Abortion in women with cardiac disease
Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland
The presentation will cover:
Presentation of cardiac conditions and their treatment in which continuation of pregnancy predisposes the woman to high-risk of cardiac or obstetric complications. These include conditions such as history of cardiomyopathy (especially with comprised cardiac function), pulmonary hypertension and/or conditions in which cardiac disease or its treatment requires anticoagulation or treatment with teratogenic medication(s);
Management of abortion (either medical or surgical) in women with cardiac disease, especially as concerns management of haemodynamics, and current recommendations concerning anticoagulation and possible antibiotic prophylaxis;
Recommendations concerning multidisciplinary treatment of women with underlying cardiac disease faced with unwanted pregnancy and situations where continuation of pregnancy is considered contraindicated.
Challenges in post-abortion contraception
Oskari Heikinheimo (Finland)
Department of Obstetrics and Gynecology, Helsinki University Central Hospital, POBox 140, 00029-HUS, Helsinki, Finland
The influence of contraceptive use and counseling on the risk of repeated abortion is unclear. In a recent prospective study, specialist counseling and provision of contraceptives did not have an effect on the rate of repeated abortion (Schunmann and Glasier, Human Reproduction, 2006). However, in randomized clinical trials the use of intrauterine contraception, initiated at the time of surgical abortion, has been effective in reducing further unintended pregnancies (Pakarinen et al., Contraception, 2003).
We analyzed recently risk factors for repeat abortion among a cohort of 1269 women undergoing medical abortion between August 2000 and December 2002 (Heikinheimo et al., Contraception, 2008). Contraceptive use was assessed at the time of follow-up performed at 2-3 weeks following the abortion; intrauterine contraception was initiated at the clinic at the time of follow-up, or within 2 months. The subjects were followed prospectively via the Finnish Registry of Induced Abortions until December 2005, the follow-up time (mean ± SD) being 49.2 ± 8.0 months.
In comparison with combined oral contraceptives, use of intrauterine contraception was most efficacious in reducing the risk of another pregnancy termination. In multivariate analyses the hazard ratios (95% Cl) of repeat abortion were 0.33 (0.16 to 0.70) among Cu-IUD users and 0.39 (0.18 to 0.83) among LNG-IUS users when compared to users of combined oral contraceptives. The incidence of repeat abortion was highest among women the postponing initiation of contraceptive use.
Contraceptive choices made at the time of abortion have an important effect on the rate of re-abortion. Use of intrauterine contraceptives for post-abortal contraception is most efficacious in decreasing the risk of repeat abortion.
One-and two day mifepristone-misoprostol intervals are both effective in medical termination of second trimester pregnancy
Oskari Heikinheimo, Satu Suhonen and Maija Haukkamaa, Department of Ob&Gyn, Helsinki University Central Hospital, Finland
Termination of pregnancy because of fetal anomaly requires the utmost clinical sensitivity and individualized patient care. We compared the efficacy of a one-day mifepristone and misoprostol –interval in medical termination of second trimester pregnancy performed because of fetal anomaly with that of the standard two-day interval among the first 100 women in each group. A 200 mg dose of mifepristone was used; 0.4 mg of misoprostol was administered vaginally at three-hour intervals until abortion occurred.
When calculated from ingestion of mifepristone, the time to abortion was 28:25 h (23:10 – 50:40 h) (median (range)) and 52:43 h (45:55 – 83:15 h) (p<0.0001) in the one- and two-day MIFE-MISO groups, respectively. However, following initiation of misoprostol administration the time to abortion (7:25 h (1:00 – 23:15 h)) was longer (p<0.05) in the one-day interval group than in the two-day interval group (6:20 h (0:45 – 36:30 h); by 12 h 82 and 87% (n.s.), respectively, of the subjects had aborted. The proportions of cases undergoing surgical evacuation of the uterus were 64 and 45% (p<0.001), in the one- and two-day interval groups, respectively.
Thus both one- and two-day mifepristone-misoprostol intervals are both valuable in termination of second trimester pregnancy.
Risk factors for repeated abortion
Oskari Heikinheimo, MK, Prof., Department of Ob&Gyn, Helsinki University Central
Hospital, Helsinki, Finland
The frequency of repeated abortion varies in different countries and depends greatly on
the overall abortion incidence. In Finland the annual abortion incidence is ~9/1000 fertile
aged women; the proportion of repeated abortion has been ~30% of all abortions for
several years. Low socioeconomic status, parity and older age have emerged as risk
factors for repeat abortion in previous studies.
In order to further characterize the risk factors for repeated abortion we have initiated two
large scale cohort studies employing the national abortion register, where 99% of all
abortions performed in Finland are being reported. Woman’s age, previous pregnancies,
duration of pregnancy, method of pregnancy termination as well as planned future
contraception are reported to the national register.
Helsinki study comprises of ~1400 women chosing medical abortion at our institute
between 2000-2002. At 2-3 weeks following abortion, all women attended the clinic for a
control visit, where the outcome, as well as compliance and initiation of contraception was
assessed. Detailed demographic, life-style and abortion related data of the subjects have
been collected. Also, the contraceptive method and the date when contraception was
initiated have been recorded. The first assessment of repeat abortion until the end of year
2005, and it’s risk factors is being performed. However, the study will continue until 2012.
Similarly, a nationwide study employing the national abortion register has been initiated. In
the nationwide study cohorts of ~23.500 women choosing medical abortion and 65.000
women choosing surgical abortion between 2000-2005 are being followed. The first
assessement of repeat abortion will be performed until the end of year 2005. Among other
things, the study allows estimation of the true risk for repeat abortion following different
methods of pregnancy termination.
