Abortion
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INTRODUCTION ¡@

Background: In the US and worldwide, elective termination of pregnancy remains common. Accurate statistics have been kept since the enactment of the 1973 Supreme Court decisions legalizing abortions. Since then, approximately 1.3-1.4 million abortions have been performed annually in the US, and worldwide some 20-30 million legal abortions are performed annually, with another 10-20 million abortions performed illegally . Illegal abortions are unsafe and account for 13% of all maternal mortality and serious complications. Death from abortion is almost unknown in the US or in other countries where abortion is available on demand.

In spite of the introduction of newer, more effective, and more widely available contraceptive methods, more than one half of the 6 million pregnancies occurring each year in the US are termed unplanned by the women who are pregnant. Of these pregnancies, approximately one half end in elective terminations. Abortion is still one of the most common medical procedures performed in the US each year, and more than 40% of all women will have a pregnancy terminated by abortion at some time in their reproductive lives. Each year in the US, almost 3% of all women of reproductive age terminate their pregnancies. While women of every social class seek terminations, the typical woman who terminates her pregnancy is young, white, unmarried, and poor.

The development of more advanced surgical techniques has allowed for safe second trimester terminations and, statistically, more of these have been performed. The Food and Drug Administration (FDA) recently has given approval to Mifeprex (mifepristone, RU-486) for medical abortions. Multiple regimens for medical terminations using medications approved by the FDA for indications other than termination of pregnancy have come into use. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination. This may be difficult to track statistically but may actually lead to an increased number of abortions in the US.

A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the US. An understanding of the laws (enacted, enjoined, and pending) on local and federal levels is important to providers, and these legal ramifications are reviewed in this chapter as well .

Abortion postoperative care often is provided at sites that did not perform the termination of pregnancy, and strategies for follow-up care for women whose pregnancies have been terminated are important for all providers of primary care for women.

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Surgical termination

The development of accurate over-the-counter (OTC) pregnancy tests allows for the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in this very early time frame have been termed "menstrual extractions,?a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed extremely early suction evacuations without histologic tissue confirmation, allowing for maximum confidentiality for both patient and provider.

Abortions performed prior to 9 weeks from last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. From 9 weeks until 14 weeks, an abortion is performed by a dilatation and suction curettage procedure. After 14 weeks, surgical abortions are performed by a dilatation and evacuation procedure. After 20 weeks of gestation, abortions can be performed by labor induction, prostaglandin labor induction, saline infusion, hysterotomy, dilatation and extraction, or intact dilatation and extraction. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.

Medical abortion

Medical abortion is a term applied to a medication-induced elective abortion. This can be accomplished with a variety of medications administered either singly or in succession. Medical abortion has a success rate that ranges from 75-95%, with about 2-4% of failed abortions requiring surgical abortion and about 5-10% of incomplete abortions, depending upon the stage of gestation and the medical products used. For a review of multiple studies see Kahn et al 2000. Patients who select a medical abortion express a slightly greater satisfaction with their route of abortion and, in the majority of cases, express a wish to choose this method again should they have another abortion. Research needs to be done to more clearly establish which protocol is best, which medications are preferable, and how successfully women and adolescents can diagnose a complete versus an incomplete abortion.

Although a critical shortage of providers to provide surgical abortions exists, in a recent study by Koenig et al providers who do not perform surgical abortions have indicated a willingness to provide medical abortions.

Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Some patients require an emergency surgical abortion, and for safety concerns, patients undergoing medical abortions need access to providers willing to perform an elective termination.

The in September of 2000 the FDA approved mifepristone (RU-486) for use in a specific medical regimen that includes misoprostol administration for those who do not abort with mifepristone alone. Methotrexate and misoprostol are approved drugs for other indications that can be used for medical termination of pregnancy. Additional research will determine exactly which regimen is the best for medical abortions.

Medical abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed the patient must be seen for evaluation of the completeness of the process.

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Frequency:
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Mortality/Morbidity: The safety of abortion is well established, with infection rates less than 1%, and less than 1 per 100,000 mortalities occurs from first-trimester abortions. At every gestational age, elective abortion is safer for the mother than carrying a pregnancy to term.

Race: In 1996, of the women who obtained legal abortions, 59.1% were white, 35, 2% were black, and 5.7% were other (of the other, 16.1% were Hispanic).

CLINICAL ¡@

History: Most terminations of pregnancy are performed after a brief and targeted gynecologic and obstetric history. Providers should obtain information about any prior pregnancies and information regarding any treatment or care during this pregnancy. The history taking also should focus on prior gynecologic disease with particular attention to previous or current sexually transmitted infections (STIs). Information regarding medical history that might be important includes a history of diabetes, hypertension or heart disease, anemia or bleeding disorders, or previous gynecologic surgery. A history of active medical problems may mean that the patient needs to be medically stabilized prior to the abortion or have the procedure performed in a facility that can handle special medical problems.

