Chapters Transcript Video Updates on Abortion Integration in Primary Care Good morning, everyone thank you for this opportunity to discuss the important role that primary care providers and pediatricians can play in improving access to comprehensive reproductive health care services for our patients. I'm pleased to co present today with Dr celeste allen pediatric residency program, Director for UCSF Benioff Children's Hospital, Oakland and DR Rebecca McEntee based on La Clinica de la Raza lifelong medical and a faculty member with the UCSF Family Medicine residency teaching at planned parenthood. Marmont, I'm dr Leila back crack adolescent health lead for our federally qualified health center here at Children's as well. Between the three of us, we have close to 60 years of clinical experience serving the community. We have seen firsthand the challenges that patients face in accessing quality reproductive health care services and how these barriers are magnified for adolescents. We have no financial ties to any pharmaceutical companies that make the medicines that will discuss today. We recognize that some who seek pregnancy related services do not identify as women, so we will use the term women and pregnant people interchangeably gender sexuality and family planning are inherently complex topics when speaking about abortion. The complicating factor is that many views are values based, where one stands is often a moral ethical or religious choice. Yet the United States is in principle a pluralistic society. While many people believe wholeheartedly that abortion access is a human right and the foundation of bodily autonomy. Others believe as intensely that abortion at any stage is murder in medicine. We strive to provide evidence based clinical practice. We need to closely examine the intersections between the existing scientific evidence and our personal beliefs to make sure that we are truly providing patient centered care. Today, we will discuss the current landscape of abortion care in the United States and recognize a role and responsibility as pediatricians in promoting reproductive autonomy and justice. We will review how to perform patient centered nonjudgmental pregnancy options, counseling, and how to support patients who want to terminate a pregnancy as they evaluate available abortion options, including medication and aspiration. Our talk today will be based in reproductive justice concepts. This framework was developed by a group of black women in collaboration with several organizations representing indigenous latin X asian american and trans voices. They launched the nonprofit sister song to build a national reproductive justice movement that both recognizes the historical context of reproductive harms experienced by many individuals and strives for a better future, reproductive justice is defined as the human rate right to maintain personal bodily autonomy to have Children not have Children and to parent the Children we have in safe and sustainable communities. There are multiple intersectional structural factors that require our attention, including dismantling racism, the availability of safe and affordable housing, food security, paid parental leave and high quality child care. We need to ensure access to health care, including prenatal care and safe abortion services. Unfortunately, we have a long way to go to make reproductive justice a reality. In the United States maternal mortality is real and rates in the US are embarrassingly high compared to those in other wealthy countries. We have distressing disparities in maternal mortality. Black mothers are 4-6 times more likely to experience pregnancy-related mortality than other us women. Another challenge we face is addressing stigma, shame and silence. Whether we are talking about HIV prevention, gender affirming care, human trafficking, opioid addiction or abortion stigma and shame can lead to silence and delays in care, which can kill people though. We try to do a good job of protecting reproductive rights in California. The fact that my colleagues and I have seen patients come in with coathanger injuries, blunt trauma to the abdomen when trying to end an unwanted pregnancy. And even suicide attempts related to unwanted pregnancies. We need to recognize that stigma and shame can harm people as healers. It's important to let our patients know that we are willing to help and support even when dealing with stigmatized conditions. Despite all the condemnation, abortion is common by age, 31 of every four us women has had an abortion regardless of race, ethnicity, cultural background and religious affiliation. The majority of those seeking abortions are mothers. As this picture reminds us among older US women who had less access to I. U. D. S. And implants. The most effective birth control methods. Half have had an abortion, 62% of abortions were obtained by people in their 20's and 12% were adolescents. Though the rate of unintended pregnancy has been going down. The most recent data showed that 45% of pregnancies in the us are unintended. Of those, 42% ended in abortion Among teens ages 15 to 19 over, 75% of pregnancies were unintended. According to the most recent youth risk behaviour survey of high school students in Oakland, 56% of 12th graders have had sexual intercourse, 59% had not used a condom during last intercourse, 55% were not using hormonal contraception and 94% we're not using Iuds or implants. The most reliable and effective methods. As I mentioned, rates of unintended pregnancies have been decreasing. Um but there are still significant disparities for families living below the federal poverty line. Also, because of all the ways racism has impacted generational wealth in this country, families of color more frequently find they do not have the resources required to support a child or an additional child. In june of 2022 the U. S. Supreme Court overturned 50 years of precedent set in the roe versus wade decision, which had guaranteed women across the U. S. Access to abortion and returned regulation of abortion to states. Over 20.9 million women have lost access to all elective abortion services in their home state, 36% of us women between the ages of 15 and 44 have lost access to abortion services. This will have a disproportionate impact on those that already face barriers to care, including adolescents, people of color and families facing poverty. These changes will also impact the training pipeline for health care providers. Making it even more important that clinicians and states that protect reproductive rights step up to help demand has already quadrupled at some California abortion clinics. Since roe fell earlier, we talked about the importance of basing clinical care on the best evidence available. So I want to review a brilliant study by DR Diana Greene Foster, based at UCSF's Answer um center, which stands for advancing