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lR;eso t;rs
Handbook on
Medical Methods of Abortion to Expand Access to New Technologies
for Safe Abortion
Ministry of Health & Family WelfareGovernment of India
lR;eso t;rs
JANUARY 2016
iiiHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
vHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
viiHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
ixHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
xiHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
xiiiHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
List of Acronyms
AIDS AcquiredImmunodeficiencySyndrome
ANM AuxiliaryNurseMidwife
ACOG AmericanCongressofObstetriciansandGynaecologists
BP BloodPressure
CAC ComprehensiveAbortionCare
Gm Gram
HIV HumanImmunodeficiencyVirus
IEC InformationEducationCommunication
IUCD IntrauterineContraceptiveDevice
IV Intravenous
PC-PNDT PreConceptionandPreNatalDiagnosticTechniques
LMP LastMenstrualPeriod
MTP MedicalTerminationofPregnancy
MMA MedicalMethodsofAbortion
Mcg Microgram
NHM NationalHealthMission
POC ProductsofConception
P/S Per Speculum
P/V Per Vaginum
Rh Rhesus(Bloodgroup)
USG UltraSonography
VA VacuumAspiration
SRS SampleRegistrationSystem
LSCS LowerSegmentCaesareanSection
OPD OutPatientDepartment
WHO WorldHealthOrganization
RMP RegisteredMedicalPractitioner
xvHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
List of Contributors
1. ShriC.K.Mishra AdditionalSecretary&MissionDirector(NHM),MoHFW
2. DrRakeshKumar JointSecretary(RMNCH+A),MoHFW
3. DrDineshBaswal DeputyCommissioner(InchargeMaternalHealth),MoHFW
4. DrVeenaDhawan AssistantCommissioner(MaternalHealth),MoHFW
5. ProfessorSuneetaMittal Director&Head,DepartmentofObstetrics&Gynaecology,FortisMemorialResearchInstitute
6. Dr.BelaGanatra Scientist,DepartmentofReproductiveHealth&Research,WorldHealthOrganization,Geneva
7. Dr.PratimaMittal Professor&Head,DepartmentofObstetrics&Gynaecology,VMMC&SafdarjungHospital,New-Delhi
8. Dr.PoonamVarmaShivKumar
Professor&Head,DepartmentofObstetrics&Gynaecology,MGIMS,Sewagram,Maharashtra
9. Dr.VidushiKulshrestha AssistantProfessorDepartmentofObstetrics&Gynaecology,,AIIMS,NewDelhi
10. Dr.VinitaDas Professor&Head,DepartmentofObstetrics&Gynaecology,KingGeorge’sMedicalUniversity,Lucknow,UttarPradesh
11. Dr.SudhaPrasad Professor&Head,DepartmentofObstetrics&Gynaecology,MaulanaAzadMedicalCollege&Hospital,New-Delhi
12. Dr.AbhaSingh DirectorProfessor,DepartmentofObstetrics&Gynaecology,LadyHardingMedicalCollege,NewDelhi
13. Dr. Sudha Salhan Professor,DepartmentofObstetrics&GynaecologyNDMCMedicalCollegeandHinduRaoHospital,NewDelhi
14. Dr.SangeetaBatra Senior Director (Health Systems), Ipas DevelopmentFoundation
15. DrPushkarKumar LeadConsultant,MaternalHealth,MoHFW
16. DrRajeevAgrawal SeniorManagementConsultant,MaternalHealth,MoHFW
17. Dr. Tarun Singh Sodha Consultant(MaternalHealth),MoHFW
18. Ms.JenitaKhwairakpam Consultant(MaternalHealth),MoHFW
19. Dr.AshishBanerjee Consultant(MaternalHealth),MoHFW
20. Dr.SalimaBhatia SeniorConsultant(MaternalHealth),MoHFW
xviiHandbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Contents
Message ............................................................................................................................................... iii
Foreword .............................................................................................................................................. v
Preface ................................................................................................................................................vii
Acknowledgement ............................................................................................................................ ix
AbouttheHandbook ........................................................................................................................ xi
ListofAcronyms ............................................................................................................................. xiii
ListofContributors .......................................................................................................................... xv
IntroductiontoMedicalMethodsofAbortion(MMA) .................................................................1
Section 1: Medical Methods of Abortion - An Overview ..................................................................2
1.1:AdvantagesandLimitationsofMMA ......................................................................................2
Section 2: Law (MTP Act) and MMA ....................................................................................................3
2.1:EligibilityoftheProvider ............................................................................................................3
2.2:EligibilityofthePlace ..................................................................................................................3
2.3:DocumentationofMMAProcedure ..........................................................................................4
Section 3: Indications/Contraindications for MMA ...........................................................................5
3.1:IndicationsforMMA ...................................................................................................................5
3.2:ContraindicationsforMMA .......................................................................................................5
3.3:SpecialPrecautionsforMMA .....................................................................................................6
Section 4: MMA Drugs .............................................................................................................................7
4.1:DrugsusedinMMA ....................................................................................................................7
Section 5: MMA Protocol and Process ................................................................................................10
5.1:DrugProtocol ..............................................................................................................................10
5.2:ProcessofMMA..........................................................................................................................10
5.3:PostMMAContraception .........................................................................................................18
Section 6: Side Effects and Complications with MMA ...................................................................19
6.1:SideEffectsandtheirTreatment ..............................................................................................19
6.2:ComplicationsandtheirManagement ....................................................................................20
6.3.WarningSymptomsandSigns .................................................................................................22
xviii Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Section 7: Safety and Effectiveness .....................................................................................................23
Section 8: Comparison: VA and MMA Procedure ............................................................................24
Section 9: Suggested Agenda for MMA Reorientation ...................................................................26
References .................................................................................................................................................27
AnnexuresAnnexure1:MedicalMethodsofAbortionSkillsChecklist .............................................................28
Annexure2:EssentialEquipmentandSuppliesforMMA ................................................................31
Annexure3:MMA:DocumentationFormats ......................................................................................32
Annexure4:MMAFollow-upCard ......................................................................................................36
Annexure5:MedicalMethodsofAbortion(MMA)Reorientation PreandPost-trainingAssessment ..............................................................................................37
1Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Introduction to Medical Methods of Abortion (MMA)
Unsafeabortionsmakeasignificantcontributiontomaternalmorbidityandmortality.AsperSRS2001-03,abortion-relateddeathsaccountfornearlyeightpercentofallmaternaldeathsinIndia,whichtranslatestoabout3,520deathsannually.Numerousbarrierslimitaccesstosafeabortionservicesincludingshortageoftrainedproviders;lackofinfrastructureatthefacilities;andlackofinformationaboutlegalityandavailabilityofservicesamongwomenandthecommunity.
MedicalMethodsofAbortionisoneofthesafetechnologiesforabortioncarewhichoffersanopportunitytoincreaseaccesstoabortioncareservicesespeciallyinearlypregnancy.Itcanbeofferedatalllevelsofhealthcare,includingprimarylevels.Itcanalsobeprovidedonanoutpatientbasis.MMAisanon-invasivetechnologyandsimplifiestherequirementsofplaceandequipmentrequiredforvacuumaspirationprocedures.
