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Topics:

• Surgical Abortion
• Medical Abortion
• Post Surgical Information
• Alternatives to Abortion, Birth Control & Continuing Care
• Emergency Contraception (Morning After Pill)
• PAP Smears

Surgical Abortion

What is an abortion?
It is a surgical procedure that ends a pregnancy. If a woman finds herself with an unwanted pregnancy, she can choose to voluntarily end her pregnancy with this procedure.

Is abortion safe?
Yes. In fact, it is eleven times safer than giving birth. However, a serious complication sometimes occurs for example:

• An allergic reaction to the general or local anesthetic drug administered during the procedure
• Incomplete abortion
• Blood clots in the uterus
• Infection caused by germs from the vagina or cervix
• Heavy bleeding that requires treatment
• Perforation of the wall of the uterus, this occurs in about one in one thousand cases
• Failed abortion, this occurs in less than 1%
• Death can occur, as with any other surgical procedure

Is abortion painful?
Having an abortion can be painful, if you choose Local Anesthesia, but with IV Sedation, there is no pain.

How is an abortion performed?

1. The vagina is washed with an antiseptic solution.
2. The local anesthetic (like Novocain) is injected near the cervix.
3. The opening of the cervix is gradually stretched.
4. A blunt plastic tube is inserted into the uterus.
5. This tube is attached to a suction machine.
6. The machine is turned on and the uterus is emptied by gentle suction

What about future pregnancies?
Having an abortion with no complications (such as infection), in most cases, should not affect your ability to have a child and should not make a miscarriage more likely in future pregnancies. Fertility is not affected.

About the Rhogam Injection

1. You will need a blood test at the time of the procedure.
2. Your blood test will show your blood type (A, B, AB, or O), and a RH factor of either Positive or Negative.
3. If you are a RH Negative blood type, you must get a Rhogam Injection within 72 hours of the abortion to prevent RH Disease.
4. The Doctor will give you the Rhogam Injection after the procedure on the day of the procedure, if you have RH Negative blood type. Please note that you will be charged $50 for a Rhogam Injection.

What is RH Disease?
When a woman with RH Negative blood is carrying a baby with RH Positive blood, very serious complications could occur in future pregnancies such as mental retardation and death. A Rhogam injection is given to prevent future complications arising from such differences in the Rh factor between the pregnant mother and the child.

Medical Abortion

1. Mifeprex, RU-486

Q. What is Mifeprex?
A. Mifeprex is the first Food and Drug Administration (FDA) approved early option pill providing women with a non-surgical option for ending early pregnancy. This option blocks a hormone necessary to sustain a pregnancy. Mifeprex is the brand name of mifepristone in the United States. Mifepristone is sometimes referred to as the early option pill, non-surgical abortion, medical abortion, the abortion pill or RU-486.

Q. How Does Mifeprex Work?
A. Mifeprex blocks progesterone, a hormone necessary for a pregnancy to continue. Mifeprex must be followed by misoprostol, which causes uterine contractions that help to end pregnancy.

In more detail, Mifeprex blocks progesterone, a naturally produced hormone that prepares the lining of the uterus for a fertilized egg and helps maintain pregnancy. Without progesterone, the lining of the uterus softens, breaks down and bleeding begins. Mifeprex is followed by a prostaglandin that causes the uterus to contract, which helps to complete the process. Prostaglandins are substances made naturally by the lining of the womb during menstruation that cause contractions of the uterus. The prostaglandin used following Mifeprex is Misoprostol.

Q. When is Mifeprex Appropriate?
A. Mifeprex is an early option pill that can be used to end a pregnancy up to 49 days from the first day of your last normal menstrual period. This must be confirmed by a sonogram.

Q. How Effective is the Early Option Pill?
A. Mifeprex followed by misoprostol is approximately 92-95% effective. Compared to a surgical abortion, the failure rate is 5% which will require the surgical procedure (the surgical abortion failure rate is 1%).

Q. What are the advantages of Mifeprex?
A. Mifeprex is a non-invasive early option for ending pregnancy. Mifeprex comes in pill form and is taken orally. This method allows you to avoid surgery or anesthesia in most cases. Technology has made it possible to detect pregnancy very early and now with Mifeprex you can take immediate action.

