drugs to be used for safe medical abortion. Upon completing this lesson successfully, you will be able to explain both drugs' classification, administration, and pharmacological effects.
2.1 Methods of Medical Abortion
Medical abortion has been the single most significant advancement in abortion care since vacuum aspiration, and has revolutionized abortion service delivery. It has allowed for safe abortion services to be provided outside of, or with reduced visits to, a health facility. This reduces cost for clients and allows women to play a greater role in their own care.
The symptoms of an abortion with pills are very similar to a spontaneous miscarriage. This similarity offers many advantages to women. Medical abortion is often perceived as a more natural process that can be undertaken in a safe and private location, it does not require surgical instrumentation, and it may mimic menstrual bleeding (although the pain and amount of bleeding will be variable and is dependent on the duration of the pregnancy).
Globally, the two recommended drugs to be used for a medical abortion include Mifepristone and Misoprostol.
Mifepristone: Mifepristone, also known as RU- 486, is a hormone with a strong affinity to progesterone receptors in the uterus. When given orally, it competes with progesterone while binding with receptors and limits progesterone’s effects. This leads to:
- The detachment of the gestational sac from the uterine wall;
- The softening and dilation of the cervix; and
- An increase in the uterine wall’s ability to contract, working as a primer for Misoprostol
Mifepristone must be administered orally, with the effects noted in 12 -24 hours. Depending on the process by which the drug is manufactured, its shelf-life can vary from 24 – 48 months8
Savitz, D. A., Terry, J. W., Dole, N., Thorp, J. M., Siega-Riz, A. M., & Herring, A. H. (2002). Com-parison of pregancy dating by last menstrual period, ultrasound scanning, and their combi-nation. American journal of obstetrics and gynecology, 187(6), 1660-1666.
Wegienka, G., & Baird, D. D. (2005). A comparison of recalled date of last menstrual periodwith prospectively recorded dates. Journal of Women's Health, 14(3), 248-252.
Burger W, Chemnitius JM, Kneissl GD, Rucker G. Low-dose aspirin for secondary cardiovas-cular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005;257(5):399–414
Misoprostol: Misoprostol is a synthetic prostaglandin (Type E1) that was initially registered for the prevention of gastric ulcers associated with non-steroidal anti-inflammatory drugs. However, since its initial discovery, a number of uses for Misoprostol have been identified in Obstetrics and Gynaecology. Misoprostol is currently used in many countries to start labour, prevent and treat post –partum bleeding, and treat incomplete or induced abortion. Given its wide range of uses, Misoprostol is included in the WHO List of Essential Medicines for Adults. It is also recognized in the UN Commission on Life saving commodities for women and children, specifically for its use in safe abortion.
Misoprostol can be administered through a wide range of modes, such as sub- lingual, buccal or vaginal. However, note that ingestion or swallowing of Misoprostol is not recommended due to poor efficacy for uterine action.
Although there are many routes of administration for Misoprostol, it is best to choose one method and use that route for all doses when undergoing a medical abortion.
Once it is absorbed into the blood, Misoprostol is converted to Misoprostol acid. This triggers strong contractions in the uterus, and causes the cervix to soften and dilate. Both processes facilitate the expulsion of the products of conception.
Misoprostol is a relatively heat stable compound (particularly when compared to Oxytocin) but can rapidly deteriorate in the presence of high humidity and high temperature. Hence, it is important that Misoprostol tablets should be in double aluminum blister packaging and stored in a cool and dry place.
A woman will usually begin to experience cramping and bleeding within 1 to 2 hours of the first set of Misoprostol pills being absorbed into the body. In most women, the pregnancy will usually be expelled within 24 hours of taking the last pills of Misoprostol, though the abortion may take longer than that to fully complete.
Note: Medical abortion is sometimes called medication abortion, pharmacological abortion, pharmaceutical abortion or the abortion pill. It is important to note that MA is different from emergency contraception, also known as “EC” or the “morning-after pill.” EC is a contraceptive that prevents pregnancy from occurring.