Physical:

DIFFERENTIALS ¡@

Anemia
Cervicitis
Early Pregnancy Loss
Ectopic Pregnancy
Missed Abortion
Pelvic Inflammatory Disease
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Other Problems to be Considered:

Bacterial vaginosis
Cervical dysplasia or neoplasia
Ovarian masses
Uterine fibroids
Uterine anomalies
Multifetal gestations
Fetal anomalies
Maternal illnesses
Maternal allergies
Bleeding or clotting disorders
Grand multiparity
Cervical incompetence
Sexual Assault
Psychological trauma
Bacterial endocarditis prophylaxis
Benign Lesions Of The Uterine Corpus

WORKUP ¡@

Lab Studies:
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Imaging Studies:
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Other Tests:
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Histologic Findings: Pathologic analysis of tissue typically is performed for documentation purposes, but visual inspection of the products of conception postprocedure is mandatory. Washing the blood clots off the tissue obtained prior to visual inspection is helpful, and the presence of villi can be detected more reliably after back lighting the specimen. In cases in which very little tissue is obtained, the use of colposcopy may reveal villi. Pathologic confirmation should be available within 24 hours if an ectopic pregnancy is suspected or within a week to 10 days if no pathology is suspected. Many fetal anomalies can be detected on anatomic inspection of the fetus, but only intact procedures or induction of labor reliably offer a fetal specimen that can be evaluated adequately.

Placental analysis typically reveals products of conception consistent with gestational age. Preoperative ultrasound typically reveals placental abnormalities, such as a molar gestation or choriocarcinoma, when present. However, having histologic analysis reveal the presence of a partial molar pregnancy or an incomplete molar pregnancy is not uncommon.

TREATMENT ¡@

Medical Care: Once the pregnancy has been confirmed, gestational age has been established, and the patient has decided to abort, the procedure offered typically reflects the patient's stage of gestation. Early abortions can be accomplished medically or surgically, but most facilities do not have the technical ability or the protocols established to offer medical abortions. Therefore, most abortions are performed surgically.

Surgical Care: Documentation is an important part of the surgical procedure. Preoperatively prepared standard operative reports are the standard of care and should include documentation of several important features including the patient's anatomical assessment (including uterine size), the procedure and instruments used (including the size of the dilators and the cannula used), the amount of blood loss, and the amount of tissue obtained.

Consultations: The counseling process should offer referrals for those who need ongoing support.

Diet: Patients may eat a regular diet.

Activity:

MEDICATION ¡@

The procedure usually is performed under local anesthesia. For those modestly tolerant of pain, either intravenous sedation or administration of a preoperative antianxiolytic agent can be used. Narcotics can be used for pain control but usually are not necessary. A variety of agents may be useful for contracting the uterus postprocedure, although in a typical first trimester procedure, none are necessary. Agents useful to control bleeding include Pitocin, Methergine, or prostaglandins. Mechanical devices to control hemorrhage can be useful as well, which typically consists of intrauterine insertion of a Foley catheter.

Postprocedure pain and cramping are effectively treated with a variety of analgesic agents (ie, NSAIDs, Tylenol, codeine, Vicodin).

Dinoprostone (Cervidil, Prepidil, Prostin E2) is a prostaglandin administered vaginally and is approved specifically for the use at term in labor for cervical preparation. It works almost as well as misoprostol, but it is very expensive and not used for abortions for this reason alone.
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Drug Category: Local anesthetics -- A few patients can tolerate cervical dilatation and suction curettage with no anesthesia and also through relaxation techniques. Paracervical blockade provides some additional cervical compliance in the dilatation phase as well as all the anesthetic that is necessary for early abortion procedures.

