Module 2 Study Guide Differentiate the three levels of preventive screening (pg 64) ● Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviours that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Examples include: ○ legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets) ○ education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking) ○ immunization against infectious diseases. ● Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent re-injury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems. Examples include: ○ regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer) ○ daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes ○ suitably modified work so injured or ill workers can return safely to their jobs. ● Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: ○ cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.) ○ support groups that allow members to share strategies for living well ○ vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible. Understand how to interpret the different pap smear results using the ASCCP guidelines. ● http://www.asccp.org/asccp-guidelines (PLEASE SEE ADDITIONAL PDF DOCUMENTS OF GUIDELINES ON THE DRIVE!) ● This is the info from USPSTF Module 2 Study Guide What is “dual methods” in relation to contraception? ● Dual Methods or another term for it is “Dual Protection” it is utilizing two forms of protection. One for pregnancy and one for STIs. Most commonly it is the use of the pill & condom utilization, but it is pairing whatever contraception weather it be a LARC or OC with a condom to protect and prevent sexually transmitted infections. Describe the contraindications for prescribing combined hormonal contraception. Table 1 Medical conditions classified as category 3 and category 4 contraindications to initiation of combined oral contraceptive use according to the World Health Organization Medical Eligibility Criteria (3rd edition) and assessment of contraindications in the Border Contraceptive Access Study. WHO Medical Eligibility Criteria Category 3 Contraindication for COC Postpartum < 21 days and not breastfeeding Breastfeeding ≥ 6 weeks to < 6 months postpartum Age 35 or older and smoker HTN Gallbladder Disease Hyperlipidemias Diabetes Anticonvulsant medication or Rifampicin therapy Migraine headaches without aura & 35 or older Category 4 Contraindications for COC Breastfeeding < 6 weeks postpartum 35 & older smokes more than 2 packs per day Elevated BP (greater than 160/100) Hx or current DVT or PE Thrombogenic mutations Major Surgery w/Prolonged Immobilization Hx or current Ischemic Heart Disease or Stroke Complicated Valvular Heart Disease Migraine Headaches w/aura Current Breast Cancer Viral Hepatitis, Severe Cirrhosis, Hepatocellular Adenoma, Or Malignant Liver Tumors COC-related Cholestasis Module 2 Study Guide Understand the difference between combined hormonal contraception and progestin-only contraception. ● Combined hormonal contraception contains estrogen + progesterone ● Estrogen-progestin → COC (daily) , patch (weekly), nuvaring (monthly) ○ Mechanism of Action: ■ Estrogen ● Cycle control ● Endometrial proliferation ● Effects ovulation (suppress FSH, follicle development) ■ Progestin ● Prevent ovulation (suppress LH surge) ● Thicken cervical mucus ● +/- Inhibit endometrial proliferation ○ Contraindications to Estrogen: ■ Hx DVT, clotting disorder CVA, MI, cardiomyopathy ■ Breast cancer, other cancers of reproductive organs ■ Smoking + >35 years old ■ Postpartum <6wk (increased risk DVT) ■ Multiple CAD risk factors (HTN, DM, older age, smoking) ■ HTN (uncontrolled?) ■ Migraine w/ aura (or age >35 w/out aura) ■ Liver adenoma or tumor ■ Certain medications (anticonvulsants, antibiotics, sedatives) ● Progestin-only → OC (mini-pill, daily), IUDs (3-5 years), nexplanon (3 years), DMPA (3 months), emergency contraception (ella, Plan-B) ○ Mechanism of Action: ■ Prevent ovulation (suppress LH surge) ■ Thicken cervical mucus ■ +/- inhibit endometrial proliferation What are some basic guiding principles to providing preconception counseling (supplements, vaccinations, lab tests, patient education)? (pgs. 784-791) ● Women who are trying to conceive or who are pregnant should be warned to avoid ill children and adults and if working in occupations with bodily fluid exposure, they