It is hoped that these register based strategies will be valuable in identifying the incidence
and risk factors for repeat abortion. In addition, true efficacy and cost-benefit ratio of
various contraceptive methods can be assessed. These data are valuable when
developing and designing family planning services aiming to shift from abortion to effective
Use of levonorgestrel-releasing IUS (Mirena®) following medical termination of pregnancy
Oskari Heikinheimo and Satu Suhonen MD, Department of Ob&Gyn, Helsinki University Central Hospital, Finland
Immediate insertion of levonorgestrel-releasing IUS (Mirena®) following first trimester surgical abortion is safe and effective.
We evaluated the post-abortal contraceptive practices among 417 women who chose medical termination of pregnancy (MTP) during the first year of use of MTP in our hospital between August 2000 and 2001. MTP was offered to women with unwanted pregnancy with duration of up to 56 days, and it was carried out by administration of 200 mg of mifepristone on day 0 (visit I) followed by 0.4 mg of misoprostol administrered vaginally on day 2 (visit II). A 3rd visit was scheduled at 3 weeks to control the outcome of MTP.
Future contraception was planned during visit I. 61% of women chose combined oral contraceptive (COC, whereas 29% of women chose intrauterine contraception. A total of 65 women opted for Mirena® (i.e. 16%) and 53 women (i.e. 13%) for Cu-IUD. Of the IUD’s 55% (66% of the Cu-IUDs and 46% of the Mirena® IUSs) were inserted on visit III, and 25% at a later occasion at the clinic. The insertions were uneventul, and no complications requiring removal of the IUD occurred.
We conclude that similarly as following surgical abortion, Mirena® is a safe contraceptive option also following medical abortion. Despite the slight bleeding, Mirena® can be inserted at the time of control visit at approximately 3 weeks following MTP.
Self-assessment of urine hCG – a novel option in the follow-up after induced abortion?
Helsinki University Central Hospital and University of Helsinki, Department of Obstetrics and Gynecology, Helsinki, Finland - email@example.com
There is controversy concerning the need for routine follow-up after an uncomplicated abortion. This is also reflected in the various guidelines on induced abortion. The WHO guideline states that following safe, induced abortion, post abortion care may not require follow-up visit, whereas according the Royal College of Obstetricians & Gynaecologists guideline there is no need for routine follow-up after surgical or medical abortion if successful abortion has been confirmed at the time of the procedure. The Finnish guideline states that ‘the follow-up is important’. This controversy is also reflected in women’s compliance with a follow-up: in research studies, up to 50% of the women do not attend the scheduled follow-up visit. Ideally, during follow-up, completeness of the abortion can be verified, possible complications excluded and the use of post-abortion contraception encouraged. In addition, counseling and psychological support could be provided. The completeness of the abortion can be ascertained in several ways. The value of pelvic examination or ultrasonography have been questioned, whereas the use of serum or urine hCG to exclude ongoing pregnancy has been advocated. Recent studies have focused on development of semi-quantitative urine hCG tests as possible self-assessment tools to verify the completeness of an abortion. We have recently completed a randomized multicenter study to compare self-assessment at home using a two-step urinary hCG tests vs. assessment at the clinic following early medical abortion (Oppegaard et al., accepted for publication). The results show that the rate of complete abortion (94% vs. 95%) or the need for surgical evacuation of the uterus did not differ between the groups. Nine in ten of the women found the urine hCG test easy to use, and significantly higher proportion of the women (82% vs. 59%) would prefer the self-assessment should they undergo an other abortion. It is concluded that self-assessment by means of urinary hCG test performed at home might be an important option for many women to verify the completeness of an induced abortion.
When planning post-abortal contraception it is important to note that women seeking trimester termination of pregnancy (TOP) have demonstrated their high fertility and are at risk of subsequent induced abortion. The importance of the efficacy of the post-abortal contraceptive method has been increasingly recognized during the last decade. A safe and highly effective method with minimal dependency on the user compliance, i.e. long-acting reversible method of contraception (LARC) is clearly of value. When compared to use of LARCs and especially intrauterine contraception (IUD), use of oral contraceptives or postponing initiation of contraception is associated with a significantly increased risk of subsequent TOP.
Placement of an IUD immediately at the time of first trimester surgical abortion is the standard of care and it is also recommended in international guidelines. In comparison to delayed insertion, the expulsion rate is somewhat higher (5 vs. 3 %). following immediate insertion. However, the number of IUD users during the follow-up is increased when compared to delayed insertion (92 vs. 77 %).
Increasing use of the medical TOP and home administration of misoprostol pose challenges to provision of post-abortal contraception. However, progestin implants can be safely inserted on the day of mifepristone administration. A recent RCT comparing fast-track insertion (≤3 days vs. 2-4 weeks after misoprostol administration) of the levonorgestrel-releasing intrauterine system (LNG-IUS) after first trimester TOP has shown that also rapid initiation of intrauterine contraception is feasible. Fast-track insertion is associated an increased risk of partial expulsion (12.5 vs. 2.3%).
However, fast tract insertion was safe with similar rate of adverse events, and identical bleeding profile as that associated with later insertion. At one year of follow-up the user rate was higher and number of new pregnancies lower if the LNG-IUS had been inserted immediately.
Thus, an effective, quickly-started long acting contraception should be the goal of treatment regardless of the method of TOP as long as a new pregnancy is not planned. To reach this contraceptive initiation should be an integral part of comprehensive patient friendly abortion care with low threshold and easy access. This will also reduce the need of additional visits, subsequent TOP, and allows initiation of an effective contraception, with all its added health benefits.