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MEDICAL ABORTION Orawee Chinthakanan, MD, MPH MEDICAL ABORTION Orawee Chinthakanan, MD, MPH

OVERVIEW • Identify current medication abortion methods and present • • Mechanisms of action OVERVIEW • Identify current medication abortion methods and present • • Mechanisms of action Regimens, efficacy, and safety Eligibility requirements and contraindications Side effects and complications • WHO guideline • Current study in Thailand

Medication Abortion Advantages • 95 -99% effective • Avoids surgical and anesthetic risk • Medication Abortion Advantages • 95 -99% effective • Avoids surgical and anesthetic risk • Greater patient autonomy & privacy • Less invasive • More “natural”

MEDICATION ABORTION REGIMENS: THREE CHOICES Mifepristone + Misoprostol Methotrexate + Misoprostol alone MEDICATION ABORTION REGIMENS: THREE CHOICES Mifepristone + Misoprostol Methotrexate + Misoprostol alone

MEDICATION ABORTION METHODS OF ACTION OF THE MEDICATIONS • Mifepristone (RU-486) • Anti-progestin that MEDICATION ABORTION METHODS OF ACTION OF THE MEDICATIONS • Mifepristone (RU-486) • Anti-progestin that blocks the action of progesterone • Alters the uteral lining • Methotrexate • Anti-metabolite • Interferes with DNA synthesis and cell growth • Misoprostol • Prostaglandin E analog • Stimulates uterine contractions and induces cervical softening 1

MEDABON • Medabon® consists of two medicines: mifepristone and misoprostol. • The Medabon® regimen MEDABON • Medabon® consists of two medicines: mifepristone and misoprostol. • The Medabon® regimen is in line with current (as of June 2009) WHO recommendations for medical abortion 1: one 200 -mg tablet of mifepristone given orally, followed 24– 48 hours later by four 200 -μg tablets of misoprostol. The four misoprostol tablets can be administered vaginally or sublingually. • Medabon® is registered for use in pregnancies through nine weeks (63 days) since a woman’s LMP.

USE OF MIFEPRISTONE WORLDWIDE Millions of women have used mifepristone for medical abortion. Year USE OF MIFEPRISTONE WORLDWIDE Millions of women have used mifepristone for medical abortion. Year that mifepristone was licensed France-1988 China-1988 UK-1991 Sweden-1992 Austria-1999 Belgium 1999 Denmark 1999 Finland-1999 Luxembourg 1999 Netherlands 1999 Spain-1999 Switzerland 1999 Norway-2000 Russia-2000 Taiwan-2000 South Africa 2001 Azerbaijan— 2002 Belarus— 2002 Georgia--2002 India--2002 Latvia--2002 Uzbekistan--

MECHANISM OF ACTION: MIFEPRISTONE + MISOPROSTOL MECHANISM OF ACTION: MIFEPRISTONE + MISOPROSTOL

ROUTE การใชยา MISOPROSTOL ( CYTOTEC) กน (oral) เหนบชองคลอด (vaginal) เหนบทวารหนก (rectal) อมใตลน (sublingual) อมกระพงแกม ROUTE การใชยา MISOPROSTOL ( CYTOTEC) กน (oral) เหนบชองคลอด (vaginal) เหนบทวารหนก (rectal) อมใตลน (sublingual) อมกระพงแกม (buccal)

การใชยา MISOPROSTOL ในทางสตกรรม 1. Cervical priming 2. Termination of 3. Incomplete abortion pregnancy 4. การใชยา MISOPROSTOL ในทางสตกรรม 1. Cervical priming 2. Termination of 3. Incomplete abortion pregnancy 4. Induction of labour 5. Postpartum hemorrhage

WHO regimen Up to 9 weeks since LMP 200 mg mifepristone + 24 48 WHO regimen Up to 9 weeks since LMP 200 mg mifepristone + 24 48 -h 800 mcg misoprostol (vag, sublingual( Success rate = 92 -98%

