T ERMINATION OF P REGNANCY E VIDENCE B ASED M EDICINE S PRING 2009 Kila Diyla Nsamenang Family Medicine Advisor: Anna Smith Preceptor: Xudon Xu

PICO Q UESTION In all pregnant women wanting to terminate their pregnancies for medical or personal reasons is Mifeprex and Misoprostol combination compared to surgical evacuation more effective to terminate pregnancy without complications of infection or abnormal bleeding to the mother and abortion confirmed by ultrasound images showing no fetal remnants. Patient : All pregnant patients age y/o wanting to terminate pregnancy for medical or personal reasons. Interventions : Mifeprex and Misoprostol Comparison : Surgical abortion Outcome : Termination of pregnancy without adverse effects or complication to the mother such as infection or abnormal bleeding. Ultrasound of pelvis and uterus shows no remnants of fetus in the uterus.

Outcomes of Unintended Pregnancies (Approximately 3.1 Million Annually) Source: Finer, 2006 (2002 data) % of unintended pregnancies (excluding miscarriages)

P URPOSE S TATEMENT I chose this topic for my EBM project because of my observation of 16 women in a Family Medicine private practice location in Houston TX requesting to terminate their pregnancies for so many personal reasons which include; Concern for/responsibility to other individuals 74%, Cannot afford a baby now 73%, A baby would interfere with school/employment/ability to care for dependents 69%, Would be a single parent/having relationship problems 48%, and Has completed childbearing 38% (Lawrence et al 2005). I never expected abortion to be so common and I also wanted to investigate whether medical abortion with the use of a combination mifepristine and misoprostone was a safe and effective option for women as compared to surgery.

W HO H AS A BORTIONS : A GE Source: Henshaw adjustments to Strauss et al., 2007 (2004 data)

W HO H AS A BORTIONS : R ACE /E THNICITY Source: Jones et al., 2002*Non-Hispanic

A BORTION R ATES A MONG W OMEN A GED 15–44 Abortions per 1,000 women Source: Jones 2008

R ATE OF A BORTION BY A GE -G ROUP Abortions per 1,000 women Age-group Source: Henshaw adjustments to Strauss et al., 2007 (2004 data)

B ACKGROUND I NFORMATION It has been projected that Abortion is one of the most common medical procedures undergone by women aged 15– 44y/o in the United States, partly because of the high level of unintended pregnancy. The number of abortions in the United States declined from 1.61 million (the all-time high) in 1990 to 1.31 million in Similarly, the abortion rate declined from 27 per 1,000 women aged 15–44 in 1990 to 21 per 1,000 in Some reasons that could account for this decrease is the shift in services from hospital based to specialized abortion clinic based practice, contraception education, decline in the number of providers due to antiabortion activist, difficulty in locating new facility, and affordability of services, laws that limit abortions past 15 weeks gestation only in licensed surgical centers, and access to expensive ultrasound machines at the site of the abortion clinics. (Jones et al 2008).

B ACKGROUND I NFORMATION The approval of mifepristone and misoprostol analogue regimen for medical abortion in September 2000, by the U.S. FDA involving a single 600-mg oral dose of mifepristone followed approximately 48 hours later by misoprostol, 400g orally, in women up to 49 days (7 weeks) of gestation results in complete abortion in 92% to 99% of women (Grimes & Creinin 2004, Haimov-Kochman et al 2007, Vyjayanthi & Piskorowskyj 2002). Prior to the approval of mifepristone also known as RU-486 for use for early medication abortion its usage rate accounted only for 6% of all abortions and most early abortions were provided by clinics that also offered surgical abortions. As knowledge about the effectiveness and comfort with mifepristone has increased there has been an introduction of mifepristone into settings where surgical abortions were previously not provided such as family planning clinics and the private practices of family doctors (Jones et al 2008). This trend might lead to a surge in demand for abortion in the future years.

P ROPORTION OF TERMINATION OF PREGNANCY PERFORMED SURGICALLY AND MEDICALLY BEFORE AND AFTER J UNE 1997 (Ojidu & Sangeeta 2001).

