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Pregnancy Termination: Understanding and Supporting Women Who Undergo Medical Abortion
PREGNANCY TERM
Gay L. Goss, PhD, WHNP
Understanding and Supporting Women Who Undergo Medical Abortion
INATI N A
bortion—the termination of a pregnancy—is a time of turmoil, self-introspection and intense contemplation for most women.
Although legally available since 1973, from a personal standpoint, abortion is never easy, never a stress-free experience for women or health care providers. However, it’s the responsibility of professionals, particularly nurses, to ensure safe, humane and medically sound care to those women facing this arduous choice. Medical abortion is now a viable choice for women, and an alternative to surgical intervention. Armed with current information on all options, the nurse can provide accurate vital information regarding surgical and medical abortion for pregnant women considering such in the U.S. Providing these choices, professionally and compassionately, can and will make a difference in the emotional outcome of a woman’s choice, not only whether to seek an abortion but also how to minimize health risks through the process.
Nonsurgical Abortion Since 1973, abortion has been a legal choice for women with unintended pregnancies. Early treatment modalities centered on invasive surgical techniques, that is, dilation and curettage and vacuum aspiration (Caspi, Appelman, & Barash, 1992). Although limited, complications with surgical abortion involve risks of hemorrhage, perforation and infection. Today, technology has produced another avenue of choice for women: medical termination or nonsurgical abortion (Crenin & Edwards, 1997). Prior to 2000, an experimental protocol for nonsurgical abortion became available in the U.S. This regimen, methotrexate and misoprostol (Cytotec), remains an effective method of termination up to the 63rd day of pregnancy, carries little risk to women and reports a 98 percent success rate (Crenin, Vittinghoff, & Keder, 1996). Slight dif-
Table 1. Methotrexate/Misoprostol Protocol Pregnancy Confirmation
< 63 days
Counseling regarding options Informed consent Laboratory evaluation
Rh/HGB/CBC
Dietary guidelines Methotrexate injections
250 mg
Misoprostol
5 days postinjection
Pain management
Vicodin, if appropriate
Follow-up sonography
7 days
Examination and prevention counseling
7-30 days
Based on protocol at Buena Vista Womens’ Clinic; San Francisco, CA.
Table 2. RU486 Protocol Confirmation of pregnancy
< 49 days
Counseling regarding options Informed consent
Willing to complete procedure
Sonography
48 hours postadministration
Laboratory evaluation
Rh/HCT/CBC
Administration of RU486
600 mg, orally
Sonography
48 hours later
Insertion of misoprostol if sac noted
400 mg suppositories, 48 hours after RU486
Pain management
Vicodin, if appropriate
Examination and prevention counseling
Table 3. Patient Selection Criteria Misoprostol/(RU486)
Methotrexate/Misoprostol
Confirmed IUP < 7 weeks**
Confirmed IUP < 9 weeks
Understands procedure
Understands procedure
Willing to adhere to follow-up
Willing to adhere to diet restrictions, such as avoidance of foods high in folate (dark leafy greens, etc.) and follow-up
Support system in place
Support system in place
Pain tolerance
Pain tolerance
HGB > 10 mg/dl
HGB > 10 mg/dl
HCT > 30 percent
HCT > 30 percent
**some protocols < 9 weeks.
ferences exist among protocols for providers and institutions, yet the outcome data described with the techniques are consistent (Hausknecht, 1995). Table 1, “Methotrexate/Misoprostol Protocol,” presents a sample protocol of care utilizing methotrexate and misoprostol in a women’s clinic in Northern California. In September 2000, the Food and Drug Administration approved the use of RU486 (mifespristone) for terminations
up to 49 days of gestation or 7 weeks of pregnancy (Mahler, 2000). While RU486 has been available in Europe and Asia for decades, limited experience with this protocol in the U.S. is evidenced. Moreover, the literature available is centered on medical issues with little report on nursing implications. Table 2, “RU486 Protocol,” outlines the manufacturer’s recommendations for the use of mifespristone.
Pharmacology Gay L. Goss, PhD, WHNP, is an associate professor and women’s health nurse practitioner at California State University–Dominguez Hills, in Carson, CA.
