Speeches
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Oct. 23, 2010, 02:00
Results from a 4-year study on 15447 medical abortions performed by privately-practicing general practitioners and gynecologists in France
Sophie Gaudu, Hôpital Cochin-Saint Vincent de Paul, Centre d’orthogénie et de planification familiale
Co-authors: Drs I. Dagousset, L. Esterle, S. Eyraud, P. Faucher, D. Hassoun, and M. Teboul
The French legislation allows women to get a medical abortion at home under the control of GPs or gynecologists in private surgeries. In 2007, these abortions represented almost 9 % of induced abortions in France and 18% of the medical abortions (DREES, Etudes et résultats, n°712, 2009). The process is strictly defined by law. The termination of pregnancy (max 49 amenorrhea days) should be carried out by doctors who have signed a contract with a referral hospital. This hospital takes the charge of treating any complication that may arise. REVHO, a network of private physicians and hospitals, has been created in Paris and suburban areas in order to train the doctors, to set-up contract-based links with hospital family planning centers and to evaluate the quality of the method as well as the users’ satisfaction.
Five years after the creation of REVHO, 20 200 abortions at home using mifepristone and misoprostol have been performed within the network. This paper presents the results of 15 447 abortions carried out in the network. Data were entered on a PC held database and analyzed using EPI INFOTM Version 6. The women were 41 days of amenorrhea on average (90 % between 35 and 49 days) and their age varied from 14 to 55 (median: 28 years).
From 2005 to 2008, 162 physicians with private practices were involved: respectively 44 % and 56 % of abortions were carried out by GPs and gynecologists. The quantity of supervised abortions varied from 1 to more than 3600 per physician on the 4-year period. Twenty-three physicians (14%) performed more than 200 medical abortions and three, more than 1500.
About 80% of the abortions were followed up two weeks later. The success rate (as defined by the absence of surgical completion) was 97.9%, which is among the highest rates reported for medical abortion. There was a statistically significant difference between GPs (success rate of 98.2 %) and gynecologists (success rate 97.5 %) which can be discussed. The global rate of continuing pregnancy was 0.7%. No serious complication was observed.
These results demonstrate that medical termination of pregnancy at home can be performed under the control of physicians in their private practices without increasing the risks of failures or complications. GPs are efficient as well as gynecologists, which could allow an increase of the number of practitioners involved and contribute to health care proximity. Five years after its creation, REVHO demonstrated its capacity to incorporate the medical abortion into primary practices, with referral hospital services available for complications or surgical completions.
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Oct. 19, 2012, 02:00
Review of telephone follow-up of women having
early medical termination of pregnancy
Michie, L1,2; Cameron, S1,2; Johnstone, A1,2;
Dewart, H1,2
1 NHS Lothian; 2 University of Edinburgh, UK
Introduction: Telephone follow-up2 weeksaftermedical
terminationofpregnancy(TOP)(£9 weeksofgestation)withaself-
performedlowsensitivityurinepregnancy(LSUP)test,was
introducedatahospitalTOPserviceinEdinburgh.Womenwho
screened‘positive’attelephonefollow-up(ongoingpregnancy
symptoms,scantbleeding,orLSUPresult)subsequentlyattended
foranultrasound.Apreviousserviceevaluationconfirmedthatthis
waseffectivefordetectingongoingpregnancyandhadgoodfollow-
uprates.Wesoughttodetermineifthismethodoffollow-up
continuedtobesuccessfulduringtheyearfollowingitsintroductionMethods: Retrospective computerised database review of outcome
of telephone follow-up of women having a medical TOP
(£9 weeks of gestation) over 12 months (March 2011–February
2012).
Results: One thousand and eighty-four women of mean age
25 years had a medical TOP during this period. One hundred and
twelve women were scheduled to attend the clinic for follow-up
and three women did not require follow-up as complete TOP was
confirmed on the day of treatment. Ten women (out of 969)
attended hospital before the planned telephone contact (1%). Of
the 959 requiring telephone follow-up, 656 (68%) were
successfully contacted. Two of those who were not contactable
had ongoing pregnancies. Five hundred and seventy-three (87%)
of those contacted, screened ‘negative’ with no false negatives
occurring. Of the 83 (13%) who screened ‘positive’, three had
ongoing pregnancies. The sensitivity of follow-up was 100% and
specificity was 88% (95% CI 84.9–90.1).
Conclusion: Although slightly lower follow-up rates were obtained
in the 12 months following initial introduction, telephone follow-
up with LSUP was shown to be effective for detecting ongoing
pregnancy. -
Oct. 14, 2006, 02:00
Risk factors for failure in medical abortion
Marie Duriez, MD, Philippe Lefebvre, MD
Service d’Orthogénie (Hospital Family Planning Service), Roubaix, France
Aim: To identify potential risk factors of inefficiency for elective medical termination of
pregnancy based on records of failures of this technique in a hospital environment.