MMAcanbeusedatvariousstagesofpregnancyincludingsecondtrimester,butthefocusofthismanualisonearlypregnancyuptosevenweeks,asapprovedundertheMTPRules,2003.
Abortion should never be used as a method of family planning.
2 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
MMAisanon-surgical,non-invasivemethodforterminationofpregnancybyusingadrugoracombinationofdrugs.Itprovideswomenwithanotheroptionforterminationofpregnancy,andshouldbeofferedinadditiontoothersafeabortionmethodswheneverpossible.
1.1: Advantages and Limitations of MMA
MMAisoneofthesafetechnologiesavailableforpregnancytermination.Itisanon-surgicalmethodforearlyabortionsandhasbothadvantagesaswellaslimitationsoverothermethodsofpregnancytermination.
Advantages of MMA
1. Abortioncanbeofferedatanearlystageofpregnancy
2. Potentiallymoreprivate,beingsimilartoanaturalmiscarriage
3. Non-surgicalmethodofabortion,andhencenon-invasive
4. Noanaesthesiarequired
5. Limitedinfrastructureneeded,canbeofferedinsettingswherevacuumaspirationmaynotbepossible
Limitations of MMA
1. AminimumofthreeclinicvisitsarerequiredduringtheMMAprocess
2. Bleedingmayoccurfor8-13days
3. Theremaybesideeffectsofthedrugs
4. OnceMMAdrugsaretaken,pregnancyhastobeterminated,sinceifpregnancycontinues,thereisariskoffoetalmalformation.
1Section
Medical Methods of Abortion - An Overview
3Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
AlthoughMMAisnotasurgicalintervention,beingterminationofpregnancy,itfallsunderthepurviewoftheMTPAct1971.
2.1: Eligibility of the Provider
IncaseofterminationofpregnancyusingMifepristoneandMisoprostol,onlyaRegisteredMedicalPractitioner,asdefinedbytheMTPAct,canprescribethedrugs.
‘Registered Medical Practitioner (RMP)’meansamedicalpractitionerwhopossessesanyrecognizedmedialqualificationasdefinedinclause(h)ofsection2oftheIndianMedicalCouncilAct,1956(102of1956);whosenamehasbeenenteredinaStateMedicalRegister;andwhohassuchexperienceortrainingingynaecologyandobstetricsasmaybeprescribedbyRulesunderthisAct.
TheMTPRules,2003,requirethatanRMPshouldhaveoneormoreofthefollowingexperienceortrainingingynaecologyandobstetrics:
1. post–graduatedegreeordiplomainObstetricsandGynaecology.
2. completedsixmonthsasHouseSurgeoninObstetricsandGynaecology.
3. atleastoneyearexperienceinthepracticeofObstetricsandGynaecologyatanyhospitalthathasallfacilities.
4. assistedanRMPin25casesofmedicalterminationofpregnancyofwhichatleastfivehavebeenperformedindependentlyinahospitalestablishedormaintainedbythegovernmentoratraininginstituteapprovedforthispurposebythegovernment.
2.2: Eligibility of the Place
InaccordancewiththeMTPAct,noterminationofpregnancyshallbemadeatanyplaceotherthan–
a) ahospitalestablishedormaintainedbyGovernment,or
b) aplaceforthetimebeingapprovedforthepurposeofthisActbyGovernmentoraDistrictLevelCommittee(DLC)constitutedbytheGovernment,withtheChiefMedicalOfficerorDistrictHealthOfficerastheChairpersonofthesaidCommittee.
2Section
Law (MTP Act) and MMA
4 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
ItshouldbenotedthattheDistrictLevelCommitteeshallconsistofnotlessthanthreeandnotmorethanfivemembersincludingtheChairperson,asspecifiedbytheGovernment.
IncaseofterminationofearlypregnancyuptosevenweeksusingMifepristoneandMisoprostol,RMPasundertheMTPAct,canprescribethedrugsathis/herclinicprovidedhe/shehasaccesstoaplaceapprovedforterminatingpregnancyundertheMTPAct.
The clinic should display a certificate to this effect from the owner of the approved place. In other words, the clinic where medical abortion drugs are prescribed by an RMP as under the MTP Act, does not need site approval as long as it has referral linkage to an MTP approved site.
2.3: Documentation/Reporting of MMA Procedure
SinceMMAcomesunderthepurviewofMTPAct,thedocumentationissimilartothatrequiredforvacuumaspirationprocedure.ItismandatorytofillandrecordinformationforabortioncasesperformedbyMMAinthefollowingforms:
1. FormC–ConsentForm
2. FormI–RMPOpinionForm
3. FormII–MonthlyReportingForm(tobesenttothedistrictauthorities)
4. FormIII–AdmissionRegisterforcaserecords
AlldocumentationformatsareattachedasAnnexure–3
Followingarethekeyconditions/requirementsofMTPusingmedicalmethods,undertheMTPAct:
• Itcanbeperformedonlybycertifiedabortionproviders
• It can be performed for gestation age up to sevenweeks, from approved sites aswell asclinicofaRMPwithreferrallinkages,providedacertificateofaccesstoanapprovedsiteisdisplayed
• Alldocumentationformats,filledforvacuumaspiration,aretobefilledforMMAalso.
5Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
3.1: Indications for MMA
OptionforMMAshouldbegiventoallwomencomingtoahealthfacilityseekingterminationofpregnancyupto7weeksofgestation(49daysfromthefirstdayofthelastmenstrualperiodinwomenwithregularcyclesofapproximately28days)1
Figure 1: MMA Drugs (Mifepristone and Misoprostol)
3.2: Contraindications for MMA Women being prescribed MMA should be screened for the following common contraindications:
• Anaemia(haemoglobin<8gm%)
• Confirmedorsuspectedectopicpregnancy/undiagnosedadnexalmass
• UncontrolledhypertensionorBP>160/100mmHg
3Section
Indications/Contraindications for MMA
1InDecember2008,CombipackwithMifepristone+Misoprostol(1tabletofMifepristone200mgand4tabletsofMisoprostol200mcgeach)wasapprovedbytheCentralDrugsStandardControlOrganization,DirectorateGeneralofHealthServices,India,fortheterminationofintra-uterinepregnancyforupto63days/9weeksgestation.
CACTraining&ServiceDeliveryGuidelines,2010byMoHFW,GoIrecommendsitsuseupto49daysinpublicsectorsites,inlinewiththeMTPRules2003.
AproposedamendmenttotheMTPAct,1971,toincreasethegestationlimitforMMAto9weeksinpublicsectorsitesisunderprocess.Tilltheproposalisapproved,MMAinpublichealthfacilitywouldbeallowedonlyupto7weeks.