Q. What are the side effects?
A. Bleeding and cramping are a normal part of the process. You will experience bleeding and cramping that is greater than and lasts longer than your normal period. You can expect bleeding or spotting for an average of 9-16 days. In some cases, women may have severe bleeding and need to contact their doctor right away. Your provider will tell you how to manage any pain or side effects. Side effects that may occur include nausea, headache, vomiting, diarrhea, dizziness, fatigue and back pain. The death rate is 1 out of 100,000 due to severe infection (the death rate for surgical abortion is 1 out of 500,000).

Q. How is Mifeprex Provided?
A. Mifeprex is provided through a doctor’s office or clinic. The early option pill can be taken only during the first seven weeks of pregnancy. During the office visit, your provider will perform a sonogram to determine if you are a candidate for this method. You will then be given a Medication Guide (to help you understand how the early option works) and you will receive counseling. You will also be asked to sign a statement declaring that you have decided to end your pregnancy. You then take one or three tablets, containing 200 milligrams of Mifeprex. According to Danco, the manufacturer of Mifeprex, the recommended dosage is three tablets. However, independent studies show that only one tablet of Mifeprex is as effective as three tablets**. Literature pertaining to these findings will be provided upon your request. If you choose to follow the recommendation of three tablets, there will be an extra charge of $180.

Two days later, you will need to take two tablets each containing 200 micrograms of misoprostol. A follow up visit approximately 14 days later is very important to check that the pregnancy has ended. If it has not ended there is a chance there may be a birth defect. About 5-8% of women who take Mifeprex will need a surgical procedure to end the pregnancy or stop heavy bleeding. This can be compared less than 1% of women who undergo the surgical procedure. Your Healthcare provider will communicate to you how s/he has planned to handle this possibility. In the event that you will need a surgical procedure performed, there will be an extra charge. Mifeprex offers you a more private option, with support and counseling readily available throughout the process. Your provider will give you a telephone number to call if you have any questions and, if different, a name and number to call in an emergency.

Bleeding and cramping are a normal part of the process. Some women will have light bleeding after taking Mifeprex. If you are not already bleeding after taking Mifeprex, you probably will begin to bleed once you take misoprostol on Day 3. This bleeding may be similar to, or greater than, a heavy period. Bleeding or spotting can be expected for an average of 9-16 days. In some cases, women may have severe bleeding and need to contact their doctor right away. Some women may not experience any kind of bleeding or cramping. This does not necessarily mean that the pills are not working. As an expected part of the process, you may pass blood clots and tissue. Your Healthcare provider will give you a telephone number to call if you have any questions and, if different, a name and number to call in an emergency.

Q. What Experience Has There Been with Mifeprex?
A. Mifeprex has gone through the rigorous Food and Drug Administration approval process for safety and effectiveness. Mifeprex is the first FDA approved early option pill for ending pregnancy. More than 2,000 women in the United States participated in clinical trials; the results were published in the New England Journal of Medicine and the American Medical Association’s Archives of Family Medicine Journal. In the past decade nearly one million women worldwide, excluding China, have used this drug for ending early pregnancy. Worldwide, this option has now been approved for use in twenty-seven countries including major European countries and the U.S. In the two years since FDA approval of Mifeprex, over 100,000 women in the United States have used Mifeprex for an early, non-surgical abortion.

Q. What Kind of Follow-Up Care is Necessary?
A. While bleeding and cramping are a normal part of the process, they are not necessarily indicators that a pregnancy has ended. The follow-up visit is very important to confirm that the pregnancy has ended. Counseling and support are available throughout the process and you should report any problems you have during or after taking Mifeprex to your Healthcare provider.

2. Methotrexate

Q. When is Methotrexate appropriate?
A. When there is no pregnancy detected by the sonogram but the urine pregnancy test and blood pregnancy test is positive.

Q. What is Methotrexate?
A. Methotrexate is an injection which terminates a pregnancy by blocking the production of folic acid. Studies have proven this method to be very successful and over 90% of all patients experience a complete expulsion of the pregnancy within two weeks. The risk of infection and perforation is significantly reduced. Failure to expel the pregnancy will necessitate the use of vacuum aspiration to complete the abortion.