Patients and methods: A retrospective study was conducted on elective medical
pregnancy terminations performed up to 49 days post amenorrhoea in the Family Planning
Service of Roubaix hospital between January 1st 2001 and December 31st 2005. The
service's termination protocol consists in an oral dose of 600mg mifepristone, followed by
an oral dose of 400µg misoprostol 48 hours later. A 2nd oral dose of misoprostol (400µg) is
given 3 hours later if there has been no expulsion.
Every patient is required to return 15 days later to check their βHCG levels.
Failure is defined as ongoing pregnancies, total or partial retentions, and cases requiring
emergency surgery. Success is defined as complete abortion requiring no additional
surgical or medical treatment.
Five items were analysed: patient age, patient parity, duration of pregnancy, βHCG levels
on the day mifepristone (D1) was given, and the dose of misoprostol received.
Results: 1,975 medical terminations were performed during this period. 125 (6.33%) of
these patients did not return to be checked and have been excluded from the study. The
analysis was thus performed on 1,850 patients.
The method was a success in 97.08% of cases (1,796/1,850). 54 failures (2.92%) were
recorded, including 7 ongoing pregnancies (0.38%) .
Patients for whom the method resulted in a success compared to patients who had failures
have a significantly lower age.The duration of pregnancy was not different for the two
groups.
Nulliparous (873/1,850) patients had significantly fewer failures (12/873: 1.37%) than
multiparous patients (42/977: 4.30%).
Age is significantly higher for failures amongst the nulliparous patients. Conversely, for
patients who have had at least one child, age is not a determining factor.
28 patients did not receive any misoprostol because they expulsed prior to the 48th hour
(1.51%). Amongst the 673 patients who received only a single dose of misoprostol, 11
(1.63%) required additional actions including one emergency admission for haemorrhage.
Amongst those who received two doses of misoprostol, 43 failed (3.74%), including 2 re-admitted the same day for haemorrhages and 1 for pelvic pains.
Discussion and conclusion: The overall efficiency results for the method are excellent
despite an exhaustive and detailed analysis of the failures.
The various studied factors have demonstrated that there is an increase in failure rates for
the method with parity and, to a lesser extent, with the patient's age.
High plasma beta HCG levels also seem to be more often associated with failures of the
method. The addition of a second dose of misoprostol is likely to increase the chances of
an expulsion during the hospital stay but, this non-comparative retrospective study can not
conclude on the beneficial effect of a second dose of misoprostol on overall efficiency.
Finally, it should be noted that none of the criteria evaluated in this study can be used as a
diagnosis factor to predict the outcome of an elective termination as none of them has the
sensitivity / specificity that is required to identify 'at risk' patients from amongst other
patients. -
Oct. 14, 2006, 02:00
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
contraception. -
Oct. 2, 2014, 12:00
RU OK? Provider perspectives on follow-up with remote technologies after early medical abortion
Lesley Hoggart1, Patricia Lohr1, Jeanette Taylor1, Chelsea Morroni1, Hillary Bracken2, Beverly Winikoff2 1bpas, Stratford Upon Avon, UK, 2Gynuity Health Projects, New York, USA - hbracken@gynuity.org Objective: Guidelines from the World Health Organization and Royal College of Obstetricians and Gynaecologists suggest that routine in-clinic follow-up is not required after early medical abortion. New diagnostic and communication technologies promise to allow women to assess their abortion outcome at home. Yet little is known about healthcare providers' attitudes and opinions about the elimination of clinic follow-up. Methods: Providers in 4 clinics in the bpas clinic network in the United Kingdom were interviewed after participating in a randomized clinical trial testing the feasibility of using remote communication technologies for follow-up after early medical abortion. Clinicians and non-clinical staff (N=10) at participating clinics and the bpas call centre participated in 3 focus group discussions guided by a qualitative researcher. Participants were asked about their perspectives on in-clinic follow-up and home follow-up by phone, text message or email. Focus group discussions were recorded, transcribed, and analyzed thematically by the authors. Results: Participants were open to alternative approaches to follow-up after medical abortion. Staff recognized the need to improve follow-up rates but were sceptical improvement was possible, and uncertain about how to balance time management issues with women's needs. Providers described a tension between two imperatives: to respect women's postabortion preferences and to ensure contact and knowledge of postabortion outcomes. Providers felt responsibility for follow-up was part of their duty of care; although some acknowledged that retaining this responsibility clashed with the bpas culture of trusting women to control their own bodies and reproductive lives. Conclusions: Overall, although there was an evident diversity of views, clinic staff felt that they had a responsibility to follow-up women after early medical abortion. Efforts to introduce home follow-up after medical abortion must be accompanied by training that addresses providers' concerns and ambivalence about allowing women to manage the procedure at home.