6 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
• Knowncasesof:
• Heartproblemssuchasangina,valvulardisease,arrhythmiawhichcanleadtosuddencardiovascularcollapse
• Renal, liver or respiratory disease (Bronchial asthma is not a contraindication sinceMisoprostolisabronchodilator)
• Currentlong-termsystemiccorticosteroidtherapy
• Uncontrolledseizuredisorder
• Chronicadrenalfailure
• HypersensitivitytoMifepristone/Misoprostolorotherprostaglandins
• Inheritedporphyrias
3.3: Special Precautions for MMA
Besides absolute contraindications for MMA, there are conditions where caution has to be exercised. Such conditions are enumerated below:
1. WomennotsureaboutLMPorwithlactationalamenorrhea
2. Pregnancy with IUCD in situ: IUCDtoberemovedbeforegivingMMAdrugs
3. Pregnancy with uterine scar: Althoughsafe,exercisecautionwithhistoryofLSCS,hysterotomyormyomectomy
4. Pregnancy with fibroid: Large fibroid encroaching on endometrial cavity can cause heavybleedingandcaninterferewithuterinecontractility
5. Women on anti-tubercular drugs:Rifampicinisaliverenzymesinducingdrug,whichcanleadtoincreasedmetabolismandhencedecreasedefficacyofMMAdrugs
6. Breastfeeding: WomenhavetowithholdfeedingforfourhoursafterMisoprostoladministration
7Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
4.1: Drugs Used in MMA
RecommendeddrugsforMMAareMifepristoneandMisoprostol.
MMA drugs are Schedule H drugs and are to be sold by retail on the prescription of a Registered Medical Practitioner only.
Mifepristone isanantiprogestin,whichblockstheprogesteronereceptorsintheendometrium,causingthenecrosisofuterinelininganddetachmentofimplantedembryo.Itcausescervicalsofteningandanincreasedproductionofprostaglandins,causinguterinecontractions.Asmallpercentageofwomen(3%)mayexpelproductsofconception(POC)withMifepristonealone.
Misoprostol isasyntheticprostaglandinE1analogue.Itbindstothemyometrialcells,causingstronguterinecontractions,cervicalsofteninganddilatation.ThisleadstotheexpulsionofPOCfromtheuterus.Misoprostolhasanadvantageoverotherprostaglandinsasitiswellabsorbedfromdifferentroutesofadministration,iseconomical,andstableatroomtemperaturesincomparisontoPGF2alphaderivatives.
Itwasearlierusedforpreventionandtreatmentofgastriculcer.
Action of Misoprostol through different routes of administration:
Sublingual: Rapidonsetofaction(likeoralroute)andlongerdurationofaction(likevaginalroute);
Figure 2: Sublingual administration of Misoprostol
4Section
MMA Drugs
8 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Buccal: Onsetanddurationofactionisquitesimilartothevaginalroutealthoughtheserumlevelsachievedarelower.
Figure 3: Buccal administration of Misoprostol
Vaginal: Gradualonsetbutlongerdurationandsustainedaction.Misoprostoltabletsonvaginaladministrationmaynotcompletelydissolve.Asthecoreofthetabletisnon-medicated,thisdoesnotaffectitsefficacy.Moisteningthetabletbeforevaginaladministrationdoesnotimproveefficacy(ACOG,2009)
Figure 4: Vaginal administration of Misoprostol
Oral: Rapidonsetbutshorttotaldurationofaction
Figure 5: Oral administration of Misoprostol
9Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Figure 6: Graph comparing pharmacokinetics of Misoprostol administered by different routes
Table 1: Effectiveness of Misoprostol administered by different routes
Route of Administration
Onset of Action
Duration of Action Preferred/Recommended Route
Sublingual Fastest Highestplasmalevelsandprolongedaction
Mostrecommended
Buccal Quick Prolongedaction RecommendedVaginal Quick Prolongedaction Recommended Oral Quick Leastduration Leastrecommendedbutstillcanbegiven
10 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Thestepsoftheprocedurearedividedbelowonthebasisofthedayofthevisit.Typicallyitrequiresthreevisits(Day1,3and15)whentheMMAdrugsareusedbythewomanandtoconfirmthecompletionoftheabortionprocess.
5.1: Drug Protocol
Table 2: MMA Drug Protocol
Visit Day Drugs usedFirst One • 200mgMifepristoneoral;
• Anti D 50 mcg, if Rh negative (give 300 mcg if 50mcg notavailable
Second Three • 400mcgMisoprostol(twotabletsof200mcgeach)sublingual/buccal/ vaginal /oral;
• Analgesics(Ibuprofen);
• Antiemetic;
• OffercontraceptionThird Fifteen • Confirmandensurecompletionofabortion;
• Offercontraception,ifnotalreadydoneso
5.2: Process of MMA
First Visit/Day 1/Day of Mifepristone Administration
Firstvisitstartswithassessingthesuitabilityofthewomantoundergomedicalmethodsofabortion.Suitabilityisjudgedbyconductingaclinicalexamination,necessaryinvestigationsandexcludingthecontraindications.
FirstvisitmaysometimesnotbethedayofMifepristoneadministration.ItisthedayofMifepristoneadministrationwhichistakenasDay1.
5Section
MMA Protocol and Process
11Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
1. Detailed History
a) Demographicprofile:age,religion,addresstobenoted
b) Menstrualhistory:length&durationofcycle,flow(excessornormal),LMP
c) Obstetrichistory:parity,livebirths,abortion(inducedandspontaneous),previouscaesareansection(ifany),lastchildbirth/abortion,presentlylactatingornot
d) Historyofpre-existingmedical/surgicalconditions:
• Hypertension
• Heartdisease
• Diabetesmellitus
• Epilepsy
• Asthma-notacontraindicationwithPGE1
• Renaldisease
• Drugallergies
• Bleedingdisorders
• Currentmedication
• Previousuterine/tubal/abdominalsurgery/ectopicpregnancy
• Treatmentforinfertility/Tuberculosis/pelvicinflammatorydisease
e) Historyofanyinterference/drugstakeninthispregnancytoattempttermination
f) Contraceptivehistory:typeanddurationofcontraceptiveused
g) Statusoftetanusimmunization:lastdosereceived
h) Psychosocialassessment–toassessfamilysupport
i) Historyofsexualassaultanddomesticviolence
2. Counselling: General and Method-specific Counselling
General Counselling
While counselling, attention must be paid to the following points:
• Tellheraboutallthemethodsavailableforabortionandhoweachmethoddiffersfromtheother.
• Askaboutherexistingknowledgeandbeliefsaboutabortionoptions.
• Discusshercontraceptiveneedsandcounselheraccordinglyforcontraceptionafterabortion.
• Discussinfectionpreventionaspectslikelocalhygiene,handwashinganduseofcleansanitarynapkins,etc.
12 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Figure 7: Counselling on MMA procedure
Method-specific Counselling
IfthewomanchoosesMMA,sheshouldbeprovidedthefollowinginformation:
a) Itisanon-invasiveandnon-surgicalmethod
b) Theprocessissimilartoanaturalmiscarriage
c) Sheneedstomakeaminimumofthreevisitstothefacility(day1,3,&15).HomeadministrationofMisoprostolisallowedonprovider’sdiscretion.Insuchcases,thenumberoffacilityvisitswillreducetotwo.
d) Shehastofollowadefinitedrugprotocol
e) Counsellingaboutdifferentroutesofadministration
f) ShehastobereadyforVAprocedureincaseoffailureofthemethodorexcessivebleeding(soakingtwoormorethickpadsperhourfortwoconsecutivehours)
g) Shehastostaywithintheaccessiblelimitsoftheappropriatehealthcarefacility.Sheshouldnotbeleftunattendedathome
h) Explainthesymptomsthatwouldbeexperiencedbyher,forexample:
• Bleeding per vaginum is an essential part of the MMA process since it is similar tomiscarriage. Bleeding is usually heavier thanwhat is experiencedduring amenstrualperiod.Bleedingoftenlastsfor8to13days.SoakingoftwothickpadswithinonetotwohoursaftertakingMisoprostol,butdecreasingovertimeisconsiderednormal.