new standards in reproductive health. This was a prospective longitudinal study examining the effects of unwanted pregnancy on women's lives. The study included 1000 women seeking an abortion at clinics in 21 states in the us recruited between 2008 and 2010, those that were under the gestational age cut off for the clinic were able to have the abortion, They requested those that were over the gestational age limits set at the site where they were seeking care were turned away and were often unable to have an abortion. These women were interviewed by phone every six months over the following several years. The turn away study examined the effect of receiving or being denied an abortion on women's mental health and well being. Despite historical concerns, there was no evidence that having an abortion causes mental health problems being denied a wanted abortion was associated with elevated levels of anxiety, stress and lower self esteem. The turn away study showed that the financial well being and development of Children is negatively impacted when their mothers are denied an abortion for years after these women um had been turned away, they were more likely to not have enough money to cover basic living expenses like food housing and transportation being denied an abortion lowered a woman's credit scores, increased bankruptcies and evictions. Giving birth is connected to more serious health problems than having an abortion. Women who are denied an abortion and gave birth, reported more life threatening complications like preeclampsia, postpartum hemorrhage compared to those who received a wanted abortion. This was tragically demonstrated as two women who had been denied and wanted abortion died following delivery. No women died from abortion complications or after having had the abortion. Women turned away from getting an abortion are more likely to stay in contact with a violent partner and to end up raising the resulting child alone. The turn away study also delved into maternal and child health. They examined how women feel about Children they bore from an unwanted pregnancy compared to a child of a later pregnancy that they chose to carry to term women who were denied abortions reported feeling less emotionally bonded to their new babies than women who had an abortion and had another baby. Later They used the postpartum bonding questionnaire to measure maternal bonding with Children under 18 months old. Women denied abortions scored significantly lower on the scale of bonding than women who had another child. Later. For example, women denied an abortion were less likely to agree with the statement. I feel happy when my child laughs or smiles and more likely to say I feel trapped as a mother. Given all the evidence showing the health and well being benefits to empower pregnant people to choose if and when to become parents. We were eager to expand access in our clinical settings where we regularly see adolescents who are pregnant and don't want to be the implants and I. O. D. S. Are extremely effective contraceptive methods. Many adolescents tell us I don't want to have something stuck inside of me. The fact that medication, abortion does not involve a pelvic procedure makes it appealing to many of our patients. In the past, patients were often confused that we couldn't help them get this medicine when we provide so many of their other medicines. This also didn't seem logical as a pediatrician given that we write for insulin, sometimes we do T. P. N. We can do an H. Pylori regimen which in many ways is much more complicated than helping a patient with medication abortion. We were excited to partner with UCSF's answer team starting in 2019 to increase access for our patients as one of several sites in Dr. Grossman's mail order medication, abortion. Study. The purpose of this study was to investigate the effectiveness, acceptability and feasibility of medication abortion with mifepristone dispensed via mail order pharmacy. An additional aim was to highlight that the FDA requirement for mifepristone to be dispensed in clinic was unnecessary. One other comment about this last slide um at our six sites, six primary care pediatricians got trained and were quickly up and running in medication abortion. Um The answer team helped with some training and we also use this excellent online module developed by Dr Schwartz and Dr Goodman um at UCSF, which is free and has um cmI involved. The feedback we got from patients was overwhelmingly positive. They appreciated getting the care they needed with physicians, they knew and trusted in clinics they were familiar with and in a timely fashion 1 17 year old with type one diabetes and elevated hemoglobin A one C. Came in at six weeks and had a medication abortion with our mail order study. She opted to include her mom and her care and her mom wrote, we can't tell you how grateful we are for the kind care you provided. We've been going through a lot. In addition to this situation, my older child was recently shot to be able to get the care my daughter needed in a timely fashion was such a blessing. All right. Next slide, the main findings of the medication, abortion, mail order study was that dispensing the meds this way was effective, feasible and acceptable to patients seeking early abortion outcomes were similar to mifepristone being dispensed in clinic with excellent safety coincidentally, the covid 19 pandemic caused service disruptions that lead to changes in abortion protocols um such as no test protocols, telehealth protocols and between our study and the pandemic changes. Um all lead to the FDA is recent review of the myth of kristen risk evaluation mitigation strategy and contributed to the exciting new decision to allow retail pharmacies to dispense medication abortion In terms of next steps now that that study has wrapped up and as we try to continue to offer medication abortion to our patients um with support from essential access. We lead a training in November of 2022 for 20 primary care providers. Our outpatient pharmacy has agreed that they can stock and dispense medication, abortion and we hope to offer medication abortion services via our federally qualified health center sites soon pending some bureaucratic and legal reviews. I'm gonna now turn it over to DR Allen to discuss the case. Thank you. So we're gonna start to just with a kind of, we have a case throughout the rest of our presentation, it's a patient who we actually all three cared for at different points along the way. Um to 19 year old G one P. Zero identifying this female, followed by our team clinic and our Youth Uprising Castleman Health Center in East Oakland, one of our school based health centers um followed also by one of our therapists at the Youth Uprising. Castleman Health Center. the history of PTSD and depression and had actually had a medication abortion through our mail order study. It