should continue to use universal precautions and have a low threshold for using advanced personal protective equipment to avoid airborne pathogens. ● Vaccinations: flu at any time during gestation; Tdap during the 3rd trimester (ideally 27-36 weeks’ gestation) ○ Hepatitis B is advised if at risk ○ MMR and varicella is contraindicated ● Labs: ○ all women and with each pregnancy: ■ Blood tests: CBC, blood type and Rh factor, antibody screen, rubella titer, HBsAg, HIV, syphilis test ■ Urine tests: culture, chlamydia and gonorrhea ○ As indicated by the woman’s history and preferences: ■ Blood tests: screening for diabetes (hx of impaired glucose metabolism or gestational diabetes, or with a current BMI 30), varicella antibody screen (for women with no history of natural infection), hepatitis C (hx of blood transfusion before 1992 or any injected drug use), TSH (hx of thyroid abnormalities), maternal genetic testing (cystic fibrosis testing—optional or hemoglobin electrophoresis for women of African descent), fetal genetic and development screening (maternal serum markers for women 10-14 weeks gestation—optional, noninvasive prenatal testing for women at risk of fetal genetic disorders, and quad screening for women 15-20 weeks’ gestation—optional) ■ Pap test Module 2 Study Guide ● ● ● ● ● ● Priorities for the 1st visit teaching: ensuring the woman has adequate resources and encouraging lifestyle modifications. List of warning signs: bleeding more than light spotting, severe abdominal pain, and extreme nausea and vomiting. General information on: sexuality during pregnancy, continuing exercise habits, wearing a seat belt, and avoidance of hot tubs/saunas Nutritional assessment: appropriate weight gain based on BMI; balanced diet with an increase of approximately 350 calories per day for the first trimester, spread over 3 meals and 2 snacks daily ○ Foods to avoid: unpasteurized milk, soft cheeses, gorgonzola, Mexican cheeses; prepackaged lunch meat, hot dogs and meat spreads; unpasteurized juices; unwashed fruits and vegetables; raw alfalfa sprouts; raw eggs; rare meat; raw fish and shellfish A generic prenatal vitamin supplement should be prescribed to ensure iron, folic acid, and vitamin needs are met. Caffeine intake during pregnancy should be limited to approximately 200 mg daily, which is equivalent to two 8-oz cups of coffee. What are the two main types of sexual problems reported? ● Problems ○ Arousal ○ Desire ○ Orgasm ● Pain disorders ○ Dyspareunia ○ Vaginismus Describe an approach to assessment of sexual problems. General Assessment for Sexual Concerns ● Health history: physical and psychosocial history questions; assess sexual health. ● Surgeries; chronic illnesses; medications; allergies; partner(s); relationship(s). ● Major depression; mental health problems. ● Female Sexual Function Index (FSFI): desire, arousal, lubrication, orgasm, satisfaction, pain. ● Lab tests identifying sexual dysfunction: low. What are some medications that may influence sexual function? Antidepressants ● Tricyclic antidepressants, including amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil) and nortriptyline (Aventyl, Pamelor) ● Monoamine oxidase inhibitors (MAOIs), including phenelzine (Nardil) and tranylcypromine (Parnate) ● Antipsychotic medications, including thioridazine (Mellaril), thiothixene (Navane) and haloperidol (Haldol) ● Antimanic medications such as lithium carbonate (Eskalith, Lithobid) ● Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil). Describe possible treatment plans for dysmenorrhea. ● Nonpharmacologic treatments ○ Heat ○ Lifestyle changes: vigorous exercise (more than 3 times per week); breakfast every day ○ Vitamin and herbal treatments: vitamin E; herbal medicine Shirazi Thymus Vulgaris; ibuprofen ○ Acupuncture ● Pharmacologic treatments ○ Nonsteroidal anti-inflammatory drugs (NSAIDs): most common and effective ○ Oral contraceptives ○ Progestin implants ○ Levonorgestrel (progestin) intrauterine device (IUD) ○ Depot medroxyprogesterone acetate (DMPA) injections Module 2 Study Guide ○ Surgical interventions: not recommended Differentiate between PMS, PMM, and PMDD. ● PMS ○ Distinct pattern of symptoms occurring before menses (within 7 days) and lasting through first days of menses, with little to no symptoms after