Speeches
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Oct. 14, 2006, 09:00
Is monthly bleeding optional?
Elisabeth Aubeny, MD, Paris, France
Since prehistoric times women have endured menstruation, whether they liked it or not.
The timing of the bleeding was not necessarily predictable nor could it be modified.
Hormonal contraception has changed all that. For the first time in mankind’s history, it is
possible to manipulate the timing of menstruation and even to stop it altogether. Some pills
have been especially designed to be taken continuously for 3 months or even for a full
year thereby reducing the number of withdrawal bleeds experienced over time. Long term
progestogen contraceptives can, theoretically, give women a break from menstruation for
3 to 5 years. However these regimens are often associated with frequent episodes of
breakthrough bleeding. So research continues in order to try to improve these
methods.But what do European women think about these new options?A survey in 1980
showed that, in U.K, like in many countries, the majority of women wanted to have monthly
menstruation. Recent surveys in Europe indicate that women’s attitudes to menstruation
are changing. In 1999 a survey from Holland found that only 35% of women wanted to
menstruate once a month, and 31.1 % of women of 25 to 34 years would prefer never to
menstruate; in a German survey from 2004 35% of women between 25 to 35 years wanted
a monthly menstruation and 37% would have preferred never to menstruate; in 2005 in
France only 11% of women wanted to menstruate, while 75 % thought that it was a burden
and 57 % would take a pill which would stop menstruation; in 2006 an Italian survey
showed that 50 % of women without menstruation–related symptoms would like to change
the rhythm of their menstruations. So a majority of women would like to modify the timing
of their menstrual periods. The motivation for the changed of attitudes include: the fact that
there less medical problems associated with lack of menstruation, the women feel they
have a better quality of life, with better hygiene and a reduction of blood loss. However a
large minority of women still prefer to have menstruation each month because this
reassures them that they are not pregnant, they think that menstruation is a natural
phenomena, that it allows elimination of “bad blood”, that is a sign of feminity and they are
afraid of the adverse effects of hormones. However it seems that at the beginning of the
21st century, more and more women would prefer to have control over whether or not they
menstruate. In the next years menstruation will probably become entirely optional. -
Sept. 11, 2004, 02:00
Is there a lower limit in gestational age?
Annet Jansen MD, 1979-1984 Curaçao (Dutch Antilles), 2 years department gynaecology and obstetrics, 1984 rehabilitation outpatient department university hospital Groningen, 1985-1998 primary health center baby and child care (prevention), 1993- medical supervisor center for sexual and reproductive health Amsterdam
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It is acceptable to perform an abortion from 2.5- 3 weeks gestation if the pregnancy test is positive and the pregnancy is detected intra uterine by ultrasound examination.
In the Netherlands there is quite a lot of experience with early first trimester surgical abortions with good results. The percentage of failures is 2-5%, comparable with failures by use of the abortion pill.
The failures are usually not on going pregnancies, but retained placentaparts.
A higher risk of failed abortion is seen by uterine anomalies, by twin pregnancies, extreme position of the uterus, retroflexion or anteflexion.
The follow up after 3 weeks is offered to each woman. It includes a laboratory test and if positive an ultrasound examination will follow to exclude an on going pregnancy.
Depending on the complaints of the failed curettage there is required a repeat curettage.
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Oct. 19, 2012, 09:00
Is there possible sexism in termination of
pergnancy decision-making?
Mejı´a, MRI
Centro de Atencio´n Integral a la Pareja, A. C, Mexico
In April 2007 voluntary termination of pregnancy (TOP) up to
week 12 of gestation was legalised in Mexico City. Since its
decriminalisation we have observed at least four hegemonic
attitudes in male sexual partners with respect to reproductive and
contraceptive decision-making in the medical services of Centro
de Atencio´n Integral a la Pareja, A. C: (i) those who go with their
partner and support the decision; (ii) the ones who decide and
pressure their partner, (iii) those who do not support the decision
and do not go with their partner in order to prevent her from
having an abortion and (iv) those who do not support the
decision but who go with their partner.
There is insufficient research on the subject of males’ role in
reproductive decision-making and its implications on males’
subjectivities and in their partners’ bonding. This study responds
to the following questions: In what circumstances do men support
or deny women’s decision-making? What is the perception of
women regarding their partners’ participation in the process?
