Speeches
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Oct. 14, 2006, 02:00
Management of follow up/ need of backup curettage
Christian Fiala, MD, PhD, Gynmed Clinic, Vienna, Austria
Currently there is no generally accepted standard for follow up after a surgical first
trimester abortion. Some providers perform an ultrasound immediately after the aspiration
in order to verify that the uterine cavity is empty. The patient can be discharged then andthere is no medical reason for a routine follow-up in these cases where the completeness
of the abortion has been verified.
However most providers do not have an ultrasound machine in the operation theatre and
they estimate completeness during aspiration based on their clinical experience. Many of
them also check the products of conception (POC) in the aspiration bag for foetal parts.
This old routine is rarely questioned although most post-abortion complications are caused
by remnants of endometrial tissue or placenta which can not be discovered by inspection
of the POC.
It is therefore suggested that an ultrasound should be done immediately after aspiration to
verify that the uterine cavity is empty. The ultrasound can be done abdominally in more
than 90% of cases and the speculum can remain in place. If residua or endometrium is
discovered, aspiration can be repeated under ultrasound guidance. An immediate post-
operative ultrasound is the only situation where a truly empty uterine cavity can and should
be found. At any time later there can be some blood in the uterine cavity which might
be indistinguishable from residua by ultrasound examination. Therefore any diagnosis of
residua which is based exclusively on ultrasound needs to be interpreted with caution. The
decission for a backup curettage might not be based on such a finding alone. It should
rather take into consideration clinical symptoms. And even sparse villi in the histological
examination of a re-curettage can be a normal finding after complete surgical abortion. -
Oct. 25, 2008, 02:00
Obligatory counselling: Germany's example
Ulla Ellerstorfer (Germany)
ellerstorfer@web.de
Today, 2008, far away from the sixties and seventies, sexuality and moralities have changed. With one exception. When a woman and a man are making love, having sex with each other, the possibility to become pregnant has not changed for a woman, who can be fertile for more than thirty years. Getting pregnant is no more unusual than forty years ago. Self-determined sexuality does still include fertility.
In case of being pregnant unexpectedly, it seems, everything today runs smoothly and easy for her. Rare complications in case of abortion, no more long-lasting diseases and no more deaths. There are cost-free counselling services offered by different service-providers which a woman can choose from. The out-patient medical treatment, mostly in day-clinics, is of good quality and includes different methods of abortion.
Don’t you agree, there is nothing to complain about in Germany?
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Sept. 15, 2018, 11:00
Outcomes of various medical abortion research have been difficult to compare. Outcomes such as “effective”, “successful”, “complete” are defined differently in various studies or sometimes not defined. “Adverse events” similarly may not be reported or reported without clear definition.
The goal of Medical Abortion Reporting of Efficacy (MARE) guidelines is to standardize early medical abortion efficacy reporting to facilitate comparison of outcomes between studies and to enhance data synthesis from different studies. This brief presentation will discuss the MARE guidelines for research methods.
Eligibility: the eligibility criteria for participants should be clearly stated, including the range of gestational age, the methods used to determine gestational age, and the conditions for ineligibility.
Interventions: the study should state the medications used, including dose(s) and route(s) of administration. The planned time interval (in hours) between medications should be stated.
Outcomes: researchers should define primary and secondary outcome measures, including how and when they were assessed.- Define successful medical abortion: MARE guidelines propose that “successful” medical abortion should be defined as successful expulsion of the intrauterine pregnancy without need for surgical intervention.
