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AbortionBrenda Pereda, MDAssistant ProfessorFamily Planning
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Options Counseling Lucy presents to your office for an
annual exam and when you take the menstrual history, she reports that her last period was 7 weeks ago. You astutely obtain the history that she is sexually active using no contraception, and obtain a pregnancy test which is positive.
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Options You are an OB-GYN morally opposed to
abortion. How would you talk to Lucy?
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Options You are an OB-GYN not
morally opposed to abortion.
How would you talk to Lucy?
After counseling, she decides on an abortion. What do you do next?
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Surgical Abortion
Description:Uterine aspiration when <14wksStandard Dilation and Evacuation >14wks
Effectiveness: 98-99% , failures due to incomplete abortion
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Surgical AbortionProcedure:Informed consent (local law), procedure type determined by GA, pt pref.Bimanual to assess size and uterine positionIf 2nd trimester cervical dilators, prostaglandin analoguesPerioperative antibiotics reduce risk of post procedure infection-doxycyclineCervical anesthesia: cervical block: lidocaine, vassopressin
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Medical Abortion Most medical abortions in the US use
mifepristone. Mifepristone is an: anti-progesterone blocks progesterone receptors causing decidual
necrosis and detachment of products of conception
causes cervical softening
Dose: 600mg FDA approved Dose evidence based: 200mg
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Medical AbortionEffectiveness:92-98% depends on GA and mifepristone dose Can be used up to 63 days
Contraindications:Ectopic pregnancyChronic corticosteriod users, adrenal failures, porphyriasComplications:Mortality ~1/100,000Infection<1%, Incomplete abortion 0.5-1.0%, hematometra <1%, asherman’s
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Complications Sylvia just underwent uterine aspiration
at 10 weeks. At the time of placing the suction cannula, brisk bright red bleeding began. Bleeding continues. Differential? Management?
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Complications Melanie had a medical abortion. She
placed the misoprostol 24 hours ago and had bleeding and cramping that peaked 20 hours ago. She now has severe abdominal cramping, no fever. Differential? Management?
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Complications Mariam presents to the ER in Bamako,
Mali, with severe abdominal pain and fever. On physical exam, there is bowel coming out of the vagina. Differential? Management?
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Legal abortion is safe
Sources: All births and abortions: Grimes DA, 2006; Abortion by gestation: Bartlett et al., 2004 (1988–1997 data)
Deaths per 100,000 abortions
Abortions by gestational age
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Safety of Abortion Abortion is one of the safest common
surgical procedures for women in the United States.
Abortion is safe over the long term and carries little or no risk of fertility-related problems, cancer or psychological illnesses.
Laws criminalizing abortion make abortions unsafe, but do not eliminate them.
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Complications of unsafe abortion
Complications from unsafe abortion 13% of maternal deaths 67,000 deaths per year.
220,000 children lose a mother every year because of abortion-related deaths.
Singh, 2006; WHO 2007; Grimes 2006
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Ethics Is it moral to require an individual to
participate in an abortion? An OB-GYN? What if the woman’s life is in danger
and there is no one else to perform it?
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Ethics Answering a phone call from a patient
who wants an abortion? Getting a speculum out of the Pyxis for
an abortion? Talking to a patient who has had an
abortion in the past?
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Ethics
Is it moral to be against legal abortion?
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The legal status of abortion does not predict its incidence
Lowest abortion rates: Europe, where abortion is legal and available.
< 10 per 1,000
Highest: Africa, Latin America and Caribbean, where abortion law is most restrictive and illegal
30 per 1,000
The U.S. is in-between:
21 per 1,000
Sedgh et al., 2007
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Abortion rates in countries where it is illegal or highly restricted
Source: Boonstra, 2006
Abortions per 1,000 women 15–44
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Percentage of Maternal Mortality Worldwide Due to Unsafe Abortion
Source: WHO, 1998(Estimates for 1995–2000)
Unsafe abortion
Other causes
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Efforts to provide medical services by videoconference, a notion known as telemedicine, are expanding , but Planned Parenthood of the Heartland in Iowa is the first in the nation, and so far the only ones, experts say, to provide abortions this way. Advocates say the idea offers an answer to an essential struggle that has long troubled those who favor abortion rights: How to make abortions available in far-flung, rural places and communities where abortion providers are unable or unwilling to travel.
Abortion Drugs Given in Iowa via Video Link
93% of counties in Iowa have no abortion provider
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Contraception
All methods can be started on day of abortion procedure
Advantages… we know patient is not pregnant, immediate protection!
For medication abortions start on follow up day when termination of pregnancy confirmed.
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refs Managing Contraception National Abortion Federation