48
A W H O N N Lifelines
Mifespristone (RU486) is an antiprogestin derived from norethindrone. RU486 binds to progesterone, thus blocking
Volume 6, Issue 1
the activation of progesterone receptors. The pregnancy cannot be sustained without the effects of progesterone. In addition, RU486 alters the endometrial lining and softens the cervix. The usual dose of RU486 is 600 mg orally. Misoprostol (Cytotec) is commonly used in conjunction with RU486 to complete the termination. Misoprostol is an adjunct medication used for medical abortions. Originally this medication was approved for the prevention of gastric ulcers in patients on long-term nonsteroidal anti-inflammatory agents. Misoprostol is a PGE1 analogue and has been used for cervical ripening for the induction of labor (Hausknecht, 1999). The usual dosage for medical abortion is 800 mg vaginally in conjunction with methotrexate, although varying protocols have proven effective (Crenin & Darney, 1993). Methotrexate is a folic acid analogue. When administered, the production of folates needed for DNA synthesis is decreased. This, in turn, interferes with cell division. Methotrexate is a common therapy for extrauterine pregnancies, and when used in conjunction with misoprostol, is effective in terminating pregnancies up to 63 days of gestation (Weibe, 1996). The usual dosage for methotrexate in medical abortion is 250 mg.
lows: “This was very good overall. I think that women should be told how extremely painful and uncomfortable this procedure is.” Another woman reported, “I never had cramps in my life, so that night when I started cramping, it was painful for me.” Additionally, because nonsurgical abortion takes time, health care providers need to stress to women that patience is necessary for successful completion of the procedure. Table 3, “Patient Selection Criteria” summarizes the criteria for appropriate patient selection for medical termination of early pregnancies.
The decision to terminate and the selection of a method to do so is a mutual process between the woman and her health care professional, and is primarily predicated on the length of the gestation and the patient’s willingness to actively participate in her care.
A Woman’s Choice
Nursing Care for Medical Abortion
When a woman chooses to terminate a pregnancy, she now has choices that were not previously available. The decision to terminate and the selection of a method to do so is a mutual process between the woman and her health care professional, and is primarily predicated on the length of the gestation and the patient’s willingness to actively participate in her care. Initially, pregnancy confirmation is performed using sensitive urine tests (HCG) or ultrasonograpy. Verification as early as five weeks gestation is possible, thus allowing for the choice of medical abortion. Depending on how far the pregnancy has developed, a woman faces the following abortion options:
There are few issues in health care that are more politically and emotionally debated than abortion. The moral and ethical complexion of terminating a pregnancy cannot be overlooked, yet a thorough discussion is not within the scope of this article. However, in the U.S., women are guaranteed under current law the legal right for and access to safe abortion services. Nurses may encounter women in the process of obtaining abortion, during follow-up visits or in the event of complications postprocedure. The following suggestions are meant to guide nurses during interactions with women who have undergone abortion. It’s important to acknowledge that women choosing termination experience physiological alterations of pregnancy that can add to the emotional crisis of decision making. Counseling is an integral and vital aspect, and counseling begins with verification of pregnancy. Once the suspicion of pregnancy is evident, and a home/office/lab pregnancy test is positive or sonography confirms a gestation, women may find themselves on an emotional roller coaster. Feelings of guilt, relief, sadness and fear are common, and women may begin using coping strategies to confront the decision-making process (Garrity & Castle, 1996). Some of the common emotions that can be experienced with an unintended or unwanted pregnancy include,
• Misoprostol—up to 7 completed weeks gestation • Methotrexate/Misoprostol—up to 9 completed weeks gestation • Surgical dilation and curettage—9 to 14 weeks, varies by state Regardless of the method a woman chooses, all procedures require that women have emotional support, a stable environment in which to recover and the cognitive ability to comprehend the instructions and carry through with the procedure with medical interventions. A woman also must be able to tolerate the possibility of viewing blood and the expulsion of uterine contents. Patient selection is the first step in the decision for medical abortion. It’s critical for health care professionals to evaluate the physiological and social ramifications for the pregnant woman. Because cramping, bleeding and pain are realities with medical abortion, women must be advised as to consider their ability to tolerate these side effects. Patients who have undergone medical abortion have remarked as fol-
