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Information for Clients Having a Medication Abortion
Welcome to our clinic. This information is to give you an idea of what will happen during your time here. Our Assessment Clinic Nurse will go over the details with you, so you can ask her about anything that is not clear. You will be here for about two hours. A medication abortion is caused by a drug rather than by a surgical procedure. There are several different drugs in use around the world for causing abortions, and by now millions of medication abortions have been performed in controlled conditions in North America, Europe, and Asia. The medications that we use at this clinic cause a complete abortion in 95% of cases. About 5% of women using these drugs will eventually have a surgical procedure to complete their abortions, although this is rarely an emergency. Abortion with either surgery or medication is very safe. More than one million surgical abortions are performed each year in North America. Legal surgical abortion leads to fewer complications than tonsillectomy. Having an abortion is actually safer for the woman than carrying the pregnancy to term. With medication abortion, the chance of a complication or problem is the same as with a natural miscarriage. A medication abortion starts today, with an injection of a drug called methotrexate. You will have to use a second medication called misoprostol at home. This will be in the form of tablets that you take by placing them in your vagina. The nurse will describe these medications and their side effects in more detail when you meet with her. The forms we ask you to complete are about your health history. It is important that you tell us about any health problems you may have. We try very hard to protect your privacy, and any information you give us is confidential. There are a few situations where no health care institution can guarantee confidentiality. Please ask the nurse about this if you are concerned. If we need to call you, we can use a code name rather than saying “Choice in Health Clinic”. Our telephone number is automatically blocked from appearing on another telephone’s call display. If you have call privacy, you will need to set it to allow the caller to input a name or number. After you complete the forms, you will meet with the nurse. If you have not already had a vaginal ultrasound, she will do this examination first. This is to confirm that Choice in Health Clinic Information for Clients Having a Medication Abortion Page 1 of 2 Approved by QAC August 2007 your pregnancy is early enough for a medication abortion. We do our ultrasound examinations through the vagina for a more accurate picture. She will also get a drop of blood from your finger tip to test for iron and the Rh factor, and she will check your blood pressure and heart rate. Next she will confirm that you are clear in your decision to end your pregnancy and will make sure you know what to expect with both a medication abortion and a surgical abortion. She will review your medical history, answer your questions, and ask you to sign a consent form. She will offer to discuss birth control options with you, and will see that you have any birth control supplies that you need and that you know how to get started with them after the abortion. If you are not sure about your abortion decision, or if you change your mind and prefer a surgical abortion, the nurse will arrange for another appointment if necessary. After you see the nurse, the physician will review your medical history and do a routine pelvic examination and infection tests. She does this by placing one hand on your abdomen and two fingers in the vagina. This gives her an idea of the size and position of your uterus. Then she places a sterile speculum in the vagina, just as your own doctor has done if you have ever had a routine check-up and Pap test. When you and the nurse and physician are satisfied that the medication abortion is safe and is what you want, the nurse will give you an injection of methotrexate. She will give you written instructions for using the misoprostol at home between 3 and 7 days from today. You can choose the time that is most convenient for you. You will have written instructions for what to do and what to expect at home, and you will be able to contact the nurse or physician through a pager at any time if necessary. You will have a return appointment for two weeks from today, to see whether the abortion is complete, but you can return sooner if you think that the abortion is complete before then. Choice in Health Clinic Information for Clients Having a Medication Abortion Page 2 of 2 Approved by QAC August 2007 CLIENT INFORMATION AND CONSENT FOR MEDICATION ABORTION There are several medications that are used around the world to cause abortion. We use a combination of two drugs that are available in Canada for other uses. The first drug is called methotrexate, which blocks cell growth. It has been used in Canada for over 50 years to treat cancer, some kinds of arthritis, and ectopic (tubal) pregnancies. Methotrexate helps end a pregnancy by stopping the growth of the placenta. The second drug is called misoprostol. This drug is sold for prevention and treatment of stomach ulcers. It is also used to help bring on labour at the end of a pregnancy, and for softening the cervix before abortion procedures. It is used in medication abortion to make the uterus contract and push out the pregnancy tissue after the methotrexate has stopped its growth. Methotrexate is given by injection into a muscle. The dose is calculated according to your height and weight. You will get this injection at your first visit (Day 1). Misoprostol comes as tablets, with four tablets used at one time. The tablets must be placed in your vagina, as far in as you can put them. You will have to use these at home, between Day 3 and Day 7. If you do not have much bleeding or cramps after you use the misoprostol, you should use a second dose 24 hours later. The