Gestational Age Mifepristone Dose Misoprostol Dose, Route and Timing Up to 9 weeks 200 Gestational Age Mifepristone Dose Misoprostol Dose, Route and Timing Up to 9 weeks 200 mg orally After 24 -48 hours, 800 mcg buccally, sublingually or vaginally for one dose Between 9 -12 weeks 200 mg orally After 36 -48 hours, 800 mcg vaginally followed by 400 mcg vaginally or sublingually every 3 hours for a maximum of 5 doses of misoprostol Above 12 weeks 200 mg orally After 36 -48 hours, 400 mcg orally or 800 mcg vaginally followed by 400 mcg vaginally or sublingually every 3 hours for a maximum of 5 doses of misoprostol, administered in a healthcare facility

15 MIFEPRISTONE/MISOPROSTOL REGIMENS COMPARISON OF PROTOCOLS French Regimen US: FDA Regimen Evidence-Based Regimen Mifepristone 15 MIFEPRISTONE/MISOPROSTOL REGIMENS COMPARISON OF PROTOCOLS French Regimen US: FDA Regimen Evidence-Based Regimen Mifepristone Dosage 600 mg (Day 1) 200 mg (Day 1) Misoprostol Dosage 400 µg, PO Or 1 mg gemeprost, PV 400 µg, PO or 800 µg, PV Gestational Limit ≤ 49 days ≤ 63 days Location of misoprostol administration At medical office/clinic or at home Timing of misoprostol administration Day 2 or 3 Day 2, 3, or 4 Timing of initial followup examination Day 10 to 14 Day 4 to 14 Number of clinic visits required Three or more Two or more

Medabon Regimen Home regimen pregnancy < 91 tab oral week mifepristone Day 0 Day Medabon Regimen Home regimen pregnancy < 91 tab oral week mifepristone Day 0 Day 1 -2 misoprostol 4 tab vaginal or sublingual Day 14 follow up and contraception Efficacy 95 -98 % Abortion within 2 -3 h( sublingual miso) or 3 -6 h (vaginal miso) bleeding = 5 -14 days

MIFEPRISTONE/MISOPROSTOL REGIMEN CONTRAINDICATIONS TO USE • Confirmed or suspected ectopic (extra-uterine) pregnancy • Allergy MIFEPRISTONE/MISOPROSTOL REGIMEN CONTRAINDICATIONS TO USE • Confirmed or suspected ectopic (extra-uterine) pregnancy • Allergy to either mifepristone or misoprostol • Presence of an intrauterine device (IUD) • Chronic systemic use of corticosteroids • Chronic adrenal failure • Coagulopathy or current therapy with anticoagulants • Inherited porphyria

18 MIFEPRISTONE/MISOPROSTOL REGIMEN SIDE EFFECTS Effects of abortion process • Cramping • Often described 18 MIFEPRISTONE/MISOPROSTOL REGIMEN SIDE EFFECTS Effects of abortion process • Cramping • Often described as similar to menstrual cramps • Vaginal bleeding • Median bleeding time 913 days • Often described as similar to a heavy period or spontaneous miscarriage Common side effects • Nausea • Vomiting • Diarrhea • Headache • Dizziness • Fever, chills, hot flashes, warmth

Medical abortion ขอด ปลอดภ ย สะดวก No anesthes Women’s greater ia control ขอดอ ย Medical abortion ขอด ปลอดภ ย สะดวก No anesthes Women’s greater ia control ขอดอ ย Failed cases need surgical methods Multisteps)ตองมาโร งพยาบาลหลายคร ง

"Women who die of unsafe abortion ; they are not dying because of diseases that we cannot treat. . they are dying because societies (and I might add including some of our medical fraternity in Thailand ศาสตราจารยกำแหง and in the world for that จาตรจนดาประธานมลนธเพอ matter), . . . have yet to make สทธอนามยการเจรญพนธขอ the decision that IWAC 2012 are งสตรไทย their lives worth saving. "

THANK YOU! THANK YOU!