February/March 2002
• • • • • • •
Denial Guilt Shame Sadness/loss Conflict with personal values Fear of procedures Concern for future childbearing
A W H O N N Lifelines
49
Table 4. Protocol for Initial Visit for Pregnancy Termination
Getting All the Facts ❏ National Abortion Federation: www.naf.org ❏ Planned Parenthood Federation of America: www.ppfa.org
♦ Thorough History ♦ Informed Consent
❏ Alan Guttmacher Institute: www.agi-usa.org
♦ Review of Options
❏ Association of Reproductive Health Professionals: www.arhp.org
♦ Laboratory Evaluation (RH, CBC) ♦ Sonography
❏ AWHONN position statement on abortion: www.awhonn.org
♦ Procedure Review/Decision ♦ Evaluation of STDs ♦ Review Follow-Up Guidelines ♦ Pain Management ♦ Review Emergency Information ♦ After Care
Women frequently turn to friends or family for support yet often receive conflicting information or lack of accurate instructions. A woman considering abortion may feel lost and confused. One woman interviewed in a clinic stated, “I feel so ignorant and embarrassed. I am so stupid.” Nurses can address these feelings and fears, facilitate the grieving process and initiate resolution by the following: • • • • •
Offering objective information on abortion methods Recognizing and validating the woman’s myriad feelings Projecting a nonjudgmental attitude Assessing the patient’s current emotional functioning Asking questions/reflecting
Some women make pregnancy termination decisions with confidence and without regret, and some women have lingering grief, feelings of loss and guilt (Williams, 2000). A testimony by a woman who had a child and then chose to terminate her second pregnancy stated the following emotional feelings: “Regrets, depression, a strong sense of responsibility . . . thoughts of life/death/karma.” Professional guidance coupled with openness and compassion can facilitate a positive outcome.
The Procedure Because most counseling services offered during the abortion visit are provided by the nursing staff, it’s imperative that these nurses impart in-depth information regarding the clinical aspects of the procedure as well as reacting to the emotional cues exhibited by the woman. An evaluation from one woman stated, “Providing detailed medical information about the procedure reduced a lot of anxiety.” Table 4, “Protocol for Initial Visit for Pregnancy Termination,” provides a sample protocol for an initial visit addressing pregnancy termination. The follow-up visit is as important as the procedure itself. In terms of medical abortion, follow-up confirms successful termination, allows contraceptive options to be outlined and provides the woman an avenue for debriefing the 50
A W H O N N Lifelines
experience. The following should be addressed with women during follow-up: • • • • • • •
Birth control Pap smear evaluation Breast self-exam and mammography Smoking cessation STDs and HIV Violence Heart health
Nurses can use this valuable follow-up time to address with the women pertinent women’s health issues across the life span from a prevention context. ♦ References Caspi, B., Appelman, Y., & Barash, A. (1992). Early pregnancy termination: An improved technique for “menstrual regulation” with ultrasound assistance. Advanced Contraception, 6, 349. Crenin, M. D., & Darney, P. D. (1993). Methotrexate and misoprostol for early abortion. Contraception, 48, 339-348. Crenin, M. D., & Edwards, J. (1997). Early abortion: surgical and medical options. Current Problems Obstetrics Gynecology and Fertility, 20, 1-32. Crenin, M. D, Vittinghoff, E., & Keder, L. (1996). Methotrexate and misoprostol for early abortion: A multicenter trial I. Safety and efficacy. Contraception, 53, 321-327. Garrity, J., & Castle, M. (1996). A physician’s guide to patient centered care: Providing support to women during first trimester abortion procedures. New York: Planned Parenthood of New York. Hausknecht, R. U. (1995). Methotrexate and misoprostol to terminate early pregnancy. New England Journal of Medicine, 333, 537-540. Hausknecht, R. U. (1999, September). Methotrexate plusU.S. misoprostol: A new alternative for medical abortion. Contemporary OB-GYN, pp. 119-124. Mahler, K. (2000). Early medical abortion regimen U.S.usinging different dosages of mifespristone are equally successful. Family Planning Perspectives, 32, 259. Weibe, E. R. (1996). Abortion induced with methotrexate and misoprostol. Canadian Medical Association Journal, 154, 165-170. Williams, G. B. (2000). Grief after elective abortion. AWHONN Lifelines, 4(2), 37-40. Volume 6, Issue 1
Gay L. Goss, PhD, WHNP
Understanding and Supporting Women Who Undergo Medical Abortion
INATI N A
bortion—the termination of a pregnancy—is a time of turmoil, self-introspection and intense contemplation for most women.