- There are several categories of medical abortion failure:
- Ongoing pregnancy. Continuing pregnancy should be defined as a viable pregnancy following treatment (differentiated from a retained gestational sac)
- Incomplete abortion
Heavy or problematic bleeding
Assessment: Describe follow-up assessment used to determine outcome, for example, combination of ultrasound and physical exam, any pregnancy tests, symptoms checklist, etc. State the length of time planned to follow participants to determine outcomes. Reporting outcomes in a standardized manner will enhance data synthesis to produce evidence-based guidelines. -
Oct. 23, 2010, 11:00
Medabon introduced by Concept Foundation
Peter Hall, Chief Executive Officer, Concept Foundation, Bangkok, Thailand and Geneva, Switzerland
In order to make medical abortion more widely available, Concept Foundation, a not-for-profit organization based in Bangkok, Thailand, has been working to get a product available of assured quality at an affordable cost. It has been responsible, though a public-private partnership between WHO, Concept Foundation and industry, for the development of Medabon®, a co-packaged product containing 200mg mifepristone and 800µg misoprostol. The issue of abortion is often highly controversial, sensitive, emotive and with significant socio-cultural and moral dynamics and thus the introduction and use of products for medical abortion products requires careful planning. It is necessary to develop and implement an appropriately designed introductory process, which takes a systematic and incremental approach; ensures coordination and collaboration between the public health system and all key stakeholders; and utilizes a supportive health system. This has been undertaken with Medabon® in Cambodia, Nepal and Zambia.
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Oct. 23, 2010, 02:00
Medical abortion: analysis of three marketing websites selling misoprostol
Deyanira González de León, A., Universidad Autónoma Metropolitana Xochimilco, Mexico City, Mexico
Co-authors: Erika Troncoso, María Elena Collado, Raffaela Schiavon (Ipas Mexico)
The use of Internet has increased considerably and has become a common tool to search for information on issues like abortion, especially among young people. Internet is an important source of information about the use of misoprostol as abortifacient and currently there are websites selling the drug (commercially distributed as Cytotec). In this paper we present the results of a study aimed to explore the information about medical abortion (MA) offered through websites selling Cytotec, as well as the most common questions from its users. The final purpose of this study was to obtain evidence that could be used to improve information strategies on the use of misoprostol as abortifacient.
MA is, alongside with manual vacuum aspiration, one of the standard methods recommended by the World Health Organization (WHO) to terminate pregnancies. The practice of MA has increased in many countries over the recent years and has substantially contributed to improving the quality of legal abortion services. The combined use of mifepristone and misoprostol is currently the most effective regimen for early MA and has been included in the complementary List of Essential Medicines of the WHO since 2005. Millions of women worldwide have used this combination of drugs and have found it to be safe and
effective.
Mifepristone is not legally available in most countries of the developing world and the use of misoprostol alone has become a safe alternative to provide early MA in places where the drug is available. An optimal regimen for the use of misoprostol alone is still under research, but clinical studies report high efficacy rates –around 85% and more- when applied vaginally or sublingually for pregnancies of 63 days’ gestation or less.Because of legal restrictions on abortion the use of misoprostol alone has gained interest and acceptability among physicians in Latin America. Besides, the drug is increasingly being self-administered by women as an alternative to other dangerous methods. In many countries, misoprostol is available at pharmacies without medical prescription, and in some, such as Brazil and Peru, its use has been associated with less complications and deaths.
In Mexico, abortion laws remain highly restrictive except for Mexico City where abortion was decriminalized in 2007 and is permitted on demand during the first 12 weeks of gestation. Since then, public health services governed by the local Department of Health provide abortions using the WHO recommended methods. In 2008, 39% of all legal pregnancy terminations were done using misoprostol alone.11 On the other hand, the use of misoprostol as abortifacient is common and increasing in Mexico, but as in other Latin American countries both women and pharmacists, and even many physicians, lack of enough information on the safest and most effective doses of the drug, or about what to expect during the process or what to do if it fails.
A search performed in 2008 found seven websites offering misoprostol, out of which three were selected for further analysis: Ayuda Cytotec, Cytotec México, and Soluciones Cytotec. Criteria used for the selection was that these websites had question/answer sections, open not only to buyers but also to all visitors. 20% of all questions and answers registered between January and June 2008 were randomly selected for each one of these websites. The search was done giving a marker to each question and then making a random selection of them using the SPSS. The analysis was performed on 215 cases, which were incorporated into an Excel database. The database included the specific website, questions, dates of questions and answers, and answers from the website. Although the database included information on sex and age of those consulting, as well as weeks of pregnancy and use of misoprostol at the time of the query, these data were not always consistent because of insufficient information at the websites.