was familiar with that. Um and had had a pretty positive experience with that. So just to give an idea of the journey that she had in seeking contraception and some of the challenges she sought an I. U. D. Placement. It was it was not possible in the outpatient setting, do a tight due to a tightly closed cervix. She had a contraceptive implant placed and was removed due to side effects. She had several visits for emergency contraception and was placed on the progestin only pill. Um because of a history of migraine with aura. So a contra indication to estrogen containing birth control and did acknowledge a few missed doses. So when I met her, she presented to us in our East Oakland site for an urgent visit for emergency contraception and was found to be pregnant. She was quite unsure about her last menstrual period. She wasn't sure if it had been possibly even four months prior. So in thinking about options counseling, we want to review some really important concepts. The first is that patients always have to be counseled appropriately even if a provider does not perform abortions or as it is against their personal beliefs. It's still important that they know how to counsel their patients and provide resources. The patient has the right to self determination. It is unethical to steer a person toward a choice that reflects the clinicians or an organization's belief. We have really pretty amazing laws here in California protecting um, miners to be able to consent to services. Um, and as well as, um, we'll review some of the more recent laws that are protecting abortion services in the state. So it's really important to make yourself familiar with the policies um, related to options counseling. Another fundamental principle is that the patient really has the answer. Um, the patient is making this decision and there's not one decision that is more moral than another and that it is important for us to empower our patients to make the decision that is right for them. So in options counseling, it's really important to, to sometimes, you know, we'll speak from the perspective of a teen or a young adult patient who often comes in, not not expecting a positive result on their pregnancy test. So it's really important to start by being potentially even silent and just listen with very open ended questions and curiosity and interest. Um, you need to give the results of a pregnancy test in a very straightforward and direct nonjudgmental fashion. Um, and not withhold information, but it's their right to know all of that information. They should be allowed to react to the results and be counseled sensitively and appropriately with enough time to process what they're hearing. Some patients aren't even able to really engage in the conversation initially. So it's just making sure that you're going at their pace. Um all options should be discussed and they should never be forced to make a decision right away if they're not ready. Um Most things can wait unless there is really a timing issue around whether or not they're eligible for a medical abortion and we'll talk about that. So it's really important also to recognize there are patients who come to us with a known positive pregnancy test. We sometimes have patients who said I did five pregnancy tests from the dollar store and they were all positive. And so by the time they reach us, they have thought quite a lot about what's going on and may have their decision made. So it's really important to understand that as well. It's very important for us to use very basic information when explaining and really to avoid a lot of medical terminology um to use words that are neutral such as pregnancy or pregnancy tissue, sometimes embryo or fetus, although those words can be triggering for some patients and um not to use terms like baby or not to use terms that imply that this pregnancy will continue in some way. So, um it's also very important to um recognize where the patient is at with their emotions. So if they're sharing um feelings of guilt or shame or feeling really um sad about what's happening. It's really ok to say um you know, it's okay to feel this way. It's very common to feel this way um and to validate how they're feeling. It's also helpful to validate that we take care of a lot of patients with unwanted pregnancies and unplanned pregnancies and that one out of three people with a uterus in their lifetime have an abortion. Um So that they don't feel alone. Um So I think all of these things can be important and recognizing it's a bit of an art to figure out when to have these portions of the conversation. You don't necessarily want to have all of them as they're sitting there just processing this. The first piece of information was that the pregnancy test was positive. So you have to kind of modulate it and you may need to have multiple visits or check ins with them throughout this process. It's very important to reflect upon your own biases which situations are hard for you based on your own experiences or personal beliefs and just to be aware of those as you as you head into any type of counseling in general, but certainly related to options counseling. Next slide. So what are the options and how do you go about explaining those? Um The path that I usually take and I think is the most um neutral is to just explain. There's really two options at first the first fork in the road is that you're deciding whether to continue a pregnancy or determinate the pregnancy and that may be all that they know at that point and that might be the only decision they're able to make at that point. Um, and then you can talk about what, what does continue to pregnancy look like, What options do you have there? So your options are to parent or your options are to proceed with adoption. Um, and then termination of pregnancy. And we'll talk much more about this. Um, you have two options medication, abortion and aspiration, abortion, excited. So in in counseling, just to kind of wrap up some key, take home points and especially these are focused towards working with youth. Um, is that you really want to help them understand their rights. And so I often will even say to patients whose decision is this and they'll look at me puzzled and sort of say, I don't know, maybe it's my partner or maybe it's my family, but it's really important to recognize that in the state of California for sure it is their right to choose and decision to make and that you don't want them to feel alone in that, but you want them to recognize that you're going to help them make the decision. That's right for them, not the decision. That's right for anybody else. Um, you want to help them kind of anticipate confidentiality and I would say this goes along as well with contraceptive care that some of our patients don't know the pitfalls don't realize that somebody's gonna find their pill bottle or somebody's going to um see