Within the context of legalisation and in light of new ways of
sexual and loving bonding practices, is it important to integrate
males and create friendly services that allow people to express
their needs and emotions without abuse. Is it fundamental, as
well, to review their contributions to the process of women’s
citizenship within this context? This study acknowledges the
fundamental role of men in the processes undergone by women,
despite the lack of services to integrate and strengthen the
democratic advance in equity contexts. -
Oct. 13, 2006, 02:00
Is ultrasound necessary
Danielle Hassoun, MD, Paris, France
The question remains whether Ultrasound (US) is a mandatory requirement for performing
medical abortion. In fact, it is very useful in diagnosing early pregnancy, in allowing early
diagnosis of ectopic pregnancy and finally in confirming success or failure of the method.
However, not having access to US technology should not be considered as a barrier to
introducing medical abortion.
To diagnose very early pregnancy requires very good equipment and highly trained
providers. Without a vaginal probe, the diagnosis of a pregnancy less than 6 weeks
remains nearly impossible.
At the follow up visit, the use of US can confirm the success or failure of the method and
especially the reassurance there is no on going pregnancy but it can also be responsible
for unnecessary interventions because of faulty interpretations of the images.
In high resource settings, where the equipment is readily available and the providers are
highly trained, the possible risk is that US may be used as a replacement for clinical exam,
resulting in a potential loss of clinical skills.
In low resource settings, where the equipment is possibly inadequate and providers not
sufficiently trained to use it, relying on their very good clinical skill
can make them good medical abortion providers.
Lessons learned after almost 20 years of experience in this field show that US is not a
requirement when clinical exam and BHCG (when accessible) are concordant with the
condition that the providers maintain a good level of clinical skill. -
Nov. 25, 2000, 04:00
The law legalising abortion came into force in 1978, the limit is 12 weeks of
amenorrhoea. A medical certificate is necessary, and a waiting period of 7 days
has to be respected. Terminations are performed in the public sector. Access
varies from one region to another. -
Oct. 13, 2006, 05:15
IUD
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. -
Oct. 25, 2008, 02:00
IUD after medical abortion: Should it remain underused?
Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)
University Hospital of Marseille, France
pascaleroblin@yahoo.fr
Objective. Immediate post-abortum IUD insertion remains an underused option in daily practice. We evaluated the safety and acceptability of IUD insertion shortly after medical abortion at the office.
Patients and Methods. In a prospective series of 300 women who underwent medical abortion in a private office before 49 days, we observed the incidents that occurred among the 104 patients (34,6%) that opted for an insertion of IUD shortly after abortion. Uterine vacuity had been controlled by ultrasound between the 8th and 12th days post abortum. IUD were inserted between the 8th an 30th day following abortion. None of the patients had received prophylactic antibiotics. 62 (60%) patients had hormonal IUD and 42 (40%) had Copper IUD.
Results. Women’s mean age was 31 years, 26% were nulliparous and 37% had already had previous abortions. None of the patients had long term reversible contraceptions before requesting an abortion and only 5 (1,6%) had used emergency hormonal contraception. 72% of IUD were inserted at the control visit on the 8th day. When uterine vacuity seemed incomplete, IUD insertion was postponed but for 90% of our patients insertion was possible before day 30. No mechanical (expulsion or perforation) and no infectious complications were registered. At insertion, the mean pain score on an analogical visual scale was 2/10. Mean duration of bleeding following IUD insertion was 6.5 days. With a follow up of 24 months in our database, 8 patients (7,7%) requested IUD removal : in 2 cases because of pelvic pain but no evidence of pelvic inflammatory disease, in 2 cases for excessive bleeding and in 4 cases for desire of pregnancy.
Conclusion. Our preliminary findings suggest that IUD may be offered shortly after an induced medical abortion before 49 days. When such method is chosen by the patients, safety and continuation rates seem high. Proposing an IUD immediately after a first trimester abortion at the office may help reduce repeat abortions.
