Pascale Roblin


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    Contraception before and after abortion at home

    Pascale Roblin, Claire Ricciardi, Aubert Agostino and Raha Shojai, France

    Objective: In France, despite a wide range of highly effective, easily accessible and reimbursed contraceptive methods, the rate of abortions remains high and one third are repeat procedures. We analyzed womens’ contraceptive path surrounding a medical abortion.

    Methods: A retrospective study of 450 women who had medical abortion at home before 7 weeks was realized in a community care office in Marseille between 2006 and 2010. All women were seen at the post abortion visit and had received contraceptive counselling before and after the procedure with emphasis on long acting reversible contraceptives (LARC). The last declared failed contraceptive method leading to the unwanted pregnancy and the method finally adopted by the patient at the immediate follow-up visit were noted.

    Results: Before abortion, 43 (9,5%) used no contraception, 92 (20,5%) used natural methods and 244 (54,2%) used condoms. Women declared using COC in 71 cases (15,8%) and the vaginal ring in one case. None had an IUD or an implant. After abortion, 37 (8,2%) requested no prescription of contraception, 259 (58%) had  COC, 15 (3,3%) used a vaginal ring and 12 (2,7%) opted for a transdermal patch. Following  abortion, 31% of patients switched to LARC (121 IUD and 18 implants) and 37% to highly effective forgettable methods. Among the 244 pre-abortion condom users, 163 (73%) switched to COC. Among the 71 pre abortion COC users, 45% still maintained COC as their preferred method and 34% switched to IUD.

    Conclusion: Most unwanted pregnancies occurred with the use of male condoms. Immediately after abortion, the majority of women opted for combined oral contraceptives. On the short term, peri-abortion contraception counseling may however encourage women to switch to more effective and forgettable methods (IUD or implant).

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    Does a previous abortion modify womens’ contraceptive choice?

    Pascale Roblin, Lisa Tichane, Sylvie Camil, Aubert Agostini and Raha Shojai, France

    Objective: Care givers often expect that women with a previous abortion are more likely to use highly effective contraceptive devices to prevent further unwanted pregnancies. We assessed the failed contraceptive method used before an abortion between  women with and without a previous abortion.

    Methods:In a series of 450 women requesting a medical abortion at home before 7 weeks in a community care center in Marseille, France, there were 157 (35%) patients who had a history of at least one previous abortion.  We realized a case –control study to compare the failed contraceptive method leading to an unwanted pregnancy between 157 women with a previous abortion and 293 women without a previous abortion. Chi-2 test was performed and considered significant for p<0.05.

    Results: The rate of women using no contraception, natural methods or condoms  were similar in both groups. The rate of COC users was 16% in the group of patients with a previous abortion vs 14,7% in the control group (p=0,8).  None of the patients used IUD or implants in both groups.

    Conclusion:The contraceptive profile of women with an unwanted pregnancy is similar between women with and without a previous abortion. In our population, a history of abortion did not modify womens’ contraceptive choice towards more effective methods.

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    IUD after medical abortion: Should it remain underused?

    Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)

    University Hospital of Marseille, France

    Objective. Immediate post-abortum IUD insertion remains an underused option in daily practice. We evaluated the safety and acceptability of IUD insertion shortly after medical abortion at the office.

    Patients and Methods. In a prospective series of 300 women who underwent medical abortion in a private office before 49 days, we observed the incidents that occurred among the 104 patients (34,6%) that opted for an insertion of IUD shortly after abortion. Uterine vacuity had been controlled by ultrasound between the 8th and 12th days post abortum. IUD were inserted between the 8th an 30th day following abortion. None of the patients had received prophylactic antibiotics. 62 (60%) patients had hormonal IUD and 42 (40%) had Copper IUD.

    Results. Women’s mean age was 31 years, 26% were nulliparous and 37% had already had previous abortions. None of the patients had long term reversible contraceptions before requesting an abortion and only 5 (1,6%) had used emergency hormonal contraception. 72% of IUD were inserted at the control visit on the 8th day. When uterine vacuity seemed incomplete, IUD insertion was postponed but for 90% of our patients insertion was possible before day 30. No mechanical (expulsion or perforation) and no infectious complications were registered. At insertion, the mean pain score on an analogical visual scale was 2/10. Mean duration of bleeding following IUD insertion was 6.5 days. With a follow up of 24 months in our database, 8 patients (7,7%) requested IUD removal : in 2 cases because of pelvic pain but no evidence of pelvic inflammatory disease, in 2 cases for excessive bleeding and in 4 cases for desire of pregnancy.

    Conclusion. Our preliminary findings suggest that IUD may be offered shortly after an induced medical abortion before 49 days. When such method is chosen by the patients, safety and continuation rates seem high. Proposing an IUD immediately after a first trimester abortion at the office may help reduce repeat abortions.

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    Medical abortion in France. The benefits of a complex procedure

    Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)

    University Hospital of Marseille, France

    Objective. Medical abortion in an ambulatory setting is possible in France since 2004. However, many physicians have been reluctant to use this new option at the office because of the complexity of the protocol. Our aim was to evaluate the feasibility of this procedure in a private practice and to show it’s benefit in terms of contraception counselling.

    Patients and methods. A prospective study was realized among 300 consecutive women, with gestational age less than 49 days, choosing a medical abortion at a general practionner’s office. Under the French law, patients had to undergo five supervised visits (V). The first visit (V1) was to inform patients on the procedure and proposition to encounter a social worker for alternatives to abortion. V2 was for medical examination, cervical cytology, screening for IST and counselling on contraception. After a reflection period of seven days, the third visit was for administration of 600mg of mifepristone under the physician’s supervision. The fourth visit was for administration of 400µg of oral misoprostol at the office. Medications were bought by the physician at the pharmacy. Women were not obliged to remain under supervision and could depart within minutes of receiving medications but were not given the possibility to take the medications themselves at home. They had access to a 24-hour hotline and walk-in emergency service. The fifth visit was for post-abortion control at 10 days with HCG and/or sonography.

    Results.Among the 300 patients, 10 (3%) were lost at follow-up. The rate of complete abortion with no major complications among the 115 patients with a known outcome was 97%. Four patients (3,5%) required surgical aspiration : 2 for haemorrhage, 1 for incomplete abortion and 1 for continuation of pregnancy. Seventy-six women (63%) fully adhered to the protocol and came to the 5 scheduled visits. The mean number of visits at the office was 4,1. An unscheduled visit was required in 7 cases (6%) for repeat administration of misoprostol and 19 patients (16%) phoned for advice. The reflection period of seven days was not possible to respect in 55% of cases because of the time limit of 49 days but all patients had at least 48 hours to confirm their decision. None of our patients requested to encounter a social worker. Concerning contraception, 75% had no use of birth control methods and only 2 women used emergency hormonal contraception. At the control visit, 46% opted for oral contraception and 38% for a long term reversible method (IUD or implant). Overall rate of satisfaction for the method was 78%.

    Conclusions.Our findings confirm that medical abortion in a general solo practice is a safe and acceptable procedure. A complex procedure based on five visits at the office may be a shortcoming and considered as a setback in the era of increased patient autonomy. In our view it improves patient-doctor relationship which is essential for counselling in post-abortion contraception.