injection of methotrexate on Day 1 may cause some nausea and fatigue over the next day or two. Some women also have vomiting, diarrhea, or a headache. After you use the misoprostol, you may have chills (shivering and feeling cold) and fever. You may also have nausea, vomiting, fatigue, diarrhea, and headache. Usually the cramps begin within a few hours, and the rest of the process is similar to a miscarriage. There will be a lot of cramps and bleeding, including passing clots and small amounts of tissue. For many women, this will last for only a few hours, but some women have these symptoms on and off for several days. Serious or dangerous side effects for the woman from either of these medications in the doses that we use are very uncommon. However, there is about one chance in 500 that the pregnancy will not be ended by the medications alone. If this happens in your case, a surgical abortion will be necessary, because these medications will cause severe birth defects. Choice in Health Clinic Client Information and Consent for Medication Abortion Page 1 of 4 Approved by QAC August 2007 The overall success rate for medication abortion with our medications is about 95%. This means that only 5% of women who try to have a medication abortion will end up having a surgical procedure as well. The usual reason for wanting a surgical procedure is that the medication process is taking too long and the woman is tired of waiting. Very few women request or need surgery just because of heavy bleeding and cramps. About one women in 500 needs surgery because the pregnancy was not ended by the medications. Here is how the average medication abortion goes, but there is a very wide variation: • time between putting misoprostol in the vagina and the beginning of the bleeding and • time between putting misoprostol in the vagina and when the tissue is expelled: 1 - 2 days • number of women with complete abortions after the first week: 75% You will have to insert the misoprostol tablets into your vagina, possibly on two occasions. You will not know exactly when to expect symptoms from the medications or from the abortion process itself. You may have trouble going to work or caring for young children at some times. You may have to explain your symptoms or missed work to family, friends, or co-workers. You will have to abstain from sexual intercourse until the abortion is complete. You will need access to a telephone in case you need to call us, and you must have transportation to the clinic and to a source of emergency care if necessary. Here is the schedule that you will follow: Day 1 - You will have a physical assessment by the nurse and physician, including a vaginal ultrasound. The nurse will check your hemoglobin (iron level) and Rh factor with a drop of blood from a finger prick, and the physician will perform a pelvic examination and take swabs for infection testing. You will be able to talk about your birth control plans. Most methods of hormonal birth control can be started within the next week, before your final visit to the clinic. You can learn about any methods that interest you. You will get an injection of methotrexate. You will get two doses of misoprostol, with instructions on how to use these at home, and some pain medication to take home. Day 15 - You will have an appointment to return on this day, but if you think the pregnancy tissue has passed before this you can come in sooner. Eighty percent of women have completed their abortions by this visit. On this visit you will have another ultrasound to see whether the pregnancy sac has been expelled. If it has, then this will be your last visit. If the pregnancy has ended but the sac has not been expelled, then you will have a choice of waiting longer or having a surgical procedure. If you choose to wait, we will stay in touch with you and follow your progress until Day 35. If the sac has not passed by Day 35 we will suggest that you have the surgical procedure. If the methotrexate did not stop the development of the pregnancy, and the pregnancy has continued, you will be advised that the medication abortion has failed. You will need a surgical procedure, because waiting longer will not help in this case, and the pregnancy will be damaged from the medications. If you need or want a surgical procedure, this will be done with a small, flexible tube and a hand pump. The medications that you have used will make this procedure easier than usual for both you and the physician. It will be very important for you and the clinic staff to be able to contact each other easily by telephone during this process. I have read all of the information contained in this document. I have had a chance to discuss this and any other questions that I have about abortion with methotrexate and misoprostol with the nurse and physician. I have also been informed of the risks of surgical abortion, as listed in the document RISKS OF THE ABORTION PROCEDURE. In signing this consent form, I confirm that I have made a free choice to end my pregnancy, and that I have freely decided to use medication abortion as my method. I understand that there is a small chance that I will still need a surgical procedure to complete my abortion. I know that if I have to seek medical attention because of this abortion, the health care facility that is treating me may call Choice in Health Clinic for information or advice concerning my care. I hereby consent to Choice in Health Clinic providing such information or advice. Choice in Health Clinic Client Information and Consent for Medication Abortion Page 3 of 4 Approved by QAC August 2007 I know that if infection tests are positive for gonorrhea or chlamydia, the laboratory will report this to the department of Public Health. I know that Choice in Health clinic will try to contact me and treat me, and that they will advise Public Health that they have done so. ___________________________________ ___________________________ client signature date __________________________________ staff person witnessing