menses end (during luteal phase) ○ Recurrence of symptoms that influence functioning at work, school, or in life (relationships) Includes physical, mood, and behavioral symptoms ● PMM ○ ○ ● Exacerbation of somatic and mood symptoms/conditions during the late luteal or menstrual phases ■ Anxiety or depressive disorders ■ Migraines ■ Seizure disorders ■ Irritable bowel syndrome ■ Asthma ■ Chronic fatigue Considered a dual diagnosis – originating condition with premenstrual magnification PMDD (premenstrual dysphoric disorder) p556 ○ A cluster of severe perimenstrual symptoms including at least one affective symptom ■ Directed towards mood/behavioral changes ○ DSM IV diagnosis (CONTROVERSIAL!) ○ Has to be severe in symptoms and influencing life, work, relationships to be diagnosed ○ 5+ symptoms that occur in the week prior to menses but are absent in the week or 2 after menses Identify other conditions that may be playing a role exacerbating PMS symptom clusters. Symptom Clusters ● “Turmoil” ○ Depression, anger, tension, guilt, tearfulness, anxiety, nervousness, irritability, loneliness, impatience ● “Fluid retention” ○ Weight gain, abdominal bloating, painful breasts, swelling of hands/feet, skin disorders ● “Somatic symptoms” ○ Nausea, fatigue, decreased food intake, abdominal pain, headaches, decreased sexual desire, aches and pains ● “Arousal” ○ Energy, increased sexual desire, impulsiveness, increased food intake, cravings What are the most common causes of vaginal bleeding in early pregnancy? ● Implantation Bleeding ● Infection ● Intercourse Describe the symptoms most commonly seen in ectopic pregnancy. ● Sharp or stabbing pain that may come and go and vary in intensity. (The pain may be in the pelvis, abdomen, or even the shoulder and neck due to blood from a ruptured ectopic pregnancy gathering up under the diaphragm). ● Vaginal bleeding, heavier or lighter than your normal period ● Gastrointestinal symptoms ● Weakness, dizziness, or fainting Define the various terms used to describe the stages of miscarriage. (p. 807) ● Threatened Module 2 Study Guide ● ● ● ● ● ○ Symptoms of spontaneous abortion present with intact products of conception ○ Minimal vaginal bleeding, abdominal cramping, uterine size is equal to dates, closed cervical os ○ Possible pregnancy loss Inevitable ○ Symptoms of spontaneous abortion increased in severity to include cervical dilation with products of conception intact ○ Moderate vaginal bleeding, mod-severe uterine cramping, uterine size equal to dates, dilated cervical os ○ Poor prognosis Incomplete ○ Symptoms of spontaneous abortion present to include cervical dilation and partial products of conception expelled ○ Heavy vaginal bleeding, mod-severe uterine cramping, uterine size equal to dates, dilated cervical os ○ Poor prognosis Complete ○ Products of conception expelled in entirety following symptoms of spontaneous abortion ○ Minimal vaginal bleeding, prior uterine cramping has subsided, uterus is pre-pregnancy size, cervical os is either closed or dilated ○ Pregnancy loss Missed ○ Products of conception retained for up to 6 wks following symptoms of spontaneous abortion ○ Vaginal bleeding has occurred, subsided, and reoccurs. No current uterine contractions, but there is a hx of uterine cramping ○ Pregnancy loss Recurrent ○ 3+ spontaneous abortions occurring consecutively ○ See above ○ Poor prognosis for maintaining future pregnancies without intervention → refer to assistive reproduction specialist Risk Factors of Spontaneous Abortions → heavy caffeine use, obesity, nonsteroidal anti-inflammatory drugs (NSAIDs) Understanding Different Stages of Miscarriage There are different kinds of miscarriages that can occur at different stages of your pregnancy. Depending on the type of miscarriage, different signs may be noticeable, and different treatments may be necessary. ● Chemical Pregnancy A chemical pregnancy is a very early miscarriage which can occur before a woman even learns that she is pregnant. With chemical pregnancy, an egg is fertilized, but dies shortly after implantation, so a heartbeat is never identified. Recently, more chemical pregnancies have been diagnosed as a result of pregnancy tests that allow earlier results. Most chemical pregnancies result from chromosomal abnormalities in the fertilized egg. There may be no signs of a chemical pregnancy. Most women simply begin to bleed around the time of their next period, though their period may arrive a few days late or be slightly heavier. ● Blighted Ovum Also known as anembryonic pregnancy, blighted ovum occurs very early in pregnancy, often before a woman even knows that she is pregnant. Blighted ovum occurs when a fertilized egg attached to the uterine wall, but an embryo does not develop. Women may feel signs of pregnancy, but when a doctor performs an ultrasound, he or she notices an empty gestational sac or cannot confirm a heartbeat. After a blighted ovum, women can miscarry the pregnancy or schedule a dilation and curettage (D&C) procedure, in which the woman’s cervix is opened and her uterus scraped. ● Missed Miscarriage With a missed miscarriage, a fetus dies early in pregnancy, but the pregnancy tissue is not expelled by the woman’s body. A woman who has experienced a missed miscarriage, also called a missed abortion, may Module 2 Study Guide continue to feel signs of pregnancy if the placenta still releases hormones, or she may notice signs of pregnancy fade. Some women may experience some vaginal discharge and cramping, but many have no symptoms of miscarriage. Sometimes the body will dispel the fetal tissue, but other times, a D&C procedure is necessary. ● Threatened Miscarriage A threatened miscarriage refers to vaginal bleeding that occurs during the first 20 weeks of pregnancy. Other symptoms of threatened miscarriage include lower back pain and abdominal cramps. Threatened miscarriages do not necessarily mean your pregnancy will end in a miscarriage. If you have experienced unexplained bleeding during pregnancy, your doctor will want to perform an examination. In a threatened miscarriage, the cervix will remain closed. However, if an examination reveals the cervix has opened, a miscarriage is much more likely. Threatened miscarriages can be frightening, but it is important to note that around half of threatened miscarriages result in a live birth. ● Inevitable Miscarriage Inevitable miscarriage refers to unexplained vaginal bleeding and abdominal pain during early pregnancy. Unlike threatened miscarriage, an inevitable miscarriage is also accompanied by dilation of the cervical canal. Bleeding is also heavier and abdominal cramps more severe in an inevitable miscarriage. The open cervix in an inevitable miscarriage is a sign that the body is in the process of miscarrying the pregnancy. ● Incomplete Abortion An incomplete abortion is often accompanied by heavy vaginal bleeding and intense abdominal pain. An incomplete abortion, which is also called an incomplete miscarriage, is also characterized by an open cervix and the passage of the pregnancy. Patients may pass some of the pregnancy tissue, or an examination may observe evidence of tissue passage. All the products of conception have not been passed, and an ultrasound may still detect some tissue in the uterus. ● Complete Miscarriage A complete miscarriage refers to a miscarriage in which all of the pregnancy tissue is expelled from the uterus. A complete miscarriage, which is also called a complete abortion, is characterized by heavy vaginal bleeding, severe abdominal pain, and passage of pregnancy tissue. With a complete miscarriage, the bleeding and pain should subside quickly. Complete miscarriages can be confirmed through an ultrasound. Describe the management options for early pregnancy loss. (p. 795) ● If transvaginal ultrasound confirms fetal death with a single, first-trimester fetus, the woman can allow spontaneous miscarriage, or referred for an intervention ● Uncomplicated miscarriage ○ Increased cramping and bleeding that resolves rapidly after passage of a small mass of tissue (products of conception) ● No spontaneous miscarriage within 2 wks or extensive bleeding (> 1 pad/hr), feels faint, extreme pain ○ Oral medications or uterine evacuation through aspiration or dilation & curettage) What are the main components of a review of systems that you should obtain when a person is concerned with PCOS? ● a. History ○ Thorough menstrual history (menarche, menstrual pattern, flow, symptoms) ○ Pregnancy history (ability to conceive, time to conception) ○ Symptoms/associated conditions of PCOS, including onset and