- Email: [email protected]
Counseling for medical abortion
Counseling for medical abortion Vicki Breitbart, EdD, MSW New York, New York Counseling and education are correlated with women’s satisfaction with all abortion care. They often assume a larger role in medical abortion because the patient is a more active participant in the abortion process. This article aims to enhance the practitioner’s expertise in providing the information and care necessary for women considering early abortion with medical regimens. It offers general counseling guidelines and several likely clinical scenarios regarding the decision-making process, the screening of patients, and the initial and follow-up visits. Through effective communication, practitioners can provide the information and support that patients need to complete the abortion process safely and can help to strengthen women’s confidence in managing their reproductive health experiences. (Am J Obstet Gynecol 2000;183:S26-S33.)
Key words: Abortion, counseling, medical abortion, methotrexate, mifepristone
Since the early 1990s >3 million women worldwide have had medical abortions1; however, not all women eligible for medical abortion choose this method. Medical abortion requires active patient participation, it takes longer to complete than does surgical abortion, and women are more aware of bleeding and cramping. On the other hand, medical abortion offers several advantages over suction curettage: success without surgery or anesthesia, similarity to a “natural miscarriage,” and a more private and proactive patient experience.2-5 Although sensitive counseling is part of both medical and surgical abortion care, counseling often assumes a larger role in the case of medical abortion because of the active involvement of patients. By offering general counseling guidelines and several likely clinical scenarios, this article aims to enhance the practitioner’s expertise in providing the information and care necessary for women considering early pregnancy termination and medical abortion. The article suggests strategies for effective communication with patients, but practitioners will want to tailor their language and communication style to each individual patient. The importance of counseling Early pregnancy counseling facilitates informed decision-making by allowing a woman to discuss her pregnancy options and any related emotional issues.6, 7 If a patient
From Planned Parenthood of New York City, Inc. The opinions expressed in this article do not necessarily reflect those of Planned Parenthood Federation of America, Inc. Reprint requests: National Abortion Federation, 1755 Massachusetts Ave NW, Suite 600, Washington, DC 20036. Copyright © 2000 by Mosby, Inc. 0002-9378/2000 $12.00 + 0 6/0/107947 doi:10.1067/mob.2000.107947
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chooses to have an abortion, further counseling about procedure options is critical. Most reproductive health centers in North America that offer abortions incorporate counseling into their services. A 1997 survey of National Abortion Federation (NAF) member clinics8 indicated that nearly all facilities offered women one-on-one counseling alone or in combination with group or video presentation. Fewer than 3% reported no routine counseling beyond the usual informed consent. Counseling and education are correlated with the overall satisfaction of patients undergoing abortion procedures. In a recent study of 2215 women who had abortions at 12 clinics in the United States, 94% expressed satisfaction with the information and counseling they received.9 The participants rated information and counseling as the most important factor influencing their satisfaction. Providers of medical abortion generally agree that appropriate screening, counseling, and support are essential for success of this method.7, 10 In contrast to surgical abortion, which is often accomplished in a single office visit, medical abortion requires the patient to engage in a longer process that may occur largely outside the office. Counseling enhances success by ensuring that patients have the necessary information and support to understand and complete all aspects of the medical abortion protocol. For the provider, effective counseling requires excellent communication skills and strategies to help patients cope with anxiety and stress. Whether the counseling is about pregnancy options, surgical abortion, or medical abortion, the same general principles apply: • Ask open-ended questions. Open-ended questions usually provide more precise information than those requiring only a yes or no response. For example asking,
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Table I. Comparison of medical and surgical abortion Medical abortion Some contraindications appropriate Available early in gestation Surgical aspiration needed in 2% to 10% at ≤7 wk Process occurs over a few days to a few weeks Avoids anesthesia and surgery Bleeding commonly perceived as heavy Possible drug side effects Patient has more control
•
•
• •
“How are you feeling about the medical abortion procedure?” encourages more meaningful dialogue than, “Are you feeling okay about this procedure?” Communication is enhanced by asking questions that invite the patient to express herself freely and by responding with sensitivity. Validate emotions rather than minimizing them. The care provider can reassure the patient that her feelings are normal and can invite her to explore them more fully or to ask for help. Encourage the patient’s questions. A woman’s questions often demonstrate her concerns and the extent to which she understands the information given by the care provider. Watch for nonverbal clues. Often a woman’s behavior expresses more than her words. Use “if-then” statements. Use of an “if-then” statement to convey important information helps a woman understand the reason behind a particular directive and thus makes a successful outcome more likely.4 For example the statement, “If you want to increase your chance of having a successful abortion, then it is important to take all the medications as directed,” offers the patient more information and control than, “Be sure to take your medications.” Challenges for the practitioner
Patient-centered health care requires open communication and trust.11 These attributes are particularly important when a clinician is helping a pregnant woman to explore her feelings, make informed choices, and gain a sense of control over her situation. Both the practitioner and patient need to feel comfortable addressing concerns that are emotionally as well as physically intimate.4 Medical abortion should be as positive an experience as possible for both the patient and clinician. Most likely neither will feel comfortable if the other has a negative experience. Practitioners can enhance their effectiveness and satisfaction with medical abortion by acknowledging and addressing aspects of the procedure that pose challenges for them.12, 13 Effective communication. Because of personal issues and societal pressures involved in ending a pregnancy,
Surgical abortion Rare contraindications given the setting and requisite skills May not be available during very early pregnancy Surgical reaspiration needed in approximately 1% at ≤7 wk Procedure most commonly over in 1 day Requires anesthesia and surgery; more “invasive” Bleeding commonly perceived as light Possible surgical complications, including uterine injury (rare) Care provider has more control
the decision to have an abortion may evoke intense emotions. Providing the level of counseling necessary for medical abortion may be a new experience for some clinicians. They may initially feel unprepared to offer the extensive education and support that are part of this process.13 Medical abortion practitioners need to provide a safe outlet for the patient’s self-expression without bias and without shying away from emotions that she displays. Occasionally, a patient may direct feelings of distress or anger at the clinician. Care providers can facilitate effective communication by not taking such expressions personally. Even if the patient is upset by the clinician, the clinician should view the situation from the patient’s perspective, avoid defensiveness, and work with the patient to help her maintain a sense of control and comfort.4 Time requirements. Helping a patient to explore her pregnancy options and possibly select an abortion method takes time, as does the sensitive management of medical and emotional issues that may arise during the abortion procedure. Providers of medical abortion recognize that time taken to convey information, answer questions, and assuage anxieties is time well spent. Patients who feel well informed and supported are more apt to have a positive experience.5 In addition, selecting the best method of abortion with the patient makes it more likely that she will follow through with the steps required for the procedure.4 Many facilities use different staff persons to counsel patients, administer the medications, and manage other aspects of patient care. This team approach considerably reduces the time that any individual care provider spends with the patient.12 Patient participation. In recent years, medicine has moved toward greater patient involvement in decisionmaking. Many women choose medical abortion precisely because it offers a greater sense of control.2, 3, 14 A wellinformed patient who actively participates in her care provides distinct clinical advantages. The patient who feels “in charge” of her own health is far more likely to choose behaviors that are in her best interest.4 Moreover, the patient who feels respected and empowered is more apt to communicate with the clinician and ask for needed
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support.15 A patient–provider partnership can result in both a more rewarding professional experience for the clinician and a better health outcome for the patient.4 The decision-making process Initial screening. Medical abortion providers may choose, at least initially, to screen and counsel patients primarily on a face-to-face basis. However, a brief telephone screening may be useful to identify women with obvious medical or social contraindications, such as the following: • Indecision about having an abortion • Pregnancy beyond the gestational age limits • Unwillingness to have a surgical abortion if the medical method fails • Lack of telephone or beeper access • Inability to return for follow-up visits • Difficulty in completing all the steps of the protocol • Inability to give consent Some facilities also offer a short telephone tape describing the method to help women determine their interest. Taking time to educate and screen patients by telephone serves to streamline counseling in the office during the patient’s first visit. Setting a tone. A productive partnership between patient and clinician begins with the first contact.4 Along with other attendant emotions, women seeking abortion frequently experience uncertainty about what to expect. The clinician can help put a patient at ease and communicate respect by a warm introduction: “Hello, I’m [name]. I am the [physician, nurse practitioner, physician assistant, counselor, etc] who will be talking with you about your options and what you can expect to happen.” Reviewing pregnancy options. After introductions the next step is to ensure that the woman knows about her pregnancy options and has all the facts necessary to make an informed decision. Pregnancy options counseling includes reviewing the alternatives of parenthood, adoption or temporary foster care, and abortion. Despite the narrow gestational window in which medical abortion takes place, options counseling should occur in an unhurried private session with a trained counselor or medical care provider who explains all the alternatives, answers questions, and helps the woman to arrive at her own informed decision.6, 15 Choosing an abortion method. Once a woman has considered her options and has decided to have an abortion, the discussion about the different methods begins. Offering a brief explanation of what she can expect helps: “I will provide you with information about the different abortion methods available to you and answer any questions you might have. In this way, we can decide what is right for you. After our discussion I will ask you to sign some forms that say you understand the method you are choosing. Only then will we start the procedure.”