2.2 Continuum of Safety in medical Abortion
In the past, the definition of safety in abortion has focused on three aspects – the knowledge of the provider, the medical or surgical skills of the provider, and safety of the surroundings in which the abortion is performed. However, an increasing body of evidence around medical abortion has shifted this safety paradigm. A safe medical abortion is now based on the accurate knowledge of the pregnancy process, the action of the medications used, and their correct dosing and administration. This means that other areas of safety, such as the surroundings and surgical skills of the provider, are less likely to influence the safety and outcome of the medical abortion process. Thus, when pharmacists or pharmacy workers are knowledgeable on the previously mentioned three factors, they can effectively support women in achieving a safe abortion.
Though both Mifepristone and Misoprostol (when used correctly) are very safe drugs, it is not to say that they are without any risks. Incorrect doses of the medical abortion drugs can often lead to potentially dangerous situations, especially with Misoprostol. Since the sensitivity of the pregnant uterus to Misoprostol increases dramatically with gestational age, it is important to remember that the earlier the pregnancy (in the first trimester), larger is the dose of Misoprostol needed to achieve an abortion. As pregnancy advances, the dose of Misoprostol should be reduced in line with gestational age.
Administering a less than needed dose of Misoprostol in early pregnancy may result in an incomplete abortion, leading to serious adverse events such as bleeding or infection. Administering a larger than needed dose of Misoprostol can result in over stimulation of the uterus, leading to a possible uterine rupture that can be life-threatening.
When exploring safe medical abortion, it is important to consider each of the following aspects: screening for eligibility, dispensing of appropriate medications, providing supportive care, and the provision of full and accurate information for clients.
These four aspects of medical abortion will be examined in the remainder of this course. Each aspect is key in contributing to a safe and high quality experience for women.
Lesson 3: Screening Of Clients
In this lesson, we will discuss the importance of screening clients for medical abortion. We will also identify the key objectives of screening, and how to satisfy these objectives in a simple and efficient manner. Upon completing this lesson, you will be able to explain the importance and goals of screening clients for a medical abortion in pharmacy settings.
3.1) Importance of screening
The screening of clients refers to a short, focused interaction between the pharmacy worker and the client to ensure that the client is medically eligible to receive the drugs, and that she can proceed with a medical abortion with minimal or no medical support and supervision.
Goal of screening: The main goal of screening is to make sure that appropriate drugs and information can be provided to women to ensure that the medical abortion process is safe, reduces the risk of avoidable complications, and improves the possibility of a successful abortion.
In most cases, there is an interaction between the pharmacist and the client when medical abortion drugs are sought. Pharmacy workers should use this interaction to elicit information around the women’s health and pregnancy to ensure that the client is eligible for medical abortion.
The pharmacy worker should explain the need to assess eligibility in a short, succinct manner. A few structured questions will elicit responses to assess eligibility. Suggested sample questions are included in the next section under goals and can be modified by individual pharmacists based on local context, customs and norms.
In some instances, it is likely that the individual who is procuring the medical abortion drugs from the pharmacy is not the woman intending to use the drugs. In such a scenario, it is important that the pharmacist explains the importance of screening to the individual. The pharmacist can provide a list of questions for the client to self assess eligibility and dispense the appropriate dose of medications.
3.2) Objectives of screening clients
The primary aim of screening clients is to improve the safety and quality of the medical abortion service.
Screening Objective 1: Correctly assess gestational age to confirm dosing of medical abortion drugs, especially for Misoprostol
The dosing regimens for medical abortion need to be appropriate for the duration of the pregnancy to ensure a safe and successful abortion. The appropriate dose of Misoprostol will reduce the chance of a failed procedure due to low dosing, or uterine over-stimulation with over-dosing.
Ask the woman for the first day of her last menstrual period and calculate the number of weeks from the last menstrual period to the date when the drugs are likely to be consumed using a calendar. Research in many settings has shown that using the last menstrual period to date pregnancies is accurate and acceptable. In most cases, women are able to recollect their last menstrual period with reasonable accuracy.
Ensure that the pregnancy is not likely to be beyond 11 weeks based on your calculation. If the pregnancy is expected to be 11 weeks or less based on your calculation, you can safely dispense the drugs as indicated in Lesson 4.