A NALYSIS Most of the research obtained for abortion statistics and research is based on questionnaires and retrospective studies after an elective abortion has been completed by the use of mifepristone/misoprostol. The effectiveness of medical abortion is determined by the passage of products of contraception with no adverse consequences. Ultrasound technology is widely used to confirm complete abortion. Surgical abortion is the use of dilators, curettage and suction to scrape and remove the products of conception from the uterus. In a limited number of cases medical abortions are converted to surgical abortions after they become unsuccessful, heavy bleeding or continuation of pregnancy. Research has acclaimed the safety and effectiveness of abortion in different women with a wide age disparity and no evidence of long term side effects.

A NALYSIS The use of transvaginal ultrasonography as an integral part of the management of pregnancy termination is of high importance. Its introduction allows the accurate preoperative assessment of the site, gestational age, viability of any pregnancy. It can be used after abortion to further confirm with passage of contraceptus with absence of the gestation sac. The presence of pelvic pathology or a congenital abnormality of the anatomy of the uterus may be detected, enabling management to be optimized from the outset (Jermy et al 1999, Ojidu & Sangeeta 2001, Haimov-Kochman 2007).

A BORTIONS BY G ESTATIONAL A GE (W EEKS S INCE L AST M ENSTRUAL P ERIOD ) Source: Henshaw adjustments to Strauss et al., 2007 (2004 data) Weeks % of abortions

A N A BORTION I S S AFER THE E ARLIER IN P REGNANCY I T I S P ERFORMED Sources: All births and abortions: Grimes DA, 2006; Abortion by gestation: Bartlett et al., 2004 (1988–1997 data) Deaths per 100,000 abortions Abortions by gestation

O UTCOME FOLLOWING MIFEPRISTONE / MISOPROSTOL THERAPY Gestation ≤ 8 weeks 9–13 weeks ≥14 weeks (n=236) (n=169) (n=76) Complete 205 (86·9%) 134 (79·2%) 67 (87%) Incomplete 30 (12·7%) 35 (20·7%) 9 (11·6%) Failed 1 (0·4%) 0 1 (1·3%) (Ojidu & Sangeeta 2001)

C AUSES OF A BORTION -R ELATED D EATHS Source: Bartlett et al., 2004 (1988–1997 data) % of abortion deaths (on average, 8 per year)

L ONG -T ERM S AFETY OF A BORTION First trimester abortions pose virtually no risk of: Infertility Ectopic pregnancy Miscarriage Birth defect Preterm or low-birth-weight delivery There is no association between abortion and breast cancer. Abortion does not pose a hazard to women’s mental health. Source: Grimes, 2004

C ONCLUSION Taking into consideration the research and review papers I used for my PICO question I would conclude that the mifepristone 600mg and misoprostol 200mg regime is effective in terminating pregnancies with very low incidences of complications. This regime is preferred to surgical evacuation because reduced cost, it eliminates complications with surgery such as infection, hemorrhage, embolism and complications from anesthesia. Medical abortion makes it easier for medical practitioners to provide abortion services to women especially poorer woman who cannot afford cost of a surgical procedure. With medical abortion women are in control of the process in the safety of their home and the process seems more natural like a miscarriage than in a surgical suit with medical staff around with instrumentation of the uterus. Compared to medical abortion which can be done are most effective and can be done at the earliest discovery of pregnancy, surgical abortions are most effective in the first trimester through 12 weeks and a pregnancy less than 6 weeks may increase the chance of failed abortion. The long term effects of first trimester abortions pose virtually no risk of infertility, ectopic pregnancy, miscarriage, birth defect, preterm or low-birth-weight at delivery. There is no association between abortion and breast cancer, or placental previa. Abortion does not pose a hazard to women’s mental health and nothing as post-abortion trauma syndrome exists (Grimes & Creinin 2004).

A PPLICATION There are a number of ways that knowledge from this project can be used and improved. The total number of abortions in a year can shade light and assess educational use of contraceptives, reproductive health services and family planning services. States can use data on abortion practices to make decision and better policy decision making. The practice of abortion can still be improved despite high success rates. Patients need better follow up after the procedure has been performed to further decrease any complications of infection and hemorrhage. Some work still has to be done to improve access to abortion clinics in rural non-metropolitan areas. About one third of women of reproductive age live in the 87% of U.S. counties without an abortion provider. Among the nation’s 276 metropolitan areas, 86 have no provider. About a quarter of women have to travel 50 miles or more to reach a clinic. This geographic barrier hinders both service provision and follow-up in case of complications (Grimes & Creinin 2004).