Unwanted Kit — Mifepristone 200 mg + Misoprostol 200 mcg ×4

Indication

Dosing Regimen

Minimum interval between mifepristone and misoprostol: 24 hours (WHO Abortion Care Guidelines, p. 108). Standard clinical practice uses 36–48 hours.

Misoprostol Administration Routes

• Vaginal: Place all 4 tablets deep in the posterior fornix. Most effective, less nausea/diarrhea.
• Buccal: Place 2 tablets in each cheek pouch, hold for 30 min, then swallow remnants.
• Sublingual: Place under tongue for 30 min. Highest systemic absorption but more GI side effects.

What to Expect After

• Cramping & bleeding begin within 1–4 hours of misoprostol — this is the expulsion process.
• Heavy bleeding with clots is normal for the first few hours.
• Lighter bleeding may continue for 1–2 weeks.

Follow-Up

• A clinical review (ultrasound or serum β-hCG) is recommended 14 days after misoprostol to confirm complete abortion.
• If abortion is incomplete, a repeat dose of misoprostol or surgical evacuation may be needed.

Key Contraindications

• Gestational age > 7 weeks (for this kit's labeled use)
• Ectopic pregnancy (must be ruled out first)
• Chronic adrenal failure, inherited porphyria
• Long-term corticosteroid therapy
• Coagulopathy or anticoagulant use
• IUD in situ (must be removed first)

Common Side Effects

• Nausea, vomiting, diarrhea (especially sublingual route)
• Uterine cramping and pain (manage with NSAIDs like ibuprofen)
• Chills, low-grade fever (transient)

Note: This kit is a prescription medication (Rx). Use under medical supervision only.

Unwanted Kit at 4 Weeks of Pregnancy

Regimen

At 4 Weeks — What's Different Clinically

• Higher success rate — the earlier the gestation, the more effective medical abortion is. At ≤4 weeks, complete abortion rates approach 95–98%.
• Lighter bleeding compared to later gestations — expulsion is faster and less painful.
• Cramping is milder — less analgesic requirement typically.
• At very early gestation (< 4 weeks / < 28 days LMP), some guidelines note a slightly higher chance of failed abortion where the sac may not yet be visible on ultrasound, making it harder to confirm success — a follow-up β-hCG or ultrasound at 2 weeks is still essential.

Bottom Line

Same dose, same timing. Earlier gestation = higher efficacy and milder side effects. Confirm complete abortion at 2-week follow-up regardless of gestational age.

Hematemesis — Management

Common Causes

Step 1 — Immediate Resuscitation (ABCs)

• Airway: If active/ongoing hematemesis, altered mental status, or respiratory compromise → endotracheal intubation before endoscopy to prevent aspiration
• IV Access: Two large-bore (≥18G) peripheral IVs
• Foley catheter: Monitor urine output
• Nasogastric tube: Consider for gastric lavage and to assess bleeding activity
• Volume resuscitation: IV crystalloids initially; blood transfusion if hemodynamically unstable
  • Transfusion threshold: Hb < 7 g/dL (restrictive strategy) — or <8 in cardiac disease
• Correct coagulopathy: FFP, platelets, Vitamin K as needed

Step 2 — Risk Stratification

Pre-endoscopy: Glasgow-Blatchford Score (GBS)

• GBS = 0 → Low risk → can consider outpatient management
• GBS ≥ 1 → Admit for further evaluation

Post-endoscopy: Complete Rockall Score

• Score 0–2 → Low risk, early discharge possible
• Score ≥ 3 → Higher risk, monitor closely

AIMS65 Score (5 variables):

• Albumin < 3.0 g/dL
• INR > 1.5
• Altered mental status
• Systolic BP < 90 mmHg
• Age > 65
• Score ≥ 2 → higher mortality risk

Step 3 — Pharmacological Treatment

All UGIB:

• IV Proton Pump Inhibitor (PPI): Start immediately
  • Omeprazole/Pantoprazole 80 mg IV bolus → then 8 mg/hr infusion for 72 hrs
  • Reduces rebleeding and need for surgery in peptic ulcer bleeding

Variceal Bleeding (suspected/confirmed):

• Terlipressin 2 mg IV q4–6h OR Octreotide 50 mcg bolus → 25–50 mcg/hr infusion
• Prophylactic antibiotics: Ceftriaxone 1g IV daily (reduces bacterial infection and mortality in cirrhosis)
• Beta-blockers: Not in acute setting; used for secondary prophylaxis later

Prokinetics (before endoscopy):

• Erythromycin 250 mg IV 30–60 min before EGD — clears stomach of blood, improves visualization

Step 4 — Endoscopy (Definitive Diagnosis + Treatment)

• Timing: Within 12–24 hours of presentation after resuscitation
  • Within 12 hours for high-risk patients (active bleeding, hemodynamic instability)
  • Within 24 hours for stable patients
• Endoscopy both diagnoses the cause and allows therapeutic intervention

Endoscopic hemostasis options:

Step 5 — Escalation for Refractory Bleeding

1. Repeat endoscopy — second attempt before escalating
2. Interventional radiology: Transcatheter arterial embolization (TAE)
3. TIPS (Transjugular Intrahepatic Portosystemic Shunt): For refractory variceal bleeding
4. Surgery: Reserved for failure of all above
   • Oversewing of ulcer, vagotomy + pyloroplasty, or gastrectomy depending on pathology

High-Risk Features Requiring ICU Admission

• Hypotension or tachycardia not responding to resuscitation
• Active hematemesis on presentation
• Hb < 8 g/dL or drop > 2 g/dL
• Rockall Score ≥ 3
• Cirrhosis or anticoagulation
• Age > 65 with significant comorbidities

Summary Algorithm

Hematemesis
    ↓
ABCs → IV access → Fluid resuscitation → Blood transfusion (if Hb <7)
    ↓
Risk stratify (GBS / AIMS65)
    ↓
Start IV PPI ± Octreotide (if varices suspected)
Erythromycin pre-endoscopy
    ↓
Upper endoscopy within 12–24 hrs
    ↓
Endoscopic hemostasis (clips/thermal/band ligation/injection)
    ↓
If fails → IR embolization / TIPS / Surgery