Drug Name
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Lidocaine (Xylocaine) -- Used for paracervical block during procedure to keep patient comfortable. Local anesthetic blocks nerve impulses by decreasing sodium influx across neuronal cell membranes. Alternatively, chloroprocaine (Nesacaine) may be used.
Adult Dose Popular mixture used (12-20 mL in divided doses to be injected in each patient):
(1) 50 mL vial of 1% or 0.5% lidocaine and draw off 5 mL (2) add 2-4 U (0.1 mL) of vasopressin (3) add 5 mL of buffer (8.4% sodium bicarbonate)
If Atropine is added, dose is 2 mg/50 mL
Deep injections are more efficacious than superficial, inject 10-15 mL halfway between the os and the periphery of the cervix at 4 sites (12, 3, 6, 9 o'clock) at a depth of 0.75-1 inch
Pediatric Dose Not established
Contraindications Documented hypersensitivity; Adams-Stokes or Wolf-Parkinson-White syndrome; SA, AV, or intraventricular heart if artificial pacemaker is not in place
Interactions Increased toxicity with cimetidine, beta-blockers; additive cardiodepressant action with procainamide, tocainide; increases effects of succinylcholine
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Associated with malignant hyperthermia; increased risk of CNS and cardiac adverse effects in the elderly; seizures, heart block, and AV conduction abnormalities have occurred; caution with heart failure, hepatic disease, hypoxia, hypovolemia, shock, respiratory depression, and bradycardia

Drug Category: Prostaglandins -- Abortifacient drugs of various types can be used for medical termination or treatment of ectopic pregnancy. Rarely they are used to complete an incomplete surgical abortion. This class of drugs includes misoprostol, gemeprost, and PG05 (15MF2 alpha prostaglandin).

Drug Name
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Misoprostol (Cytotec) -- Not approved for use in pregnancy, yet is an invaluable medication widely used for cervical preparation for abortion, labor induction, and as a medical abortifacient. Provides safe, passive method of cervical dilatation and should be considered for preabortion ripening when prior uterine surgery (ie, LEEP, C-section) are known risk factors for uterine perforation during surgical abortion. Can be administered orally or vaginally. Some studies show premoistening tablets placed vaginally helps absorption. Patients can be instructed in self-administration to help time the dose in synchrony with their abortion procedure.
In a study by Singh of primigravid women (6-11 wk gestation), 93.3% achieved dilatation of the cervix of 8 mm or greater after 3 h postintravaginal misoprostol 400 mcg, whereas only 16.7% of women achieved this after 2 h of 600 mcg. The 600-mcg group had slightly greater adverse effects (eg, bleeding, abdominal pain, fever >38ºC). Dosage intended for cervical ripening can induce abortion in some patients. Oral doses of 100-400 mcg can be combined with vaginal insertion of prostaglandins to enhance cervical dilatation.
Adult Dose Cervical ripening: 25-100 mcg (vaginally) for term pregnancies, lower doses may need to be repeated q4-6h
Termination: 200-800 mcg, most patients do not need repeat dosing for 24 h
Pediatric Dose Not established
Contraindications Documented hypersensitivity; pregnancy not intended for termination; glaucoma; sickle cell anemia; hypotension; mitral stenosis
Interactions Antacids containing magnesium may increase diarrhea
Pregnancy X - Contraindicated in pregnancy
Precautions Inform patient of potential adverse effects (eg, GI distress, cramping, bleeding); GI distress slightly greater with oral administration.

Drug Category: Antiprogesterones -- Antiprogesterone class of drugs for medical termination of pregnancy are used. Other potential uses include postcoital contraception, leiomyomatas, endometriosis, endometrial cancer, breast cancer, ovarian cancer, glaucoma, myomas, and Cushing syndrome. Antiprogesterones do not effectively treat ectopic pregnancy and should not be used for this indication.

Drug Name
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Mifeprex (RU-486) -- Progesterone receptor antagonist, which has 5 times greater affinity for the receptor than progesterone. By blocking progesterone, the hormone that maintains pregnancy, abortion can be completed. Cervix is softened and dilated; decidual necrosis and detachment of the pregnancy at the endometrium and uterine contractions ensue.
Adult Dose 600 mg PO day 1 of medical abortion regimen; doses as low as 200 mg reported as efficacious
Pediatric Dose Not established
Contraindications Documented hypersensitivity; confirmed/suspected ectopic pregnancy; undiagnosed adnexal mass; IUD in place; chronic adrenal failure; concurrent long-term corticosteroid therapy; hemorrhagic disorders; concurrent anticoagulation therapy; inherited porphyrias
Interactions Not studied yet; possibly ketoconazole, itraconazole, erythromycin, grapefruit juice; rifampin, dexamethasone, St John's Wort, some anticonvulsants
Pregnancy X - Contraindicated in pregnancy
Precautions Abdominal pain, uterine cramping, nausea, vomiting, diarrhea

Drug Category: Antimetabolites -- The antimetabolite, methotrexate, has been used for over 15 years for the medical treatment of early, unruptured ectopic pregnancies. Success rate for this indication is greater than 90%. Adverse effects are minimal and regimens are cost effective. This offers effective destruction of rapidly dividing placental cells. This class of drug to be used for the medical termination of pregnancy, although for complete expulsion, it usually has to be administered in conjunction with prostaglandin.