Q. What are the possible Side Effects?
A. No significant side effects have been reported at this dosage of Methotrexate. However, at higher dosage with long term treatment for other medical conditions side effects have been reported such as nausea and vomiting; temporary reduction in the manufacture of red and white blood cells; toxic effects on the liver; and chills and fever. In the many women treated with the single low dose of Methotrexate, none of these adverse side-effects were noted. It must be emphasized that the dose used to effect this abortion can cause anomalies, and you must be certain of your decision to end this pregnancy and be willing to have a surgical abortion should the medications not cause the abortion.

Q. How is Methotrexate provided?
A. The sonogram must fail to detect a pregnancy in the uterus, in which case, a pregnancy outside the uterus, usually in the Fallopian tube cannot be excluded. Since Methotrexate can effectively terminate a pregnancy both in and out of the uterus, this method of termination will be offered.

Of course it should be understood that this, or, for that matter any treatment is not 100% effective and future surgery might be necessary. If your medical history, exam and blood tests are normal, you may begin the procedure with a Methotrexate injection. You will be given 2 Misoprostol tablets to be taken by mouth at bedtime four days from now (day #5). Uterine cramping and bleeding should begin within 2 to 4 hours after the tablets are taken. Strong cramping is expected and you should use Tylenol as instructed. Do not use any other drugs including ibuprofen, as they interfere with the abortion. DO NOT drink alcohol, have sexual intercourse, take vitamins containing folic acid, or eat any foods that contain folic acid. A list of food restrictions will be provided for you.

Q. What if my blood type is negative?
A. If you are RH negative you must receive a Rhogam shot at the same time of the Methotrexate shot.

Q. What will happen if the abortion is not complete after Methotrexate treatment?
A. If there is still pregnancy tissue in the uterus a vacuum aspiration procedure is mandatory. It is important that you agree to have this surgical treatment if the Methotrexate abortion fails.

Methotrexate Precautions

It is very important that you follow all instructions and keep your appointments. When the treatment is complete at your follow-up exam contraception will be discussed as you choose.

1. Do not use alcohol, aspirin, NSAIDS (Motrin, Advil, Ibuprofen, etc.) diuretics, vitamins, antibiotics, steroids or anything containing folic acid for 2 weeks after receiving the injection.
   
2. Avoid food with folic acid. Read labels – if folic acid is present, do not eat it. Usually breakfast cereals are loaded with folic acid. Cooking at high temperatures will generally destroy 90% of folic acid – so McDonald’s French fries, steak and potatoes are acceptable as long as they do not interfere with any dietary restrictions. As you can see most “healthy foods” such as the following are basically off your menu:

DO NOT EAT THESE FOODS

• Beans - Especially kidney, lima, black and lentils. Check label on canned beans.
• Broccoli, peas, or beets
• Brewer’s Yeast – Found in alcohol. No alcoholic beverages.
• Whole grains – Folic acid may be in enriched breads, pasta and rice.
• Plain white or brown rice should not contain folic acid. Check the label.
• Wheat germ
• Bananas, oranges, and grapefruit. Orange juice & grapefruit juice.
• Organ meats like liver, heart, etc.

OK TO EAT

• All dairy products, seafood, poultry, pork, beef
• Plain white or brown rice (not enriched)
• Canned vegetables of any type
• Carrots, cauliflower, celery, cucumbers, eggplant, garlic
• Iceberg lettuce, leeks, mushrooms, olives, onions, peppers
• Potatoes, radishes, squash, tomatoes
• Apples, avocadoes, blueberries
• Water, milk, coffee, tea, and sodas.

WHEN IN DOUBT, CHECK THE NUTRITION INFORMATION.

References
Schaff EA, Eisinger SH, Stadalius LS, et al. Low dose mifepristone 200 mg and vaginal misoprostol for abortion. Contraception. 1999;59:1-6

Post Surgical Information:

Infection: A fever is the first sign of infection. Please take your temperature twice a day for the next 7 days. If you have a fever of 100.4 or higher, call NOVA Healthcare immediately. Be sure to have the phone number of a pharmacy that is open at the time of your call so that the Doctors will be able to phone a prescription for you if it is necessary.