If the pregnancy is likely to be beyond 11 weeks based on your calculation, then do not dispense the drugs as per the protocol in Lesson 4. You will need to adjust the dose of the Misoprostol based on the gestational age or ask the women to seek care with medical support.
Screening Objective 2: Identify contra-indications to the use of medical abortion drugs.
Like all medications and drugs, Mifepristone and Misoprostol have certain contra-indications, such as known allergy to Mifepristone, Misoprostol, or other prostaglandins, or if the women has certain medical conditions which exclude the use of these drugs.
Contra indications for Mifepristone use include:
- Current long-term systemic corticosteroid therapy
- Chronic Adrenal failure
- Inherited Porphyrias
- Hemorrhagic disorders
- Current anticoagulant therapy, and
- Intolerance or allergy to Mifepristone
Contra indications for Misoprostol use include:
- Intolerance or known allergy to Misoprostol or other prostaglandins
Where a woman has a contra-indication to the use of Mifepristone, a Misoprostol-only regimen can be used safely, provided there is no contra-indication to Misoprostol use.
In order to identify contra-indications to medical abortion drugs, complete the following:
- Simply ask the woman if she has any known allergies to prostaglandins or Mifepristone. You can also ask about any other drug allergies at this point to note what other supportive care medications you can or cannot dispense.
- Ask the women if she is taking any blood thinning medications or if she bleeds for a long time after an injury. If she answers yes, probe further to assess any bleeding disorders.
- While the presence of any inherited bleeding disorder is a contraindication for medical abortion, the concurrent use of low-dose Aspirin or Clopidrogel (an anti-platelet drug) is usually not an absolute contraindication for medical abortion drugs. While no recent study has examined the risk of bleeding for either therapy in women undergoing abortion, in general, low-dose aspirin therapy does not increase the severity of bleeding complications or perioperative mortality. However, if a client is using both low-dose aspirin and Clopidrogel, they should be medically evaluated before administration of medical abortion drugs.
- The prevalence of porphyrias is variable in different populations, and is a difficult condition to screen for in the absence of a health facility with advanced testing and multiple visits. Even in health facilities, this condition may only be diagnosed retrospectively following administration of the medical drugs. Thus, be aware of this and inform the client that an acute attack may be triggered by administration of medical abortion drugs.
In addition to the above conditions, it is important to note that there are a number of other medical conditions that can necessitate the need for medical supervision or support during a medical abortion. Pharmacists should be aware of this and recommend clients to seek appropriate medical care.
Screening Objective 3: Ensure that the woman does not have an Intra uterine contraceptive device in the uterus.
Sometimes, even when women are using the IUD, they may become pregnant. In such cases, the IUD must be removed before administration of the medical abortion drugs. Contractions caused by Misoprostol may lead to uterine injury (such as a perforation) if the IUD is inside the uterus.
Ask the woman if she is currently using an IUD or ever had an IUD inserted that was not removed. Most women will remember and can feel the thread. Instruct the women that this must be removed (either by a health care provider in a health facility or by the women herself) prior to taking the first dose of the medical abortion drugs.
Provide information on the risks of taking a medical abortion drug with an IUD inside the uterus.
Screening Objective 4: Explain that medical abortion will not work if it is an ectopic pregnancy and that the woman should seek urgent medical care for the treatment of an ectopic pregnancy
The one other medical condition that can pose a serious risk to the success of medical abortion is an ectopic pregnancy1. Because an ectopic pregnancy is different from a normal uterine pregnancy, medical abortion (both Mifepristone and Misoprostol) drugs will not be effective in terminating an ectopic pregnancy. A woman should seek immediate medical care for the treatment of an ectopic pregnancy– which is legal in all countries and is offered as part of obstetric care.
It is difficult if not impossible to diagnose an ectopic pregnancy without internal examination or an ultrasonogram. If any ectopic pregnancy (especially a tubal pregnancy) ruptures, it can lead to life-threatening internal bleeding. Thus, while this medical condition cannot be assessed during a pharmacy visit, the pharmacist should be aware of this possibility and provide appropriate information to the clients to identify and seek treatment for this condition.