Drug Name
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Methotrexate (Folex PFS, Rheumatrex) -- Antimetabolite that works by blocking enzyme dihydrofolate reductase, thereby inhibiting folate production and, thus, DNA synthesis. Primarily affects rapidly dividing cells first, such as trophoblast cells.
Adult Dose 50 mg/m2 IM; alternatively, 50 mg PO
Pediatric Dose Not established
Contraindications Documented hypersensitivity; alcoholism; hepatic insufficiency; kidney disease; inflammatory bowel disease; clotting disorder; documented immunodeficiency syndromes; preexisting blood dyscrasias; bone marrow hypoplasia; leukopenia, thrombocytopenia; significant anemia (Hct<30%)
Interactions Oral aminoglycosides may decrease absorption and blood levels of concurrent oral methotrexate (MTX); charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity of MTX; folic acid or its derivatives contained in some vitamins may decrease response to MTX

Probenecid, NSAIDs, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, can increase MTX plasma levels; may decrease phenytoin plasma levels; may increase plasma levels of thiopurines
Pregnancy D - Unsafe in pregnancy
Precautions Nausea, vomiting, diarrhea, hot flushes, headache, cramping, dizziness; toxic adverse effects on the hematologic, renal, GI, pulmonary, and neurological systems

Drug Category: Uterotonics -- The rapid and complete emptying of the uterus usually provides a natural uterine contraction process that successfully halts postabortion blood loss and eventually leads to normal uterine blood loss and normal uterine involution back to the prepregnant state. The uterotonic medications typically are used to enhance this process or to halt immediate postabortion bleeding. In some cases, these drugs can be potent enough inducers of uterine activity to lead to abortion without other drugs or regimens.

Drug Name
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Oxytocin (Pitocin) -- Produces rhythmic uterine contractions and can stimulate the gravid uterus as well as vasopressive and antidiuretic effects. Can also control postpartum bleeding or hemorrhage.
When used as in labor protocols, can induce second trimester abortion.
Adult Dose 10 U IM after delivery
Alternatively, 10-40 U IV in 1000 mL of IV fluid at rate high enough to control uterine atony
Pediatric Dose >12 years: Administer as in adults
Contraindications Documented hypersensitivity; cardiac arrhythmias with tachycardia
Interactions Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension
Pregnancy X - Contraindicated in pregnancy
Precautions Overstimulated uterus can be hazardous; hypertonic contractions can occur in a patient whose uterus is hypersensitive to oxytocin, regardless of whether it was administered appropriately; oxytocin has intrinsic antidiuretic effect that, when administered by continuous infusion and patient is receiving fluids by mouth, can cause water intoxication

Drug Category: Ergot Alkaloids -- Also in the category of uterotonics and almost exclusively used for treatment of postabortal bleeding, atony, or hemorrhage.

Drug Name
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Methylergonovine (Methergine) -- Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens third stage of labor. Administer IM during puerperium, delivery of placenta, or after delivering anterior shoulder. Also may be administered IV, over no less than 60 sec, but should not be administered routinely because it may provoke hypertension or a cerebrovascular accident. Monitor BP closely when administering IV.
Adult Dose 0.2 mg PO tid/qid for 2-7 d
Alternatively, 0.2 mg IM/IV repeat q2-4h prn
Pediatric Dose <12 years: Not established
>12 years: Administer as in adults
Contraindications Documented hypersensitivity; glaucoma; Tourette syndrome; anxiety; hypertension
Interactions Concurrent administration of methylergonovine with vasoconstrictors or other ergot alkaloids may produce additive effect
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in sepsis, obliterative vascular disease, or hepatic or renal insufficiency
Drug Name
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Carboprost tromethamine (Hemabate) -- Prostaglandin similar to F2-alpha (dinoprost) but has longer duration and produces myometrial contractions that induce hemostasis at placentation site, which reduces postpartum bleeding.
Adult Dose 250 mcg IM; repeat at 15-90 min intervals to maximum dose of 2 mg
Pediatric Dose Not established
Contraindications Documented hypersensitivity; pelvic inflammatory disease
Interactions Increases toxicity of oxytocic agents
Pregnancy X - Contraindicated in pregnancy
Precautions Caution in cardiovascular disease, asthma, hypotension or hypertension, adrenal disease, diabetes, renal or hepatic disease, a compromised uteri, or jaundice; do not inject IV (may induce hypertension and bronchospasm)

Drug Category: Sedatives -- During surgical abortion, relaxation techniques and local anesthetic is typically all that is required to adequate pain relief. In some patients, the use of intravenous, oral, or sublingual sedatives can enhance this effect.

