Going ForwardThe prevalence of contraceptive use and the
abortion rate are very different among countries.
We know that the abortion rate is high in
countries where the prevalence of use a modern
contraceptive method is low. Combined hormonal
contraceptives (COC) are one of the most popular
methods of birth control. This is a reliable form
of contraception, having a theoretical failure
rate of 0.1% and, due to problems related with
compliance an actual failure rate of 2-3%. The
pill use is very different among countries. It will
be important to try to understand why these
differences exist. Despite the safety of current
COCs, fears of adverse metabolic and vascular
effects and possible oncological effects remain.
Misperceptions and concerns about side effects,
especially those affecting menstrual cycle, fertility
and body weight increase, are often reasons for
discontinuation. Making contraception available
is not enough to prevent abortion: women should
be able to choose a contraception method that
suits their personal expectations - only then
will unwanted pregnancies be successfully
avoided and the abortion rate will decrease. For
contraceptive efﬁcacy, a woman’s/couple’s free
and informed choice is required.
Medical termination of pregnancy up to the 10th
week: an experience of two obstetric centres in
Ce´u Almeida, M; Bombas, T; Silva, I; Ribeiro, S;
Monteiro, J; Fernandes, T; Moura, P
Maternidade Bissaya Barreto – CHUC, Portugal
Since 2007, termination of pregnancy (TOP) on request is legal in
Portugal up to the 10th week of gestation and we perform mainly
This study investigated the efﬁcacy and the safety of medical
TOP up to the 10th week of gestation in the two major obstetric
services in central Portugal, over 16 months.
A retrospective study was performed of the clinical outcome of
women requesting a TOP, over the previous 16 months. We
considered three groups regarding gestational age: Group 1:
£49 days; Group 2: 50–62 days; Group 3: ‡63 days and studied
the efﬁcacy and the safety.
We included 1276 women who had had a medical TOP. Group
1: 41.5% (529), Group 2: 41.5% (530) and Group 3: 17% (217).
The mean age was 51 days. The global efﬁcacy was 99%. In three
groups, the efﬁcacy of medical TOP was 99.6%, 99.2% and 96.8%
(P < 0.01) in groups 1, 2 and 3. We performed an aspiration per
failed TOP or incomplete TOP in 1.1%, 3.3% and 6.1%
(P < 0.01) of group 1, 2 and 3, respectively. The global rate of
complications was 5.4%. Group 1: 4.2%; Group 2: 5.4% and
Group 3: 8.3% (p=NS), mainly related with an uncompleted TOP
(4.5%), haemorrhagic complications (0.6%) and infection (0.3%).
Medical TOP is a safe method up to the 10th week of gestation
with a low incidence of complications, most of them (80%) due
to incomplete TOP. In the group with a gestational age of 63 days
or more, the efﬁcacy was lower but similar to the efﬁcacy
speciﬁed on the labelling.
Unintended pregnancy can disrupt treatment and recovery for women of reproductive age with cancer. Although some cancers and treatmentss impair infertility, many women with cancer are physically capable of conceiving. Little is known about contraception counseling and abortion in cancer care. Several studies indicate that cancer surviviors in different countries have more abortions than their siblings. Women are overloaded with information at cancer diagnosis adn fertility isues are freuqently forgotten. In a Swiss study of reproductive-aged women with breast cancer 62 of 100 participants needed contraception counseling at time of cancer diagnosis. 17% of women in an Australian sample never had the question: What should I do about contracpetion ? answered during their cancer care. Also some women believe that they could not get pregnant during and after treatment, despite having no clinical diagnosis of infertility. One study found that women who had contraceptive counseling had alomost even times higher use of effective contraceptive methods. A US study demonstrated a higher use of emergency contraception among female young adult cancer survivors. In conclusion using contraception to time pregnancies for periods of better health, is highly relevant for women with a recent cancer diagnosis. Improving reproductive health care for women with cancer is essential. Collaboration between healthcare providers couselling involved into cancer treatment and family planning doctors/nurses/midwifes needs improvenment.
The time of an abortion is a window of opportunity for contraceptive counselling. Clinical practice shows us that we can and must provide contraceptive counselling at the first abortion appointment and not leave it for follow-up. There were some concerns that during the time of an abortion the women will be too distressed with the information regarding the abortion decision and abortion method and so will not able to consider the information about contraception. The women and the couples must be informed that fertility returns rapidly after first trimester abortion. Well informed women were able and motived to choose and start a contraception method at the time of the abortion. Starting a contraceptive method at the time of the abortion is safe and good practice. For medical abortion, combined hormonal contraception, oral progestogen, injectable and implant could be start or inserted on the day of misoprostol administration. For surgical abortion these methods could be started or inserted on the day of the procedure. For surgical abortion, an intrauterine device could be inserted at the time as the operation.
Immediate insertion of an IUD/IUS is safe, results in higher method uptake compared to interval insertion but the expulsion rate seems to be marginally higher. A randomized trial showed that IUD/IUS insertion as early as one week after medical abortion is safe and results in high method uptake and no difference in expulsion rate compared to the insertion at 3-4 weeks. Providing information, updated practices and access to contraception at the time of the abortion will contribute to an immediate start of a contraceptive method and to a lower risk of repeated abortion.