Lesson 4: Dispensing Medical Abortion Drugs
In this lesson, we will discuss the important considerations in dispensing medical abortion drugs. Upon completing this lesson successfully, you will be able to correctly indicate the drugs used for medical abortion, their doses, timing and route of administration for an abortion in the first 11 weeks of pregnancy.
Following the screening step, you should be have assessed the duration of the pregnancy and established that the client is eligible to take medical abortion drugs.
Based on the local situation and the availability of drugs, there are two options for a medical abortion
Option 1: A combination regimen that uses Mifepristone followed by Misoprostol
Option 2: Using repeated doses of Misoprostol only
Where both options are available, information on their effectiveness should be presented to the client along with the cost options for them to decide their preferred option.
|Mifepristone and Misoprostol||Misoprostol only medical abortion|
|Highly effective when used on the first 10 weeks of a pregnancy (95% – 99%), with success comparable to vacuum aspiration||Effective with success rates in the range of 75% – 90%|
|The risk of an continuing pregnancy as an adverse event of this method is very low (<1 %)||The risk of the pregnancy continuing even after taking the prescribed regimen is fairly significant about 5 -7%|
|More expensive as there are two types of drugs used||Likely to be less expensive|
4.2) How To Use Abortion Pills: Mifepristone + Misoprostol:
When dispensing both Mifepristone and Misoprostol, ensure that the full regimen is dispensed to the client. Do not provide only a part of the regimen, as this will not work.
Dispense one 200mg tablet of Mifepristone and four 200mcg tablets of Misoprostol to the client with the following instructions on how to take them:
Step 1: Swallow one pill of Mifepristone (200 mg) with water. Some women (up to 40%) can experience nausea after taking Mifepristone. If the client vomits within one hour of swallowing the Mifepristone pill, it is unlikely to work and she should repeat the dose. If the client vomits after an hour of swallowing the Mifepristone pill, enough drug would have been absorbed for the abortion and she does not have to repeat the dose.
Step 2: Wait 24-48 hours. You should tell the client to wait 24 hours before using Misoprostol, but wait no longer than 48 hours. While the client waits, they can do the things that they normally do in their everyday life, like taking care of family or going to work or school. Less than 10% of women experience bleeding or cramping following the administration of Mifepristone.
Step 3: After 24 hours and before 48 hours, drink some water to make your mouth moist. Put the 4 Misoprostol pills (200 mcg each) between your cheek and bottom gums (2 pills on each side), or directly under your tongue.
Step 4: Hold the Misoprostol pills in your cheeks or under your tongue for 30 minutes. It may make the mouth dry or taste chalky as they dissolve. Do not eat or drink anything for these 30 minutes. Swallow any secretions in your mouth normally and do not spit out anything during these 30 minutes.
Step 5: After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.
4.3) How To Use Abortion Pills: Misoprostol Only:
When dispensing Misoprostol only – ensure that the full regimen is dispensed to the client. Since it is difficult to identify which women will need additional doses and how many, providing less than the full dose may lead to a lower success rate in terminating pregnancies and lead to other adverse events.
Dispense 12 200mcg tablets of Misoprostol to the client with the following instructions on how to take them. When dispensing the tablets, do not take them out of their blister packaging and inform the client to take out the medication from the packaging prior to putting them in the mouth.
Step 1: Drink some water to make your mouth moist. Put the 4 pills directly under the tongue, and let it dissolve. Hold them in place under your tongue for 30 minutes. They may make your mouth dry or taste chalky as they dissolve. Do not eat or drink anything for 30 minutes. Swallow any secretions in your mouth normally and do not spit out anything during these 30 minutes.
After 30 minutes, rinse your mouth with water and drink down everything that is left of the pills.
Wait 3-4 hours before proceeding.
Step 2: After 3 -4 hours, even if you are cramping and have started bleeding, repeat Step 1 with 4 more pills.
Wait 3-4 hours after completing Step 2.
Step 3: After an additional 3 - 4 hours (i.e. 6- 8 hours from taking the first dose of Misoprostol) repeat Step 1 with the last set of 4 pills. Make sure you complete Step 3 even if you are cramping actively and bleeding and can see the products of conception coming out.