• AbdominalpainisexperiencedasapartoftheMMAprocess.Refrainfromdescribingcramping pain as similar to labour pains. Instead, it can be compared with severemenstrualcramps.SometimesthepainbeginsfollowingingestionoftabletMifepristone,butmostoftenitstartsonetothreehoursafterMisoprostoladministrationandisheaviestduringtheactualabortionprocess,oftenlastinguptofourhours.Ifthepainispersistent,thepossibilityofectopicpregnancyshouldalwaysberuledout.
• Nausea,vomiting,diarrhoea,etc.arenormalsideeffectsofdrugs.
i) Therecouldbeteratogenic(harmful)effectonthefetus,ifpregnancycontinues
j) Asmallpercentageofwomen(3%)mayexpelproductswithMifepristonealone,but totaldrugschedulewithMisoprostolmustbecompleted
k) Duringtheabortionprocess,itisidealtoavoidintercoursetopreventinfection,orusebarriermethods
13Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
l) Womenwithnosupportathome:arrangementsshouldbemadefor transportation to thehospital,incaseofemergencyorshouldbeadmittedfortheMMAprocedure.
3. General Physical, Systemic, Abdominal and Pelvic Examination
a) Check for pallor: if pallor exists, heavy bleeding during the procedure may worsen theconditionandincreasetheriskofshockandillhealth.
b) Bloodpressure;cardiovascular;andrespiratorysystemforanypre-existingdisease
c) Lookforanymass,rigidity,tendernessinabdominalexamination
d) CarryoutPelvicexamination(P/SandP/V)
Figure 8: Performing bimanual examination
• P/Sexamination:lookforinfection,cervicalerosion,polyp
• P/Vexamination:checkthesize,shape,regularityandconsistencyofuterustoconfirmtheperiodofgestationandadenexalmass
• Ruleoutectopicpregnancy2,incaseofadenexalmass/fullnessortendernessinadenexaorcervicaltenderness.
2Ectopicpregnanciescanbediagnosedwithacarefulhistory,examinationandUSG.SinceitisanobstetricUSG,itmustbedoneinaccordancewithPCPNDTAct.
Symptoms during ectopic pregnancy might include:•Amenorrhea•Nausea,vomiting•Lowerabdominalpain,usuallyone-sided,thatmaybesuddenandintense,persistent,orcramping• Irregularvaginalbleedingorspotting• Faintingordizzinessthatpersistsformorethanafewsecondsispossiblyindicativeofinternalbleeding.Internalbleedingisnotnecessarilyaccompaniedbyvaginalbleeding
Signs•Uterinesizethatissmallerthanexpected•Palpableadenexalmass•Tendercervicalmovements Inadditiontotheabovesymptomsandsigns,ruleoutectopicpregnancywhileperformingvacuumaspirationifnoPOCevacuatedaftertheprocedure
Whenectopicpregnancyissuspected,referthewomanassoonaspossibletoahigherfacilityforconfirmationofdiagnosisandinitiatingtreatment.Uterine evacuation methods whether vacuum aspiration or medical methods using Mifepristone and Misoprostol, cannot terminate an ectopic pregnancy and hence should not be attempted in case of suspicion.
14 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
4. Contraceptive Options
Woman’sacceptanceforcontraceptivemethodshouldnotbeapre-conditionforprovidingabortionservices.Allpostabortioncontraceptiveoptionsshouldbediscussedwithherandsheshouldbehelpedtochoosetheappropriatecontraceptionforherself.
5. Investigations (Recommended)
• Haemoglobin
• Routineurineexamination
• BloodGroup:ABORhespeciallyinprimigravida.
• Pregnancytest
Investigations (Optional)
Ultrasonography (USG): ItisnotmandatorytoperformUSGforallwomenundergoingterminationofpregnancywithmedicalmethods.Itcan,however,beperformedunderfollowingconditions:
• WomenunsureofLMPorhaveconceivedduringlactationalamenorrhea
• Womenwithdiscrepancybetweenhistoryandclinicalfindings
• Womenwithsuspicionofectopicpregnancy
• Provideruncertainafterbimanualexamination,or inabilitytomeasureuterinesizeduetoobesity,pelvicdiscomfort,oranuncooperativewoman
6. Informed Consent
Gettheconsentofthewoman/guardianinFormC.AlsofillintheRMPOpinionForm(FormI),beforeprescribingMMAdrugs.
7. Tablet Mifepristone (200mg) is administered orally
Anti-D(50mcg)giventoRhnegativewoman.
8. Iron and Folic Acid Tablets
180tablets(tobetakenfornextsixmonths)shouldbegiventoallwomenundergoingMMAprocedure.
9. Sanitary Napkins
TwopacketsofsanitarynapkinscouldbeprovidedtoallwomenundergoingMMA.
15Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
10. Antibiotics
Routineuseofprophylacticantibioticsisnotindicatedexceptincasesofnulliparouswomen.Antibioticsshouldalsobegiventowomenwithvaginalinfections.RecommendedantibioticsareDoxycycline100mg,twiceadayforfivedaysfornon-lactatingwomen,andAzithromycin500mg,onceadayforthreedaysforlactatingwomen.
11. Give contact address and phone number oftheserviceprovider/facilitywherewomancangoincaseofanemergency.
12. Complete the MMA follow-up card
ExplaintheMMAfollow-upcard(Annexure4)tothewomanandinstructhertonotedownhersymptomsonit.
Atthesolediscretionoftheserviceprovider,awomancanbegivenMisoprostoltobetakenathome.Insuchcases,athoroughcounsellingonwhatisexpectedaftertakingMisoprostol,shouldbedone.Sheshouldbecalledbackon15thdayforfollowup.
ThetablebelowsummarizesthetasksforDay1oftheMMAprotocol:
Table 3: Tasks for Day 1/Day of Mifepristone Administration
Provider’s task Instructions to the woman• Detailed history, rule out contraindications and
notespecialprecautions
• Generalcounselling
• MMAspecificcounselling
• Discusscontraceptiveoptionswithher
• Completephysicalandpelvicexamination
• ObtaininformedconsentinForm-C.
• FillinFormI.