Although legally available since 1973, from a personal standpoint, abortion is never easy, never a stress-free experience for women or health care providers. However, it’s the responsibility of professionals, particularly nurses, to ensure safe, humane and medically sound care to those women facing this arduous choice. Medical abortion is now a viable choice for women, and an alternative to surgical intervention. Armed with current information on all options, the nurse can provide accurate vital information regarding surgical and medical abortion for pregnant women considering such in the U.S. Providing these choices, professionally and compassionately, can and will make a difference in the emotional outcome of a woman’s choice, not only whether to seek an abortion but also how to minimize health risks through the process.
Nonsurgical Abortion Since 1973, abortion has been a legal choice for women with unintended pregnancies. Early treatment modalities centered on invasive surgical techniques, that is, dilation and curettage and vacuum aspiration (Caspi, Appelman, & Barash, 1992). Although limited, complications with surgical abortion involve risks of hemorrhage, perforation and infection. Today, technology has produced another avenue of choice for women: medical termination or nonsurgical abortion (Crenin & Edwards, 1997). Prior to 2000, an experimental protocol for nonsurgical abortion became available in the U.S. This regimen, methotrexate and misoprostol (Cytotec), remains an effective method of termination up to the 63rd day of pregnancy, carries little risk to women and reports a 98 percent success rate (Crenin, Vittinghoff, & Keder, 1996). Slight dif-
Table 1. Methotrexate/Misoprostol Protocol Pregnancy Confirmation
< 63 days
Counseling regarding options Informed consent Laboratory evaluation
Rh/HGB/CBC
Dietary guidelines Methotrexate injections
250 mg
Misoprostol
5 days postinjection
Pain management
Vicodin, if appropriate
Follow-up sonography
7 days
Examination and prevention counseling
7-30 days
Based on protocol at Buena Vista Womens’ Clinic; San Francisco, CA.
Table 2. RU486 Protocol Confirmation of pregnancy
< 49 days
Counseling regarding options Informed consent
Willing to complete procedure
Sonography
48 hours postadministration
Laboratory evaluation
Rh/HCT/CBC
Administration of RU486
600 mg, orally
Sonography
48 hours later
Insertion of misoprostol if sac noted
400 mg suppositories, 48 hours after RU486
Pain management
Vicodin, if appropriate
Examination and prevention counseling
Table 3. Patient Selection Criteria Misoprostol/(RU486)
Methotrexate/Misoprostol
Confirmed IUP < 7 weeks**
Confirmed IUP < 9 weeks
Understands procedure
Understands procedure
Willing to adhere to follow-up
Willing to adhere to diet restrictions, such as avoidance of foods high in folate (dark leafy greens, etc.) and follow-up
Support system in place
Support system in place
Pain tolerance
Pain tolerance
HGB > 10 mg/dl
HGB > 10 mg/dl
HCT > 30 percent
HCT > 30 percent
**some protocols < 9 weeks.
ferences exist among protocols for providers and institutions, yet the outcome data described with the techniques are consistent (Hausknecht, 1995). Table 1, “Methotrexate/Misoprostol Protocol,” presents a sample protocol of care utilizing methotrexate and misoprostol in a women’s clinic in Northern California. In September 2000, the Food and Drug Administration approved the use of RU486 (mifespristone) for terminations
up to 49 days of gestation or 7 weeks of pregnancy (Mahler, 2000). While RU486 has been available in Europe and Asia for decades, limited experience with this protocol in the U.S. is evidenced. Moreover, the literature available is centered on medical issues with little report on nursing implications. Table 2, “RU486 Protocol,” outlines the manufacturer’s recommendations for the use of mifespristone.
Pharmacology Gay L. Goss, PhD, WHNP, is an associate professor and women’s health nurse practitioner at California State University–Dominguez Hills, in Carson, CA.