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Most women seeking early abortion will be eligible for both medical and surgical methods. Explaining the general advantages and disadvantages of each approach early on helps women to choose between them (Table I). Medical abortion may be available sooner in pregnancy than surgical abortion, because some facilities do not offer suction curettage before 7 weeks’ gestation. Medical abortion does not require surgery or anesthesia and offers the patient more privacy, participation, and control. At the same time, medical methods take longer than does surgery. Depending on the medical abortion protocol, expulsion of the pregnancy may occur at home, and in about 2% to 10% of cases the woman will still require surgical evacuation to complete the abortion.10, 16-18 An early surgical abortion takes place most commonly in a single visit and involves less waiting and less doubt about when or whether the abortion has occurred. In addition, the woman will not see any products of conception or blood clots during the surgical procedure. Both methods carry very low rates of complications. Learning whether the patient has had previous experiences with abortion provides useful information when exploring her choice of method. If she has had a surgical abortion, how did she feel about it? Does she express a desire for more control this time, or would she rather let someone else “do” the abortion for her? Similarly, asking what she has heard about medical abortion may identify misconceptions or particular anxieties that deserve attention. Women who express further interest in medical abortion can then undergo final eligibility screening and receive information about the specific protocol. Medical eligibility screening typically includes a targeted history, physical examination, laboratory testing, and possibly ultrasonography to confirm gestational age. Providing reassurance and information about the screening process helps to relieve anxieties, especially if a patient is undergoing pelvic or ultrasonographic examination for the first time. Although medical eligibility screening is straightforward, addressing social and psychologic issues that affect the selection of method may be more challenging. Such issues might include the woman’s support system; fear of pain, bleeding, or side effects; or anxiety about confidentiality. Psychosocial considerations are often pivotal in helping the patient and care provider determine whether medical abortion is a workable and satisfactory choice. The exact nature of the conversation depends on the clinician’s style and assessment of the patient’s needs and concerns. The counseling process offers several opportunities to remind the patient that she can choose to have a surgical abortion at any point. The woman who is ineligible or opts out. Women who are ineligible for a nonsurgical method may feel disappointed or angry. They may also fear that their care will be jeopardized. After explaining the reasons for her inel-
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Table II. Patient education and counseling for medical abortion: Key points • • • • • • • • • • • • •
Discuss pregnancy options and ensure that the decision to have an abortion is informed, voluntary, and uncoerced. Compare risks and benefits of medical and surgical treatment alternatives. Explain the US Food and Drug Administration approval status of the drugs used for medical abortion. Review the known side effects of the drugs used for medical abortion. Discuss the potential teratogenicity of methotrexate and misoprostol and emphasize that once the drugs have been administered the abortion should be completed either medically or surgically. Discuss risks of continuing pregnancy, incomplete abortion (with possible infection), and hemorrhage necessitating surgical evacuation or other possible medical treatment. Clarify the time commitment and the possibility of multiple office visits. Discuss the amount of pain and bleeding associated with the abortion process, including possible heavy bleeding with clots and passage of products of conception. Instruct the patient on use of all medications, including self-insertion of vaginal misoprostol (if applicable) and use of pain medications. Advise the patient regarding substances to avoid (e.g., aspirin, alcohol, and folate-containing medications after methotrexate); caution against breast-feeding for a few days after methotrexate. Discuss issues of confidentiality and social and physical support. Offer contraceptive counseling. Review aftercare instructions, including emergency contact information.
igibility, reassure the patient that she will get the proper care4: “From what we have discussed regarding [state the specific reason], it seems that this procedure will not work well for you. This does not mean that anything is wrong with you or your health. It is still perfectly safe for you to have a surgical abortion, and you will receive the same care that any of our patients receive.” Similar concerns may arise when a woman considers opting out of the procedure. She may need to hear that she has not “failed” and will still receive high-quality care resulting in the desired outcome of a complete abortion: “Women have found that having a medical abortion can be difficult for many reasons. It is perfectly all right to decide you do not want to have an abortion this way, for any reason at all. Surgical abortion is effective and safe. If you choose at any time to have a surgical abortion, we will schedule the procedure as quickly as possible and you will receive the best possible care.” The medical abortion protocol Patients requesting medical abortion need basic information about the medications used, what symptoms and side effects to expect, and the requirements of the protocol (Table II). Medications Actions. Mifepristone is an oral antiprogestin that blocks progesterone receptors and causes decidual breakdown and disruption of the implantation site. It also increases local prostaglandin release, enhances uterine sensitivity to exogenous prostaglandins, and softens the cervix.1,17 Methotrexate, an antimetabolite, interferes with deoxyribonucleic acid synthesis and prevents the continuation of the process of implantation.19 Research supports its efficacy for early abortion when it is administered either orally or intramuscularly.1 Misoprostol is a prostaglandin analog that causes the uterus to contract when administered orally or vaginally.20 A simple explanation of these mechanisms might be as follows: “The first medication prevents
the pregnancy from continuing to implant. The second medication causes cramping to expel the pregnancy.” In addition to wondering how the medications work, patients may ask what these drugs will “do” to the “baby.” Sometimes the question conveys concern about how the embryo will “experience” the abortion. Providing facts may ease the patient’s apprehension: “You are [specific number] weeks’ pregnant, and the embryo is extremely small. The brain and the nervous system are very early in their development. At this stage it is impossible for the embryo to feel pain or to have any awareness of its surroundings.” This question may hold some other meaning for the woman as well. It may indicate feelings of guilt or ambivalence, even when the woman is certain that abortion is the right decision. Open-ended questions such as, “Can you tell me more about what is concerning you?” can help to clarify the emotional content of the patient’s inquiries and guide the clinician’s response. Efficacy and safety. Clinicians can reassure patients that these medications have long been used to induce abortion and to treat other medical conditions safely and effectively. Thousands of women worldwide have used mifepristone and misoprostol to terminate early pregnancies safely, with aggregate complete abortion rates of approximately 95%.16 In a large US clinical trial of mifepristone and misoprostol use among >2000 women, 92% of women at ≤7 weeks’ gestation had successful abortions with no serious adverse effects.17 Misoprostol is approved by the US Food and Drug Administration as an anti-ulcer agent, and the daily doses commonly prescribed for this condition cause no major sequelae.14 The US Food and Drug Administration approved methotrexate >40 years ago for the treatment of certain cancers, psoriasis, and rheumatoid arthritis; numerous studies also support its efficacy in treating unruptured ectopic pregnancy.21, 22 Since 1993 >5000 North American women have participated in studies of abortion with methotrexate and misoprostol, with reported success
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rates ranging from 88% to 100%.16 Although the multiple-dose methotrexate regimens used in cancer chemotherapy may cause serious systemic toxic effects, the single dose used for ectopic pregnancy treatment or early abortion rarely does so.10, 14, 23 Because of methotrexate’s association with cancer chemotherapy, some patients may fear that it causes cancer. Women also commonly ask whether methotrexate affects future pregnancies. Reassuring patients with facts helps to relieve anxieties24-27: “This medication has been used for >40 years, usually in higher doses and for longer periods of time. No research suggests that it causes cancer. Long-term studies show that women who have taken large doses for many weeks at a time did not have a harder time becoming pregnant and did not have increased rates of birth defects in subsequent pregnancies.” Teratogenicity. Women need to know that some of the drugs used for medical abortion can cause serious birth defects in infants should the pregnancy continue. Methotrexate is a known teratogen when used at high doses; available data are inadequate to establish the risk of anomalies at low doses. First-trimester exposure to misoprostol has been associated with skull and limb defects as well as Möbius syndrome in infants.28, 29 Although mifepristone is not teratogenic, it is typically combined with misoprostol in medical abortion regimens. Therefore clinicians must stress the need to confirm complete abortion and strongly advise women receiving these medications to undergo a surgical abortion procedure should the medical method fail. Symptoms and side effects. Side effects from the drugs used for medical abortion are generally minor and selflimiting. Some of these symptoms may be related to pregnancy. Misoprostol causes mild gastrointestinal side effects in 40% of women undergoing medical abortion, or more depending on the dose and route of administration. Nausea is typically the most common symptom, followed much less frequently by vomiting or diarrhea.10, 17, 18, 30 Warmth or chills may also occur after misoprostol administration. Similar side effects have been reported to occur in the interval between mifepristone and misoprostol administration.18, 31 Low-dose methotrexate rarely causes serious toxicity. Mild stomatitis was reported in a few women who received methotrexate for early abortion.10, 14 Other reported symptoms after methotrexate administration include headache, dizziness, hot flushes, and gastrointestinal symptoms.10 Bleeding and cramping are natural and expected symptoms that occur in most women undergoing medical abortions. The heaviest bleeding typically coincides with expulsion of the pregnancy; a lighter flow lasts 1 to 2 weeks on average but may be longer.10, 17, 18 It is important to prepare women adequately for the expected amount of bleeding: “The amount of bleeding varies from person to person. Most likely it will be much heavier