• Recordinvestigations
• TabletMifepristone200mg,tobetakenorally
• CompleteMMAfollow-upcard
• Give contact address and phone number for anyemergency
• Give180tabletsofIronandFolicAcid
• Give2packetsofsanitarynapkins
• RecorddetailsinAdmissionRegister
• ExplainwhattoexpectaftertakingtabletMifepristone
• She must return for Misoprostoladministration after two days(unless the service providerdecidesforhomeadministrationofMisoprostol)
• She may have pain and bleedingduringthesetwodays
• TaketabletIbuprofentorelievethepain
• Avoid intercourse or use barriermethod,suchascondoms
• Report to the center/provider incase of excessive bleeding/acuteabdominalpain
• RecordanyexperienceofsideeffectsontheMMAfollow-upcard
16 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Second Visit/Day 3/Day of Misoprostol Administration
1) Note any history of bleeding/pain or any other side effects after tablet Mifepristone: Some womenwillstartbleedingaftertheadministrationoftabletMifepristone.
2) Administer Misoprostol:Askthewomantoemptythebladder.Give/inserttwotabletsof200mcgMisoprostol(total400mcg)bysublingual/buccal/vaginal/oralroute.Askhertolieinbedforhalfanhouraftervaginalinsertion.
Ifshevomitstabletmisoprostolwithinhalfanhourofitsintake,thesamedosage(400mcgmisoprostol)shouldberepeated.
3) Observe the woman for four hours after Misoprostol administration in the clinic/hospital and monitor:
i. Pulseandbloodpressure
ii. Timeofstartofbleedingandexpulsionofproducts(ifitoccurs)
iii. Sideeffectsofthedrugs(e.g.chills)
4) Medication for pain relief: Usually the pain starts within one to three hours of takingMisoprostol,soanalgesiccanbetakenwell intimebeforepainbecomesintolerable.Tablet Ibuprofen 400 mg is recommended.ParacetamolisnotrecommendedforpainreliefduringtheprocessofMMA.Ifpaindoesnotsubsideontakingdrugs,thepossibilityofectopicpregnancyshould be ruled out. Receiving complete informationduring counselling and reassuranceduringtheprocesshelpsthewomantotoleratepainbetter.
5) Perform pelvic examinationbeforethewomanleavestheclinicandifcervicalosisopenandproductsarepartiallyexpelled,removethemdigitally.SheshouldbeobservedforanotherfewhoursortilltheexpulsionofthePOCiscomplete
6) In case the woman does not abort at the health centre or takes Misoprostol at home, inform her about:
• Reporting back to the center/service provider in case of excessive bleeding/acuteabdominalpain
• Warningsignsandsymptoms(givenonpage22)
• Usingcleansanitarynapkins
• Avoidingtamponsanddouche
• Reportingback if there isnobleedingeven24hoursafter takingMisoprostol (refer tofigure9fornextsteps)
• Sideeffectssuchasnausea,vomiting,diarrhoea(usuallymild),headache,fever,dizziness
• Returningforfollow-uponthe15thday
• KeepfillingtheMMAfollowupcard
17Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Figure 9: Plan of action if there is no bleeding 24 hours after administration of Misoprostol
The table below summarizes the tasks for Day 3 of the MMA protocol:
Table 4: Tasks for day 3/Day of Misoprostol administration
Provider’s task Instructions to the woman• Note bleeding/pain or other side
effectsaftertabletMifepristone
• Give two tablets of Misoprostol (400mcg) sublingual/buccal/vaginal/oral
• Observeherforfourtosixhoursintheclinic
• Prescribe tablet Ibuprofen for painrelief
• Bimanual examination just beforedischargefromthefacility
• Antiemetic and anti-diarrhoeal drugs could be prescribed
• Explain what to expect after takingMisoprostol
• OCP can be started, if chosen as acontraceptivemethod
• Lieinbedfor30minutesaftervaginalinsertionofMisoprostol
• She can have side effects such as nausea,vomiting,diarrhoea,headache,fever,dizziness,fatigue
• Avoidintercoursetillbleedingstops
• Usecleansanitarynapkinsandavoid tamponsand douche
• Avoidgoingoutofstationtillthirdvisit
• She should report in case of:
• Nobleeding24hoursafterMisoprostolintake
•Excessive bleeding, i.e. soaking twoormorethickpadsperhourfortwohourscontinuously
• Fever more than 24 hours after Misoprostoladministration
• Returnforfollow-uponthe15thday
• KeepfillingtheMMAfollow-upcard
18 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Third Visit/Day 15/Follow-up Visit
1) Noterelevanthistory/checkMMAfollow-upcard
2) Carry out pelvic examination to ensure completion of abortion process/continuation ofpregnancy
3) Reiteratecontraceptivecounsellingandservices
4) AdviseUSGif
• completeexpulsionofPOCnotconfirmed
• continuationofpregnancysuspected
• bleedingcontinues
5) Askthewomantoreportbackiftherearenoperiodswithinsixweeks
ThetablebelowsummarizesthetasksforDay15oftheMMAprotocol:
Table 5: Tasks for Day 15/Follow up visit
Provider’s task Instructions to the woman• Note history of bleeding/pain in abdomen/
expulsionofPOC
• Pelvic examination to rule out continuation ofpregnancy.USG,ifindicated
• Reiteratecontraceptivecounsellingandservices
• Contraceptiveadviceasperthemethodchosen
• Report back if there are no periodswithin sixweeksof the completionoftheabortionprocess
5.3: Post MMA Contraception• Hormonalmethods,whethercombined(estrogenandprogestogen)orprogestin-only,canbe
startedonthedayoftheMisoprostoladministration(day3)orday15oftheMMAregimen.InjectablehormonalmethodslikeDepotMedroxyProgesteroneAcetate(DMPA)canalsobestartedonday3or15oftheMMAregime.
• IUCDcanbeinsertedafterconfirmedcompleteabortion,providedthepresenceofinfectionisruledout,onday15.
• Condomscanbeusedassoonassheresumessexualactivityafterabortion
• Tuballigationcanbedoneafterthefirstmenstrualcycle.However,ifdesirousofconcurrenttuballigation,vacuumaspirationispreferred
• Vasectomy,ifchosen,canbedoneindependentoftheprocedure
19Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
6.1: Side Effects
Figure 10: Side effects with MMA drugs – headache, vomiting
Common side effects experienced with MMA are:
a) Gastrointestinalsideeffects
b) Fever,warmthandchills
c) Headacheanddizziness
• Gastrointestinal Side Effects: Diarrhoea,nauseaandvomitingarecommonlyreportedbywomenfollowingtheuseofMisoprostol.Thesesideeffectsaremildandself-limitingandpassoffwithoutanytreatment.Antiemeticandanti-diarrhoealmedicinesmaybeprescribedwhenneeded.ORScanbegivenifvomitingordiarrhoeaissevere.Tab.Loperamidemaybeprescribedfordiarrhoea.(butwithcaution)
• Fever, Warmth and Chills: Fever, feeling of warmth and chills are short-lived and self-limitingsideeffects.Treatmentisgenerallynotrequiredbutthewomanshouldknowthatshemayexperience thesesymptoms.Post-abortion infection is rareafterMMA.Persistentfever(>38°cfortworeadingsfourhourapart)mayindicateinfectionandmustbeevaluatedandtreatedaccordingly.
6Section
Side Effects and Complications with MMA and their Management
20 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
• Headache and Dizziness: SomewomenduringtheprocessofMMAreportheadacheanddizziness. Headache is treated with non-narcotic analgesics and mild dizziness of shortduration is managed by hydration. Advise the woman to take plenty of fluids, rest andexercisecautionwhilechangingposition.