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Oct. 2, 2014, 12:00
Late termination of pregnancy because of fetal anomaly complicated by placenta praevia: case report
Vid Janša, Nataša Tul Mandić Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia - vid.jansa@gmail.com
Introduction: The presence of placenta praevia totalis is an important cause of postpartum bleeding and can be a challenge for obstetricians in cases of late termination of pregnancy (TOP). Case report: A 35-year old woman, G4, P3, was referred to our hospital due to fetal heart anomaly and intrauterine growth restriction (IUGR). The previous pregnancies and deliveries were uncomplicated. The patient’s first antenatal visit in this pregnancy was at 28th week of amenorrhoea and ultrasound at 29 weeks revealed IUGR, complex heart anomaly (ventricular septal defect, double outlet right ventricle, pulmonary atresia) and placenta praevia totalis. A patient request for TOP was approved by the ethical committee. We wanted to avoid caesarean section. The risk of bleeding during TOP because of placenta praevia totalis became an important issue. A decision was made to proceed with selective uterine arteries embolization (UAE), which was performed in the Radiology department. 18 hours after the procedure fetal heart activity was absent. After 5 days of waiting for spontaneous onset of labour, we decided to continue with misoprostol and she received 100mcg vaginally, 3 hours later 100mcg buccally, followed by 200mcg and 400mcg buccally in 3 hourly intervals. The patient was transferred to the delivery room and placenta and stillborn fetus (770 grams) in breech presentation were delivered vaginally 15 hours after first application of misoprostol. After delivery karboprost was applied for prevention of bleeding and overall blood loss was less than 300ml. The patient was discharged in good condition the day after delivery. Fetal autopsy confirmed prenatal diagnostic conclusions. Discussion: The risk of heavy bleeding with vaginal delivery in cases of late TOP complicated by placenta praevia totalis can be reduced by UAE which has low complication rates, shorter hospitalization and avoids surgical risks as published. Embolization can be followed by misoprostol. Care must be taken to prevent postpartum bleeding.
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Oct. 25, 2008, 11:00
Long cycle combined hormonal contraception
Gabriele Merki (Switzerland)
Family planning clinic, University hospital, Zürich, Switzerland
gabriele.merki@usz.ch
Prolonged use of combined pill preparations (COC) has been widely performed to suppress menstruation in women with clinical conditions like premenstrual symptoms, endometriosis, or cyclic headache. At present there is in several European countries a trend to use the long-cycle to suppress normal menstruations for convenience, particularly for women who are already taking COC. Some authors medicalize and pathologize the natural event of menstruation and declare normal cycles as unnecessary annoyance and as possibly health risk. We intend to discuss open questions concerning the safety of the long-cycle and long-term health risks specially on the breast and the endometrium. Furthermore we speculate about the consequences of cycle suppression in healthy adolescents for their later attitude towards menstruation.
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Oct. 24, 2008, 09:00
Management of first trimester termination of pregnancy as an out-patient in Paisley – is it feasible, is it acceptable and is it worthwhile?
Rosemary Cochrane (Great Britain)
Crawford JH – Department of Obstetrics and Gynaecology, Royal Alexandra Hospital, Paisley, UK
rosemary.cochrane@ntlworld.com
Introduction. The earlier in pregnancy an abortion is performed, the lower the rate of complication. The RCOG recommends that ideally all women requesting pregnancy termination should undergo the procedure within 7 days of the decision to proceed being agreed. As a minimum standard, all women should undergo the procedure within 2 weeks of agreement, with no woman waiting longer than 3 weeks between initial referral to time of procedure. Medical termination of 1st trimester pregnancy (MTOP) has been shown to be effective, safe and acceptable if carried out on an entirely out-patient basis. It has therefore been suggested that a service to allow “home” MTOP might be beneficial, however patients would have to fulfil several strict criteria.
Method. To ascertain eligibility every patient attending the pregnancy termination assessment clinic was asked to complete a confidential questionnaire.
Results. 65 women completed the questionnaire (71% of those who attended). Of the 33 (51%) women opting for MTOP only 7 were eligible. 32 (49%) opted for a surgical TOP; of these, 12 would have considered a home MTOP if available but only 4 women were eligible. Reasons for ineligibility are discussed.
Conclusion. Overall 11 (16.9%) patients requesting TOP would have fitted the criteria if the service was available. On the basis of this small sample we were unable to demonstrate a significant need for a home MTOP service.