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than a period, and you will need a supply of sanitary pads. You may see large clots of blood; this is normal. It is also normal for light bleeding to continue for a few weeks after the abortion is completed.” In a study examining the acceptability of medical abortion, women stated that they expected more bleeding with medical abortion than with surgical abortion.5 Care providers can reassure patients that research shows comparable blood loss with the two methods, although they may perceive more bleeding with medical abortion.30 The severity of cramping varies among patients but is well controlled with oral analgesics in nearly all cases.10, 18 Counseling focuses on the woman’s anticipation of the pain and her ability to manage it. It helps to point out that the cramping is normal and usually signifies that everything is proceeding properly: “It is likely that there will be some strong cramping from the misoprostol. This medication causes cramping as the pregnancy tissue is being expelled from the uterus. The cramps mean that the medicine is working the way it should.” Being honest about the level of pain is also important: “Some women do not need pain medication for the cramps. Others have the same kind of cramps that they get with their periods, only stronger. It varies for each individual. Very few require more pain medication than we will provide for you. Do not hesitate to take the pain medication if you need it. It will make you more comfortable, and it does not interfere with the abortion. You may also find a heating pad helpful for the cramps.” If a woman plans to insert the misoprostol at home, practical advice includes telling her to have a supply of sanitary pads available and to fill the prescription for pain medication beforehand. Protocol requirements Commitment to completing the process. A medical abortion requires at least two visits: an initial visit that includes receipt of the medications and a follow-up to determine whether the abortion is complete. Some protocols stipulate that after receiving mifepristone women should return to the office for administration of the misoprostol and remain under observation for approximately 4 hours. Other protocols give women the option of self-administering the misoprostol at home. Delayed passage of the gestational sac or state laws mandating a waiting period between consent and the abortion procedure may necessitate additional visits. Because success depends on compliance with the drug regimen and because of the teratogenic risks to ongoing pregnancies, clinicians must inform patients of the importance of completing the process: “The first medication that you receive will most likely not complete the abortion. Most women need to take the second medication. These medications are designed to work together to end the pregnancy safely. They can cause severe birth defects if the pregnancy continues. It is important that you complete all the steps in the process.”
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The woman needs to know that bleeding does not necessarily signify that the abortion has occurred. A return visit, which may include a sonogram, is therefore essential: “The only way to be certain that the abortion is complete is to come back for a return visit. We will schedule this appointment for you before you leave today.” Willingness to undergo a surgical abortion procedure. All women must be informed of the need for surgical aspiration should the medical method fail: “Most likely these medications will be successful in bringing on an abortion. In the event that the medications do not work for you, however, the embryo can be severely damaged and you will need to have a surgical abortion. What do you expect it might be like if the medications do not work completely?” Many women choose medical abortion precisely because they want to avoid surgery. For these women the possible need for surgical intervention requires extra explanation and sensitivity on the part of the practitioner.4 Adhering to the protocol. Counseling also includes identifying any social, psychological, or logistical barriers to compliance with the protocol that the woman may have. For example, the waiting period between the first and second medications poses difficulties for some women: “You will receive the first medication today and go home. You will need to wait before you take the second medication. For the medications to be effective, it is important to wait the required time before you take the second medication. Some women find that the waiting makes them feel impatient, lonely, or worried. What do you think the waiting will be like for you?” If the protocol requires insertion of the misoprostol vaginally, another possible barrier to compliance is the patient’s level of comfort with inserting the medication. Although research shows that home use of vaginal misoprostol is safe and highly acceptable to women,18, 31 patients occasionally find this prospect unsettling. Practitioners should assess the woman’s reaction to the request before sending her home with the misoprostol: “You can do part of the procedure yourself by inserting tablets into your vagina at home. How do you feel about putting the tablets in your vagina? Have you ever used any product that you had to insert yourself, such as tampons, a diaphragm, or birth control sponges or suppositories? If you are uncomfortable with the idea, you can return here to have the tablets inserted.” With medical abortion, the patient may expel the products of conception at home. Some women prefer to have greater control of the process, whereas others feel anxious about it. To identify any concerns the clinician might make the following remark: “Women who have used both surgical and medical methods say that having an abortion this way feels more private, and they feel more in control of the situation. Other women find it hard to be aware of what is going on within their bodies, and some find it difficult and lonely to have the abor-
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tion at home. What do you imagine the experience would be like for you?” A patient curious about what the products of conception will look like may benefit from seeing a sonogram or a photograph of a typical early embryo. After answering her questions with straightforward descriptions, the clinician can explore the patient’s feelings on the subject: “At this stage the embryo is very small and hardly has any real shape. It may be passed in a blood clot. If you do not see it, there is no need to worry, because it is very easy to miss. I can show you a picture if you like. Would that be helpful? How do you think that you will react if you see it?” The discussion also includes assessing the woman’s need for support during the process. The clinician might ask, “Where will you be that day?” or “Who will be there with you?” If a woman expresses concerns about others knowing that she is having an abortion, probe gently to determine the nature of the anxiety: “Most likely no one will know you are having an abortion, although someone might be aware of your bleeding. Can you tell me a little more about what is on your mind? Is there a particular person or situation that you are thinking about? What will it be like if this person learns you are pregnant and having an abortion?” Medical abortion may offer for some women the flexibility to use the misoprostol at a time that does not interfere with work or other activities. However, some women may have to make arrangements for time away from work, children, and other responsibilities for a limited period: “If you have a medical abortion, you may need several hours away from other responsibilities. What will this mean in terms of your job? Who will be available to look after your children?” In addition, patients undergoing medical abortion may need to avoid certain substances, such as alcohol and aspirin. Methotrexate protocols sometimes advise women to discontinue vitamins containing folic acid and to refrain from breast-feeding for a few days.1 Although providers often discourage women from sexual intercourse until the abortion is complete, no evidence supports this admonition.32 Clinicians who make this recommendation need to assess the patient’s concerns about abstaining: “I suggest that you stop having intercourse until we can be sure that you are no longer pregnant. Sometimes this takes as long as 4 weeks. How will you and your partner deal with this?” Emergency preparedness. Women considering medical abortion need to have access to a telephone and transportation to an appropriate medical facility in the rare event of an emergency. Formulation of a concrete plan during the initial visit enhances safety and can reduce the patient’s anxiety and give her a greater sense of control. Whatever the woman’s strategies for managing side effects and symptoms, she should receive clear instructions about when to call the office. Common parameters in-