Drug Name
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Midazolam (Versed) -- Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Also useful for its amnestic effects.
Adult Dose 0.5-2 mg IV over 2 min; repeat q2-3min prn; total IV dose generally 2.5-5 mg
Pediatric Dose >12 years: 0.5 mg IV over 2 min; repeat q3-4min prn
Contraindications Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma; sensitivity to propylene glycol (diluent)
Interactions Sedative effects of midazolam may be antagonized by theophyllines; narcotics and erythromycin may accentuate sedative effects of midazolam due to decreased clearance
Pregnancy D - Unsafe in pregnancy
Precautions Caution in congestive heart failure, pulmonary disease, renal impairment, and hepatic failure; Romazicon is a benzodiazepine antagonist used to reverse the effects of versed (0.2-0.3 mg IV, may wear off faster than the versed itself)

Drug Category: Antiemetics -- Antiemetics are not typically necessary unless patients already have pre-existing nausea and vomiting of pregnancy or have nausea and vomiting in reaction to general anesthesia.

Drug Name
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Prochlorperazine (Compazine) -- May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.
Adult Dose 5-10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40 mg/d
25 mg PR bid
Pediatric Dose 2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed 15 mg/d
IV dosing is not recommended for children
0.1-0.15 mg/kg/dose IM and change to PO as soon as possible
Contraindications Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease
Interactions Coadministration with other CNS depressants or anticonvulsants may cause additive effects; with epinephrine, may cause hypotension
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Drug-induced Parkinson syndrome or pseudoparkinsonism occurs quite frequently; akathisia is most common extrapyramidal reaction in elderly; lowers seizure threshold; caution with history of seizures
Drug Name
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Promethazine (Phenergan) -- Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.
Adult Dose 12.5-25 mg PO/IV/IM/PR q4h prn
Pediatric Dose 0.25-1.0 mg/kg PO/IV/IM/PR 4-6 times/d prn
Contraindications Documented hypersensitivity; narrow-angle glaucoma
Interactions May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; avoid accidental intra-arterial injections

Drug Category: Antibiotics -- Most antibiotics are used prophylactically to prevent postoperative endometritis. Some institutions have used dosages that would cover CT and GC because patients are often unavailable for contact after an abortion (lack of providers means many travel very far to receive their abortion).

Drug Name
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Doxycycline (Vibramycin) -- Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Prophylaxis of postabortion infections. If contraindicated, use erythromycin or ampicillin. Suspected cervicitis for chlamydia.
Adult Dose New ACOG recommendations recommend 100 mg PO 1 h prior to abortion, then 200 mg PO postabortion; this regimen may produce nausea and vomiting
100 mg PO bid for 1-3 d postabortion
Pediatric Dose 2-5 mg/kg/d in 1-2 divided doses; not to exceed 200 mg/d, not generally applicable
Contraindications Documented hypersensitivity; severe hepatic dysfunction
Interactions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy D - Unsafe in pregnancy
Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Drug Name
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Erythromycin (E-Mycin, Ery-tab, Eryc, Erythrocin) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. Prophylaxis of postabortion infections. Use if doxycycline is contraindicated.
Adult Dose 333 mg PO tid for 3-7 d; alternatively 500 mg PO bid for 3-7 d
Pediatric Dose 30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h
Contraindications Documented hypersensitivity; hepatic impairment; concomitant use of astemizole, cisapride, pimozide, terfenadine
Interactions Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; pseudomembranous colitis

Drug Category: Immune globulins -- Pregnancies past 5 weeks of gestation may have an established fetal blood system and Rh sensitization can occur without administration. Typically, no preadministration antibody screens are performed in this patient population.

Drug Name
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Rh0(D) immune globulin (RhoGAM) -- Given to Rh(-) mothers to avoid sensitization to Rh(+) fetal blood.
Adult Dose <12 wk gestation: 50 mcg (minidose)
>12 wk gestation: 300 mcg
Administered up to 72 h postabortion
Pediatric Dose Adolescent: Administer as in adults
Contraindications Documented hypersensitivity
Interactions None
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Anaphylactic shock; fever; do not administer live virus vaccine within 3 mo
Drug Name
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Metronidazole (Flagyl) -- Recommended as an alternative for endometritis prophylaxis.
Adult Dose 500 mg tid for 7d postabortion when allergic to doxycycline; stat when treating suspected bacterial vaginosis prior to abortion.
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
FOLLOW-UP ¡@

Further Inpatient Care:
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Further Outpatient Care:
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In/Out Patient Meds:
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Deterrence/Prevention:
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Complications:
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Prognosis:
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Patient Education:
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MISCELLANEOUS ¡@