Excessive Bleeding: You may have bleeding equal to your normal period, off and on, for the next 3 - 4 weeks. This is normal and no treatment is necessary. Passing large blood clots, soaking more than 1 regular-sized pad in an hour, soaking more than 6 regular-sized pads in a 24-hour period should be reported immediately. Call the office during regular hours or call the emergency number listed above during non-regular hours.

Excessive Cramping: Taking Advil or Extra-Strength Tylenol every 4 hours may relieve light to moderate cramps. If you are having cramps that are more severe than during or directly after the procedure, call the office during regular hours or call the emergency number listed above during non-regular hours. Take Advil, Aleve or Tylenol only if you are not allergic to NSAIDs (Non-steroidal anti-inflammatory drugs), Naproxen or acetaminophen .

Bleeding, Cramping or Soreness: You may experience cramping, soreness, bleeding or spotting which is normal after surgery. Not experiencing any of these symptoms is also normal and you should not be alarmed. If you are experiencing severe cramping, soreness and excessive bleeding please follow the guidelines above for recognizing the symptoms of complication.

Breast Tenderness: You may have some tenderness or fullness in your breasts and may milk during the next 2 to 3 weeks. This is normal and no treatment is necessary. Wearing a firm bra may help.

Nausea, Vomiting & Dizziness: These symptoms could be due to the early stages of pregnancy (morning sickness) or sensitivity to antibiotics. If these symptoms persist, become stronger and you did not experience these symptoms prior to taking the antibiotics, please contact the office.

Prevent an infection or other complications from occurring, until you return for your follow-up do not:

• have sex
• use tampon
• douche
• bathe in a bathtub (use shower)
• run or exercise
• lift above 10 lbs.

Follow-up: You will be given a return appointment for a follow-up. It is very important you return on that day. If you are unable to come that day for your follow-up please call the office during regular business hours to reschedule.

Next Period: Your next normal period will occur within 6 to 8 weeks from the date of surgery or 3 to 5 weeks after your follow-up. Call NOVA Healthcare if you do not have a period after 8 weeks from surgery or 5 weeks from follow-up. Your first period might only last one day and be very light. It is also possible that your first and second periods could be more painful than usual with heavy cramping.

Alternatives to Abortion, Birth Control
& Continuing Care

Alternatives: The decision to terminate a Pregnancy is one of the hardest someone can make. It is important that you have thought through your decision carefully and considered the alternatives that are available to you.

Having a child is a big responsibility but can also be the most rewarding experiences of a woman's life. Finances and personal relationships are two main concerns. It is important that you have discussed your decision with your family or friends because some of the obstacles you see may be able to be resolved.

Going to term with your pregnancy is another option. There are many state, local and private organizations that can help information on adoption procedures.

Before your procedure, the Doctor will consult with you. You should ask any questions you have about your alternatives with her at that time.

If at any time before your procedure, you feel you have doubts about your decision, please notify the staff and we will discharge you. Do not, under any circumstances, feel embarrassed or shy about saying that you've changed your mind. We are here to help you. We do ask that you inform the staff so that we are aware that you've left the clinic.

Birth Control: Abortion should not be considered a form of birth control. Pregnancy can be easily and painlessly avoided. The birth control pill or patch is the most effective contraceptive available. There are other effective methods such as the IUD and Depo-Provera. You will be able to discuss what method of birth control is best for you during consultation.

Continuing Care: You should make sure that that you make an appointment with a gynecologist before your birth control runs out. Under any circumstances, it is important for all women to have an annual gynecological check-up and pap smear. If you do not have your own gynecologist, we will be happy to take you on as a new patient.

Emergency Contraceptive Pills

Emergency contraceptives are methods of preventing pregnancy after unprotected sexual intercourse. They do not protect against sexually transmitted diseases. Emergency contraception can be used when a condom breaks, after a sexual assault, or any time unprotected sexual intercourse occurs. Do not use emergency contraceptives as your only protection against pregnancy if you are sexually active or planning to be, because they are not as effective as any ongoing contraceptive method.