6.2: Complications and their Management
Potential complications associated with MMA are:
A. Excessivevaginalbleeding
B. Incompleteabortion
C. Continuationofpregnancy
D. Infection
Table 6: Incidence of complications in MMA
Complications IncidenceHeavybleedingrequiringvacuumaspiration 1–2%Incompleteabortionrequiringothermethodsofevacuation 1–2%Continuationofpregnancy 1–2%Heavybleedingrequiringbloodtransfusion 0.1–0.2%
A. Excessive Vaginal Bleeding
• Soakingtwoormorethickpadsperhourfortwoconsecutivehoursneedclosemonitoringofthewoman.Inthiscondition,sheshouldreporttothefacility.Conductexamination,includingbimanualexamination,toruleoutincompleteabortionandassessforhypovolemia.
• Fluidreplacement:IVinfusionwithRingersLactatesolution30dropsperminuteshouldbestarted.Simultaneously,prepareforevacuationoftheuterus.Insomecases,bloodtransfusionmayberequired.
B. Incomplete Abortion
• Generally,thereisexcessive/continuedbleedinginthecaseofincompleteabortion.Assesshervitalparameters:
1. Ifherconditionisunstable,resuscitateandstabilize.Stabilizationshouldbefollowedbyexaminationandfurthermanagement.
2. Ifherconditionisstable,proceedwiththeexamination:
a. IfPOCisfeltattheos,managewithdigitalevacuationorwithovumforcepsfollowedbyvacuumaspiration
b. Ifnoproductsarefeltattheos,decidethelineofmanagementbasedontheclinicalsymptoms,pelvicexaminationandUSGfindings:
21Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
i. If the gestation sac is visible but is non-viable, then an additional dose of Misoprostol (dosage given below) may be offered to the woman. Wait for the pregnancy to be expelled with time. The woman should be counselled to return to the clinic after one week to ensure that the abortion is complete.
One dose of Misoprostol 600 mcg oral or 400 mcg sublingual can be repeated in such cases of incomplete abortion. If bleeding continues even after an additional dose of Misoprostol, perform vacuum aspiration.
ii. If no gestation sac is visible on USG but bleeding continues due to decidual bits in the uterine cavity, manage conservatively, without any medication or intervention as these are expelled spontaneously in most cases. An additional visit after seven days will have to be planned to ensure completion of the process.
If bleeding is profuse at any time during this process, vacuum aspiration may have to be done.
iii. If USG shows viable gestation sac, pregnancy should be terminated by vacuum aspiration.
Treatment of Incomplete Abortion
22 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
C. Continuation of Pregnancy
IfthepregnancycontinuestogrowdespitetakingdrugsforMMA,itindicatesthatthedrugswereineffective.Insuchcases,thepregnancyhastobeterminatedbyvacuumaspirationinviewoftheteratogeniceffectofthedrugs3.
D. Infection
InfectionofuterusisrareintheprocessofMMA.Ifthewomanhassymptomssuchasfever,chills,foul-smellingdischargeorbleedingandpaininlowerabdomen,uterineinfectionmaybesuspected.StartbroadspectrumantibioticsassoonaspossibleandremovethePOC,usingvacuumaspiration.TherecommendedantibioticsareDoxycycline100mg,twiceadayforfivedaysfornon-lactatingwomen,andAzithromycin500mg,onceadayforthreedaysforlactatingwomen.
6.3: Warning Symptoms and Signs
ThewarningsymptomsandsignsduringtheMMAprocess,forwhichsheshouldimmediatelycontacttheserviceproviderorfacilityshouldbeexplainedtothewoman.Signsandsymptomsareasbelow:
• Excessivebleeding,soakingtwothickpadsinanhourfortwoconsecutivehours
• Persistentseverepainabdomen
• Faintingattacks
• No/minimalbleedingaftertheadministrationofMisoprostol
• NoperiodsaftersixweeksofthecompletionofMMAprocess
3DataoncontinuingpregnancyafterMifepristoneexposurewithoutMisoprostolarelimited.TheassociationbetweenMisoprostolandcongenitalanomaliesisbetterestablished.ThemosttypicalmalformationsassociatedwithMisoprostoluseareMöbiussyndrome,araredisorderofcranialnervepalsiesassociatedwithlimbanomaliesandcraniofacialdefects,andterminaltransverselimbdefects.Althoughnotclearlyestablished,theproposedmechanismisvasculardisruptionduetouterinecontractionsleadingtodisorderedfetaldevelopment
23Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
7.1: Safety
MifepristoneandMisoprostolaresafedrugsforterminatingpregnancyaslongasthewomandoesnothaveanycontraindicationsfortheiruse.
7.2: Effectiveness
AcombinationofMifepristoneandMisoprostolhasaneffectivenessof95–99%forterminationofearlypregnancyuptosevenweeks.
Failed abortion:Womenwithcontinuedsignsofpregnancyorclinicalsignsoffailedabortionshouldbeofferedvacuumaspirationasexpeditiouslyaspossible.
Vacuumaspirationmaybeneededincasesof:
• Ongoingpregnancy
• Excessivebleeding
• Ifabortionprocessisincompleteatthetimeoffollowupvisitandtheserviceproviderorthewomandoesnotwanttowaitanylonger
7Section
Safety & Effectiveness
24 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Though,bothvacuumaspirationaswellasmedicalmethodsaresafetechnologies,bothhavetheirdistinctfeatures.Keyfeaturesareenumeratedbelow:
Table 7: Comparison of VA and MMA
Feature Vacuum Aspiration Medical Methods of AbortionTechniqueused POCevacuatedthrougha
cannulaattachedtovacuumsource(manualorelectric)
POCexpelledwithdrugs(Mifepristone&Misoprostol);anon-surgicalmethod
Gestationlimitofthetechnique
Usedupto12weeksofpregnancy
Usedupto7weeksofpregnancy(forpublicsectorsites)
Effectiveness Morethan98%effective 95-99%effectiveTimetakenforprocedurecompletion
5-15minutes Inmajorityofcases,processofabortiongetscompletedwithin4–6hoursofMisoprostoladministration.However,thebleedingmaycontinueupto8–13daysinsomecases.
POC Check POC are examined and confirmedimmediately
POCmaybeexpelledathome
Mandatoryvisitsfortheprocedure
Onevisit Requireminimum3visits(2visitsincaseofhomeadministrationofMisoprostol)
Paincontrolmedicationused
Localanaesthesia&oralanalgesics
Ibuprofengivenorally
Proceduredoneby Trainedhealthcareprovider
Drugsprescribedbytrainedhealthcareprovider
Riskofcervicalanduterineinjury
Possiblebutrare Noriskofinjurytocervixanduterussincenoinstrumentationisdone
Post-procedurebleeding
Minimal* Post–medicationbleedingcouldbeheavy(esp.afterMisoprostol)*
8Section
Comparison: VA and MMA Procedure
*ThoughbleedingisheavyafterMisoprostoladministrationinMMA,overallbloodlossiscomparableinVAandMMA.
25Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Feature Vacuum Aspiration Medical Methods of AbortionPost–procedurepain
Remainsforaveryshortperiod
Paincouldbeintenseduringtheactualprocessofexpulsion
Hospitalstay Fewhours FewhoursoneachvisitRiskoffetalmalformation
None Potentialriskexists,ifthemethodfailsandpregnancycontinues
Acceptabilitytowomen
• doneasadaycare-procedure
• womanawakeduringtheprocedure
• non-invasivetechnology
• moreprivate;closetonaturalmiscarriage
• nohospitalization
26 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Reorientation on Medical Methods of Abortion
Suggested Agenda
Time Topic9.30–10.00a.m. Registration,Pretest10:00–10:15a.m. Objectiveoftheworkshop
BriefontheMMAhandbook10.15–10.45a.m. OverviewofMMA10.45–11.15a.m. MTPAct&MMA11.15–12.00Noon MMAprocessandprotocol
Sideeffectsandfollow-up12.00–12.45p.m. Counsellingandeligibilityscreening12.45–13.30p.m. Casestudiesformanagementofcomplications13.30–14.15p.m. Demonstration ofMMA follow-up card,MMA ready reckoner,MMA
sitesignage,Documentationformats14.15–14.30p.m. Posttest14.30 p.m. Discussion&Questions
9Section
Suggested MMA Reorientation Schedule (For MTP certified providers)
27Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
References
• WorldHealthOrganization(WHO)2012.Safeabortion:Technicalandpolicyguidanceforhealthsystems.Geneva,WHO.
• Ministry of Health & Family Welfare (MoHFW), Government of India: ComprehensiveAbortionCareTrainingandServiceDeliveryGuidelines2010(2ndedition2014).MoHFW.
• Ministry of Health & Family Welfare (MoHFW), Government of India: ComprehensiveAbortionCareTrainingPackage,2014.MoHFW.
• World Health Organization (WHO) 2014: Clinical practice handbook for Safe Abortions.GenevaWHO.
• Prof Suneeta Mittal, Director in charge, WHO CCR in Human Reproduction, All IndiaInstitute of Medical Sciences, MoHFW, Government of India, 2007: Guidelines for earlymedicalabortioninIndiausingMifepristoneandMisoprostol.
• ShaguftaPraveenetal:Comparisonofsublingual,vaginal,andoralmisoprostolincervicalripeningforfirsttrimesterabortion.IndianJPharmacol.2011Apr;43(2):172–175.
• SOGSclinicalpracticeguidelinesNo.133,September2003.
28 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Annexure – 1Medical Methods of Abortion: Skills Checklist
Day 1: Skills for first visit to clinic (Mifepristone administration) Yes NoPre-procedure tasksGreetsthewomaninafriendly,respectfulmanner;ensuresprivacyConfirmswithherthatshewantstoterminateherpregnancyExplainswhattoexpectduringtheclinicvisitAsksifshehascomewithsomeone,andifshewouldlikethatpersontojoinherinthecounsellingAsksabouthergeneralandreproductivehealthandmedicalhistoryExplainswhichabortionmethodsareavailable,includingcharacteristics,effectivenessandthevisitsrequiredConfirmsthatsheiseligibleforMMA(pregnancyuptosevenweeks)IfthewomanchoosesMMA,providesmoreinformationonthemethodinsimpletermsClarifiesthewoman‘sfeelingsonthepossibilityofhavingtheabortionathomeandaskswhatsupportshehasathomeEnsuresthatsheunderstands:
•Commonsideeffectsandsymptoms
•Importanceofattendingrequiredclinicvisits
•WarningsignsindicatingtheneedtoreturntotheclinicExplainshowMifepristoneandMisoprostolwillbeadministeredandwhattoexpectaftertakingitExplainsthatiftheMMAfails,vacuumaspirationwillbenecessarytoterminatethepregnancyAsksthewomanwhethershehasadditionalquestionsObtainswritteninformedconsentProvides first dose for MMAProvidesMifepristone(onetablet200mg)orallyPost-procedure tasksExplainshowtotakepainmanagementmedication(Ibuprofen)ExplainswhattodoincaseofproblemsExplainshowtorecordthesideeffectsexperienced,ifany,ontheMMAfollow-upcardGivesthewomantheaddressandtelephonenumberoftheclinicwhereshemaygoincaseofanemergencyAskshertoreturntotheclinicfortheseconddoseaftertwodays
29Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Day 3: Skills for second visit to clinic (Misoprostol administration) Yes NoPre-procedure tasksGreetsthewomaninafriendly,respectfulmanner;ensuresprivacyEnquires about her experience after taking Mifepristone (bleeding,passageofPOC,discomfort,sideeffects).Checksthefollow-upcardExplainswhattoexpectduringthisvisitProvides second dose for MMAAdministers Misoprostol in clinic : two tablets of 200 mcg each,sublingual/buccal/vaginal/oralPost-procedure tasksAsksthewomantorestintheclinicforfourhoursObservesthewomanforbleeding,cramping,expulsionofPOCIfthewomanleavestheclinicbeforesheaborts,givesherinstructionsand supplies (pain medication, written instructions) for aborting athomeExplainshowtorecordherexperienceofanysideeffectonthefollow-upcardandremindsheroftheaddressandcontactnumberoftheclinictovisitincaseofanemergencyRecords the date of Misoprostol administration and counsels thewomantocomeforafollow-upvisitonday15Reviewsafter-careinstructionsandprovidesinformationonwarningsignswhich indicate theneed to return to the clinicor seekmedicalassistanceAsksthewomanifshehasanyadditionalquestionsandclarifiesthemDay 15: Skills for third visit to clinic (Follow-up visit) Yes NoGreetsthewomaninafriendly,respectfulmanner;ensuresprivacyEnquiresaboutherexperienceoftheabortionprocess,asksherifshesawtheexpulsionofanyPOCandfeelsthattheabortioniscompleteAskswhethersheisstillhavingsymptomsofpregnancyExplainswhattoexpectduringthisfollow-upvisitAssessment to ensure abortion is completeAssessesthecompletenessoftheabortionby:
• Takingahistoryof theabortionprocess (amountanddurationofbleeding,sideeffects,cramping,anyvisiblepartsofPOCexpelled)
• Conducting a physical examination (pelvic examination to assessthesizeandconsistencyoftheuterus)
• Advising/performinganultrasound, for thepresenceofgestationsac,ifitisstillunclearwhethertheabortioniscomplete
30 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
• Iftheabortionisnotcomplete,discussestreatmentoptions:
• Expectantmanagement; additionalMisoprostol administration;orvacuumaspiration
• Ifthepregnancyiscontinuing:
• Discussesneedforvacuumaspirationtoterminateit
• ArrangestocompletetheprocedurebyVAIftheabortioniscomplete:
• Providesinformationaboutreturntofertility
• Explainsrisksofrepeatedinducedabortions
• CounselsregardingcontraceptivemethodsAsksthewomanifshehasanyadditionalquestionsandclarifiesthemTellsher that she cancomeback to the clinicwhenever shehasanyproblemordoesnothaveherperiodswithin6weeks
31Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Annexure – 2Essential Equipment, Instruments, Drugs and
Consumables for MMA
Item PHC
2 MMA
CHC
3 MMA
SDH/RH
3 MMA
DH
10 MMA1 Equipment 1.1 Gynaeexaminationtable 1 1 1 11.2 Screen/curtainforprivacy 1 1 1 11.3 Footstep 1 1 1 11.4 Autoclave 1 1 1 11.5 Boiler 1 1 1 12 Instruments 2.1 Cusco’sspeculum(medium&largesize) 3 3 4 10 3 Drugs 3.1 Analgesics–TabIbuprofen 20 20 20 1003.2 TabMisoprostol(200mcg) 8 12 12 403.3 TabMifepristone(200mg) 2 3 3 103.4 TabDoxycycline(100mg) 20 20 20 403.5 CapAzithromycin(500mg) 3 6 6 123.6 5%Dextrose 2 2 5 103.7 Ringerlactate 5 10 10 203.8 Normalsaline 5 10 10 204 Consumables 4.1 Utilitygloves 2 2 2 34.2 Cotton/gauze(packets) 2 2 2 2 4.3 I/Vsets 2 3 3 104.4 I/Vcannula/scalpveinsets 2 3 3 20104.5 PovidoneIodinesolutionbottles 2 4 4 104.6 Bleachingpowder 4.7 Disposablesyringes(2ml) 4 10 10 254.8 Surgicalgloves(pairs) 10 15 15 50
32 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Annexure – 3Documentation Formats
CONSENT FORM
33Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
tick (3) the one which is appropriate.