Lesson 5: Supportive Care During A Medical Abortion
In this lesson, we will discuss other forms of care that you can provide to women undergoing a medical abortion. Information in this lesson will help you to support clients in managing the expected and undesirable side effects of medical abortion, and increase satisfaction of clients with a medical abortion experience.
In addition to providing the medical abortion drugs, there are other efforts that you can provide as a pharmacist that will ensure a positive and comfortable experience to clients undergoing a medical abortion. These efforts are integral to ensuring that the service you offer is high quality and leads to client satisfaction.
The common symptoms experienced during a medical abortion include cramping and bleeding. Both of these symptoms are essential and expected of the medical abortion process. It is important that all women are informed of these symptoms and are provided appropriate supportive care beforehand to help manage these symptoms better.
In addition to the symptoms, as with any medication, some women may experience side effects that are not desirable and can affect the overall experience of a medical abortion for the client. It is important that women are aware of both the expected symptoms necessary for the abortion to be completed and the side effects that can be experienced as a result of taking the medications.
While prolonged or serious side effects are rare, minor side effects can be common during medical abortion. These side effects typically go away for most women within 4 to 6 hours of taking the Misoprostol. There are no long-term side effects of medical abortion.
Supportive care is aimed at effectively managing the symptoms and side effects of the medical abortion drugs and helping clients to have a safe and comfortable abortion.
5.1) Managing expected symptoms
Before starting the abortion process, make sure that women know:
- She should not be alarmed if she has more bleeding and cramping than a regular period
- She can drink and eat as she likes after she has finished taking the medication.
- She should try to stay in a comfortable place until she feels better.
- She should be clear about what side effects are and what warning signs are.
- You can provide her with medication and advice on how to manage side effects but she should also have a plan that is well thought out in line with the country situation to seek emergency medical care.
- Most women feel better in less than 24 hours.
It is important to inform the woman that most of the side effects are likely associated with Misoprostol (more than Mifepristone) and hence she should coordinate herself to be in a safe, comfortable and private place before she uses the Misoprostol.
Expected symptoms include:
Most women experience abdominal pain and cramping within the 30 minutes after using Misoprostol. Cramping is the sign that the uterus has started to contract and is in the process of expelling the products of termination. This is a sign that the medication is working. Cramping is usually associated with pain. The level of pain varies greatly and is related to the duration of the pregnancy, strength of uterine contractions, anxiety levels, and the pain tolerance limits of the individual.
Most women will experience bleeding closely associated with cramping. While less than 10% of women will experience bleeding after taking Mifepristone, most women will begin bleeding after the first dose of Misoprostol. Once started, bleeding may last several hours and is heaviest during the expulsion of the products of conception. Women may see large clots of blood or tissue during the process and should not be alarmed just by noticing these during the process of expulsion.
The amount and pattern of bleeding varies from woman to woman and is related to the duration of the pregnancy. For most women, bleeding will become less heavy 1-2 hours after expulsion of the pregnancy, and will continue for one to two weeks with diminishing intensity. Some women experience bleeding or spotting for up to four weeks after taking the medical abortion pills.
Both these symptoms are useful because they show the medicines are working. To ease the experience and provide relief from the cramping, women should always be offered pain medication.
When instructing women on how to manage pain during a medical abortion, address the following:
- Suggest general advice on non- medical methods to reduce pain and anxiety, such as being in a comfortable place, listening to music, avoiding heavy labor, and using a hot water bottle on the abdomen (similar to ones used during menstrual periods).
- Offer pain medication to all women undergoing medical abortion. This should ideally be dispensed along with the Mifepristone and or Misoprostol. Non-steroidal anti-inflammatory drugs (NSAIDS) such as Ibuprofen, Diclofenac etc. are highly effective in reducing the maximum pain experienced during a medical abortion in most women. The recommended dosing for the common NSAIDS are
- Ibuprofen – 400 – 800 mg every 6-8 hourly (maximum dose 3200mg in 24 hours)
- Diclofenac sodium – 50 mg every 12 hourly (maximum dose 150mg in 24 hours)
To ensure that oral pain medications will be most effective, they can be taken 30–45 minutes before taking the Misoprostol dose. Women should be informed to take the pain medicines beforehand as they take time to work. They should not wait until the pain is unbearable before taking these medicines. It is important to note that paracetamol (oral or rectal) is ineffective in reducing pain during medical abortion
5.2) Managing common side effects
In addition to the previously discussed effects, Misoprostol can also have some unpleasant side effects. The incidence and severity of the side effects are related to the route of administration of the Misoprostol. Both Buccal and Sub- lingual administration are commonly associated with a high reported incidence of side effects. Therefore it is important to inform and support women in managing these undesirable side effects for a comfortable experience.
Nausea and Vomiting
Nausea, dizziness and vomiting may occur for some women and will resolve 2 to 6 hours after using Misoprostol. Sometimes nausea due to pregnancy can confound or worsen with the administration of Misoprostol. This can be very bothersome for women and can lead to vomiting and dehydration. This usually resolves once the pregnancy is terminated and the effect of Misoprostol is reduced.
Supportive advice, such as eating light dry food items, can help manage nausea. Additional medications such as Domperidone, Ondansetron and Metaclopromide can be provided (given that there are no contraindications for their use) to the client to manage these side effects.
Up to 20% of women using Misoprostol can also experience dizziness that is poorly explained. Ensuring that the women are not hungry and lying down usually helps this side effect.
Stomach cramps and Diarrhea
Another bothersome side effect of Misoprostol use is that some women (up to 40%) experience mild to moderate diarrhea. In some cases, using Misoprostol with food can help limit this symptom. While this is usually self-limiting and resolves within a day after the last dose of Misoprostol, additional medications such as Loperamide can be dispensed to help women manage this
Fever and Chills
The incidence of fever is related to Misoprostol dosage and route of use ( with highest incidence found in the high-dose sublingual routes). However, there appears to be genetic variations between ethnic groups. Most women using a sub-lingual route of administration experience a transient increase in body temperature associated with chills. Fever is usually highest 1-2 hours after using Misoprostol and usually ends within 8 hours of the last dose. Ibuprofen taken for pain management usually helps with this side effect as well. If that is not adequate and the fever is bothersome, paracetamol can also be used in addition to Ibuprofen. However caution has to be taken to limit the overall use of NSAIDs in a 24 hour period.
Lesson 6: Providing Accurate And Complete Information
In this final lesson, we will discuss other key information that you should know to assist women undergoing a medical abortion for a safe outcome. By completing this module successfully, you will be able to provide clear and accurate information to some of the commonly asked queries around medical abortion, help women identify warning signs, and manage the queries of clients who return to your pharmacy with queries after a medical abortion.
6.1) Duration for Abortion
The pregnancy is usually expelled within 24 hours of taking the last Misoprostol pills. However, the entire abortion process may continue over the following days with a majority of women completing the abortion process by 7 days. Some women may continue the process for a short period beyond 7 days as well. Since the beginning and duration of bleeding and cramping is different for every woman, it is very hard to predict what the experience will be like. As long as the woman is expelling the products of conception, not experiencing any warning signs, and experiences a decrease or absence of the symptoms of pregnancy, there is nothing more to be done.
Heaviest bleeding generally occurs during the actual abortion. Most often this entails more bleeding than during a heavy menstruation period with cramps. Bleeding and cramping decrease after the products of conception have been expelled. Some bleeding similar to the amount experienced during a menstruation period will continue for up to two weeks after the abortion. However, the intensity of the bleeding must gradually decrease over time.
Follow- up after a medical abortion
Women who use Mifepristone and Misoprostol generally do not need a follow-up visit with a healthcare provider so long as after the abortion she no longer feels pregnancy symptoms, she feels in good health, and her bleeding isn’t heavy.
However, when using Misoprostol-only medical abortion, up to 10% of women may experience a continued or ongoing pregnancy – a condition where the Misoprostol may not work to terminate the pregnancy. Women should therefore be counseled on the need for a follow up after 7 days with a trusted health care provider to ensure that the process is complete and that she does not need additional care.
Based on local situations, this may be challenging due to intense stigma or the legal situation. Pharmacists can either provide information on doctors, nurses, or midwives who are known to provide safe care, or advise clients to seek care at public health facilities explaining that they experienced a spontaneous miscarriage.
6.2) Managing common side effects
- Excessive bleeding: soaking more than two sanitary pads per hour for two consecutive hours, especially if accompanied by prolonged dizziness, lightheadedness, and increasing fatigue
- No or scant bleeding (like a light period) following Misoprostol (likelihood of an ectopic pregnancy)
- Fever of 38°C (100.4°F) or higher or fever after the day the last dose of Misoprostol is used
- Foul vaginal odor and/or discharge
- Severe abdominal pain the day after using Misoprostol
- Feeling very sick with or without fever, and persistent severe nausea, vomiting or diarrhea for more than 24 hours
A woman experiencing any of these warning signs is likely to be experiencing an adverse event and should seek immediate care in a health facility. In many cases limited intervention by a trained health provider is adequate to address the above mentioned conditions. In very rare cases, women may require hospitalization, additional surgical intervention, blood transfusion or advanced care.
At the end of the interaction with a client who has procured medical abortion drugs from you, please check if:
- The woman understands when and how to use the Mifepristone and/or Misoprostol tablets before she leaves the pharmacy.
- Ensure that the woman understands when and how to self-administer supplemental medication including drugs for pain management.
- Ensure that the woman understands when to contact a health-care provider in the event of warning signs.
6.3 Returning clients – common scenarios and how to provide information
In some settings, women may come back to your pharmacy a few days or weeks after purchasing the medical abortion drugs with questions, feedback or additional concerns. Below are some common scenarios experienced by pharmacists and pharmacy workers who provide medical abortion.
- No or light bleeding following the use of medical abortion drugs:
This scenario can represent one or more of the following conditions:
- The possibility of an ectopic pregnancy. Failure to bleed and expel products of conception following medical abortion should immediately raise the suspicion of an ectopic pregnancy and the women should be advised to seek urgent care at a medical facility to treat the ectopic pregnancy.
- A failed medical abortion. In a small minority of cases, for a variety of reasons, the medical abortion care fail in spite of the women following all instructions. In such cases women should be advised that these drugs can potentially be harmful on the continuing pregnancy and therefore they should seek medical care immediately and re-evaluate their options.
- Uterine malformations. In some rare cases, abnormalities of the shape of the uterus can limit the amount of bleeding following a medical abortion. This can only be identified and managed with ultra sonogram or other imaging techniques. Hence women should be advised to seek care with an appropriate health care provider
- Continued heavy bleeding even after 7 days:
If women do not experience a decrease in the amount and pattern of bleeding after 7 days following a medical abortion they should be examined by a health care provider to ensure that the abortion is complete. In most cases, women experience an incomplete abortion with some products of conception retained that cause this bleeding. Also women with sub-mucous fibroids may continue to bleed heavily and should be advised to seek care at a health facility.
- Continuation of pregnancy signs and symptoms:
When women report this scenario following the use of a Misoprostol only medical abortion – a strong suspicion of a failed medical abortion should be raised. In such cases women should be advised that these drugs can potentially be harmful on the continuing pregnancy and therefore they should seek medical care immediately and re-evaluate their options. Depending on the local situation and availability of other safe abortion providers, you can either refer her to a safe abortion provider for a surgical abortion or attempt a repeat dose of medical abortion based on the client’s choice.
- A urine pregnancy test is still positive – what should I do?
Many women are likely to undertake a urine pregnancy test a few days after a medical abortion to ensure that the pregnancy is terminated. A routine urine pregnancy test (sold in most pharmacies) is designed to show a positive result even when low amount of the pregnancy hormone (Beta Human Chorionic Gonadotrophin- HCG) is present. Because it takes up to 3 weeks after a pregnancy less than 10 weeks is terminated for the hormone to disappear, the urine pregnancy tests can still be positive. Explain this reasoning and re-assure the client. Ask her to check in 3 weeks to be sure. Advise her that the disappearance of pregnancy symptoms is also an accurate indicator of the success of medical abortion.