Emergency contraceptives work before implantation and not after a woman is already pregnant. Depending on the time during the menstrual cycle that they are taken, ECPs may inhibit or delay ovulation, inhibit tubal transport of the egg or sperm, interfere with fertilization, or alter the endometrium (the lining of the uterus), thereby inhibiting implantation of a fertilized egg.

How long after unprotected sex can emergency contraceptive pills be taken?
The instructions for Preven and Plan B state that treatment should occur within 72 hours after unprotected intercourse. Several recent studies have found that the pills can be given up to 5 days (120 hours) after unprotected intercourse.

What is my risk of pregnancy from unprotected intercourse?
The risk of pregnancy is virtually zero during the first two days of the cycle (day 1 of the cycle is the first day of bleeding). The risk begins to rise steadily thereafter, reaching 90% on about day 13, and begins to decline slowly thereafter to about 1% on day 25, and remains at about 1% as late as day 40 and beyond. (Average cycle length is 29 days, but it is normal to have cycles that last anywhere from 20 days or less to 40 days or more.) However, it is important to note that these figures are averages and that the risk for an individual woman may be higher or lower. The important point is that almost any act of unprotected intercourse entails some risk of pregnancy and that EC can reduce this risk.

What if I engage in unprotected sex but ejaculation does not occur? Is sperm present in pre-ejaculatory fluid?
The chance of pregnancy is probably extremely low. Two small studies found no motile sperm in pre-ejaculatory fluid, but that is all the evidence there is.

If you are worried about the possibility of pregnancy, of if you are not sure whether or not ejaculation did occur, ECPs will do no harm and may do some good.

When should my next period come after I take emergency contraceptive pills?
Your next period should come more or less on time. Several studies have found that about half of women find that their next period starts within +3 days of the anticipated onset, but that is much more common for the next period to come early than to be delayed. After taking ECPs, some women have their period early, and some women have irregular bleeding that is not really their period. The duration of the irregular bleeding is not predictable. You should have another, normal period within the next month. If not, you should get a pregnancy test just to make sure you’re not pregnant.

What if I bleed after taking ECPs?
Some women do get unusual bleeding after using emergency contraceptive pills because of the hormones in the pills. If that’s the cause, it’s not dangerous, and it will probably go away by itself after you get your next period. It is also possible that your unusual bleeding could be due to some other cause, however, that could (rarely) be more serious. If you have other symptoms like abdominal pain or dizziness, or if the problem lasts longer than a few days or gets worse, of if you’re just worried, you should call your doctor.

Your next period should come about when you would have expected it or within a week earlier or later. If it doesn’t come by a week after you expected it, you might consider getting a pregnancy test.

When can I take a pregnancy test and be sure that it is accurate?
If a woman is pregnant, a home pregnancy test will reliably turn positive by the time her next period would have come. If the pregnancy test is negative and you are still worried, you can repeat the test after one week.

Can I get emergency contraception without my parent’s knowledge or consent if I am under 18 years old?
Yes.

Pap Smears:

An Investment for Health

Written by Sharla Taylor, R.N., Lois Mulholland, R.N., Vicki Guzman, R.N., University of Iowa Department of Obstetrics & Gynecology Peer Review Status: Internally Peer Reviewed, First Published: September 1988, Last Revised: September 1988

Making Smart Choices

Throughout our lives, we have many choices to make. These choices affect our family, friends, employers, and last but not least, ourselves. The choices we make today affect the choices we'll have to make in the future. Health care choices such as diet, exercise, health habits, and physical exams may be among our most important decisions. Our health is one of our most valuable assets, yet too often we neglect our physical needs or develop habits that may do us harm.

Yearly Checkup

A smart choice that we can make to ensure good health is to have a yearly Pap smear. A Pap smear is a simple test that does not involve much time or discomfort. The Pap smear will detect potential problems of the cervix (opening of the uterus) or vagina (birth canal) early so they can be diagnosed and treated. Another good reason to have a yearly Pap is because your doctor will also do a breast exam, blood pressure check, pelvic exam and listen to your heart and lungs. Other tests may be done based on your needs and health history.

It's a good feeling knowing you're healthy and that you are doing your part to stay that way.

Who Should Have a Pap Smear?