that they're they're having bleeding in the bathroom. You know, those kinds of things are really important. So it's important also that you help them recognize they don't have to share this information right away. Um Teen teens and younger can be a little bit impulsive. And so it's important to say it's okay to sit with this information until we know a little bit more about how you're feeling and about what your decision is. So sometimes we've seen residents even come out to present um, to the attending and while they're presenting the patients in the room, texting all their friends about what's going on. So it's good to have that conversation up front with confidentiality early in the visit. Just say, let's just think about this just before you share this with anybody. Let's think about what's the best plan there and and they may eventually decide to share it with certain family members or friends or partners, but, but there's definitely always time to share it. Um, and then remind them that they're not alone in this, that you can make yourself very available. They may need to talk on a daily basis with somebody whether it's a social work, a colleague, you just make yourselves really available. Um, We also carefully review danger signs in pregnancy. They really need to understand if they start having bleeding abdominal pain, um that that's something that they have to take really seriously and then the last is to anticipate challenges. So what are challenges for this patient transportation concerns? As you mentioned, confidentiality? Do they need a school excuse to get two things? Um and then access to contraception afterwards if they choose to have an abortion. So our patient back to our patient, um she we re performed um options counseling pretty quickly. She felt there was a time for her. It was it was very time sensitive and her therapist was able to be there. Um I was their social worker was there and we really just helped her try to try to think about her her options. She was very clear that she didn't wish to be pregnant and preferred a medication, abortion. And she had experienced that at our clinic prior. And so thought of course we would have those services, but our medication, abortion study had ended at that point. So we didn't have that available for our patients. So she called around, gave her referral, she called around And it was the first appointment she could get was in 10 days. And in her mind she was maybe even four months pregnant. She really didn't know how far along she was. So she was having a lot of anxiety about that. So I'm gonna turn it over to dr McEntee. We took over at this point in the next steps. Thank you. Um So, as dr Bachrach mentioned, you know, we're here today, talking about incorporating abortion care into primary care practice. And one of the first steps to make that happen is training. So this next session section is gonna be brief, but ideally is kind of your preview to the training that you will get when you start to incorporate abortion care into your own primary care practice sites. Um and I want to show you that much of what is needed to do this you actually already are doing or have or would easily be able to add without a lot of um uh needing a lot of extra things. So what do we know about abortion? Excuse me. We know that it is one of the safest and most common medical procedures as we've highlighted a couple of times the risk of any complication for an abortion procedure. In the first trimester is less than 0.05% and the risk is lower as the gestation is earlier. There are very few medical procedures that we all do on a regular basis that carry a risk of complications quite that low. Um we also know that abortion is safer than pregnancy, right? The mortality rates associated um with both methods of abortion is less than one in 100,000. Whereas we know that the risk of mortality with ongoing pregnancy is one in 10,000. We also know that first trimester abortions which in this context, I'm gonna say is less than 12 weeks. Do not increase the risk of future reproductive related morbidity is like infertility, miscarriage or ectopic pregnancy, but also don't increase the risk of future health, general health-related morbidity is like breast cancer, mental health disorders or changes in birth outcomes. So what are our options when we're talking about early abortion with patients? Dr allen already mentioned these? Right. When we're talking about ending a pregnancy, there are two options medication abortion and in office aspiration. Um for the purposes of this talk. Right? So in in medication, abortion is FDA approved up to 10 weeks gestational age or 70 days. Um in office aspiration is typically performed up to 12 weeks gestation once you get beyond 12 weeks. The procedure Is a little bit more complicated and usually performed in settings that have more specialized equipment. As we've already mentioned in California, we have abortion is available without restriction up to 24 weeks or the point of viability. Um and is actually available past viability and select cases at specialized locations. Um and just to highlight again, two thirds of all abortions are occurring at eight weeks of pregnancy or earlier and 89% occur within 12 weeks. But that and that statistic really shows us that the majority of abortion care could be done in in a primary care setting, right? Has the potential to do that if the resources are available. So, before we dive into details, I want to pause here. I think this is an important slide both for us as providers and also for our patients and I actually often use something similar when counseling patients about the M maybe process. Um And it really highlights a few of the aspects of what Dr allen and dr Bachrach have already discussed. First language is important and second addressing misinformation, addressing shame, addressing stigma are important, right? This is the pregnancy tissue that a patient may see during the M maybe process. Um The And so prior to 10 weeks there is typically no fetal tissue visible to the naked eye. And so this is really an important point of counseling with patients, especially I think with our younger patients with are adolescent patients who still may be thinking more concretely right? Or have associated the word baby with pregnancy in their minds. Really using neutral and accurate words to describe along with these concrete images to describe what the patient's gonna experience will really help inform them and prepare them as they move through the process. So with medication, abortion and aspiration abortion, we see that they're both very successful, highly successful procedures. Um The success rates do vary based on gestational age for maybe. But with that and with increased studies we've found regimens that actually increase the efficacy quite a bit usually by adding a second dose of miSOPROStol um for those later gestations. Next slide and so again, coming back to, you know, circling back to the idea of options counseling. So how being able to talk with patients and think about um what are the pros and cons. Right. And so we um you know, generally we think of medication abortion as offering greater autonomy and greater privacy and I think that's true, right? It's something that happens in can happen in a home setting as opposed to a clinic based setting. The patients choose when they take the medications and who's with them when they take the medications. Um But I think interestingly in a pediatric setting or in a team setting that's also potential. That's a pro or a con right? Depending and so kind of making sure that the teams have all of that information to be able to decide. Um Really the other key piece that I focus on in counseling is the expectations studying around bleeding cramping and the timing of both of those things so that the patients can really make the plans they need to adjust their schedule our time, the the use of the medications appropriately um or anticipating that they won't be able to be in school and planning for that um And we'll talk a little bit more about this in another in a minute. But um previously especially pre pandemic, it was really felt like ultrasound er beta HCG was needed in order to successfully confirm that a medication abortion had occurred or that you completed the process and what we're and so that's a disadvantage and to follow up, it is hard I'm gonna show you in a minute that that that's changed as things have changed over the last few years. And so that should not, I'm hoping that I'll be able to show you that there that should not having an ultrasound machine or a lab easily accessible, shouldn't be a barrier to incorporating this into your practice. So how what what we've been talking a lot about medication, abortion, but what is a medication, abortion, What do we do? But it's a two medication process. The first medication that the patient takes is called mifepristone. It's a selective progesterone receptor modulator, meaning it binds to the progesterone receptors and it leads to detachment of the pregnancy from the wall. So the way that I explained that to patients, as I say, the the mifepristone is making the pregnancy less sticky. It's gonna start to detach it from the wall and then the miSOPROStol causes uterine cramping contractions and actual expel expulsion of the pregnancy tissue. So the process is what causes the the emptying of the uterus. Um Mifepristone is given orally process can be administered in a variety of methods of manners typically for medication abortion were using it either vaginally PV or buckley. Um So in the cheek for 30 minutes. Um and this is the one medication that we're talking about in this talk that's an off label use all obstetric uses of miSOPROStol are actually technically off label the only FDA approved use of miso prosperous for treatment of gastric ulcers. But we have been using this process and obstetrics settings for longer than I have been practicing medicine and I suspect will continue to do so. So what do you need to be thinking about? Excuse me. And when you're doing the assessment with your patient and you or you have a patient presents with either expected or unexpected positive pregnancy test. The first thing is estimating the gestational age, which we're gonna talk about in just a second. Um The decision counseling which we've already talked about ruling out contraindications and I'll show you in just a minute that there aren't very many absolute contraindications to medication, abortion. Um It labs if they're relevant and considering an ultrasound or beta hCG testing if needed. And then the other piece they really want to highlight here is contraceptive counseling. So making part of abortion care is also making sure that patients have access to the contraception that they wish if they wish to have it. And then mythic stone specifically currently has very specific consent forms that need to be signed. And so that's an important part of the process. Mhm. So this was a great study that just came out last summer um in the uh I believe it was the Green Journal, which is one of the ACOG journals. Um The obstetrics and gynecology journals. And so what they did was they took 1000 people who were seeking abortion at seven facilities before ultrasound. They surveyed them and they compared their self assessments of gestational duration using 11 questions with measurements on ultrasound. And so then what they did was they looked at the they looked at all the questions and how they correlated with what the gestational age actually was. What they found was that for these two sets of three questions. So if you use one of these two sets, your you have a sensitivity of about 90% of the or the sensitivities, about 90%, meaning that Patients were very accurately identify, able to self identify as being less than 10 weeks of gestation or eligible for a medication abortion. Right? Because that's what this is really trying to do is find a way for us as primary care providers to be able to determine that a patient is eligible for a medal, be without needing an ultrasound without needing a lab study. Um what they found with both of these groups of questions was that the false negative rate was less than 3%. It was 2.7% for the first group and 2.3% for the second group. So that's quite quite good data. Um And so here again, this slide is just this is a slide for you to be able to come back to as a reference not to memorize. Now the key points I want to highlight here is that the National abortion federation and both the World Health Organization in the last couple of years have determined that Rh testing or knowing a patient's blood type and rogue um administration for those that are Rh negative is no longer required for pregnancies that are miscarrying or ending prior to 12 weeks. A cbc is not required unless the patient has a known history of severe anemia and S. D. I. Testing is not required. It's recommended but only if it were to be recommended based on the CDC criteria. So if they were seeing you for an unrelated reason, it needed S. D. I. Testing, that would be a reason to do it the same as it is here. So what is the process? Forget for a medication abortion, what are you gonna be taught? What are you going to be working with patients to do? The first step is the myth of Kristen. As I mentioned, it's a two single pill, 200 mg and it's able now just hot off the press is able to be dispensed by us as providers or by retail pharmacies. I'll tell you I haven't yet had anyone obtained it from a retail pharmacy. I think it's still in transition but where it seems like pharmacies are beginning to carry it. Um they when they take that they can take that pill at the time that they choose. And then the miSOPROStol is an 800 microgram dose. So that's four tablets because they're each 200 microgram tablets and those are typically taken anywhere from 6 to 72 hours post mifid kristen. Typically the regimens that I use and that most providers use suggest taking the miso process 24 hours after the mythic kristen. Um And most commonly probably um I see in my younger patients most commonly using it buckley so it's placed in the cheek for 30 minutes and then they just swallow whatever is left over with a little bit of water but it is okay to do vaginally and if you're doing it vaginally just tell the patients to take the pills and put them as far inside as they can, as close to their cervix as they can. And I tell them their cervix feels like the tip of their nose so they'll know they're in the right place if they feel something rubbery like the tip of their nose um Things for us to think about as providers. So we should you know the cramping can be um for a brief period you know for a few hours of time intense and so providing adequate pain relief. Um missile possible can cause a cause nausea. So thinking about anti medic medications and then preparing our patients so patients should x Cramping and bleeding within about four hours of the measles hostel placement and definitely within the 1st 24 hours. Um some regimens include a second dose of miSOPROStol a few hours after the first but definitely if there's been no bleeding it's okay for patients to repeat the miSOPROStol 24 hours later. Exline. And so then what happens after. So the most important thing is to have, it's ideal to have some sort of follow up afterwards to confirm that the process was successful. Typically that occurs 1 to 2 weeks after the myth of kristen is administered um in the before pre covid times that was always hoped to be an in person visit. But what covid and other things have shown us is that really um telehealth works for this as well. And I think in an adolescent population that's a very valuable tool. Um potentially you really want to focus on a history that tells you that you that can give you a high likelihood the abortion is completed. There's no corollary to the gestational dating um date survey, say gestational duration dating study saying that there are validated questions to ask. But really if a patient can give you a history of significant bleeding and cramping for a few hours. Some patients do notice the passage of the actual pregnancy tissue and so I can show you that or I've had patients send me pictures or bring me pictures and that show the pregnancy tissue. Um You know ultrasound or beta HCG to to confirm are also very reasonable tools and for a long time ultrasound was considered the gold standard. But it's not my point I want to make here is it's not required. If you are doing a beta HcG you should see an 80% decrease within seven days from the day. The myth of kristen was taken to the day to the seven day point later. And then the other um if patients can't come in or there's any doubt the other thing you can always do as a home pregnancy test. So pay a home pregnancy test should be negative for weeks after a medication after the myth of Kristen was taken. So patients can always do that themselves. And then again thinking about contraception if desired. A lot of you know the contraceptive options can often be addressed like I said in that initial visit um Next one on can be placed on the same day you're taking with Kristen. Um Any estrogen containing method. We usually recommend starting two or three days after taking mifepristone and then an I. E. D. Um would need to be inserted after confirmation that the process has ended depo Provera. We usually recommend giving it the follow up visit as well. And so then just a couple of quick slides around aspirations so that you feel able when you're starting to do this in your own practice to counsel your patients about options. Um aspiration is a safe. It's a fast usually typically less than 10 minutes in the first trimester and cost effective procedure that has high efficacy. One of the pros is that they're depending on the clinical setting. There are usually multiple options for anesthesia including um conscious sedation and and for patients that want this, they often leave the clinic with minimal bleeding and cramping. Since the uterus has been um predominantly empty during the procedure. The other potential pro for patients is that it does bring the fastest resolution of pregnancy symptoms, especially nausea. And so when you're thinking about coming back to our, maybe that's another thing you can use in your assessment to try and determine if something was successful is asking about resolution of pregnancy symptoms or whether those things like breast tenderness and nausea are still persisting with aspiration. Um It's it's invasive. Someone is performing a procedure um with any risks with any procedure. There are risks associated with instrumentation, um infection and bleeding, although again those are extremely low risk in this procedure. And then I think of thinking again about our specific pediatric population, but for all people it does require someone to know and accompany them if they're going to choose to use any sort of anesthesia. And so that coming back to that confidentiality piece. And then this is just a quick slide just to kind of again show the different steps of the procedure um and show that um it is something that is safe and accessible and can be reasonably done in a primary care setting. And so now I'm gonna turn back to DR allen to wrap us up. Thank you. Um So understanding that our patient had a lot of anxiety and a sense of urgency about this, I'm not really feeling clear um what her last menstrual period was. I reached out to my friend dr McEntee for advice about how to navigate the long wait times and what she recommended. And she was kindly able to add her onto her her own schedule the next day at planned parenthood. And we worked together with her therapist myself, our social worker. We were needing to coordinate transportation and she was able to include her mother in the care. So her family was able to help her get to her appointment. Um She based on her gestational age she was actually quite early. She was about 5 to 6 weeks. So she was eligible for a medication abortion or aspiration. And given that she was in the office and had the option for aspiration, she did elect for that because it allowed her to have an immediate post procedure I. U. D. Placed which if you remember she was not able to have an I. U. D. Place before because of the tightness of her cervix. So this was a really great option for her excited. So that you can tell is a very complicated case that involved a lot of people wrapping around our patient and she when she came in pregnant for the second time she really wanted to have a medication abortion and that wasn't available to her. But we're hoping that that changes very very promptly and that will be able to provide those in our F. Q. H. C. Here in Oakland. Um What can you do? So first we all need to vote. We need to advocate, we need to use our voices and we need to stay informed. Um It's really important to always remember to do a psychosocial screening even if brief wherever you are whether you're in E. D. Annex or in a hurried well like urgent care type of a visit. Just do a quick check in and make sure they don't need something that they're not able to tell you if there's a parent present um and assess the need for contraception, pregnancy testing and counseling, investigate what services you can provide directly as the landscape is rapidly changing. Um and then get to know your colleagues and local clinics that offer abortion care and don't hesitate to make connections and ask us for support. Um We very much want you to think of us if you have a pregnant patient who's meeting urgent services. Um We are we want to make ourselves very available um to help you navigate that for your your patients and clients um depending on whether or not they're seeking whether in a mental health providers office. Um You know asking these questions can be really important in many settings in in in all capacities as providers just so that everyone is aware about some of the new California based initiatives. Um California passed a bill mandating on campus access to medication, abortion and all of our U. C. And um state campuses. So that's really important to know as as our patients may be calling you as their pediatrician and you may be able to say hey you have access to that on your own campus if you're far far away from your medical home. Essential. Access is a wonderful organization that helped with our trainings and they're helping to roll out um medication abortion throughout FQ HCS as there's now a new billing pathway for F. Q. H. C. S to provide medication abortion. So really important to just be aware um that f THC is around, you may be able to provide this. Um and we are certainly hoping to be able to do that very shortly. Um And then the California Primary Care Association has a working group. Um There is incredibly creative people across the country working on creative solutions to how to address other states needs. And as dr Patrick mentioned, there's been a huge influx of people seeking care in California and that's been a priority for Governor. Newsom is to be a place that will provide services for patients coming from out of the area and then in september Governor Newsom signed the A. B. 1 1918 um which is uh to develop the California reproductive health service corps and I was pleased reading about it to see that a big focus of it is to provide culturally responsive care um in languages that that patients speak. And in many other ways that will expand services to rural parts of California which are often areas that may not realize they can be providing these services safely um as an improving access to care. So here's our contact information. Don't be shy, reach out with questions. Um You know, you can do this too and we really want to help you feel comfortable with any questions that come up. Um There's a lot of resources within UCSF and here in Oakland. Um that can support you in this. Um and lots of resources um on the next slide, just with different organizations and websites that can be be helpful. Um And there was a question already in the Q. And A. Just about will we provide these slides? Of course. We're happy to make them available um to anybody uh who would like them. Alright, so we have some great questions. Um The first one that um well I think you and I can probably talk about together. So do you have resources for how our approach to abortion care will change between states, for example, are college students calling us from out of state for medical care. I think one excellent resource um is the website Clancy pills and it has um guidance about, you know, what is legal in which state and helps people navigate. So I think just kind of bigger picture like celeste was saying as primary care pediatricians, we tell our patients we are available, we encourage them to have a medical home, for example, at their college health center, ironically the patient whose um mom I quoted is now in college out of state and they were texting me yesterday and got them in touch with their student health center. So I think um having a local primary care provider being in touch with their original primary care provider. And when it comes to figuring out, you know, if they end up wanting medication, abortion, checking out the plan c pills website, what do you guys have to add? Yeah, there's also um uh there's a newer group called my abortion network. Um and I'm not gonna remember their website, but they they're a group of uh family doctors and other abortion providers that are working to try and clarify some of the some of this, trying to incorporate more m maybe services, but also help people think about this this exact question. And there was just an article that came out in new york, there's telehealth providers trying to figure out how to how to find laws that will protect providers prescribing out of state, but at the moment it's hard to you're not allowed to mail medication to somebody's address out of state, potentially. So it's things like people opening P. O boxes and it's really complicated and so I think just being familiar with what's available and then um knowing who to who to have them talk to in their area right? And making sure patients understand to the potential risks that people get creative right? You pick up, they come and pick up the medication for the the individual and then they're mailing it themselves so you're not actually mailing it but it's still potentially risky for those involved. Um Another question. Um So in terms of reducing miSOPROStol, so in the process for that um. Yes so when I do, when I prescribe so that when I'm doing typically is handing patients the myth of kristen um because we have it in our clinic and then or or at our um I have it in clinic at lifelong for the in the residency program for miscarriage management and then a planned parenthood, we do the same thing and then what I do is I prescribe um for 800 micrograms of the apostle with one refill. And so I tell the patients to go back and pick up that refill if they don't have any bleeding onset instead of having to call because at least in those systems I'm working in calling can often be quite burdensome and so I want to make it as easy as possible um in terms of um anti medic and pain relievers. So um I be pro you know 600 mg of ibuprofen can be quite effective. I also have give patients um extra strength Tylenol. Um if there's if the patients really concerned that that's not going to be enough. Very um small amount of Norco is reasonable. I usually don't give more than five tablets