severity – rapid vs slow onset ○ Medication history ○ Family history of associated conditions ● b. Exam ○ Anthropometric measurements – height, weight, BMI, waist circumference ○ Blood pressure ○ Skin examination – look for hirsutism, acne, alopecia ○ Acanthosis nigricans often seen with insulin resistance Module 2 Study Guide ○ ○ ○ ■ A skin condition characterized by dark, velvety patches in body folds and crease Thyroid exam Breast exam Pelvic exam – assess for uterine/ovarian masses ● What are the lab tests that should be considered FIRST when considering PCOS? ● TSH, prolactin, fasting lipid profile, 2hr OGTT (fasting glucose test) Describe pharmacologic and nonpharmacologic treatment modalities for PCOS. Pharmacologic ● Oral Contraceptives (1st line) - managing hyperandrogenism, endometrial hyperplasia, and menstrual dysfunction ● Antiandrogens (ie: spironolactone) for hyperadrenergic symptoms ● Gonadotropin-releasing hormone (GnRH) agonists are also sometimes used to suppress ovarian androgen production ● For women pursuing pregnancy: clomiphene citrate, metformin, letrozole all help induce ovulation in women with PCOS ● Antidepressant therapy Non-pharmacologic ● Diet ● Exercise ● Weight reduction Define urinary incontinence. ● Various definitions exist; they all lead to the same idea that it’s an involuntary leakage of urine that causes bothersome hygienic and social issues. ● “The complaint of any involuntary leakage of urine”; “a pelvic floor disorder; a social or hygienic problem when searching for the prevalence of bothersome urinary incontinence”; “involuntary loss of urine that is a social or hygienic problem” Describe the initial lab work recommended for abnormal uterine bleeding. ● General tests to consider for all types of AUB: ○ Pregnancy test = urine +/- serum hCG ○ CBC (anemia) ○ TSH (hypo/hyperthyroidism) ○ Prolactin (if headaches, galactorrhea +/- peripheral vision changes) ○ Pap smear (unless age < 21) ○ Nucleic acid amplification test (NAAT) for gonorrhea & chlamydia ○ Microscopic examination of vaginal secretions with NS and KOH ○ Coagulation studies (PT, PTT) if suspicious hx of bleeding or easy bruising; unexplained menorrhagia ○ Serum progesterone (if suspicion of anovulation) obtained between cycle days 22 and 24 ● Usually based on differential diagnosis → see below Differentiate between ovulatory and anovulatory uterine bleeding. (p. 580) ● Ovulatory (p. 576) ○ Regular, predictable bleeding ○ Tends to demonstrate the same interval, amount, and duration from cycle to cycle unless significant health changes occur that negatively affect the hypothalamic-pituitary-ovarian axis (HPOA) ○ Consistent pattern once ovulation is established ○ Often experiences PMS (bloating, fatigue, constipation, mood changes) d/t higher progesterone level ● Anovulatory (p. 580) ○ Abnormal cycle intervals, excessively heavy bleeding, or lighter than normal amounts of bleeding ○ Lack of progesterone in the luteal phase leading to unstable, excessively vascular endometrium ○ Always in the follicular phase of the ovarian cycle and in the proliferative phase of the endometrial cycle Module 2 Study Guide ○ ○ ■ No luteal or secretory phase because there’s no ovulation or cycle The only ovarian steroid signal the endometrium receives is estrogen, levels of which constantly fluctuates, rising and falling as each new cohort of follicles begins to grow but ultimately loses its developmental momentum and, sooner or later, lapses into atresia. Although the amplitude of the signal may vary, the message, growth, stays the same Generally caused by 1 of 3 hormone imbalances ■ Estrogen withdrawal ■ Estrogen breakthrough ■ Progesterone breakthrough Describe the differential diagnoses for AUB in a perimenopausal woman. (p. 588) ● Lab testing & differential diagnoses (p. 587) ○ Urine hCG ■ Pregnancy; threatened, missed, or incomplete spontaneous abortion ○ Serum hCG ■ Ectopic pregnancy or impending spontaneous abortion ○ CBC with PLT → Hb < 10; PLT < 150,000 ■ Anemia, clotting abnormalities ○ PT, PTT, increased bleeding time ■ Von Willebrand’s disease, leukemia, prothrombin deficiency ○ Decreased serum iron/ferritin ■ Iron-deficiency anemia secondary to bleeding ○ FSH >30-40 ■ Amenorrhea d/t menopause or premature ovarian failure ○ Progesterone < 10 ■ Anovulatory ○ TSH < 0.8 or >4 ■ Hypothyroidism or hyperthyroidism ○ Pap test w/atypical cells suggestive of dysplasia +/- carcinoma ■ Dysplasia, carcinoma ○ Prolactin > 100 ■ Pituitary adenoma ○ Cultures +/- microscopic examination of vaginal secretions ■ Vaginal infection (gonorrhea, chlamydia, trichomoniasis, vulvovaginal candidiasis) ● Differential diagnoses and lab tests (p. 588) ○ Endocrine causes of AUB ■ General labs + prolactin, FSH, LH levels (if premature ovarian failure is suspected) ○ Adrenal causes ■ General labs + adrenal studies, testosterone levels ■ Adjunct: CT scan of the abdomen, cortisol levels ○ Hormone-producing tumor ■ General labs + MRI, CT scan, cortisol levels ○ Structural abnormalities ■ General labs + ultrasound ○ Infection ■ General labs + gonorrhea and chlamydia tests + wet mount; consider need for WBC ○ Cervical or uterine pathology ■ General labs + colposcopy with biopsy; endometrial biopsy; hysteroscopy ○ Amenorrhea ■ General labs + FSH, LH, prolactin levels, TSH, T3, T4 ○ Von Willebrand Disease (VWD) ■ Ristocetin cofactor assay ○ Liver disease ■ Liver function tests Module 2 Study Guide ○ ○ Renal disease ■ Renal function tests Coagulation disorders other than Von Willebrand Disease (VWD) ■ PTT, PT, assessment of PLT function Define amenorrhea and its associated causes. (p. 581) ● Absence of menses ● Part of the spectrum of ovulatory disorders classified as AUB-O ● Causes: ○ Pregnancy (most common) ○ Hypothalamic amenorrhea ○ PCOS ○ Physiologic causes: ■ Anatomic defects, ovarian failure, chronic anovulation, anterior pituitary disorders, and central nervous system disorders ● Criteria: ○ No menses by age 14 in the absence of growth or development of secondary sexual characteristics ○ No menses by age 16 regardless of the presence of normal growth and development of secondary sexual characteristics ○ In women who have menstruated previously, no menses for an interval of time equivalent to a total of at least 3 previous cycles or 6 months Describe the preferred approach to discussing a positive pregnancy test. ● Hi, I’m ____, the midwife/FNP here with you today. (Or Hi, I’m ______, it’s good to see you again.) ● Your pregnancy test today is positive. ○ Pause and wait for a verbal response, facial expression, body changes. ● Tell me how you’re feeling about that. ● Okay, let’s talk about that. ● http://www.feministmidwife.com/2016/07/15/feminist-midwife-scripts-positive-pregnancy-test/ Describe the available options for medication and aspiration abortion. (p. 407) ● 4 methods for abortions: aspiration, medication, labor induction, surgery (hysterectomy, hysterotomy) ○ Aspiration abortion (p. 410) ■ Most common ■ Removal of products of conception by introducing a cannula through the cervical os into the uterine cavity. ■ +/- D&C to ensure the procedure is complete (but increased risk of complications) ■ Only used for abortions < 14 wks ● If after 1st trimester → forceps + suction (Dilation & Evacuation) ○ As safe as labor induction, but less physical/emotional stress for pt ■ Cervix dilation needed unless very early aspiration abortions ● Degree of dilation depends on gestational age of pregnancy ● Via insertion of dilating rods osmotic dilator several hours to 1 day prior to the intervention ○ Osmotic dilator usually used for later abortions ■ Misoprostol can also be used to soften the cervix ■ Paracervical block prior to cervical dilation ■ Some clinics offer general anesthesia, IV or PO pain meds → weight risks & benefits ■ Nonpharmacologic: positive suggestion, relaxation, guided imagery ○ Medication abortion (p. 411) ■ Mifepristone 200 mg PO [first] + [then] misoprostol 400-800 mcg vacinally, buccally, or PO ● 1/5th of abortions ● Effective up to 63 days’ gestation ● Bleeding starts 2-4h up to 24h after misoprostol administration Module 2 Study Guide ● ● ○ Normal to have subsequent bleeding May do transvaginal ultrasound to ensure it worked ○ Clinical examination, pregnancy testing, and pt symptomatology also acceptable ■ Methotrexate + misoprostol (similar efficacy) ■ Misoprostol alone (less efficacious) ■ Used for early abortions Labor induction abortion ■ Through medication prostaglandins +/- misoprostol to stimulate uterine contractions that lead to expulsion of the fetus ■ Oxytocin may also be used (less common)