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clude severe pain unresponsive to oral analgesics, documented fever lasting ≥6 hours, or soaking ≥2 sanitary maxipads/hr for 2 consecutive hours. Unless the patient is obviously hemorrhaging or symptomatic, it is acceptable to monitor her periodically by telephone to see whether the bleeding abates.1 Although hemorrhage requiring transfusion occurs in only about 1 in 1000 cases,16 patients must have access to a medical facility equipped to provide blood products and emergency surgical evacuation if necessary. Follow-up counseling By the end of the first visit, the patient should feel comfortable and confident about handling what comes next. Provision of written instructions helps to reinforce the key points covered in counseling and facilitates compliance. These instructions include information on the following: • How and when to self-administer the misoprostol at home, or when to return to the office for administration, depending on the protocol • What activities and medications to avoid • How to manage symptoms and side effects • When to call the care provider • How to deal with emergencies, including a 24-hour emergency contact number • When to return for follow-up care Follow-up visits. When the patient returns to the office, it is supportive and comforting for her to see the same practitioner whenever possible. During follow-up the clinician should continue to ask and answer questions, provide information, listen, and observe just as attentively as at the first visit. If the woman returns to the office for administration of the misoprostol followed by observation, issues about bleeding and pain may re-emerge. The patient also may have expulsion of the embryo during this time and may need some assistance with her reactions to the event. Women who do not abort during the observation period or who self-administer the misoprostol at home must return to the office to determine whether the method has worked. If the abortion is found to be incomplete on follow-up, treatment alternatives include prompt suction curettage, administration of additional misoprostol, or simply waiting for an additional period. Patients who require surgical intervention because of ongoing pregnancy may need help handling any disappointment or fear that accompanies this change of plans. The patient with a retained but nonviable gestation may need assistance in deciding whether to wait for the pregnancy to pass or to undergo a surgical abortion procedure. If the patient decides to wait, it is important to address her feelings about prolonging the process. Letting the woman know that she will no longer have any pregnancy symptoms may ease her anxieties about the
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delay. By providing information and exploring the patient’s concerns, the clinician can create the dialogue necessary for a discouraged or highly stressed patient to regain a sense of control. Once the abortion is complete, counseling focuses on the woman’s experiences with the procedure. What were her emotional and physical responses during the process? How did she manage pain and bleeding, side effects, and any feelings that arose? Extensive research reveals that most women feel relieved after surgical abortion, although some have feelings of sadness or guilt for a short time.7 To date, few data are available on psychological responses to medical abortion. One prospective study, however, showed no differences in post-abortal depression, anxiety, or self-esteem among women randomly assigned to receive mifepristone and prostaglandin or to undergo suction curettage.33 Review of the medical abortion experience allows women to gain a feeling of self-confidence about how they handled this challenging event in their lives. This visit also includes reviewing the patient’s contraceptive options. Moreover, it provides an opportunity to offer other important health services, such as human immunodeficiency virus counseling and testing. Comment Women seeking early abortion can now choose among safe and effective medical and surgical options. Research reveals that both medical and surgical methods are acceptable to women who choose them.34 Medical abortion is less invasive than surgery and offers women more privacy and control. To date, women have found the process very satisfactory and would recommend it to a friend.2, 3, 5, 18 Medical methods are technically simpler but logistically more complex than surgical abortion. Adequate counseling and support enhance success and patient satisfaction with medical methods. Through effective communication, practitioners can provide the information and support that patients need to complete the process safely and can help to strengthen women’s confidence in managing their reproductive health experiences.7 REFERENCES
1. Creinin MD, Aubeny E. Medical abortion in early pregnancy. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors. A clinician’s guide to medical and surgical abortion. New York: Churchill Livingstone; 1999. p. 91-106. 2. Winikoff B. Acceptability of medical abortion in early pregnancy. Fam Plann Perspect 1995;27:142-8, 185. 3. Creinin MD, Park M. Acceptability of medical abortion with methotrexate and misoprostol. Contraception 1995;52:41-4. 4. Planned Parenthood of New York City. Counseling guide for clinicians offering medical abortion. New York: Planned Parenthood of New York City; 1996. 5. Harvey SM, Beckman LJ, Satre SJ. Acceptability of methotrexateinduced abortion among women in the US. A report of the Pacific Institute for Women’s Health. Los Angeles: Pacific Institute for Women’s Health; 1999.
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6. Beresford T. Short-term relationship counseling. 2nd ed. Baltimore: Planned Parenthood of Maryland; 1988. 7. Baker A, Beresford T, Halvorson-Boyd G, Garrity JM. Informed consent, counseling, and patient preparation. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors. A clinician’s guide to medical and surgical abortion. New York: Churchill Livingstone; 1999. p. 25-37. 8. Lichtenberg ES, Paul M, Jones H. 1997 NAF provider clinical survey: first trimester surgical abortion practice. Washington, DC: National Abortion Federation; 1997. 9. Picker Institute. From the patient’s perspective: quality of abortion care. Menlo Park (CA): Henry J. Kaiser Family Foundation; 1999. 10. Creinin MD, Vittinghoff E, Keder L, Darney PD, Tiller G. Methotrexate and misoprostol for early abortion: a multicenter trial. I. Safety and efficacy. Contraception 1996;53:321-7. 11. Garrity J, Castle M. A physician’s guide to patient-centered counseling: providing support to women during first-trimester abortion procedures. New York: Planned Parenthood of New York City; 1996. 12. Harvey SM, Beckman LJ, Satre SJ. Listening to and learning from health care providers about methotrexate-induced abortions: a report of the Pacific Institute for Women’s Health. Los Angeles: Pacific Institute for Women’s Health; 1998. 13. Joffe C. Reactions to medical abortion among providers of surgical abortion: an early snapshot. Fam Plann Perspect 1999;31:35-8. 14. Hausknecht RU. Methotrexate and misoprostol to terminate early pregnancy. N Engl J Med 1995;333:537-40. 15. Baker A. Abortion and options counseling: a comprehensive reference. Granite City (IL): The Hope Clinic for Women; 1995. 16. Grimes DA. Medical abortion in early pregnancy: a review of the evidence. Obstet Gynecol 1997;89:790-6. 17. Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med 1998;338:1241-7. 18. Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low-dose mifepristone 200 mg and vaginal misoprostol for abortion. Contraception 1999;59:1-6. 19. Creinin MD, Stewart-Akers AM, DeLoia JA. Methotrexate effects on trophoblast and the corpus luteum in early pregnancy. Am J Obstet Gynecol 1998;179:604-9. 20. Danielsson KG, Marions L, Rodriguez A, Spur BW, Wong PYK, Bygdeman M. Comparison between oral and vaginal administration of misoprostol on uterine contractility. Obstet Gynecol 1999;93:275-80.
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21. Theon LD, Creinin MD. Medical treatment of ectopic pregnancy with methotrexate. Fertil Steril 1997;68:727-30. 22. Lipscomb GH, Bran D, McCord ML, Portera JC, Ling FW. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol 1998;178:1354-8. 23. Schaff EA, Eisinger SH, Franks P, Kim SS. Combined methotrexate and misoprostol for early induced abortion. Arch Fam Med 1995;4:774-9. 24. Schein PS, Winokur SH. Immunosuppressive and cytotoxic chemotherapy: long term complications. Ann Intern Med 1975;82:84-95. 25. Pastorfide GB, Goldstein DP. Pregnancy after hydatiform mole. Obstet Gynecol 1973;42:67-70. 26. Walden PA, Bagshawe KD. Reproductive performance of women successfully treated for gestational trophoblastic tumors. Am J Obstet Gynecol 1976;125:1108-14. 27. Ramsey-Goldman R, Mientus JM, Kutzer JE, Mulvihill JJ, Medsger TA Jr. Pregnancy outcome in women with systemic lupus erythematosus treated with immunosuppressive drugs. J Rheumatol 1993;20:1152-7. 28. Gonzalez CH, Vargas FR, Perez ABA, Kim CA, Brunoni D, Marques-Dias MJ, et al. Limb deficiency with or without Möbius sequence in seven Brazilian children associated with misoprostol use in the first trimester of pregnancy. Am J Med Genet 1993;47:59-64. 29. Pastuszak AL, Schüler L, Speck-Martins CE, Coelho KFA, Cordello SM, Vargas F, et al. Use of misoprostol during pregnancy and Möbius’ syndrome in infants. N Engl J Med 1998;338:1881-5. 30. Elul B, Ellertson C, Winikoff B, Coyaji K. Side effects of mifepristone-misoprostol abortion versus surgical abortion. Contraception 1999;59:107-14. 31. Schaff EA, Stadalius LS, Eisinger SH, Franks P. Vaginal misoprostol administered at home after mifepristone (RU486) for abortion. J Fam Pract 1997;44:353-60. 32. McIntosh KM, Stewart GK, Teplin D. Routine aftercare and contraception. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors. A clinician’s guide to medical and surgical abortion. New York: Churchill Livingstone; 1999. p. 185-96. 33. Henshaw R, Naji S, Russell I, Templeton A. Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration: a patient-centered, partially randomised prospective study. Acta Obstet Gynecol Scand 1994;73:812-8. 34. Henshaw RC, Naji SA, Russell IT, Templeton AA. Comparison of medical abortion with surgical vacuum aspiration: women’s preferences and acceptability of treatment. BMJ 1993;307:714-7.
