Willow
Women’s Clinic
Suite 1013 – 750 West Broadway
Vancouver BC V5Z 1H9
Ph 604-709-5611 Fax 604-873-8304
Email: willowwomensclinic@yahoo.ca
INFORMED CONSENT FOR METHOTREXATE/MISOPROSTOL ABORTION
TELEMEDICINE
You have requested a medical abortion to end your pregnancy. We use
methotrexate (a folic acid antagonist) with misoprostol (a prostaglandin) to
induce an abortion. These medications are approved for use in Canada for other
conditions. They have been used by over 25,000 women in this clinic for
abortions, and studies have shown this treatment to be a safe, effective method
for early abortions.
Before you get the medications, the doctor will review your medical history,
ultrasound (if done) and blood work and you will talk to the counselor. If the
ultrasound shows your pregnancy is 7 weeks or less from the first day of your last
period (5 weeks since you got pregnant), and/or your blood work level is <3000
and you are healthy enough, you may start the treatment as follows:
Day 1: 50 mg/m2 methotrexate will be given by 10 mg tablets (usually 75100mg, 8-10 tablets). You will be given 3 doses (4 pills in each dose = 800mcg)
of misoprostol pills to use vaginally at home. You will be given an antibiotic to
prevent infection. If your blood type is Rh-negative you will also need to have an
injection of WinRho immune globulin therapy.
Insertion of Misoprostol : You may choose when to start the misoprostol no
more than 7 days from methotrexate dose. All three sets of pills must be used
within a 24-hour period.
You will wash your hands and insert them one at a time high into your vagina
with your finger. At least 4 hours later, but no more than 12 hours, put 4 more
misoprostol pills into your vagina. Repeat with the last set of 4 misoprostol,
again at least 4 hours later but no more than 12. You can expect to have vaginal
bleeding, cramps, and to pass blood clots within 24 hours of beginning the
misoprostol.
Day 8: You will have another blood test done.
Day 9: You will have another Skype visit with the doctor. If the blood test shows
that the abortion is complete, then you are done. You can expect to continue
having bleeding for 2 weeks or longer, which may be heavy at times and you may
pass more clots.
If the blood test does not show an adequate drop in number another blood
test or ultrasound and further appointment will be arranged.
Consent (TM) July 2012
If the blood test shows that the pregnancy has stopped growing, but that the
pregnancy tissue is still in your uterus (a delayed reaction), you will be offered 3
choices:
1. You can take more misoprostol (we can send a prescription to a local
pharmacy) and wait for the pregnancy to pass.
2. You can have a surgical aspiration of the pregnancy tissue (in our office, or at
a local hospital/clinic)
3. You can wait for a miscarriage, usually within 4 weeks, and we will monitor you
during this time.
If the ultrasound shows that the pregnancy has not stopped growing,
arrangements will have to be made for a surgical aspiration.
PLEASE READ AND SIGN:
You should not change your mind about having an abortion after you have
taken methotrexate or misoprostol, since both of these medications are
known to damage the current growing pregnancy. If the medication fails we
strongly recommend that you agree to a Surgical Abortion. If you change
your mind about having a Medical Abortion, you may have a Surgical
Abortion at any time.
Possible Risks: With these doses of methotrexate and misoprostol, there are no
known long term side effects. Short term side effects include diarrhea,
nausea, vomiting, abdominal pain, flatulence (gas), fever, chills, and headaches.
Approximately 4% of women will choose to have a surgical aspiration of
pregnancy tissue (D & C) for too much bleeding, pain, or because they are tired
of waiting to pass the pregnancy tissue. 1-2% of women will require a surgical
aspiration because the pregnancy has not stopped. In comparison, the risk of a
surgical abortion being incomplete and requiring a D&C is <1%. Infections that
can be treated with antibiotics occur in less than 1% of women and very rarely
(less than 1/100,000) will a serious, life-threatening infection occur. By not
coming in to our clinic, you are missing the physical examination by our doctor
and therefore some medical problem might be missed.
All records are kept in a secure database, and all information will be kept
confidential. Willow Women’s Clinic and SKYPE security policies are available on
our website.
I have had the opportunity to discuss any and all questions I have concerning the
medical treatment which I may receive. I have read, understood and given verbal
consent for treatment based on this form. I may print a copy of this consent form
for my records.
_______________________________ ______________________________
Signature
Date
Interpreter’s Signature
Date
____________________________________Witness Signature
Consent (TM) July 2012
Date