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Sept. 14, 2018, 04:00
Women are seeking abortion at increasingly earlier gestations, with 41% of first trimester patients in the U.S. receiving an abortion at <6 weeks gestation. The efficacy of medical abortion at <6 weeks gestation is not significantly different than at 6-7 weeks, however, seeking abortion very early in gestation increases the likelihood that providers will have difficulty visualizing the pregnancy on ultrasound, the current standard of care in many clinics.
The most serious risk of treating women with an undesired pregnancy with mifepristone and misoprostol without first confirming a diagnosis of intrauterine pregnancy is a missed diagnosis of ectopic pregnancy. Studies suggest an incidence of ectopic pregnancy of 0.2-0.3% among women presenting for medical abortion. Data support the practice of providing mifepristone and misoprostol medical abortion in the setting of undesired pregnancy of unknown location (PUL) using serial serum hcg testing to simultaneously exclude ectopic pregnancy and determine the efficacy of the medical abortion. Guidelines that enable provision of medical abortion in the setting of PUL, when the patient is asymptomatic, low-risk for ectopic and when combined with close follow up to exclude ectopic pregnancy exist to support this service development.
This presentation will review the evidence for providing medical abortion at <6 weeks gestation including in the setting of PUL. -
Oct. 14, 2006, 02:00
Selfperception of Swedish gynaecologists performing abortions
Meta Lindström, Umeå University, Department of Clinical Sciences, Obstetrics and
Gynecology, Sweden
Background. The Swedish gynecologists possess three decades of experiences of
working with legal abortion. It is of great importance both for women in society and for the
gynecologists themselves to learn from their experiences. The aim of our study was to
describe Swedish gynecologists’ clinical and emotional experiences when working in
abortion care. Further aims were to elucidate their perception of women’s motives for
having abortion as well as looking for possible demographic and gender differences.
Methods. A questionnaire comprising both structured and semi-structured questions was
sent to a random sample of 269 Swedish gynecologists. The response rate was 85%.
Results. The female gynecologists were younger (27-59 yrs) and numerically more than
the males (33-66 yrs). Almost all believed that gynecologists should be involved in abortion
care, and half were opposed to the privilege of refusing to work with TOP (termination of
pregnancy). The gynecologists supported the shift from surgical to medical abortions but
not to them being managed in primary healthcare. A few gynecologists (n=42) had
considered changing their job because of TOP being part of their work. Misgivings
occurred sometimes in connection with surgical and late abortions (n=60 and n=108
respectively). Few gynecologists (n=33) had felt inadequate when encountering abortion
patients and more than half thought that working with TOP was a positive experience. The
gynecologists expressed that continuing professional development and ongoing guidance
of TOP matters were important.
Conclusions. In general, Swedish gynecologists have no doubts about taking part in and
performing TOP. However, there are differences in opinions especially regarding surgical
and late term abortions. Due to the fact that female gynecologists were younger and
therefore had fewer years of work with TOP comparisons of females’ and males’
experiences could not be done. Trends of gender differences were noticed concerning the
right of having possibility to refuse taking part in TOP on personal grounds and with male
gynecologists feeling to a higher extent inadequacy compared with females meeting the
abortion seeking women. Gynecologists’ clinical and emotional experience, as expressed
in this study, as well as their perception of women’s motives for abortions, indicate that
they have gained deep insights and developed their professionalism in their work with
TOP. -
Oct. 2, 2014, 12:00
Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a checklist in Rajasthan, India: study protocol and intervention adaptation of a randomized controlled trial
Mandira Paul2, Kirti Iyengar1 ,4, Sharad Iyengar4, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin3 ,1 1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden, 4Action Research, Training for Health (ARTH) Society, Udaipur, India - mandira.paul@kbh.uu.se
Background: The WHO suggests that simplification of the medical abortion regimen will contribute to an increased acceptability among women and providers. It is expected that home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic. This study protocol describes an RCT that aims to evaluate the efficacy of home-based self-assessment after a medical abortion and the acceptability and feasibility of the intervention in a low-resource setting. Method/Design: The study is a randomised, controlled, non-superiority trial that will evaluate the effectiveness and acceptability of self-assessment using a low-sensitivity pregnancy test and a checklist two weeks after medical abortion. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. Eligible women randomised to the self-assessment group will use the low-sensitivity pregnancy test and the checklist at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. To ensure feasibility of the self-assessment intervention an adaptation phase took place at the selected study sites before study initiation. This was to optimize and tailor-make the intervention and the study procedures and resulted in the development of a pictorial instruction sheet on how to use the low-sensitivity pregnancy test and the checklist of danger signs after a medical abortion. Discussion: In this paper, we will describe the study protocol for a randomized controlled trial investigating the efficacy of simplified follow-up in terms of home-based self-assessment, two weeks after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor.