Speeches
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May 25, 2002, 11:00
Medication After Medical Abortion -
NSAIDs in pain treatment, Rh-immunoglobulin
Christian Fiala
Management of pain during medical abortion has been hampered by recommendations in the product information and guidelines from various sources that non-steroidal anti-inflammatory drugs (NSAIDS) should not be given to women at least until the follow-up visit eight to 12 days after mifepristone administration. Currently the summary of product characteristics for mifepristone includes advice that, ‘A decrease of the efficacy of the method can theoretically occur due to the antiprostaglandin properties of NSAIDS. Use preferably non-NSAI agents.’ The published evidence does not support these recommendations against the use of NSAIDs.
Furtheromore NSAIDS are prostaglandin synthetase inhibitors and should have no adverse effect on exogenous prostaglandins. Stated alternatively, NSAIDs don't interfere with misoprostol and there are some good arguments for their use.
The efficacy of medical abortion in Karolinska Institute and in the General Public Hospital in Korneuburg/Austria has been the same when NSAIDS are used
Anti-D immune globulin is given in most places after early abortion, although evidence is lacking for the usefulness of this intervention at this early stage of pregnancy. Evidence-based guidelines for the administration of anti-D immune globulin (anti-D IgG) for women undergoing early spontaneous or induced abortions are missing. This is especially true for medical abortion, which is increasingly used in recent years.
An ongoing study in Sweden is presented.
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Oct. 2, 2014, 12:00
Nurse’s role in medical abortion up to nine weeks of pregnancy in a day hospital unit
Jasmina Kostoski, Sanja Perić, Vlasta Slapničar University Medical Centre Ljubljana, Ljubljana, Slovenia - jasmina.kostoski@gmail.com
Introduction: The Day Hospital is part of a Reproductive Unit which contains an operating room for aseptic interventions and three hospital rooms with 14 bed units. This is the main unit for all kind of abortions and minor operative procedures in gynaecology. The average annual number of patients is between 2500 and 2700. 1,232 abortions up to 10 weeks are performed, of which 766 medical abortions were recorded last year. Organization and workflow: Patients are coming to the Day Hospital with an already signed application for termination of pregnancy up to 10 weeks of gestation. A nurse will interview the patient in order to determine which kind of abortion will be the most appropriate (depending on the level of pregnancy, her expectations and any additional diagnosis). If medical abortion is appropriate, the patient is going back to the nurse who will give her a prescribed tablet of mifepristone. Together, they will make a plan for the further course of pregnancy termination considering the patient’s career and family responsibilities. The patient will not leave the hospital without having received all the needed spoken and written instructions from the nurse. Approximately 36-48 hours after taking the tablet, the patient is returning. After a brief interview in relation with the course of the first part of the medical abortion, the nurse will give the patient a tablet of NSAID and place the patient into the bed unit. After that the nurse or the resident will insert 4 tablets of misoprostol in her vagina. During that time, nurses are taking good care of the patient, helping to alleviate the possible pain and sickness by giving medications and controlling bleeding and pain. After 3 to 4 hours, the nurse is giving further instructions to the patient who will be able to safely leave the hospital.
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Oct. 25, 2008, 02:00
Outpatient use of mifepristone and misoprostol before and after 8 weeks gestation
Marisa Moreira, Renato Martins, Teresa Bombas, Teresa Sousa Fernandes, Manuel Pitorra, Maria Céu Almeida, Paulo Moura (Portugal)
Genetics, Reproductions and Fetal Maternal Medicine Department, Coimbra University Hospitals, and Bissaya Barreto Maternity, Coimbra Hospital Center, Portugal
renato.alessandre@gmail.com
Introduction. Since 16th of July of 2007, abortion is legal by women request before 10 weeks. The use of medical abortion is associated with lower complications. According to OMS protocols, the use of Mifeprostone and Misoprostol for abortion in out patient therapy can be used, for early pregnancies.
Objectives. We analyzed the use of medical therapy in abortions under 10 weeks gestational age comparing two groups – under 8 weeks (Group 1) and between 8 and 10 weeks (Group 2).
Material and Methods. We analyzed the clinical reports of women that came for abortion, during one year of experience, since 16th of July of 2007, in both medical facilities of Coimbra.
Results. We included 600 women. The average age was 28.2 ± 7.6 years. Most women are Portuguese (about 90%) and lived in Coimbra. More than half of these women are married and live with their partner. The authors split these women into 2 different groups: Group 1 (before 8 weeks gestacional age) with 450 women, and Group 2 (between 8 and 10 weeks) - 150. Both groups showed no statistical difference in all demographic aspects analysed. In terms of abortion method, correlation between the 2 groups revealed no statistical difference. Both groups revealed 5% complications, mainly due to failure of medical therapy. Between the two groups no statistical difference was found in terms of complications.
Conclusions.The use of medical abortion in out patient regimen can be safely used. The authors showed in this study that results between two different groups had no statistical significance. Moreover, when questioned, patients showed a high level of satisfaction with this protocol.
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Oct. 13, 2006, 09:00
Pain treatment during second trimester abortion
Inga-Maj Andersson, K. Gemzell-Danielsson, O. Stephansson, K. Christensson,
Dept of Woman & Child Health, Karolinska University Hospital,/Institutet
Stockholm, Sweden,Objectives To assess pain intensity, methods of pain treatment and predictors for the
need of analgesia in women undergoing second trimester abortion.
Design Descriptive study with consecutive inclusion of patients.
Material and methods A combined treatment with mifepristone and misoprostol was used
for the termination of pregnancy. From February 2002 to June 2003 data from 122 women,
undergoing second trimester abortion, was collected into a protocol to describe pain-
intensity measured by Visual Analoge Scale (VAS) and methods of pain treatment.
Demographic data such as age, gestational duration and reproductive history were
collected. The indication for the termination of pregnancy was noted as well as the
presence or absence of a partner or friend during the abortion.
Results The age of the women varied from 14 years to 46 years and the length of
gestation between 86 and 153 days. Indication for the abortion was socio-economic in
66% of the women. Young women, women with no previous birth and women with higher
gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
treatment was higher for these women during second trimester medical abortion. Pain-
intensity VAS >7 (severe pain) was reported by 63% of the women at some time during
the abortion. Intavenous morfine was given to 80% of the women. Paracervical blockade
(PCB) was given to 21% of the women. There was no significant difference in pain-
intensity, morphine- or PCB-requirements related to the presence of a partner, parent or
friend during the abortion nor to the indication for the termination of the pregnancy
(unwanted pregnancy or foetal malformation).Univariat analyses, Chi2-test (p=0.05) and
Mann-Whitney´s test were used for the data analyses.
Discussion Management of pain during second trimester abortion must be focused on the
women’s need. Individual care is crucial for optimal pain treatment. To reduce the high
frequency of severe pain one step is early active pain treatment to women with known
predictors for higher pain experience. Different methods of pain treatment should also beavailable (i.ex. NSAID, PCB). Education of the staff in pain management and caring is
needed to make the abortion care more focused on pain treatment and create a high
quality and non-judgemental atmosphere. Further research is needed to improve the care
of women undergoing second trimester abortion.
Conclusions Young women, women with no previous birth and women with higher
gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
treatment was higher for these women during second trimester medical abortion. -
Oct. 25, 2008, 02:00
Perception of pain during misoprostol-induced medical abortion
Marja Tikka, Satu Suhonen, Timo Kauppila, Seppo Kivinen (Finland)
Helsinki University Central Hospital, Finland
tikkamar@kolumbus.fi, satu.suhonen@hel.fi
Counselling, information about the process of medical abortion as well as sufficient pain relief are important factors when a woman chooses medical abortion. Menstrual pain, parity and woman’s age may influence pain perception and satisfaction with the chosen method of abortion. Medical abortion can be performed with misoprostol administered in home. How painful the abortion experience is, and can this pain be predicted would be useful to know when medical abortion is chosen and especially when home-use of misoprostol is planned.
Fifty-six women who had chosen medical abortion were allocated in this study. Their mean age was 26.2 years (SD 6.2, range 15-43). On the day the medical abortion was started, the median length of pregnancy evaluated by transvaginal ultrasound was 47 days (range 32-63). This was the first pregnancy for 4 women. Altogether 29 women (51.7 %) were nulliparous.
The women were asked to describe their menstrual pain by describing how intense (sensory discriminative component of pain) and unpleasant (affective-motivational component) the pain was. Visual analogue scale (VAS) and a pain drawing of the body area where the pain was felt were applied. When the participants were at the ward after receiving misoprostol, they were asked to describe similarly the pain they felt during the abortion. Afterwards, the type of pain at home, its duration and need for painkillers were recorded, too. At the control visit after medical abortion, their willingness to have gone through the abortion at home was also asked.
The intensity of menstrual pain correlated significantly with the intensity of pain perceived during medical abortion. Both intensity and unpleasantness of menstrual pain correlated with the affective-motivational component of pain perception during medical abortion, too. Older and parous women reported less pain. In these women the area where pain was felt was also smaller. At the time of control visit, 55 % women were willing to choose home administration of misoprostol as a method of choice for abortion. Their VAS scores for pain during abortion were lower than in women who would not prefer home administration of misoprostol (12 vs 68 mm, median). Most of the women who were willing for home-administration were parous. However, neither the length of pregnancy at the time of abortion nor the age of the woman had an influence on her view.
In nulliparous women, dysmenorrhea predicts the pain perceived during medical misoprostol-induced abortion. Sufficient pain relief is important to all women, but especially if home-administration of misoprostol is planned during medical abortion.
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Oct. 24, 2008, 11:15
Physiological and reproductive outcomes
Michel Tournaire, Sophie Gaudu, Philippe Faucher (France)
Paris, France
m.tournaire@svp.aphp.fr
Surgical abortion. The influence of surgical abortion on subsequent reproductive outcome, reported for several decades in the literature can be summarized with seven criteria.
- Fertility. Four studies did not find an increased infertility after surgical abortion and one retrospective study showed a slight increase.
- Uterus. Synechiae have been diagnosed by hysteroscopy in 17 to 30% of the cases after curetage and 7.7% after suction.
- Miscarriage. In five studies from 1986 to 1998 the incidence of miscarriage after surgical abortion was not significantly increased. In a large series published in 2000 the risk of miscarriage was increased if the interval between abortion and the following pregnancy was lower than three months.
- Ectopic pregnancy. In seven studies no association was found between past history of surgical abortion and ectopic pregnancy, but two studies found such an association.
- Placental abnormalities. In nine studies there was an inceased risk of placenta praevia (OR 1.7 in a metaanalysis) after curetage but not after suction. The frequency of placenta accreta was not higher in two studies.
- Prematurity. In a metaanalysis published in 2003 twelve studies found a higher riskof prematurity (OR 1.3 to 2). In seven studies the risk increased with the number of previous surgical abortions. Eight found an increased risk for severe prematurity (<32w). However in the two most recent studies there was no augmentation of prematurity.
- Preeclampsia. In a majority of studies the ratio of pre eclampsia after induced abortion was reduced but only with women conceiving again with the same partner.
Medical abortion. Despite the increasing proportion of abortion by means of medication, limited information is available regarding the effects of this procedure on subsequent pregnancies.
A recent (2008) metaanalysis including eight studies on reproductive outcome compared the influence of medical and surgical abortion. The incidence of miscarriage and post partum hemorrage was significantly lower for the pregnancy immediatly following a medical abortion. No other significant difference was found.
For the outcome of the future pregnancies, medical abortion may thus be safer than the surgical option.
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Oct. 22, 2010, 08:00
Pilot project: potential for midwives to manage medical abortions independently
Anneli Pehrsson and Pia Karlsson, Licensed Midwives; Karolinska University Hospital, Sweden
Background: According to rules issued by Sweden’s National Board of Health and Welfare, Advice on Abortions 2004: Section 4; Chapter 2, when a woman has made the decision to have an abortion it should be carried out at the earliest possible time.
Our previous routines could not adequately address the waiting times for the required ultrasound examination by physicians. Not every woman who had contacted the clinic <9 weeks gestation could be offered medical abortion. Hence, a project was initiated to train two midwives in transvaginal ultrasonography.
In 2007, the National Board of Health and Welfare decided to make the regulatory changes necessary to broaden the authority of midwives in this context.
Aims: - To train and certify midwives to independently manage medical abortions, perform dating scans by transvaginal ultrasonography, and prescribe mifepristone and misoprostol.
- To provide women with rapid and effective care.
- To be able to offer a medical abortion to any healthy woman <9 weeks gestation.
- To ensure continuity, i.e. the woman meets one and the same person during the entire abortion process.
Methods: - Auscultation/training in transvaginal ultrasonography, at IVF clinic.
- Individual training and supervision in ultrasonography, Center for Fetal Medicine.
- Individual training and supervision in transvaginal ultrasonography, by Prof. Seth Granberg.
- Transvaginal ultrasonography with the department’s gynecologists. Images were reviewed, commented on, and approved by Prof. Seth Granberg. Accompanied by theoretical studies.
- Ten cases of abortion counseling with ultrasound examinations, supervised by C. Rasmussen (Section Chief at the time).
Results: - For the past 2 years we have performed transvaginal ultrasonography in healthy women early in pregnancy. We have been delegated authority to prescribe mifepristone and misoprostol, to prescribe contraceptives, and to deliver patient care encompassing the abortion itself and follow-up visits.
- We have shortened the waiting times at the clinic; freed time for physician appointments; increased the number of medical abortions; and reduced the demand on surgical time and recovery unit beds.
- We can offer medical abortion to all healthy women who request it, and most can begin the abortion with the first visit.
Conclusions: - Midwives with adequate education have the capability to independently manage healthy women requesting an abortion early in pregnancy. Usually the problems are more of a psychosocial than medical nature. The abortion is not the problem, but often the solution to the woman’s problem.
- In the past 2 years we have become proficient in performing and assessing ultrasonography and detecting anomalies, whereupon we contact the attending physician.
It is important for midwives and physicians to collaborate in the care of these women. It must not become a matter of prestige.
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Oct. 22, 2010, 02:00
Post-abortal infection - prevention strategics
Dr. Sharon Cameron, United Kingdom
The reported incidence of post -abortal infection (in countries where abortion is legal ranges from 1% to10%, depending on the population, diagnostic criteria used to define infection, use of peri-abortal antibiotics and the method used. Prospective comparative studies have suggested that medical abortion may be associated with an overall lower risk of infection, possibly because it is less invasive procedure. The presence of chlamydia, gonorrhoea or bacterial vaginosis in the lower genital tract at the time of abortion has been shown to be associated with an increased risk of post-abortal infection. Strategies for preventing post- abortal infection include (i) a screen-and-treat policy (ii) universal antibiotic prophylaxis or (iii) a combined approach, of both screening and prophylaxis. Meta-analysis of randomised trials have shown that antibiotic prophylaxis at the time of abortion is associated with a reduction in the risk of subsequent infection of around 50%. Furthermore, antibiotic prophylaxis has been shown to benefit women who have negative pre abortion genital swabs and is less costly than the other strategies. However, failure to test for sexually transmitted infections pre-abortion and to identify infected women, perpetuates the risk of re-infection by an infected partner. This is important since it is believed that re-infection with chlamydia may increase the likelihood of complications such as tubal infertility.
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Oct. 23, 2010, 11:00
Post-abortion contraception
Gabriele Susanne Merki-Feld, MD, PhD, Universtiy Hospital, Zürich, Switzerland
Contraceptive counseling is an important part of postabortion care and should include accurate and comprehensive information about different contraceptive options. Surprisingly not all studies provide evidence for a higher acceptance and lower rate of repeat abortions in women after extensive postabortion counseling. Other studies investigate preabortion counseling in comparison to postabortion counseling.
Today most abortions are performed with medical procedures. Use of combined contraceptive pills is recommended to start already on day 3 of abortion ( day of misoprostol administration). After abortion 80% of all women ovulate before the first menstrual period and many of them ovulate within 22 days. Thus providing the pill before leaving the hospital is of importance. Immediate IUD insertion after surgical abortion is effective and safe, even if some studies suggest a slightly increased rate of partial or complete expulsions. Since medical abortion takes longer than surgical abortion, IUD insertion is recommended during the first menstrual cycle after medical abortion. This procedure is of course associated with a small risk for another pregnancy. Progestagen-only methods can be started immediately after medical abortion. The implant in an important alternative for women with desire for longterm contraception.