Objectives: The overall main objective of this study is to improve post abortion care in Malawi by increasing the use of manual vacuum aspiration (MVA) in the treatment of incomplete abortions. More specifically our aim is to investigate if an intervention of training health personnel could increase the safer and cheaper method of MVA by 15%.
Methods: A prospective cross-sectional assessment of the pre/post use of MVA was performed at three public hospitals in Malawi. Health personnel at these hospitals were trained in MVA using theory and practice in April 2016. Two hospitals served as controls. Ethical approval was obtained from Malawian and Norwegian Ethics Committees.
Results: The intervention was successful with an overall increase of 21.3% in the use of MVA after one year. The control hospitals only had 3.0% increase during the same time period.
Conclusion: Training health personnel in using MVA is an efficient way of increasing a safer and cheaper method of treating incomplete abortions in Malawi. However, other factors, such as equipment, is crucial as well.
Viveca Odlind MD, Department of Woman and Child Health, Uppsala University, Uppsala,
and Medical Products Agency, Uppsala, Sweden,
Reduction of unintended pregnancy and the subsequent need for induced abortion is a
great challenge to everyone working with contraceptive method development or family
planning services. Today, a number of effective and safe contraceptive methods are
available, but consistent and correct use remains a problem and discontinuation rates are
often high, particularly with barriers and oral pills. Intrauterine devices (IUD) are among
methods that can provide a high degree of compliance and continuation.
Modern copper IUDs are highly effective, safe, long–acting, easy to insert, reversible, do
not interfere with sexual life and are inexpensive and could therefore be expected to be
highly acceptable to many women. However, use of the IUD varies considerably between
countries. Whereas IUDs are used by 30-40% of fertile women in China, in the USA, only
1–2% of women use an IUD. In the Nordic countries it has been estimated that around
20% of fertile women use IUDs.
Important issues surrounding IUD use include the risk of PID. Safety concerns and
litigations regarding the Dalkon Shield IUD and PID, originating in the 1970s, continue to
taint the reputation of all IUDs, even now, 30 years later. Recent reviews of studies on the
risk of PID have provided reassuring data about the safety of IUDs in women at low risk for
STI, suggesting that development of PID is most strongly related to the insertion process
and to the background risk of STI but not to continued IUD use. According to WHO
medical eligibility criteria for contraceptive use, IUDs could generally be used also by
nulliparous women in monogamous relationships.
The mechanism of action of copper IUDs has been extensively studied and most evidence
suggests that the main contraceptive effect is exerted through prevention of fertilisation.
IUD use should, therefore, not be a concern to those who would object to a method which
only prevented implantation of a fertilized ovum.
The levonorgestrel-releasing IUD (LNG-IUD), through its efficacy and non-contraceptive
benefits on menstrual blood loss, is particularly suitable to women in their later
reproductive years. The low dose of levonorgestrel results in little interference with the
ovarian cycle and few systemic effects. Studies of users of the LNG-IUD have not
suggested an increased risk of breast cancer.
Whilst intrauterine contraception is one of the most important long–term family planning
methods, there are common perceptions which can limit method acceptability. Therefore, it
is important that careful counselling, medical follow–up and removal facilities always
accompany promotion and use of intrauterine contraceptive methods.
Problems in abortion care for immigrants in Spain
Marta Okelly (Spain)
In the last few years, Spain has become a receptor country for an increasing number of people coming from other countries. About half of these people are women who have their own way of dealing with their sexual and reproductive health and after emigrating from their nations, they have to get used to new conditions and situations.
The Association of Clinics Authorized to perform TOPs (ACAI in Spanish) has conducted an investigation aimed to get more knowledge about this group of immigrants in Spain. The surveys carried out on almost 1000 women show important data about their sexual and reproductive health, such as:
Effectiveness of intracardiac potassium chloride for feticide prior to termination of pregnancy between 20 and 24 weeks
Emeka Oloto (Great Britain)
Background.There is a rising trend in the number of abortions carried out for England and Wales residents and the total was 193737 in 20061. Only 1.5% (2948) of these was carried out at 20 weeks and over of which 34% (1002) were reported as involving feticide. In United Kingdom, termination of pregnancy (TOP) can only be carried out in a National Health Service (NHS) hospital or in a place approved for the purpose by the Secretary of State for Health (non-NHS setting). In 2006, 75328 (39%) of all abortions were performed in the NHS hospitals of which 679 (<1%) were at gestations of 20 weeks and above. The distribution of the feticide procedures between the two settings was not obvious from the published data1.
Objective. This study was conducted to assess the effectiveness and safety of intracardiac Potassium Chloride administration in inducing fetal demise prior to second trimester pregnancy termination in a non-NHS setting.
Patients and Methods.Data regarding the age, parity, gestation, dose of KCl required to achieve asystole, presence or absence of cardiac activity at delivery or immediately before surgery, duration of procedure (from entering to leaving the theatre) and complications were prospectively collected in an excel spreadsheet from February 2007 till date. The feticide was carried out in theatre under general anaesthesia, aseptic conditions and continuous ultrasound guidance. A 16 cm 17-G Chiba needle (Cook Ob/Gyn, Spencer, Indiana, USA) was inserted into the fetal heart and a concentrated KCl (15% , 20mM/10ml ; B-Braun Melsungen AG, Germany) was injected 1 ml at a time until fetal asystole was achieved. A minimum of 5 mls of KCl was given in each case but the dose required to achieve asystole was recorded. Fetal cardiac activity was then observed for about 1-2 minutes to confirm that asystole persisted, but scan was not repeated thereafter. Anti-D immunoglobulin (500 iu) prophylaxis was given to all RhD-negative women. Following feticide, labour was induced for those undergoing medical TOP and surgery the following day for the rest.