Pap smears of the cervix are recommended every year as soon as a woman is sexually active; otherwise, every year starting from ages 18-21.

How is a Pap Smear Done?

Some women find the Pap smear and pelvic exam embarrassing, but it should be seen strictly as a necessary medical process and not as a procedure to embarrass you. It is the only way to examine you internally and to take a Pap smear.

For the exam, you will be asked to lie on you back on the exam table, bend you knees and put your feet on the foot rests. The doctor will want you to let you legs rest out to the sides. The important word at this point is RELAX. Concentrate on letting your muscles go soft and take slow, easy breaths in through your nose and out through your mouth. The more relaxed you are the more comfortable the exam will be. A speculum is gently inserted into the vagina, and then opened to allow the examiner to see your cervix. When the cervix is in good view a sampling of cells is taken from the cervix or vaginal wall by gently scraping a wooden spatula and soft brush on your cervix. You may feel a pressure feeling and maybe a small cramp. The cells are placed onto a glass slide and sent to the laboratory to be examined.

What Does a Pap Smear Tell Us?

A Pap smear gives us information about the cells of the cervix or vagina. An abnormal Pap smear means that changes in the cells have been found. These changes can be referred to as "warning cells" (cells that can later become cancer cells.) This is why it is important to have regular Pap smears and to treat any abnormalities at an early stage.

Some abnormal Pap smears are due to infections of the cervix or vagina. Many abnormal Pap smears caused by infection will return to normal once the infection is treated.

It is not possible to remove every cell of the cervix with a Pap smear. Therefore, cells that are taken for the Pap smear can be normal and the cells remaining on the cervix may be abnormal. This does not happen often, but it is possible. This is another reason to have Pap smears regularly.

What Will Happen if Your Pap Smear is Not Normal?

The doctor will notify you in one to two weeks by phone or letter if your Pap smear is abnormal and to discuss recommendations for follow-up and treatment.

Further testing may be needed. Colposcopy, an office procedure, may be used to help the doctor view the cervix with a microscope to look for infection or any abnormal cells on the cervix or vaginal wall. This would help him/her to see signs of infection or any abnormal cells. If an area on the cervix doesn't look normal, the doctor may want to take a biopsy (sample cells) for further testing.

Who is At Greater Risk for Abnormal Paps?

Women

• who have had sexual contact before age 18.
• with a history of many sexual partners.
• whose mothers took DES (Di-Ethyl-Stilbestrol) - a medication which used to be taken for certain pregnancy complications from the 1940s to the 1960s.
• with frequent infection which may be spread by sexual contact.
• who smoke.
• who become pregnant before age 18.

What are the Warning Signs of Cancer?

• Bleeding between your periods
• Any unusual vaginal discharge or pain
• Bleeding after intercourse
• Bleeding after menopause

Remember that these are just warning signs which may or may not indicate cancer. If you notice any of the symptoms listed above, it is important for you to see your doctor to find out the cause and to receive treatment.

It is also important to realize that often there are no warning signs. Because of this, it is important to have regular Pap smears. Most women with abnormal Pap results can look forward to a normal Pap smear in the future with appropriate treatment and follow-up.

Planning for your Pap Smear

You can help your doctor do the very best exam by having the following information available:

1. Date of your last period
2. Current medications such as birth control pills or other hormone pills or creams (the name and dose)
3. Any bleeding at times other than your period and when it occurred
4. Any discharge (white, thick, or watery liquid)
5. Any history of abnormal Pap smears or surgery such as a hysterectomy (having the uterus removed)

These facts help the doctor and the specialist looking at your cells to decide if your Pap smear is normal or not.

If you are having your period at the time of the exam, it is best not to have a Pap done that day. You should also avoid douching or using vaginal cream for at least 24 hours before having a Pap smear.

In summary, there are many good reasons to make the choice to have a Pap smear:

• It's a simple procedure
• A Pap costs little
• It's a source of valuable information
• It can help prevent further health problems
• You're doing something for yourself
• You can also get a general physical at the same time
• It can be a time to ask questions about other health topics

It can leave you with the positive feeling of knowing you made a "smart choice" and a "good investment for your health."
Think of your yearly physical as an important way of taking care of yourself. You're worth it.