REPRODUCTIVE HEALTH SERVICES

 

CONSENT FOR ABORTION WITH MIFEPREX^TM (MIFEPRISTONE) AND MISOPROSTOL

 

I hereby give permission for Reproductive Health Services (hereinafter “Provider”) to perform a nonsurgical/medical abortion with Mifeprex^TM (Mifepristone) and misoprostol and have received a Mifeprex Fact Sheet.

 

DESCRIPTION

 

I acknowledge that I am fewer than 9 weeks (63 days) pregnant and I have decided to have an abortion with the medications Mifeprex^TM and misoprostol.  Mifeprex^TM blocks the action of progesterone; a hormone needed to continue pregnancy.  Mifeprex^TM has been approved by the U.S. Food and Drug Administration (FDA) for early abortion.  Misoprostol causes the uterus to contract and expel the pregnancy.  It is a drug used in the United States to prevent irritation or ulcers in the stomach of people using aspirin or aspirin-like pain medicine.  This method is known as non-surgical abortion because it allows a pregnant woman to end a pregnancy without surgery, in other words without putting instruments into the uterus. Studies have shown that Mifeprex^TM and misoprostol, when used together, are approximately 94% to 98% effective in causing an abortion in early pregnancy.

 

PROCEDURE

 

The following procedure is an evidence-based regimen, rather than the FDA approved regimen.  This is because it uses a 200-mg. dose of Mifeprex^TM and an 800 mcg. dose of vaginal misoprostol.  The FDA approved regimen is 600 mg. Mifeprex^TM and 400 mcg. of oral misoprostol.  Clinical trials in the United States and elsewhere have demonstrated that this alternative regimen is safe, effective and causes less stomach upset

 

1. A medical history will be taken and an ultrasound examination will be done to determine the size of my pregnancy.  Blood samples will be taken to determine my RH status and to test for anemia.
2. I will swallow one 200-mg. Mifeprex^TM tablet in the office.  I have been told that I should not use alcohol while using this medication..
3. I will be given four 200 mcg. Misoprostol to insert into my vagina between  6 and 72 hours after swallowing the pill. 
4. I will insert the misoprostol into my vagina at home.  After insertion I will remain in bed for the next 1-3 hours or until bleeding and/or cramping occur.
5. If I experience cramping, I will take the prescription for pain given to me at the time of my visit .
6. I will contact my provider at the office number, or after hours at 301-930-6016 if I soak 2 or more maxi pads per hour for 2 consecutive hours; have a sustained fever greater than 100.4F; onset of fever, nausea, vomiting, diarrhea or overall weakness or discomfort more than 24 hours after using misoprostol; severe abdominal pain not helped by pain medication; have vomited for more than  4 hours; have no bleeding within 24 hours after using misoprostol.
7. I will return to the office around day 14 for a follow-up visit. There  is a no charge visit unless more than 4 weeks have elapsed and then the charge is $25.00.  I understand that I must bring a sample of my first morning urine on the day of my follow-up appointment.  I realize the importance of this visit to confirm that my pregnancy has been terminated.  If the pregnancy is still growing, then I agree to a surgical abortion.

RISKS

 

Incomplete abortion – As with a surgical abortion, some pregnancy tissue may remain in my uterus.  If this occurs, the provider will discuss a plan for care with me.  This plan could include waiting one or more weeks to allow the medications more time to work; using more misoprostol, or having a surgical abortion.  The risks of a surgical abortion include making a hole in the uterus, tearing the cervix, infection, excessive bleeding and failure to remove all of the tissue from the uterus.

 

Vaginal bleeding – As with a surgical abortion, heavy bleeding can occur and blood clots may come out of my vagina.  If I have extremely heavy vaginal bleeding or dizziness, an aspiration curettage may be necessary to stop the bleeding.  The risks of an aspiration curettage are stated above.  The risk of having very heavy vaginal bleeding after using Mifeprex^TM is about 1 per 100 (1%).  The risk of needing a blood transfusion after using Mifeprex^TM/misoprostol is about 1 per 1000 (0.1%).

 

Continued pregnancy and birth defects -  My pregnancy may not end after receiving the medications.  Deciding to continue the pregnancy to term is NOT AN OPTION as birth defects are possible.  I understand the abortion has begun when I swallow the Mifeprex^TM and the decision to terminate becomes irreversible at this time.

 

I understand that I could experience side effects when using Mifeprex^TM and misoprostol.  Some of these may include abdominal cramping, nausea, vomiting, diarrhea, fever, headaches and chills.  Most of these side effects last less than a day.

 

I understand that an ectopic pregnancy (pregnancy in the fallopian tube) is a rare condition, which is a complication of pregnancy rather than abortion.  I have been told that if the pregnancy is in the fallopian tube or outside the uterus, neither surgical abortion nor a Mifeprex^TM /misoprostol abortion will remove the pregnancy.  Due to the possible threat of rupture of the fallopian tube, hospitalization may become necessary as soon as it is discovered.

 

COSTS AND PAYMENTS

 

I will receive medical care for my abortion, including information about birth control, at a fee of $350.00.  This fee includes the cost of a surgical abortion performed at Reproductive Health Services, if needed.  The fee does not include any charges incurred for an emergency room visit or for care at another facility.  It does not include the cost of medication if it is determined that my blood is RH negative. The fee for this medication is $35.00.  If additional blood work is needed prior to or at my follow-up visit, I understand that the cost of this blood work is my responsibility.

 

VOLUNTARY CONSENT

 

I have been informed of other choices during early pregnancy, including continuing the pregnancy to term and becoming a parent, continuing the pregnancy and making adoption arrangements, and surgical abortion.  I am aware of the risks involved with a surgical abortion and a non-surgical abortion.  I acknowledge receipt of the fact sheet on “Abortion with Mifeprex”.

 

I have fully disclosed my medical history, including the date of my last menstrual period, allergies, blood conditions, prior medications or drugs, and reactions to medications or drugs.  I certify that I have read this form or it has been read to me.  I understand its contents, have been given an opportunity to ask questions and my questions have been answered to my satisfaction.  .  I have been told that this consent forms amends the signed Patient Agreement.

 

I hereby release the physician and staff from any and all claims arising out of, or connected with, the above procedure or any resulting complications and expense.  My signature below authorizes release of my medical records pertaining to health care services associated with this abortion.  I understand that I am pre-signing a medical release form for Reproductive Health Services to obtain copies of any subsequent medical records related to this abortion.

 

 

 

 

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Patient Signature                                                              Date                                                         Witness