Key words: Abortion, counseling, medical abortion, methotrexate, mifepristone
Since the early 1990s >3 million women worldwide have had medical abortions1; however, not all women eligible for medical abortion choose this method. Medical abortion requires active patient participation, it takes longer to complete than does surgical abortion, and women are more aware of bleeding and cramping. On the other hand, medical abortion offers several advantages over suction curettage: success without surgery or anesthesia, similarity to a “natural miscarriage,” and a more private and proactive patient experience.2-5 Although sensitive counseling is part of both medical and surgical abortion care, counseling often assumes a larger role in the case of medical abortion because of the active involvement of patients. By offering general counseling guidelines and several likely clinical scenarios, this article aims to enhance the practitioner’s expertise in providing the information and care necessary for women considering early pregnancy termination and medical abortion. The article suggests strategies for effective communication with patients, but practitioners will want to tailor their language and communication style to each individual patient. The importance of counseling Early pregnancy counseling facilitates informed decision-making by allowing a woman to discuss her pregnancy options and any related emotional issues.6, 7 If a patient
From Planned Parenthood of New York City, Inc. The opinions expressed in this article do not necessarily reflect those of Planned Parenthood Federation of America, Inc. Reprint requests: National Abortion Federation, 1755 Massachusetts Ave NW, Suite 600, Washington, DC 20036. Copyright © 2000 by Mosby, Inc. 0002-9378/2000 $12.00 + 0 6/0/107947 doi:10.1067/mob.2000.107947
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chooses to have an abortion, further counseling about procedure options is critical. Most reproductive health centers in North America that offer abortions incorporate counseling into their services. A 1997 survey of National Abortion Federation (NAF) member clinics8 indicated that nearly all facilities offered women one-on-one counseling alone or in combination with group or video presentation. Fewer than 3% reported no routine counseling beyond the usual informed consent. Counseling and education are correlated with the overall satisfaction of patients undergoing abortion procedures. In a recent study of 2215 women who had abortions at 12 clinics in the United States, 94% expressed satisfaction with the information and counseling they received.9 The participants rated information and counseling as the most important factor influencing their satisfaction. Providers of medical abortion generally agree that appropriate screening, counseling, and support are essential for success of this method.7, 10 In contrast to surgical abortion, which is often accomplished in a single office visit, medical abortion requires the patient to engage in a longer process that may occur largely outside the office. Counseling enhances success by ensuring that patients have the necessary information and support to understand and complete all aspects of the medical abortion protocol. For the provider, effective counseling requires excellent communication skills and strategies to help patients cope with anxiety and stress. Whether the counseling is about pregnancy options, surgical abortion, or medical abortion, the same general principles apply: • Ask open-ended questions. Open-ended questions usually provide more precise information than those requiring only a yes or no response. For example asking,
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Table I. Comparison of medical and surgical abortion Medical abortion Some contraindications appropriate Available early in gestation Surgical aspiration needed in 2% to 10% at ≤7 wk Process occurs over a few days to a few weeks Avoids anesthesia and surgery Bleeding commonly perceived as heavy Possible drug side effects Patient has more control
•
•
• •
“How are you feeling about the medical abortion procedure?” encourages more meaningful dialogue than, “Are you feeling okay about this procedure?” Communication is enhanced by asking questions that invite the patient to express herself freely and by responding with sensitivity. Validate emotions rather than minimizing them. The care provider can reassure the patient that her feelings are normal and can invite her to explore them more fully or to ask for help. Encourage the patient’s questions. A woman’s questions often demonstrate her concerns and the extent to which she understands the information given by the care provider. Watch for nonverbal clues. Often a woman’s behavior expresses more than her words. Use “if-then” statements. Use of an “if-then” statement to convey important information helps a woman understand the reason behind a particular directive and thus makes a successful outcome more likely.4 For example the statement, “If you want to increase your chance of having a successful abortion, then it is important to take all the medications as directed,” offers the patient more information and control than, “Be sure to take your medications.” Challenges for the practitioner
Patient-centered health care requires open communication and trust.11 These attributes are particularly important when a clinician is helping a pregnant woman to explore her feelings, make informed choices, and gain a sense of control over her situation. Both the practitioner and patient need to feel comfortable addressing concerns that are emotionally as well as physically intimate.4 Medical abortion should be as positive an experience as possible for both the patient and clinician. Most likely neither will feel comfortable if the other has a negative experience. Practitioners can enhance their effectiveness and satisfaction with medical abortion by acknowledging and addressing aspects of the procedure that pose challenges for them.12, 13 Effective communication. Because of personal issues and societal pressures involved in ending a pregnancy,
Surgical abortion Rare contraindications given the setting and requisite skills May not be available during very early pregnancy Surgical reaspiration needed in approximately 1% at ≤7 wk Procedure most commonly over in 1 day Requires anesthesia and surgery; more “invasive” Bleeding commonly perceived as light Possible surgical complications, including uterine injury (rare) Care provider has more control
the decision to have an abortion may evoke intense emotions. Providing the level of counseling necessary for medical abortion may be a new experience for some clinicians. They may initially feel unprepared to offer the extensive education and support that are part of this process.13 Medical abortion practitioners need to provide a safe outlet for the patient’s self-expression without bias and without shying away from emotions that she displays. Occasionally, a patient may direct feelings of distress or anger at the clinician. Care providers can facilitate effective communication by not taking such expressions personally. Even if the patient is upset by the clinician, the clinician should view the situation from the patient’s perspective, avoid defensiveness, and work with the patient to help her maintain a sense of control and comfort.4 Time requirements. Helping a patient to explore her pregnancy options and possibly select an abortion method takes time, as does the sensitive management of medical and emotional issues that may arise during the abortion procedure. Providers of medical abortion recognize that time taken to convey information, answer questions, and assuage anxieties is time well spent. Patients who feel well informed and supported are more apt to have a positive experience.5 In addition, selecting the best method of abortion with the patient makes it more likely that she will follow through with the steps required for the procedure.4 Many facilities use different staff persons to counsel patients, administer the medications, and manage other aspects of patient care. This team approach considerably reduces the time that any individual care provider spends with the patient.12 Patient participation. In recent years, medicine has moved toward greater patient involvement in decisionmaking. Many women choose medical abortion precisely because it offers a greater sense of control.2, 3, 14 A wellinformed patient who actively participates in her care provides distinct clinical advantages. The patient who feels “in charge” of her own health is far more likely to choose behaviors that are in her best interest.4 Moreover, the patient who feels respected and empowered is more apt to communicate with the clinician and ask for needed
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support.15 A patient–provider partnership can result in both a more rewarding professional experience for the clinician and a better health outcome for the patient.4 The decision-making process Initial screening. Medical abortion providers may choose, at least initially, to screen and counsel patients primarily on a face-to-face basis. However, a brief telephone screening may be useful to identify women with obvious medical or social contraindications, such as the following: • Indecision about having an abortion • Pregnancy beyond the gestational age limits • Unwillingness to have a surgical abortion if the medical method fails • Lack of telephone or beeper access • Inability to return for follow-up visits • Difficulty in completing all the steps of the protocol • Inability to give consent Some facilities also offer a short telephone tape describing the method to help women determine their interest. Taking time to educate and screen patients by telephone serves to streamline counseling in the office during the patient’s first visit. Setting a tone. A productive partnership between patient and clinician begins with the first contact.4 Along with other attendant emotions, women seeking abortion frequently experience uncertainty about what to expect. The clinician can help put a patient at ease and communicate respect by a warm introduction: “Hello, I’m [name]. I am the [physician, nurse practitioner, physician assistant, counselor, etc] who will be talking with you about your options and what you can expect to happen.” Reviewing pregnancy options. After introductions the next step is to ensure that the woman knows about her pregnancy options and has all the facts necessary to make an informed decision. Pregnancy options counseling includes reviewing the alternatives of parenthood, adoption or temporary foster care, and abortion. Despite the narrow gestational window in which medical abortion takes place, options counseling should occur in an unhurried private session with a trained counselor or medical care provider who explains all the alternatives, answers questions, and helps the woman to arrive at her own informed decision.6, 15 Choosing an abortion method. Once a woman has considered her options and has decided to have an abortion, the discussion about the different methods begins. Offering a brief explanation of what she can expect helps: “I will provide you with information about the different abortion methods available to you and answer any questions you might have. In this way, we can decide what is right for you. After our discussion I will ask you to sign some forms that say you understand the method you are choosing. Only then will we start the procedure.”