34 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
only)
35Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Form III(Seeregulation5)
36 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Annexure – 4
MMA Follow up Card
37Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Annexure – 5
Medical Methods of Abortion (MMA) Reorientation
Pre-training Assessment
Statement True False1. MMA is a safe alternativemethod to vacuumaspiration to terminate
earlypregnancy.2. MMAmayaffectthewoman'sfuturefertilityadversely.3. Physical examination of thewoman is not required before providing
MMAservices.4. Awrittenconsentofthewomanseekingmedicalmethodsofabortionis
mandatoryontheprescribedformat.5. AminimumoffourvisitsarerecommendedtocompletetheGovernment
ofIndia’sstandardMMAdrugprotocol.6. Only a Registered Medical Practitioner, as under the MTP Act can
prescribeMMAdrugs7. Fertilitycanreturnwithin10daysofanabortion.8. After MMA, most of the contraceptive methods can be started
immediatelyafterconfirmingthattheabortioniscomplete.9. MMAdrugscancausecongenitalanomalies.10. SaleofMMAdrugsoverthecounterislegallyallowedinIndia.
Please encircle the correct answer in the following questions:
11.WhichofthefollowingisrecommendedforpainmanagementduringMMA?
a) TabletParacetamol
b) TabletIbuprofen
c) InjectionDiazepam
d) Paracervicalblock
12.WhichofthefollowingistheLEASTeffectiverouteforMisoprostoladministrationduringtheMMAprocess:
i. Sublingual
ii. Vaginal
iii. Oral
iv. Buccal
38 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
13. WhichcontraceptivemethodscanbestartedonthedayoftakingMisoprostol?
a) Oralpills
b) Tubectomy
c) IUCDs
d) Vasectomy
14.OnlywaytomanageanincompleteabortionduringtheprocessofMMAis:
• Vacuumaspiration
• RepeatdoseofMisoprostol
• Eitherofthetwodependingontheseverityofbleeding
15. IfpregnancycontinuesafterMMA,itshouldbeterminatedbyarepeatdoseofMMAdrugs:
• True
• False
39Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
Medical Methods of Abortion (MMA) Reorientation
Post-training Assessment
Please encircle the correct answer in the following questions:
1. Whatare thepreferredmethods foruterineevacuation in thefirst trimesterofpregnancyaccordingtotheWorldHealthOrganization(WHO)?
a) Medicalabortiononly
b) Sharpcurettage
c) VacuumAspirationandMedicalAbortion
d) Uterotonicinstillation
2. EffectivenessofMedicalMethodsofAbortionforpregnancyuptosevenweeksis:
a. 95-99%
b. 80%
c. 82-83%
3. InIndia, it is legaltobuytabletsofMifepristoneandMisoprostolover-the-counterfromachemistshop:
a. True
b. False
4. WhichofthefollowingarecontraindicationstoMMA?
a) Suspectedectopicpregnancy
b) HIV/AIDS
c) Breastfeeding
d) Multiplepregnancy
5. InformationtowomenonMMAshouldinclude:
a) Therangeofexpectedbleeding
b) PossiblesideeffectsaftertakingMisoprostol
c) Warningsignsforwhichthewomanshouldcontactherprovider
d) Alloftheabove
40 Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
6. GovernmentofIndia’sstandardMMAdrugprotocol(forgestationupto49days)is:
a) 600mgMisoprostolfollowed2dayslaterby400mcgMifepristonevaginal/sublingual
b) 200mgMifepristoneorally followed2days laterby400mcgMisoprostol sublingual/buccal/vaginal/oral
c) 600mgMifepristoneorallyfollowed2dayslaterby400mcgMisoprostoloral/vaginal
d) 200mgMisoprostolorallyfollowed2dayslaterby800mcgMifepristonevaginal/buccal
7. WhichofthefollowingistheLEASTeffectiverouteforMisoprostoladministrationduringtheMMAprocess:
i. Sublingual
ii. Vaginal
iii. Oral
iv. Buccal
8. WhichofthefollowingisrecommendedforpainmanagementduringMMA?
a. TabletParacetamol
b. TabletIbuprofen
c. InjectionDiazepam
d. Paracervicalblock
9. AfterMisoprostoladministration,mostwomenabortwithin:
a.4hours
b.½hour
c. 1 hour
d.oneday
10. AftergivingMisoprostol,thewomanshouldbecalledforfollow-uponwhichday:
a.5th
b.15th
c.7th
d.10th
41Handbook on Medical Methods of Abortion to Expand Access to New Technologies for Safe Abortion
11.WhichcontraceptivemethodscanbestartedonthedayoftakingMisoprostol?
a. Oralpills
b. Tubectomy
c. IUCDs
d. Vasectomy
12.WhatarethesymptomssuggestiveofcomplicationsduringMMAprocess?
a) Excessivebleeding,soakingmorethantwothickpadsperhourfortwoconsecutivehours
b) FeveranydayafterthedayMisoprostolisused
c) Unusualorfoul-smellingvaginaldischarge
d) Alloftheabove
13.PossiblecomplicationswithMMAinclude:
a) Mildcramping
b) Uterineperforation
c) Continuationofpregnancy
d) Injurytocervixanduterus
14.MMAdrugshavebeendesignatedbytheDrugControllerGeneralofIndiaas:
a. Schedule K
b. ScheduleH
c. Schedule X
d. Schedule G
15.DocumentationoftheMMAprocedureisdoneinthefollowingformats:
a. FormC
b. RMPOpinionForm
c. Admissionregister
d. Alloftheabove
.
ThehandbookisdisseminatedbyIpasDevelopmentFoundationaspartofoureffortstoimprovequalityofcomprehensiveabortioncareservicesinIndia.
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