Results.Till date241 feticide procedures have been carried out for women between 20 and 24 weeks gestation (mean gestational age of 22 weeks) of which 2 (0.8%) failed to achieve fetal demise. Fifty women (21%) had medical TOP while the rest had surgery. The average age of the patients was 22 years (range 13 – 42 years) and the average parity was 1 (range 0 – 5). 48% of the women were teenagers. The average duration of procedure was 12 minutes (range 5 – 40 minutes) and the average dose of KCl required to achieve asystole was 3 mls (range 1 – 15 mls). No live birth occurred and no maternal complication. The two cases where feticide failed were for planned surgery which was carried out successfully.
Discussion.The Royal College of Obstetrician and Gynaecologists (RCOG) recommended that the method chosen for all terminations at gestational age of more than 21 weeks and 6 days should ensure that the fetus is burn dead. Feticide prior to TOP at late gestation is necessary to avoid resuscitation dilemma for patients, nurses and doctors2; to avoid medico-legal and economic consequences of live birth that survives3; to shorten the mean ‘initiation-expulsion interval4; to reduce the prostaglandin requirement for mid-trimester medical abortion5; and to soften fetal cortical bones which aids surgery and minimises risk to the patients4. Of the available methods for feticide6, intracardiac injection of potassium Chloride (KCl) appears to be the most effective. The average dose of KCl required in this study (3mls) is similar to that reported recently7, but much less than the amount reported by Bhide et al.8
Conclusion.This is, to my knowledge, the first report of the experience of using intracardiac KCl for feticide prior to mid-trimester abortion in non-NHS setting in United Kingdom. It is an effective and safe procedure in non-NHS settings with appropriately trained team and should not be limited to tertiary fetal medicine unit as suggested by Pasquini et al.7
1. Department of Health Abortion Statistics, England and Wales: 2006, Statistical Bulletin 2007/xx. London: Department of Health 2007.
2. Royal College of Obstetricians and Gynaecologists. Further Issues Relating to Late Abortion, Fetal Viability and Registration of Births and Deaths. RCOG Statement London; RCOG Press; 2001.
3. Clark et al. An Infant who survived Abortion and Neonatal Intensive Care. Blumenthal PD et al. Abortion by Labour Induction. A Clinician’s guide to Medical and Surgical Abortion.
5. Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol 1999;94:139-41.
6. National Abortion Federation – Clinical Practice Bulletin: Digoxin Administration. May 2, 2007.
7. Pasquini L, Pontello V, Kumar S. Intracardiac injection of potassium chloride as Method for feticide: experience from a single UK tertiary centre. BJOG 2008;115(4):528-531.
8. Bhide A, Sairam S, Hollis B et al. Comparison of feticide carried out by cordocentesis versus cardiac puncture. Ulrasound Obstet Gyncol 2002;20:230-2.
30 years legal abortion in Ascoli Piceno, Italy
Tiziana Antonucci, social worker, Daniela De Anglis, Sociologist, Adriana Bisonni,
Consultant, Massimo Cutulli, Gynaecologist, Ennio Painvain Gynaecologist, Maurizio
AIED was founded on 10th October 1953, and the diffusion of the concept and custom of
liberal and responsible sexual relationships has represented from, the very beginning, one
of its principle objectives. The Ascoli Piceno section was created in 1974 and since then its
practise has assisted approximately 20,000 women, and in particular around 11,000
requests from patients and certification for IVG, a few hundred of these received before
the introduction of law 194, in collaboration with CISA. As a consequence of constant
moral objections on the part of every member of staff in the city hospital, the AIED section
of Ascoli Piceno, from 1978 to date, thanks to an agreement with the health authority,
guarantees its patients a path to IVG, in the practise, and during the hospital stay, the
operation and discharge, an experience which is probably unique in Italy.
The method the practise uses is principally characterised by the speed in which the patient
is seen: in almost all cases a woman can be given an internal examination and an ultra
sound scan to determine date, within a week of the request.
Extremely close attention is paid to counselling which is entrusted to the same health
worker who will be working alongside the doctor in the hospital: as well as providing the
patient with the fullest possible information on the practical aspects of the IVG we also give
the woman ample time to make an informed decision about the termination of her
unwanted pregnancy and help her to make a choice of effective contraception.
The operation is carried out using the KARMAN method, and from 1980 to date, without
general anaesthetic, except in extremely rare cases, and is carried out with a strict limit of
three people in theatre: the AIED staff, and the patient.
We find the following very interesting: the percentage of patients who return to the practise
after the operation was maintained at about 30% up to the 70?s, around 40-50% during
the 80’s and 90’s and about 50% rising to a high of 60% from 2000.
Conclusions: - The woman’s satisfaction with the entire IVG process is the element which
we feel guarantees an increased percentage of returns for check - ups and the possible
preventions of recurrence.
In the hospitals where these operations are not carried out, as per law, there is the
possibility of provision for an alternative service, with a possible forward role for lay
consultants, for the quality of care of the IVG service and the prevention of unwanted
pregnancies, in consultation with the health authority.
The IVG process also needs projects that provide for the intervention of local institutes to
promote the use of intrauterine contraception and offer free services for the immigrant
population and those on low incomes.
The clinical evidence will be described and considerations made on the IVG phenomenon,
the application of the law, the freedom of choice of surgical method and doctor.