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Most women seeking early abortion will be eligible for both medical and surgical methods. Explaining the general advantages and disadvantages of each approach early on helps women to choose between them (Table I). Medical abortion may be available sooner in pregnancy than surgical abortion, because some facilities do not offer suction curettage before 7 weeks’ gestation. Medical abortion does not require surgery or anesthesia and offers the patient more privacy, participation, and control. At the same time, medical methods take longer than does surgery. Depending on the medical abortion protocol, expulsion of the pregnancy may occur at home, and in about 2% to 10% of cases the woman will still require surgical evacuation to complete the abortion.10, 16-18 An early surgical abortion takes place most commonly in a single visit and involves less waiting and less doubt about when or whether the abortion has occurred. In addition, the woman will not see any products of conception or blood clots during the surgical procedure. Both methods carry very low rates of complications. Learning whether the patient has had previous experiences with abortion provides useful information when exploring her choice of method. If she has had a surgical abortion, how did she feel about it? Does she express a desire for more control this time, or would she rather let someone else “do” the abortion for her? Similarly, asking what she has heard about medical abortion may identify misconceptions or particular anxieties that deserve attention. Women who express further interest in medical abortion can then undergo final eligibility screening and receive information about the specific protocol. Medical eligibility screening typically includes a targeted history, physical examination, laboratory testing, and possibly ultrasonography to confirm gestational age. Providing reassurance and information about the screening process helps to relieve anxieties, especially if a patient is undergoing pelvic or ultrasonographic examination for the first time. Although medical eligibility screening is straightforward, addressing social and psychologic issues that affect the selection of method may be more challenging. Such issues might include the woman’s support system; fear of pain, bleeding, or side effects; or anxiety about confidentiality. Psychosocial considerations are often pivotal in helping the patient and care provider determine whether medical abortion is a workable and satisfactory choice. The exact nature of the conversation depends on the clinician’s style and assessment of the patient’s needs and concerns. The counseling process offers several opportunities to remind the patient that she can choose to have a surgical abortion at any point. The woman who is ineligible or opts out. Women who are ineligible for a nonsurgical method may feel disappointed or angry. They may also fear that their care will be jeopardized. After explaining the reasons for her inel-
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Table II. Patient education and counseling for medical abortion: Key points • • • • • • • • • • • • •
Discuss pregnancy options and ensure that the decision to have an abortion is informed, voluntary, and uncoerced. Compare risks and benefits of medical and surgical treatment alternatives. Explain the US Food and Drug Administration approval status of the drugs used for medical abortion. Review the known side effects of the drugs used for medical abortion. Discuss the potential teratogenicity of methotrexate and misoprostol and emphasize that once the drugs have been administered the abortion should be completed either medically or surgically. Discuss risks of continuing pregnancy, incomplete abortion (with possible infection), and hemorrhage necessitating surgical evacuation or other possible medical treatment. Clarify the time commitment and the possibility of multiple office visits. Discuss the amount of pain and bleeding associated with the abortion process, including possible heavy bleeding with clots and passage of products of conception. Instruct the patient on use of all medications, including self-insertion of vaginal misoprostol (if applicable) and use of pain medications. Advise the patient regarding substances to avoid (e.g., aspirin, alcohol, and folate-containing medications after methotrexate); caution against breast-feeding for a few days after methotrexate. Discuss issues of confidentiality and social and physical support. Offer contraceptive counseling. Review aftercare instructions, including emergency contact information.
igibility, reassure the patient that she will get the proper care4: “From what we have discussed regarding [state the specific reason], it seems that this procedure will not work well for you. This does not mean that anything is wrong with you or your health. It is still perfectly safe for you to have a surgical abortion, and you will receive the same care that any of our patients receive.” Similar concerns may arise when a woman considers opting out of the procedure. She may need to hear that she has not “failed” and will still receive high-quality care resulting in the desired outcome of a complete abortion: “Women have found that having a medical abortion can be difficult for many reasons. It is perfectly all right to decide you do not want to have an abortion this way, for any reason at all. Surgical abortion is effective and safe. If you choose at any time to have a surgical abortion, we will schedule the procedure as quickly as possible and you will receive the best possible care.” The medical abortion protocol Patients requesting medical abortion need basic information about the medications used, what symptoms and side effects to expect, and the requirements of the protocol (Table II). Medications Actions. Mifepristone is an oral antiprogestin that blocks progesterone receptors and causes decidual breakdown and disruption of the implantation site. It also increases local prostaglandin release, enhances uterine sensitivity to exogenous prostaglandins, and softens the cervix.1,17 Methotrexate, an antimetabolite, interferes with deoxyribonucleic acid synthesis and prevents the continuation of the process of implantation.19 Research supports its efficacy for early abortion when it is administered either orally or intramuscularly.1 Misoprostol is a prostaglandin analog that causes the uterus to contract when administered orally or vaginally.20 A simple explanation of these mechanisms might be as follows: “The first medication prevents
the pregnancy from continuing to implant. The second medication causes cramping to expel the pregnancy.” In addition to wondering how the medications work, patients may ask what these drugs will “do” to the “baby.” Sometimes the question conveys concern about how the embryo will “experience” the abortion. Providing facts may ease the patient’s apprehension: “You are [specific number] weeks’ pregnant, and the embryo is extremely small. The brain and the nervous system are very early in their development. At this stage it is impossible for the embryo to feel pain or to have any awareness of its surroundings.” This question may hold some other meaning for the woman as well. It may indicate feelings of guilt or ambivalence, even when the woman is certain that abortion is the right decision. Open-ended questions such as, “Can you tell me more about what is concerning you?” can help to clarify the emotional content of the patient’s inquiries and guide the clinician’s response. Efficacy and safety. Clinicians can reassure patients that these medications have long been used to induce abortion and to treat other medical conditions safely and effectively. Thousands of women worldwide have used mifepristone and misoprostol to terminate early pregnancies safely, with aggregate complete abortion rates of approximately 95%.16 In a large US clinical trial of mifepristone and misoprostol use among >2000 women, 92% of women at ≤7 weeks’ gestation had successful abortions with no serious adverse effects.17 Misoprostol is approved by the US Food and Drug Administration as an anti-ulcer agent, and the daily doses commonly prescribed for this condition cause no major sequelae.14 The US Food and Drug Administration approved methotrexate >40 years ago for the treatment of certain cancers, psoriasis, and rheumatoid arthritis; numerous studies also support its efficacy in treating unruptured ectopic pregnancy.21, 22 Since 1993 >5000 North American women have participated in studies of abortion with methotrexate and misoprostol, with reported success
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rates ranging from 88% to 100%.16 Although the multiple-dose methotrexate regimens used in cancer chemotherapy may cause serious systemic toxic effects, the single dose used for ectopic pregnancy treatment or early abortion rarely does so.10, 14, 23 Because of methotrexate’s association with cancer chemotherapy, some patients may fear that it causes cancer. Women also commonly ask whether methotrexate affects future pregnancies. Reassuring patients with facts helps to relieve anxieties24-27: “This medication has been used for >40 years, usually in higher doses and for longer periods of time. No research suggests that it causes cancer. Long-term studies show that women who have taken large doses for many weeks at a time did not have a harder time becoming pregnant and did not have increased rates of birth defects in subsequent pregnancies.” Teratogenicity. Women need to know that some of the drugs used for medical abortion can cause serious birth defects in infants should the pregnancy continue. Methotrexate is a known teratogen when used at high doses; available data are inadequate to establish the risk of anomalies at low doses. First-trimester exposure to misoprostol has been associated with skull and limb defects as well as Möbius syndrome in infants.28, 29 Although mifepristone is not teratogenic, it is typically combined with misoprostol in medical abortion regimens. Therefore clinicians must stress the need to confirm complete abortion and strongly advise women receiving these medications to undergo a surgical abortion procedure should the medical method fail. Symptoms and side effects. Side effects from the drugs used for medical abortion are generally minor and selflimiting. Some of these symptoms may be related to pregnancy. Misoprostol causes mild gastrointestinal side effects in 40% of women undergoing medical abortion, or more depending on the dose and route of administration. Nausea is typically the most common symptom, followed much less frequently by vomiting or diarrhea.10, 17, 18, 30 Warmth or chills may also occur after misoprostol administration. Similar side effects have been reported to occur in the interval between mifepristone and misoprostol administration.18, 31 Low-dose methotrexate rarely causes serious toxicity. Mild stomatitis was reported in a few women who received methotrexate for early abortion.10, 14 Other reported symptoms after methotrexate administration include headache, dizziness, hot flushes, and gastrointestinal symptoms.10 Bleeding and cramping are natural and expected symptoms that occur in most women undergoing medical abortions. The heaviest bleeding typically coincides with expulsion of the pregnancy; a lighter flow lasts 1 to 2 weeks on average but may be longer.10, 17, 18 It is important to prepare women adequately for the expected amount of bleeding: “The amount of bleeding varies from person to person. Most likely it will be much heavier
