What to Expect After Taking Medical Abortion Pills.
Answers to most common calls from medication abortion patients
Document all calls in the
patient’s medical record. Keep track of the questions women ask when they call,
as these can guide you in counseling future patients and ultimately decrease
the number of calls you receive.
1.
I vomited
after I left your office and am not sure if I threw up the first pill
(Mifepristone). What should I do?
If she swallowed the pill more
than 1 hour ago, then it was probably
absorbed. If she took the pill less than 1 hour ago, the dose of the Mifepristone should be repeated along with an
anti-nausea medication.
2.
I took the
mifepristone in the office yesterday and started to bleed before using the
second pills (misoprostol). Do I still need to use the misoprostol? Yes.
The process is most effective when the mifepristone and misoprostol are both
used. If she was planning to insert the misoprostol tablets vaginally and she’s
still bleeding, she may want to switch to buccal administration.
3.
I wasn’t
able to take the misoprostol pills as scheduled and now it has been more than
72 hours since I took the mifepristone. Should I still use the misoprostol? Do
I need to repeat the mifepristone?
The misoprostol should still be
used if she didn’t already cramp and bleed and expel the pregnancy
(mifepristone alone works about 65% of the time), but there is no need to
repeat the dose of mifepristone. Research most strongly supports using
misoprostol between 24-48 hours after the Mifepristone. Misoprostol also works
when it is used earlier or later, and using it late is much more effective than
not using it at all.
4.
I used the
misoprostol pills 24 hours ago and I still haven’t had any bleeding. What
should I do?
This happens most often with
very early pregnancies. If an intrauterine pregnancy was seen on ultrasound,
there is nothing to worry about and a little more time is often all that is
needed. In this case, options include waiting another 24 hours and having the
woman call back if she still hasn’t bled or dispensing a second dose of
misoprostol right away.
If an ultrasound wasn’t
performed prior to the medication abortion or an intrauterine pregnancy wasn’t
seen on the ultrasound, then ectopic pregnancy should be considered. Women
should be asked about symptoms of ectopic, given ectopic precautions and be
evaluated in the office as soon as possible.
5.
I accidently
swallowed the misoprostol pills before the 30 minutes was up. Is this OK?
Yes. The pills are still safe
and usually effective if swallowed. If the woman doesn’t have any bleeding
within 48 hours she should be advised to call back. There may be more
gastrointestinal side effects when the pills are swallowed rather than placed
in the cheeks or vagina, but though uncomfortable this is not dangerous. For
pregnancies between 7 and 9 weeks the efficacy of misoprostol used orally is
slightly lower than when used buccally or vaginally, but it still works the
vast majority of the time.
6.
I took the
misoprostol 6 hours ago and am still having heavy bleeding and passing large
blood clots, is this normal?
Yes, bleeding with a medication
abortion is usually heavier than a period and often accompanied by clots. The
heaviest bleeding typically occurs 2-5 hours after using misoprostol and
usually slows within 24 hours. Some women, however, bleed heavily for up to 48
hours and may pass clots days or even weeks later. This is common and is not
dangerous, if there are no symptoms of anemia or hypovolemia.
When a patient calls for
bleeding:
1)
Quantify how often she is soaking through a thick
sanitary pad. If she hasn’t been using pads (e.g. using tampons or sitting on
the toilet), ask her to start using pads.
2)
Ask about symptoms of anemia and hypovolemia
(dizziness, orthostasis, feeling faint, racing heart, pre-syncope). This is very rare, unless she was dehydrated to
begin with, and is one of the reasons to advise women during the initial
counseling to eat and drink before inserting
the misoprostol.
3)
If she is using fewer than 2 pads per hour and she has
no symptoms of hypovolemia, reassure her that the bleeding and clots are normal
and will probably decrease after 24 hours. Tell her to call back if the
bleeding increases or she develops symptoms.
4)
If she is soaking through more than 2 pads/hour for 2
hours in a row, but she has no symptoms of hypovolemia:
-- Advise her to:
•
Take Ibuprofen 600 mg every 8 hours
•
Increase fluids
•
Rest, avoid strenuous activity, change position
gradually
•
Call back for any new symptoms
-- Call the patient back in 1-2 hours to check
on bleeding and symptoms.
5)
If persistent, heavy bleeding (greater than 2
pads/hour) for several hours despite the above advice or symptoms of hypovolemia arrange for evaluation as soon as
possible (in office if possible, ER if office closed).
For more information on triaging calls from medication
abortion patients concerned with bleeding see Algorithm for phone triage of
bleeding with medication abortion.
7.
I had my
medication abortion 3-5 weeks ago and I’m still bleeding. On average, women
bleed for 9 -14 days following a medication abortion. Some women bleed or pass
clots for as long as 4 weeks. After the first few days of heavy bleeding some
women will have little or no bleeding, some will have bleeding that stops and
starts, and others will have bleeding similar to a menstrual period for several
weeks. Sometimes the first menses following a medication abortion is especially
heavy. In the absence of other symptoms, the bleeding is not dangerous and it
is safe to wait for it to stop on its own. Triage these calls as above
(question #6).
If a woman experiences heavy
bleeding (not spotting) greater than 4 weeks after mifepristone, or if she has
symptoms of anemia, hypovolemia, or infection, she should be evaluated in the
office.
8.
My
girlfriend took the misoprostol 4 hours ago and for the last 2 hours she has
been vomiting and has a fever of 101 degrees. I’m worried something is
wrong. Low grade fever, chills,
nausea, vomiting, diarrhea and flu-like symptoms are all side effects of
misoprostol and should resolve within 6 hours of using the misoprostol. The
fevers, chills and cramping caused by misoprostol can be alleviated by using
Ibuprofen 600mg. Women can be counseled to use NSAIDs prior to or after
misoprostol use to help with these symptoms.
If a woman feels ill, has
abdominal pain, nausea, vomiting or diarrhea, or has a fever >100.4 more than 24 hours after using misoprostol she should be evaluated in the
office for possible infection.
9.
How long
after having a medication abortion can I become pregnant?
Medication abortion does not
have any long term impact on women's health or fertility. Most women will
ovulate within two or three weeks and will resume menstruation within four to
five weeks after the abortion. Thus, a woman can become pregnant within weeks
of having a medication abortion and immediate use of an effective family
planning method is recommended.
10. How long after having a medication abortion
can I use tampons or resume sexual intercourse?
In general, women are advised
not to insert anything into the vagina for approximately one week after a
medication abortion. Women who choose the vaginal ring (Nuvaring) for birth
control should insert it 2 or 3 days after taking mifepristone.
11. Are there psychological consequences to
medication abortion?
There is no evidence that early
medical abortion is associated with an increase in psychological problems such
as depression, anxiety, or suicidality. Studies have shown that among women who
have an unplanned pregnancy, the risk of mental health problems is no greater
if they have a single first-trimester abortion than if they deliver that
pregnancy.
A range of emotions is normal following abortion. Women often experience feelings such as sadness, happiness, empowerment, anxiety, grief, relief and/or guilt. Feelings vary and they often change over time. Women who are concerned about their emotions should be are encouraged to talk with their physician. Another resource is Exhale -- a free, after-abortion Talkline that provides emotional support, resources and information
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