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Safe medical abortion in early pregnancy for unwanted pregnancy

Medical abortion, also known as non-surgical abortion, is one way to terminate an early pregnancy using medications. Medical abortion is provided by trained health care providers in private office settings, family planning clinics and hospitals.

A medical abortion can be performed from the time a woman suspects and confirms she is pregnant up until nine weeks from her last menstrual period. However, some insurance companies limit medical abortion to pregnancies of seven weeks or less.
In clinical practice, medical abortion is about 95 percent to 98 percent effective, causing a woman to completely pass the pregnancy without the use of surgery. In comparison, early surgical abortion is effective 98 percent of the time.

Medication abortion procedure

Medication abortion involves using the medications mifepristone and misoprostol instead of surgery to end a pregnancy. It can be done as soon as a pregnancy can be seen in an ultrasound. In India, medication abortion is performed up to five weeks of pregnancy.

A pregnancy needs high levels of the hormone progesterone to continue. Mifepristone works by blocking the action of progesterone to cause the pregnancy to stop progressing. Misoprostol causes the cervix to soften and the uterus to contract to allow the pregnancy to be expelled from the uterus.

The process and number of appointments for having a medication abortion varies depending on the type of clinic setting you attend, and whether certain tests you need (such as ultrasound and blood tests) are available on site or require separate appointments. A number of clinics are able to offer necessary tests and medication abortion in a single initial appointment.

The process of having a medication abortion generally involves the following steps:

• You will have a medical consultation with a Gynecologist and often a nurse as well, which involves a clinical assessment of medical and other relevant information, and arrangements for you to have an ultrasound and blood tests.
• You will be given information about the methods of abortion to help you to make an informed decision about the best method for you.
• If you decide to have a medication abortion, you will be asked to sign a consent form and will be given all the relevant information about what to expect, the steps you will need to take, and about pre- and post-abortion care.
• You will discuss what sort of pain relief, and any other appropriate medication you may require, and how to obtain it, in preparation for the abortion.
• If you have an intrauterine device, it will need to be removed before you take the first medication (mifepristone).
• You will take a tablet of mifepristone either at the clinic or at home and obtain the other appropriate medications.
• You will take a tablet of misoprostol 24 to 48 hours later. This softens the cervix and helps the uterus push out the pregnancy. This stage nearly always occurs at home. (If you need to travel after taking misoprostol and before the abortion is complete, it is recommended that you have a responsible adult who can drive you.)
• The abortion is usually completed some hours later, although it may take longer. You will usually need a day or two of rest or reduced activity.
• You will be encouraged to have telephone contact with the clinic you attended or another source of expert support in case you have any questions or concerns at any time during and after the procedure.

What to expect during and after a medication abortion

After taking the second medication abortion tablet at home, you may experience the following:

• nausea, vomiting, diarrhoea, dizziness, headache and fever
• pain – usually within half an hour and generally much stronger than period pain
• bleeding one to four hours later – heavier than a period and there may be large clots
• after two to six hours the bleeding usually settles to the level of your normal period
• bleeding is usually similar to a normal period for another three to seven days
• unpredictable, irregular or prolonged bleeding can last for up to four weeks after a medication abortion.

Note: The timing of the pain and bleeding is unpredictable. It occasionally starts before taking the second medication, but may take up to 24 hours to start.

Follow-up after a medication abortion

It is important to have a follow-up appointment to make sure the procedure is complete and the pregnancy has ended. Many doctors order a blood test to check that the pregnancy hormone level has dropped. You will be given an appointment for review in two weeks’ time.
Medication abortion does not work in around one percent of cases. Around two to five per cent of women will have some pregnancy tissue remaining in the uterus (womb) and will need further treatment such as additional tablets or a small surgical procedure to complete the abortion. Your Gynecologist will discuss this with you.