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than a period, and you will need a supply of sanitary pads. You may see large clots of blood; this is normal. It is also normal for light bleeding to continue for a few weeks after the abortion is completed.” In a study examining the acceptability of medical abortion, women stated that they expected more bleeding with medical abortion than with surgical abortion.5 Care providers can reassure patients that research shows comparable blood loss with the two methods, although they may perceive more bleeding with medical abortion.30 The severity of cramping varies among patients but is well controlled with oral analgesics in nearly all cases.10, 18 Counseling focuses on the woman’s anticipation of the pain and her ability to manage it. It helps to point out that the cramping is normal and usually signifies that everything is proceeding properly: “It is likely that there will be some strong cramping from the misoprostol. This medication causes cramping as the pregnancy tissue is being expelled from the uterus. The cramps mean that the medicine is working the way it should.” Being honest about the level of pain is also important: “Some women do not need pain medication for the cramps. Others have the same kind of cramps that they get with their periods, only stronger. It varies for each individual. Very few require more pain medication than we will provide for you. Do not hesitate to take the pain medication if you need it. It will make you more comfortable, and it does not interfere with the abortion. You may also find a heating pad helpful for the cramps.” If a woman plans to insert the misoprostol at home, practical advice includes telling her to have a supply of sanitary pads available and to fill the prescription for pain medication beforehand. Protocol requirements Commitment to completing the process. A medical abortion requires at least two visits: an initial visit that includes receipt of the medications and a follow-up to determine whether the abortion is complete. Some protocols stipulate that after receiving mifepristone women should return to the office for administration of the misoprostol and remain under observation for approximately 4 hours. Other protocols give women the option of self-administering the misoprostol at home. Delayed passage of the gestational sac or state laws mandating a waiting period between consent and the abortion procedure may necessitate additional visits. Because success depends on compliance with the drug regimen and because of the teratogenic risks to ongoing pregnancies, clinicians must inform patients of the importance of completing the process: “The first medication that you receive will most likely not complete the abortion. Most women need to take the second medication. These medications are designed to work together to end the pregnancy safely. They can cause severe birth defects if the pregnancy continues. It is important that you complete all the steps in the process.”
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The woman needs to know that bleeding does not necessarily signify that the abortion has occurred. A return visit, which may include a sonogram, is therefore essential: “The only way to be certain that the abortion is complete is to come back for a return visit. We will schedule this appointment for you before you leave today.” Willingness to undergo a surgical abortion procedure. All women must be informed of the need for surgical aspiration should the medical method fail: “Most likely these medications will be successful in bringing on an abortion. In the event that the medications do not work for you, however, the embryo can be severely damaged and you will need to have a surgical abortion. What do you expect it might be like if the medications do not work completely?” Many women choose medical abortion precisely because they want to avoid surgery. For these women the possible need for surgical intervention requires extra explanation and sensitivity on the part of the practitioner.4 Adhering to the protocol. Counseling also includes identifying any social, psychological, or logistical barriers to compliance with the protocol that the woman may have. For example, the waiting period between the first and second medications poses difficulties for some women: “You will receive the first medication today and go home. You will need to wait before you take the second medication. For the medications to be effective, it is important to wait the required time before you take the second medication. Some women find that the waiting makes them feel impatient, lonely, or worried. What do you think the waiting will be like for you?” If the protocol requires insertion of the misoprostol vaginally, another possible barrier to compliance is the patient’s level of comfort with inserting the medication. Although research shows that home use of vaginal misoprostol is safe and highly acceptable to women,18, 31 patients occasionally find this prospect unsettling. Practitioners should assess the woman’s reaction to the request before sending her home with the misoprostol: “You can do part of the procedure yourself by inserting tablets into your vagina at home. How do you feel about putting the tablets in your vagina? Have you ever used any product that you had to insert yourself, such as tampons, a diaphragm, or birth control sponges or suppositories? If you are uncomfortable with the idea, you can return here to have the tablets inserted.” With medical abortion, the patient may expel the products of conception at home. Some women prefer to have greater control of the process, whereas others feel anxious about it. To identify any concerns the clinician might make the following remark: “Women who have used both surgical and medical methods say that having an abortion this way feels more private, and they feel more in control of the situation. Other women find it hard to be aware of what is going on within their bodies, and some find it difficult and lonely to have the abor-
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tion at home. What do you imagine the experience would be like for you?” A patient curious about what the products of conception will look like may benefit from seeing a sonogram or a photograph of a typical early embryo. After answering her questions with straightforward descriptions, the clinician can explore the patient’s feelings on the subject: “At this stage the embryo is very small and hardly has any real shape. It may be passed in a blood clot. If you do not see it, there is no need to worry, because it is very easy to miss. I can show you a picture if you like. Would that be helpful? How do you think that you will react if you see it?” The discussion also includes assessing the woman’s need for support during the process. The clinician might ask, “Where will you be that day?” or “Who will be there with you?” If a woman expresses concerns about others knowing that she is having an abortion, probe gently to determine the nature of the anxiety: “Most likely no one will know you are having an abortion, although someone might be aware of your bleeding. Can you tell me a little more about what is on your mind? Is there a particular person or situation that you are thinking about? What will it be like if this person learns you are pregnant and having an abortion?” Medical abortion may offer for some women the flexibility to use the misoprostol at a time that does not interfere with work or other activities. However, some women may have to make arrangements for time away from work, children, and other responsibilities for a limited period: “If you have a medical abortion, you may need several hours away from other responsibilities. What will this mean in terms of your job? Who will be available to look after your children?” In addition, patients undergoing medical abortion may need to avoid certain substances, such as alcohol and aspirin. Methotrexate protocols sometimes advise women to discontinue vitamins containing folic acid and to refrain from breast-feeding for a few days.1 Although providers often discourage women from sexual intercourse until the abortion is complete, no evidence supports this admonition.32 Clinicians who make this recommendation need to assess the patient’s concerns about abstaining: “I suggest that you stop having intercourse until we can be sure that you are no longer pregnant. Sometimes this takes as long as 4 weeks. How will you and your partner deal with this?” Emergency preparedness. Women considering medical abortion need to have access to a telephone and transportation to an appropriate medical facility in the rare event of an emergency. Formulation of a concrete plan during the initial visit enhances safety and can reduce the patient’s anxiety and give her a greater sense of control. Whatever the woman’s strategies for managing side effects and symptoms, she should receive clear instructions about when to call the office. Common parameters in-
