Clinical questions and recommendations
1 What are potential indications for referral to a hospital-based provider?
|Central Nervous System|
|• Vascular–untreated aneurysm|
|• Space occupying lesions|
|• Impaired renal function (serum creatinine >2.5 mg/dL)|
|• Uncontrolled BP (systolic blood pressure >160 or diastolic blood pressure >105)|
|• Uncontrolled hyperthyroidism, uncontrolled diabetes, pheochromocytoma|
|• Congenital (cyanotic disease, right or left ventricular dilation, uncontrolled tachyarrhythmia)|
|• Coronary disease — (history of myocardial infarction, treatment angina)|
|• Cardiomyopathy — (dilated, hypertrophic, history of peripartum cardiomyopathy)|
|• Valvular disease — (AS peak gradient ≥60 mmHg, MS valve area <1.5 cm2, MR or AR with LV dilation)|
|• Uncontrolled asthma|
|• Restrictive lung disease|
|• Pulmonary hypertension|
|• Lupus flare|
|• Lupus inhibitor requiring anticoagulation|
|• Hepatic disease elevated PT|
|• Esophageal varices with history of bleeding|
|• Uncontrolled inflammatory bowel disease|
|• Severe anemia|
|• Sickle cell disease with a history of crisis|
|• Idiopathic thrombocytopenia purpura with active thrombocytopenia|
|• Thrombophilia requiring anticoagulation|
|• Counseling regarding treatment options and timing of abortion|
|• Gynecologic cancers restricting access to the uterus|
|• Significantly impaired renal function (creatinine >2.5 mg/dL)|
|• History of recent rejection|
|• Poorly functioning transplanted organ|
|• Inability to obtain informed consent|
|• Inability to tolerate an outpatient procedure|
|• History of suicide attempt|
2 When is surgical management preferred over medication abortion?
Surgical abortion is preferred when mifepristone is contraindicated
Surgical abortion is preferred when methotrexate is contraindicated
3 When is medication abortion preferred over surgical abortion?
4 What are special issues related to use of routine abortion medications?
5 What considerations are important for common chronic conditions?
von Willebrand disease
6 How does anticoagulation affect management?
7 Should additional antibiotics be administered at the time of abortion for patients to prevent infective endocarditis?
- Wilson W.
- Taubert K.A.
- Gewitz M.
- et al.
- Wilson W.
- Taubert K.A.
- Gewitz M.
- et al.
Conclusions and recommendations
- •There is no level A evidence to support our practice recommendations.
- •The dose of mifepristone should be increased above 200 mg when medical abortion is undertaken for women who are also being given inducers of the hepatic cytochrome p450 system.
- •In steroid-dependent conditions, mifepristone's antiglucocorticoid properties necessitate an increase in usual steroid doses.
- •Women with stable, controlled hypertension, diabetes, or asthma can be safely managed in an outpatient setting.
- •Hospital-based abortion is recommended for women with certain medical conditions (see Table 1).
- •Patients with high-risk cardiac conditions do not require additional antibiotics for the prevention of infective endocarditis.
- •Surgical abortion is preferred for women who have a bleeding disorder or who are anticoagulated in the first trimester.
4. Important questions to be answered
- 1.Do first-trimester abortion outcomes differ between women with preexisting conditions and their healthy peers?
- 2.Is the efficacy of mifepristone, which is metabolized by the hepatic p450 system, affected by co-administration of medications that induce p450 enzymes?
- 3.Should women on anticoagulant therapy continue, modify or discontinue such therapy when undergoing surgical abortion?
Conflict of interest
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