48
A W H O N N Lifelines
Mifespristone (RU486) is an antiprogestin derived from norethindrone. RU486 binds to progesterone, thus blocking
Volume 6, Issue 1
the activation of progesterone receptors. The pregnancy cannot be sustained without the effects of progesterone. In addition, RU486 alters the endometrial lining and softens the cervix. The usual dose of RU486 is 600 mg orally. Misoprostol (Cytotec) is commonly used in conjunction with RU486 to complete the termination. Misoprostol is an adjunct medication used for medical abortions. Originally this medication was approved for the prevention of gastric ulcers in patients on long-term nonsteroidal anti-inflammatory agents. Misoprostol is a PGE1 analogue and has been used for cervical ripening for the induction of labor (Hausknecht, 1999). The usual dosage for medical abortion is 800 mg vaginally in conjunction with methotrexate, although varying protocols have proven effective (Crenin & Darney, 1993). Methotrexate is a folic acid analogue. When administered, the production of folates needed for DNA synthesis is decreased. This, in turn, interferes with cell division. Methotrexate is a common therapy for extrauterine pregnancies, and when used in conjunction with misoprostol, is effective in terminating pregnancies up to 63 days of gestation (Weibe, 1996). The usual dosage for methotrexate in medical abortion is 250 mg.
lows: “This was very good overall. I think that women should be told how extremely painful and uncomfortable this procedure is.” Another woman reported, “I never had cramps in my life, so that night when I started cramping, it was painful for me.” Additionally, because nonsurgical abortion takes time, health care providers need to stress to women that patience is necessary for successful completion of the procedure. Table 3, “Patient Selection Criteria” summarizes the criteria for appropriate patient selection for medical termination of early pregnancies.
The decision to terminate and the selection of a method to do so is a mutual process between the woman and her health care professional, and is primarily predicated on the length of the gestation and the patient’s willingness to actively participate in her care.
A Woman’s Choice
Nursing Care for Medical Abortion
When a woman chooses to terminate a pregnancy, she now has choices that were not previously available. The decision to terminate and the selection of a method to do so is a mutual process between the woman and her health care professional, and is primarily predicated on the length of the gestation and the patient’s willingness to actively participate in her care. Initially, pregnancy confirmation is performed using sensitive urine tests (HCG) or ultrasonograpy. Verification as early as five weeks gestation is possible, thus allowing for the choice of medical abortion. Depending on how far the pregnancy has developed, a woman faces the following abortion options:
There are few issues in health care that are more politically and emotionally debated than abortion. The moral and ethical complexion of terminating a pregnancy cannot be overlooked, yet a thorough discussion is not within the scope of this article. However, in the U.S., women are guaranteed under current law the legal right for and access to safe abortion services. Nurses may encounter women in the process of obtaining abortion, during follow-up visits or in the event of complications postprocedure. The following suggestions are meant to guide nurses during interactions with women who have undergone abortion. It’s important to acknowledge that women choosing termination experience physiological alterations of pregnancy that can add to the emotional crisis of decision making. Counseling is an integral and vital aspect, and counseling begins with verification of pregnancy. Once the suspicion of pregnancy is evident, and a home/office/lab pregnancy test is positive or sonography confirms a gestation, women may find themselves on an emotional roller coaster. Feelings of guilt, relief, sadness and fear are common, and women may begin using coping strategies to confront the decision-making process (Garrity & Castle, 1996). Some of the common emotions that can be experienced with an unintended or unwanted pregnancy include,
• Misoprostol—up to 7 completed weeks gestation • Methotrexate/Misoprostol—up to 9 completed weeks gestation • Surgical dilation and curettage—9 to 14 weeks, varies by state Regardless of the method a woman chooses, all procedures require that women have emotional support, a stable environment in which to recover and the cognitive ability to comprehend the instructions and carry through with the procedure with medical interventions. A woman also must be able to tolerate the possibility of viewing blood and the expulsion of uterine contents. Patient selection is the first step in the decision for medical abortion. It’s critical for health care professionals to evaluate the physiological and social ramifications for the pregnant woman. Because cramping, bleeding and pain are realities with medical abortion, women must be advised as to consider their ability to tolerate these side effects. Patients who have undergone medical abortion have remarked as fol-