and tell them that if they think that if they're going to need more than five then I want to know because that would be a typical for the process. Um and then in terms of anti medic, the best data is around um composing or prochlorperazine. Um but to be honest, I often use on dan citron just because I think it works faster and is more easily tolerated with less sedation. Mm hmm. Um Other than that with our male study, we didn't have any patients that needed the second dose of mrs Russell granted. We were enrolling you know, patients up to um nine weeks to allow time for mailing. So it was perhaps an earlier cohort. But even though we were ready to provide extra miso, they didn't need it. Um also for our patients that ibuprofen and Tylenol was sufficient, we didn't have anybody that ended up needing opiates, right? Um when you're suggesting so maybe celeste for you when you're suggesting that they wait to share info of pregnancy with others. Do you also advise not to use social media sites that may turn over their discussion in prosecution cases. In some states such as Nebraska again, thinking about college students or those traveling for care. Yeah, I think that sounds very wise. I think even just having that conversation with a, with a younger adolescent just about confidentiality and sharing things, um, can, can get them to think because they're, they're necessary. Not necessarily thinking of all the downstream issues. But I do think even without the law complications, helping them not put this on social media would probably be advised just so that they're not exposing themselves to other people's opinions and judgments and all the things that can impact how they feel pre imposed and allows them to kind of take time. I, what I would, I typically say is there's always time to share that you were pregnant or are pregnant, but once you share that information, it's not something you can take back so that it's okay to even wait if you're deciding to continue a pregnancy until you feel really ready to share that and really ready to hear people's responses and navigate all of that. So, I think just having that conversation really early on about the fact that they can always share anything with us. We can think about who do they feel, who can support them unconditionally, who would be by their side regardless of any decision, who they don't feel necessarily would try to influence them or judge them. Um, and so those are the conversations to have early on, especially with our younger patients who may not have experienced something like this in their life before um in the kind of the downstream complications or implications. Um two more questions so and related lee any thoughts on how to navigate this for women with developmental disabilities who are teenagers and or and or who are young adults but not concerned. So I think similar to what celeste was just saying, making sure that their trusted counsel of people that support them with any other medical situation, are there supporting them? Um Trying to think definitely with contraceptives, we've navigated that and have had patients with trisomy 21 choosing long acting methods or just trying to use clear language reviewing things um making sure that the patient understands and participates as best they can and then involving um their chosen you know caregiver who wants to be involved that the patient wants to have involved and I would just add for for follow up, you know we said follow up in a week but you may follow up in a day or follow up multiple times that week throughout this whole process depending on your patient. So I think just really being communicative amongst providers in the clinic who if you're not there that day like people know what's going on. Um we had a warm line for patients to be able to reach us during the medication abortion study. So really thinking in your practice about resources because it is really important for patients to be able to identify if there is a complication if they're having heavy bleeding or there's something that needs to be identified. And I think there have been cases where patients have tried to handle that on their own and not not known to kind of what to seek care for. So I think just having that communication up front with everybody. One other thing to add. Sometimes pediatricians don't necessarily think about sexual health for youth with disabilities, but whether it's menstrual control or pregnancy prevention, universally offering it to all of our patients with the uterus money, do we have time for one more question? Um, it's kind of a big one, but we can see what we can do. So now that job's reverse roe versus wade. Antiabortion groups are pursuing making em maybe illegal um, what to do with regard to the upcoming Supreme Court cases on this issue? Just stay in California. Don't move. Yeah. Um, I mean, I think that's a thing for us to highlight in my experience. I mean, we are very fortunate to live and work in the state of California and know that the access to the full spectrum of reproductive health care and abortion services is protected. Um, and I've actually been encouraged to see that the states that I wouldn't have necessarily expected to protect that are also protecting it as well. So I think um we need to stay vigilant, we need to stay informed. And we probably the biggest thing we need to do is California providers is make sure we're supporting our colleagues in other states. That we're creating pathways for them to have both the emotional and moral support that they need. But also that we're creating pathways for the patients in their states to have access to the care that they're not able to get right now. And also going back to evidence based medicine given we have over 20 years of experience with the safety and efficacy of medication, abortion. We've seen complications of, you know, self managed procedures when abortion is banned. Um I don't think the FDA is going to take away method kristen So it's an amazing tool that we have access to now mm hmm. Um You know, we're supposed to wrap up and I clicked the wrong button so I'm just gonna very quickly say to the person who asked about inpatient consultation resources. Um Not that I'm aware of um in terms of like a dedicated service but you could probably always, there's there's always an F. Q. H. C. Provider, the primary care provider on call, who can easily reach one of us or we can help answer questions. So there's pretty much always a provider in one of our team sites five days a week during the daytime. So please know that you can reach out to adolescent health and the primary care center for questions. Alright with that. Thank you all for your time this morning and for being present with us. Thank you. And somebody wanted the slide, the last slides with the resources, and please don't hesitate to reach out with any questions. Thank you. Created by