signature HOME INSTRUCTIONS FOR MEDICATION ABORTION After your injection of methotrexate today, you may be more tired and nauseated than before, and you might have some vomiting, diarrhea, or headache. The misoprostol will begin the bleeding and cramping part of your abortion. Misoprostol will cause the uterus to contract and push the pregnancy tissue out. Many women have a low grade fever (up to 38°C) and chills for a few hours after inserting it. You may also have nausea and fatigue, diarrhea, and some vomiting. Pick a time to insert the misoprostol when you have no responsibilities for the next few hours. You might find it easiest to do this at bedtime. Before you start, make sure you have sanitary maxi pads, ibuprofen, a stronger pain medication in case you need it, a heating pad or hot water bottle, and liquids to drink to stay well hydrated (without caffeine or alcohol). You can insert the first four misoprostol tablets anytime from _____________________________ to ____________________________. Wash your hands and use one finger to push each of the first four tablets into your vagina, as far in as the length of your finger. You will not cause yourself any harm, and the farther the tablets are inserted the better they will work. Take a dose of ibuprofen (one or two of the tablets we give you), and drink plenty of fluids. Put on a maxi pad. If it is bedtime, just go to sleep as usual. The cramps and bleeding could start from one to twelve hours after this. When the cramps start, continue to use ibuprofen as often as every 4 hours if you need it, as long as you don’t use more than 6 tablets in 24 hours. You can also use 2 extra strength acetaminophen (Tylenol®) every 6 hours, or 1 - 2 tablets of Tylenol #3 every 6 hours in addition to the ibuprofen. Tylenol #3 may cause stomach irritation and constipation, so use it as a last resort. Sometimes there are not many symptoms after the misoprostol use. If you do not bleed as much as a period, you should repeat the misoprostol insertion with the remaining four tablets 24 hours after the first time. If you had a lot of pain after the first dose, the second dose will probably cause less pain. Bleeding commonly (but not always) starts within the first few hours after you insert the misoprostol. This will be similar to a very heavy period, with large clots. You may see some pale solid tissue. This could be the pregnancy sac or the tissue that lines the uterus. The embryo will be no larger than a large grain of rice, even at 7 weeks of pregnancy, so you will not be able to identify it. After the sac passes, the bleeding will become lighter and be no more than spotting after a few days. This spotting could go on for another couple of weeks. If you have to use a second dose of misoprostol, you may have little bleeding after the second dose as well. This does not mean that the medications have failed - you might have a “delayed” passage of the pregnancy. About 20% of women have not passed the tissue by the Day 15 visit, but most of these women will still pass it within the next three weeks. Choice in Health Clinic Home Instructions for Medication Abortion Page 1 of 2 Approved by QAC August 2007 Expect to have very heavy cramps! These are caused by the contractions of your uterus, which will eventually push the tissue out. The cramps may start before or after the bleeding. Once the pregnancy sac passes, the cramps will decrease but may continue mild, on and off, for a few days. Taking care of yourself during the abortion You should use the misoprostol when you have a few hours clear of responsibilities, or at bedtime. Do not eat a heavy meal just before this, in case you should vomit. Follow a “nothing in the vagina” rule until we have confirmed that your abortion is complete. This means using sanitary pads (not tampons), having showers instead of tub baths, and no sexual intercourse. Drink plenty of fluids, especially if you are bleeding heavily. Do not take vitamins that contain folic acid (one of the B vitamins) for the first week after you get your methotrexate injection. Aside from these restrictions, you can go about your normal activities as well as you can. Some women have only a few hours when they are not able to do this, while others may have a disrupted life for several days. These will be very rare, but you should call us if your symptoms are not what you were told to expect. Call the
emergency pager any time at 416-379-6672. Give your name and number and say that you are having a
medication abortion. The physician or nurse in the medication abortion program will call you back. Call us if:
• your bleeding has soaked 2 maxi pads per hour for three hours (yes, six pads!) • you have pain that is not eased by ibuprofen plus Tylenol #3 • you have a temperature greater than 38°C that lasts more than 6 hours If for any reason you cannot contact us at the clinic and have to seek medical advice from someone else, be sure to take these instructions and the other written materials and supplies you received from us. This will help another medical facility understand how to treat you, since medication abortion is not as well known among physicians as surgical abortion. SUMMARY OF INSTRUCTIONS
Day 1 is today _______________________________ You received methotrexate _________ mg IM. Your Rh factor is ________, so you did/did not receive Winrho 120µg IM. Any time from Day 3 to Day 7 ___________________________________ you can insert the first dose of misoprostol (4 tablets) into your vagina. If you have less bleeding than a heavy period, insert the second dose of 4 tablets into your vagina 24 hours later. On Day 15 ______________________________ you have an appointment with us. We will do another ultrasound to see whether the abortion is complete. If you think the tissue has passed, you can call to make an appointment to come in sooner if you want to. Choice in Health Clinic Home Instructions for Medication Abortion Page 2 of 2 Approved by QAC August 2007


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