February/March 2002
• • • • • • •
Denial Guilt Shame Sadness/loss Conflict with personal values Fear of procedures Concern for future childbearing
A W H O N N Lifelines
49
Table 4. Protocol for Initial Visit for Pregnancy Termination
Getting All the Facts ❏ National Abortion Federation: www.naf.org ❏ Planned Parenthood Federation of America: www.ppfa.org
♦ Thorough History ♦ Informed Consent
❏ Alan Guttmacher Institute: www.agi-usa.org
♦ Review of Options
❏ Association of Reproductive Health Professionals: www.arhp.org
♦ Laboratory Evaluation (RH, CBC) ♦ Sonography
❏ AWHONN position statement on abortion: www.awhonn.org
♦ Procedure Review/Decision ♦ Evaluation of STDs ♦ Review Follow-Up Guidelines ♦ Pain Management ♦ Review Emergency Information ♦ After Care
Women frequently turn to friends or family for support yet often receive conflicting information or lack of accurate instructions. A woman considering abortion may feel lost and confused. One woman interviewed in a clinic stated, “I feel so ignorant and embarrassed. I am so stupid.” Nurses can address these feelings and fears, facilitate the grieving process and initiate resolution by the following: • • • • •
Offering objective information on abortion methods Recognizing and validating the woman’s myriad feelings Projecting a nonjudgmental attitude Assessing the patient’s current emotional functioning Asking questions/reflecting
Some women make pregnancy termination decisions with confidence and without regret, and some women have lingering grief, feelings of loss and guilt (Williams, 2000). A testimony by a woman who had a child and then chose to terminate her second pregnancy stated the following emotional feelings: “Regrets, depression, a strong sense of responsibility . . . thoughts of life/death/karma.” Professional guidance coupled with openness and compassion can facilitate a positive outcome.
The Procedure Because most counseling services offered during the abortion visit are provided by the nursing staff, it’s imperative that these nurses impart in-depth information regarding the clinical aspects of the procedure as well as reacting to the emotional cues exhibited by the woman. An evaluation from one woman stated, “Providing detailed medical information about the procedure reduced a lot of anxiety.” Table 4, “Protocol for Initial Visit for Pregnancy Termination,” provides a sample protocol for an initial visit addressing pregnancy termination. The follow-up visit is as important as the procedure itself. In terms of medical abortion, follow-up confirms successful termination, allows contraceptive options to be outlined and provides the woman an avenue for debriefing the 50
A W H O N N Lifelines
experience. The following should be addressed with women during follow-up: • • • • • • •
Birth control Pap smear evaluation Breast self-exam and mammography Smoking cessation STDs and HIV Violence Heart health
Nurses can use this valuable follow-up time to address with the women pertinent women’s health issues across the life span from a prevention context. ♦ References Caspi, B., Appelman, Y., & Barash, A. (1992). Early pregnancy termination: An improved technique for “menstrual regulation” with ultrasound assistance. Advanced Contraception, 6, 349. Crenin, M. D., & Darney, P. D. (1993). Methotrexate and misoprostol for early abortion. Contraception, 48, 339-348. Crenin, M. D., & Edwards, J. (1997). Early abortion: surgical and medical options. Current Problems Obstetrics Gynecology and Fertility, 20, 1-32. Crenin, M. D, Vittinghoff, E., & Keder, L. (1996). Methotrexate and misoprostol for early abortion: A multicenter trial I. Safety and efficacy. Contraception, 53, 321-327. Garrity, J., & Castle, M. (1996). A physician’s guide to patient centered care: Providing support to women during first trimester abortion procedures. New York: Planned Parenthood of New York. Hausknecht, R. U. (1995). Methotrexate and misoprostol to terminate early pregnancy. New England Journal of Medicine, 333, 537-540. Hausknecht, R. U. (1999, September). Methotrexate plusU.S. misoprostol: A new alternative for medical abortion. Contemporary OB-GYN, pp. 119-124. Mahler, K. (2000). Early medical abortion regimen U.S.usinging different dosages of mifespristone are equally successful. Family Planning Perspectives, 32, 259. Weibe, E. R. (1996). Abortion induced with methotrexate and misoprostol. Canadian Medical Association Journal, 154, 165-170. Williams, G. B. (2000). Grief after elective abortion. AWHONN Lifelines, 4(2), 37-40. Volume 6, Issue 1