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clude severe pain unresponsive to oral analgesics, documented fever lasting ≥6 hours, or soaking ≥2 sanitary maxipads/hr for 2 consecutive hours. Unless the patient is obviously hemorrhaging or symptomatic, it is acceptable to monitor her periodically by telephone to see whether the bleeding abates.1 Although hemorrhage requiring transfusion occurs in only about 1 in 1000 cases,16 patients must have access to a medical facility equipped to provide blood products and emergency surgical evacuation if necessary. Follow-up counseling By the end of the first visit, the patient should feel comfortable and confident about handling what comes next. Provision of written instructions helps to reinforce the key points covered in counseling and facilitates compliance. These instructions include information on the following: • How and when to self-administer the misoprostol at home, or when to return to the office for administration, depending on the protocol • What activities and medications to avoid • How to manage symptoms and side effects • When to call the care provider • How to deal with emergencies, including a 24-hour emergency contact number • When to return for follow-up care Follow-up visits. When the patient returns to the office, it is supportive and comforting for her to see the same practitioner whenever possible. During follow-up the clinician should continue to ask and answer questions, provide information, listen, and observe just as attentively as at the first visit. If the woman returns to the office for administration of the misoprostol followed by observation, issues about bleeding and pain may re-emerge. The patient also may have expulsion of the embryo during this time and may need some assistance with her reactions to the event. Women who do not abort during the observation period or who self-administer the misoprostol at home must return to the office to determine whether the method has worked. If the abortion is found to be incomplete on follow-up, treatment alternatives include prompt suction curettage, administration of additional misoprostol, or simply waiting for an additional period. Patients who require surgical intervention because of ongoing pregnancy may need help handling any disappointment or fear that accompanies this change of plans. The patient with a retained but nonviable gestation may need assistance in deciding whether to wait for the pregnancy to pass or to undergo a surgical abortion procedure. If the patient decides to wait, it is important to address her feelings about prolonging the process. Letting the woman know that she will no longer have any pregnancy symptoms may ease her anxieties about the
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delay. By providing information and exploring the patient’s concerns, the clinician can create the dialogue necessary for a discouraged or highly stressed patient to regain a sense of control. Once the abortion is complete, counseling focuses on the woman’s experiences with the procedure. What were her emotional and physical responses during the process? How did she manage pain and bleeding, side effects, and any feelings that arose? Extensive research reveals that most women feel relieved after surgical abortion, although some have feelings of sadness or guilt for a short time.7 To date, few data are available on psychological responses to medical abortion. One prospective study, however, showed no differences in post-abortal depression, anxiety, or self-esteem among women randomly assigned to receive mifepristone and prostaglandin or to undergo suction curettage.33 Review of the medical abortion experience allows women to gain a feeling of self-confidence about how they handled this challenging event in their lives. This visit also includes reviewing the patient’s contraceptive options. Moreover, it provides an opportunity to offer other important health services, such as human immunodeficiency virus counseling and testing. Comment Women seeking early abortion can now choose among safe and effective medical and surgical options. Research reveals that both medical and surgical methods are acceptable to women who choose them.34 Medical abortion is less invasive than surgery and offers women more privacy and control. To date, women have found the process very satisfactory and would recommend it to a friend.2, 3, 5, 18 Medical methods are technically simpler but logistically more complex than surgical abortion. Adequate counseling and support enhance success and patient satisfaction with medical methods. Through effective communication, practitioners can provide the information and support that patients need to complete the process safely and can help to strengthen women’s confidence in managing their reproductive health experiences.7 REFERENCES
1. Creinin MD, Aubeny E. Medical abortion in early pregnancy. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors. A clinician’s guide to medical and surgical abortion. New York: Churchill Livingstone; 1999. p. 91-106. 2. Winikoff B. Acceptability of medical abortion in early pregnancy. Fam Plann Perspect 1995;27:142-8, 185. 3. Creinin MD, Park M. Acceptability of medical abortion with methotrexate and misoprostol. Contraception 1995;52:41-4. 4. Planned Parenthood of New York City. Counseling guide for clinicians offering medical abortion. New York: Planned Parenthood of New York City; 1996. 5. Harvey SM, Beckman LJ, Satre SJ. Acceptability of methotrexateinduced abortion among women in the US. A report of the Pacific Institute for Women’s Health. Los Angeles: Pacific Institute for Women’s Health; 1999.
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6. Beresford T. Short-term relationship counseling. 2nd ed. Baltimore: Planned Parenthood of Maryland; 1988. 7. Baker A, Beresford T, Halvorson-Boyd G, Garrity JM. Informed consent, counseling, and patient preparation. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors. A clinician’s guide to medical and surgical abortion. New York: Churchill Livingstone; 1999. p. 25-37. 8. Lichtenberg ES, Paul M, Jones H. 1997 NAF provider clinical survey: first trimester surgical abortion practice. Washington, DC: National Abortion Federation; 1997. 9. Picker Institute. From the patient’s perspective: quality of abortion care. Menlo Park (CA): Henry J. Kaiser Family Foundation; 1999. 10. Creinin MD, Vittinghoff E, Keder L, Darney PD, Tiller G. Methotrexate and misoprostol for early abortion: a multicenter trial. I. Safety and efficacy. Contraception 1996;53:321-7. 11. Garrity J, Castle M. A physician’s guide to patient-centered counseling: providing support to women during first-trimester abortion procedures. New York: Planned Parenthood of New York City; 1996. 12. Harvey SM, Beckman LJ, Satre SJ. Listening to and learning from health care providers about methotrexate-induced abortions: a report of the Pacific Institute for Women’s Health. Los Angeles: Pacific Institute for Women’s Health; 1998. 13. Joffe C. Reactions to medical abortion among providers of surgical abortion: an early snapshot. Fam Plann Perspect 1999;31:35-8. 14. Hausknecht RU. Methotrexate and misoprostol to terminate early pregnancy. N Engl J Med 1995;333:537-40. 15. Baker A. Abortion and options counseling: a comprehensive reference. Granite City (IL): The Hope Clinic for Women; 1995. 16. Grimes DA. Medical abortion in early pregnancy: a review of the evidence. Obstet Gynecol 1997;89:790-6. 17. Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med 1998;338:1241-7. 18. Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Low-dose mifepristone 200 mg and vaginal misoprostol for abortion. Contraception 1999;59:1-6. 19. Creinin MD, Stewart-Akers AM, DeLoia JA. Methotrexate effects on trophoblast and the corpus luteum in early pregnancy. Am J Obstet Gynecol 1998;179:604-9. 20. Danielsson KG, Marions L, Rodriguez A, Spur BW, Wong PYK, Bygdeman M. Comparison between oral and vaginal administration of misoprostol on uterine contractility. Obstet Gynecol 1999;93:275-80.
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21. Theon LD, Creinin MD. Medical treatment of ectopic pregnancy with methotrexate. Fertil Steril 1997;68:727-30. 22. Lipscomb GH, Bran D, McCord ML, Portera JC, Ling FW. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol 1998;178:1354-8. 23. Schaff EA, Eisinger SH, Franks P, Kim SS. Combined methotrexate and misoprostol for early induced abortion. Arch Fam Med 1995;4:774-9. 24. Schein PS, Winokur SH. Immunosuppressive and cytotoxic chemotherapy: long term complications. Ann Intern Med 1975;82:84-95. 25. Pastorfide GB, Goldstein DP. Pregnancy after hydatiform mole. Obstet Gynecol 1973;42:67-70. 26. Walden PA, Bagshawe KD. Reproductive performance of women successfully treated for gestational trophoblastic tumors. Am J Obstet Gynecol 1976;125:1108-14. 27. Ramsey-Goldman R, Mientus JM, Kutzer JE, Mulvihill JJ, Medsger TA Jr. Pregnancy outcome in women with systemic lupus erythematosus treated with immunosuppressive drugs. J Rheumatol 1993;20:1152-7. 28. Gonzalez CH, Vargas FR, Perez ABA, Kim CA, Brunoni D, Marques-Dias MJ, et al. Limb deficiency with or without Möbius sequence in seven Brazilian children associated with misoprostol use in the first trimester of pregnancy. Am J Med Genet 1993;47:59-64. 29. Pastuszak AL, Schüler L, Speck-Martins CE, Coelho KFA, Cordello SM, Vargas F, et al. Use of misoprostol during pregnancy and Möbius’ syndrome in infants. N Engl J Med 1998;338:1881-5. 30. Elul B, Ellertson C, Winikoff B, Coyaji K. Side effects of mifepristone-misoprostol abortion versus surgical abortion. Contraception 1999;59:107-14. 31. Schaff EA, Stadalius LS, Eisinger SH, Franks P. Vaginal misoprostol administered at home after mifepristone (RU486) for abortion. J Fam Pract 1997;44:353-60. 32. McIntosh KM, Stewart GK, Teplin D. Routine aftercare and contraception. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors. A clinician’s guide to medical and surgical abortion. New York: Churchill Livingstone; 1999. p. 185-96. 33. Henshaw R, Naji S, Russell I, Templeton A. Psychological responses following medical abortion (using mifepristone and gemeprost) and surgical vacuum aspiration: a patient-centered, partially randomised prospective study. Acta Obstet Gynecol Scand 1994;73:812-8. 34. Henshaw RC, Naji SA, Russell IT, Templeton AA. Comparison of medical abortion with surgical vacuum aspiration: women’s preferences and acceptability of treatment. BMJ 1993;307:714-7.