Advantages and disadvantages of medication abortion

Advantages of medication abortion include:

• For around 95 to 98 per cent of pregnancies up to five weeks, no further treatment is needed after taking the two doses of abortion medication.
• Unlike surgical abortion, medication abortion does not need to take place in a hospital or day surgery unit as it does not require a surgeon, anaesthetist or other medical staff to be present during the later stage of the procedure. This makes it a suitable alternative for those living in remote areas provided they have access to emergency care.
• It is a less clinical and non-surgical procedure, which some women may prefer.
• Some women feel it is a more natural process.
• It happens in a home environment.

Disadvantages of medication abortion include:

• Medication abortions are generally more time consuming than surgical abortions, and there may be more doctor visits and tests.
• In a small percentage of cases the medication needs to be repeated, and sometimes a surgical procedure is needed.
• Pain and bleeding generally last longer than following a surgical abortion.
• It is difficult to predict the time it will take for a medication abortion to complete – it may take longer than the expected four to eight hours, after taking the second medication.
• A separate appointment is needed if you would like an IUD inserted.
• Mifepristone is not suitable for some women.

Mifepristone may not be recommended for you if you:

• have certain medical conditions such as bleeding problems, adrenal failure or high blood pressure
• are taking long-term steroid or blood-thinning medication
• have had allergic reactions to medication containing mifepristone.

Dr.Ruchi Tandon is a Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of abortions.

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Fibroids – Do’s and don’ts

What Are Fibroids?

Fibroids, or leiomyomata (myomas), are common noncancerous growths that usually occur in or on the muscle walls of the uterus. One cell divides repeatedly and grows into a firm, rubbery mass separate from the rest of the uterine wall. Almost half of women older than 50 have these growths. They’re more common in African American women than in Caucasian women. They can grow as a single mass or more often as a number of masses of different sizes.

What Causes Fibroids?

The cause isn’t clear. Several factors probably work together to produce fibroids. These factors may be hormones such as estrogen, genetics (runs in families), and environmental. Being overweight, never having had a child, and getting periods before age 10 also may have an effect. The fibroids usually, but not always, shrink after menopause (change of life).

What Are the Symptoms of Fibroids?

Most fibroids (30% to 50%) cause no symptoms. Problems, when they occur, are related to the size and location of the fibroids. Fibroids may grow to be quite large so that a woman may look pregnant and have symptoms of pregnancy: pressure in the pelvic area (lower belly), heaviness, and need to go to the bathroom often to urinate. Fibroids in the uterine wall or in the cavity of the uterus may cause bleeding between periods or heavier and more painful periods. Constipation, backache, pain during sex, and lower belly pains may occur. Rarely, fibroids cause sudden pain or bleeding.

How Are Fibroids Diagnosed?

The health care provider will do an examination of the pelvic area. Ultrasound or x-rays may be used but aren’t always needed for diagnosis. The doctor may do a special procedure (hysteroscopy) for women with bleeding symptoms. This simple procedure lets the doctor look into the uterus to find the cause of the bleeding or to plan or carry out therapy.

How Are Fibroids Treated?

Most fibroids need no treatment and only regular checks to be sure that they’re not growing too large or causing problems. Medicines including hormones and drugs that act against hormones can be tried. If fibroids continue to be a problem, hysterectomy (surgery to remove the uterus) is an option. Sometimes, fibroids alone may be surgically removed (myomectomy), which saves the uterus if children are wanted. Another newer method is uterine artery embolization. In this method, arteries to the uterus are blocked so they don’t feed the fibroids. Myolysis (electric current destroys fibroids and shrinks blood vessels feeding them) and cryomyolysis (liquid nitrogen is used instead of electric current) are other methods. However, fibroids can return and mean more surgery later. Newer medicines may shrink fibroids, but this change is only temporary.

DOs and DON’Ts in Managing Fibroids:

• DO get regular health care provider checkups.
• DO tell your health care provider your concerns and describe your symptoms.
• DON’T delay having children just because you have fibroids. They usually won’t get in the way of pregnancy. If you do need treatment for fibroids, some treatments can temporarily or permanently prevent you from becoming pregnant.
• DON’T worry about getting cancer from fibroids. Typical fibroids are not cancerous.

Surgery for uterine fibroids

• Medication to treat fibroid symptoms usually only works while you are taking it. Many women who have severe pain and heavy menstrual bleeding end up considering surgery as an option. There are a number of different types of surgical treatments, each with its own pros and cons.

• Surgery is done in the hope that it can permanently stop the symptoms of uterine fibroids. Some women do, in fact, experience long-term relief. But surgery always carries risks too. Whether or not surgery is an option – and, if so, what kind of surgery – will depend on how the woman feels about the different advantages and disadvantages. The size, number and location of the fibroids will also influence the choice of treatment. Not all types of surgery are suitable for women who still want to have children.

• Your doctor may recommend taking hormones such as GnRH analogues several weeks before having surgery. These kinds of artificial hormones are used to shrink the fibroids. Doctors can then make smaller cuts during surgery, allowing the womb (uterus) to recover more quickly. The drug ulipristal acetate is sometimes used for this purpose too.

• But removing individual fibroids isn’t a good idea if it might cause too much scarring in the womb, or if the risk of bleeding during or after surgery is too high. Plus, it isn’t always absolutely certain that the symptoms will improve after surgery. Hysterectomy (surgical removal of the womb) is then an option – or possibly another non-surgical treatment approach such as uterine artery embolization (UAE, sometimes also called uterine artery embolization, or UFE). Uterine artery embolization cuts off the blood supply to the fibroid.

Dr.Ruchi Tandon is a Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years experience in handling all kinds of Gynecological conditions including Fibroids.

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Fibroids surgery -laparoscopy / key hole surgery versus open myomectomy

Uterine fibroids are noncancerous growths that grow in the wall of the uterus. When fibroids cause heavy bleeding or painful symptoms, and other treatments are ineffective, a doctor may recommend surgery.

Fibroids are common, but it is challenging for doctors to determine what percentage of people have them, as not everyone experiences symptoms. According to various estimates, fibroids may affect between 20% and 80% of the female population under the age of 50 years.

Although fibroids can sometimes grow to the size of a grapefruit or even larger, they are often very small. Many people with fibroids are unaware that they have them. People with asymptomatic fibroids do not require surgery or other treatments.

However, other people experience abdominal pain, pressure, bloating, pain during sex, frequent urination, and heavy or painful periods. These individuals may require surgery.

In this article, learn more about surgery for fibroids, including the types, risks, and what to expect.

There are several different surgical approaches to treating fibroids. The types of surgery that a person can have will depend on the location of the fibroid.

A doctor will usually recommend more conservative options, such as medication, before considering surgery.

In cases where medication and other treatments do not work, surgical options include the following:

Myomectomy

Myomectomy is a surgical procedure that removes fibroids. Depending on the location of these growths, a surgeon may also have to remove other tissue in the process. Surgeons offer different myomectomy techniques.

The traditional technique is quite invasive as it uses a relatively large cut. This incision may go from the bellybutton to the bikini line or run horizontally along the bikini line. Some surgeons also perform laparoscopic surgeries, which use smaller incisions but require more skill.

Although a myomectomy preserves the uterus, women who wish to become pregnant should speak to a doctor about the possible complications. Those with very large or deeply embedded fibroids may only be able to have cesarean deliveries after this procedure.

New fibroids may develop after a myomectomy, which means that it is not a permanent solution for everyone.

Radiofrequency ablation procedure

Radiofrequency ablation destroys fibroids using either an electric current, a laser, cold therapy, or ultrasound. It requires only a small incision.

However, it can cause dangerous pregnancy complications, such as scarring and infection, so doctors do not recommend it for those who are planning future pregnancies.

Radiofrequency ablation may be a good option for people considering a hysterectomy who want a less invasive procedure.

Endometrial ablation

Endometrial ablation does not remove fibroids, but it can help relieve heavy bleeding.

During endometrial ablation, a surgeon uses a range of techniques — which may include heat, electric current, freezing, lasers, or wire — to destroy the lining of the uterus. These techniques reduce or stop heavy bleeding.

This procedure is less invasive than some other surgical options. Sometimes, doctors can even perform it on an outpatient basis in their office.

This procedure may prevent women from being able to get pregnant in the future, so it is not a good option for those who would still like to have children.

Hysterectomy

A hysterectomy is a surgery to remove the uterus and, sometimes, the ovaries. A hysterectomy permanently eliminates uterine fibroids.

This procedure is not an option for anyone planning a future pregnancy, as it removes the womb. Some people opt to leave the ovaries in place so that they continue producing estrogen.

A surgeon may be able to perform a laparoscopic hysterectomy, which uses several small incisions and a tiny camera to help the surgeon see inside the abdomen. An open hysterectomy requires a large incision between the bellybutton and the bikini line.

Another option is a vaginal hysterectomy, which is the approach that most people prefer. In this procedure, a surgeon will remove the uterus through the vagina.

A vaginal hysterectomy may not be possible if the uterus or fibroid is too large to fit through the vagina.

Individuals who undergo an open hysterectomy may have a longer recovery time. Doctors usually recommend a hysterectomy only for those whose fibroids are very large or significantly interfere with their quality of life.
People who have other reproductive health issues, such as endometriosis, may find that a hysterectomy provides significant relief from fibroids and other symptoms.

Morcellation

Morcellation is a procedure that reduces the size of fibroids so that a surgeon can remove them through a tiny incision in the abdomen. A doctor may use morcellation during a myomectomy, hysterectomy, or other surgery.
However, the Food and Drug Administration (FDA) caution that morcellation carries significant risks.

While fibroids are not cancerous, uterine cancer is more common in people having fibroid surgery than experts previously thought.

It can also be difficult to tell the difference between a fibroid and a type of cancer that looks the same. According to the FDA, morcellation may inadvertently spread cancer that resembles a fibroid.

Benefits

The benefits of surgery depend on the type of surgery and can vary from person to person. For example, there is no chance that the fibroids will grow back after a hysterectomy. However, they may regrow following other procedures.

Some potential benefits include:

• reduced bleeding
• relief from pain or pressure
• removal of fibroids
• the potential that fibroids will either not grow as large or not regrow at all

Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 13 years experience in handling all kinds of fibroids.

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Miscarriage or heavy bleeding in early pregnancy

What should you know about vaginal bleeding during pregnancy?

Vaginal bleeding or spotting during the first trimester of pregnancy is relatively common. Some amount of light bleeding or spotting during pregnancy occurs in about 20% of pregnancies, and most of these women go on to have a healthy pregnancy.

What is implantation bleeding?

Implantation bleeding is bleeding that occurs when the fertilized egg implants in the lining of the uterus. This happens around the time of the expected menstrual period. Implantation bleeding may occur before a woman realizes she is pregnant. What are the serious causes of vaginal bleeding in the first trimester of pregnancy?

What if I am pregnant and the bleeding severe?

Causes for severe bleeding during pregnancy include miscarriage, threatened miscarriage, and ectopic pregnancy. If you are pregnant and have vaginal bleeding, call 911 and go to the emergency department.

How much bleeding is normal during pregnancy?

Vaginal bleeding during the first three months of pregnancy is relatively common and usually is a cause of concern for the mother. Women wonder how much bleeding during early pregnancy is normal. While early bleeding may indicate the presence of a serious problem, this is frequently not the case. In fact, approximately 20% of pregnant women experience light bleeding or spotting during the first trimester of pregnancy. Most women go on to have uncomplicated pregnancies and ultimately deliver a healthy baby.

Spotting: Spotting usually refers to a few drops of blood that would not cover a pad or panty liner. Bleeding refers to blood flow that is heavy enough to require wearing a pad. If bleeding occurs during the first trimester, wear a panty liner or pad so that you are able to get an idea of the amount of bleeding that is occurring and can tell the health care professional. However, you should not use a tampon in the vagina or douche during pregnancy.

What other problems cause bleeding during early pregnancy (first trimester)?

Changes in the cervix: The normal hormone production during pregnancy can cause changes to the cervix, rendering it softer and more prone to bleeding. In addition, a cervical polyp (a benign overgrowth of tissue) may form, and this may bleed more easily during pregnancy. In both cases, spotting or light bleeding may be provoked following sexual intercourse or a pelvic examination.

Infection: A vaginal infection may cause spontaneous vaginal bleeding during pregnancy. The bleeding may be accompanied by abnormal vaginal discharge.

What causes heavy bleeding during early pregnancy (first trimester)?

Miscarriage

  • Bleeding, abdominal pain, and back pain are common signs of miscarriage.
  • An exam shows that the cervix is open.
  • Tissue may be extruded through the cervix and vagina.
  • A miscarriage occurs in an estimated 15% to 20% of pregnancies, usually during the first 12 weeks of gestation.
  • A genetic defect confined to the specific embryo in question represents the most common cause of miscarriage.
  • Few circumstances exist wherein a miscarriage in progress can be prevented.

Molar pregnancy

  • Molar pregnancy, also known as gestational trophoblastic disease or hydatidiform mole, is an abnormality of fertilization that results in the growth of abnormal tissue within the uterus.
  • Molar pregnancy is not a typical pregnancy, but the growth within the uterus leads to the typical symptoms of early pregnancy.
  • In a complete hydatiform mole, there is only abnormal tissue in the uterus (and no fetus).
  • In a so-called partial mole, there is abnormal tissue growth along with the presence of a fetus with severe birth defects.
  • The fetus is typically consumed by the abnormal growth of tissue in the uterus, and a molar pregnancy cannot result in a normal fetus or delivery.
  • Vaginal spotting or bleeding can be a symptom of molar pregnancy.
  • A sonogram or ultrasound is used to diagnose a molar pregnancy.

Ectopic pregnancy

  • Mild vaginal bleeding and increasing abdominal pain may indicate the presence of an ectopic pregnancy.
  • An ectopic pregnancy occurs in approximately 1 out of 60 pregnancies.
  • An ectopic pregnancy occurs when the fertilized egg implants outside of the uterus, where the blood supply is inadequate to sustain the growth of a normal pregnancy.
  • In the majority of cases of ectopic pregnancy, the embryo is located within one of the Fallopian tubes; this sometimes is referred to as a tubal pregnancy. As the pregnancy grows and the tube distends, abdominal pain becomes increasingly severe.
  • Sometimes these pregnancies can actually rupture the Fallopian tube, leading to significant blood loss.
  • In some cases, a blood transfusion and emergency surgery are needed for prompt resolution of this potentially life-threatening condition.

Threatened miscarriage

  • If a woman is bleeding during the first trimester of pregnancy, the possibility of a miscarriage must be ruled out.
  • Symptoms of a threatened miscarriage are bleeding and mild cramping, but the cervix stays closed and the fetus is still viable.
  • In many women, the bleeding stops and the pregnancy continues. For others, the bleeding continues, and they eventually have a miscarriage (i.e. spontaneous pregnancy loss).

Subchorionic hemorrhage

  • In this condition, blood collects between the gestational sac and the wall of the uterus.
  • At times, the intrauterine clot can be seen on ultrasound examination.
  • The body frequently reabsorbs these blood clots; however, occasionally there may be passage of old dark blood or even small clots from the vagina.

Dr. Ruchi Tandon is a Gynecologist practicing in leading hospitals in South Delhi, with over 14 years’ experience in handling all kinds of bleeding during pregnancy. She specializes in high risk pregnancy management and handling.