The results show that the five most common questions asked by users referred to: how to detect if the abortion was completed (21%); information about the use of misoprostol, including efficacy, risks related to previous abortions, weeks of gestation, and confirmation of pregnancy, among others (17%); routes of administration and dosage (11%); side effects (9.7%); and post-abortion care (7.9%). In addition, 79% of questions were made by women; 41% of those consulting had 9 or less weeks of gestation; and 43% were using misoprostol at the time of the query.
A first conclusion is that the selected websites not only sell misoprostol but also represent a useful source of information about the drug (dosage, gestational limit, side effects). However, these websites do not include accurate information about the evolution of an abortion using misoprostol or what to do in case of failure. This kind of information is only available to those using the question/answer sections and answers from the websites do not always meet the needs of users. Another conclusion is that self-administration of misoprostol without all the necessary information is a common practice among women. Finally, the analysis of the questions made by users demonstrates the need to elaborate documents and other resources that give women complete, accurate and reliable information about MA.
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Oct. 25, 2008, 11:00
Medical abortion at 7 - 9 weeks gestation: Considerations and challenges
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
kristina.gemzell@ki.se
Medical abortion using the antiprogestin mifepristone (Exelgyn; Paris, France) combined with a prostaglandin has been available in Europe since 1988 for termination of pregnancy up to 49 days of amenorrhea. In the UK (1991), Sweden (1992) and later on Norway the method is approved up to 63 days of amenorrhea. Recently medical abortion up to 63 days has been approved also in the rest of Europe. With the recommended regimen the high efficacy and acceptability of the method can be maintained beyond 49days. Critical aspects to consider when medical abortion is used beyond 49days of pregnancy will be discussed in the workshop. These include the regimen of mifepristone and misoprostol, the interval between the drugs, pain medication and home-use of misoprostol. An increasing number of women in Europe opt for this choice instead of surgical abortion. A shift which is expected to continue in the next years world-wide. It is crucial that providers are familiar with the method and aware of the critical differences compared to medical abortion before 49 days of pregnancy.
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Oct. 23, 2010, 11:00
Medical Abortion at 9-13 Weeks
Professor Allan Templeton, University of Aberdeen, United Kingdom
The formulation of the antiprogesterone drug mifepristone in the 1980s led to the development of safe and effective medical abortion as an alternative to surgery. Initially the regimens were used in the early first trimester and second trimester, and increasingly employed the prostaglandin E analogue misoprostol given by a variety of routes, including oral (swallowing), vaginal, sublingual and buccal.
About ten years ago this approach was also assessed for use in the late first trimester and as a result medical abortion is now used at all gestations, where preferred to surgery. This review will focus on 10 years experience of late first trimester medical abortion at one centre, including efficacy, side-effects and acceptability. It will also illustrate how frequent review has facilitated improvement and development of the regimens used.
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Oct. 22, 2010, 08:00
Medical abortion at 9+1 to 12+0 weeks of gestation - a pilot studyon efficacy, bleeding and women´s experiences
Monica Johansson, Department of Women´s and Children´s Health, Division of Obstetrics
and Gynecology, Karolinska Institutet/Karolinska University Hospital, Sweden
Background:Medical abortion up to 9+0 weeks gestation was approved in Sweden in 1992. Today a majority of induced abortions are medically induced and performed before the eight’s week of gestation. The standard method for termination of pregnancy in the late first trimester is still surgical using vacuum aspiration. However, more recently medical abortion has become increasingly used also beyond 63 days of gestation.
Objectives: The objectives of this pilot study were to evaluate women´s experiences with late first trimester abortion and to collect data on efficacy, bleeding and side effects.
Methods: All women received mifepristone 200 mg orally under nursing supervision, followed by 800 micrograms misoprostol self administered vaginally 48 hours later. Misoprostol was repeated every 3 hours orally, to a maximum of five doses if needed. A clinical examination including ultrasonography if needed was performed prior to discharge If expulsion had not occurred women were kept in hospital over night and vacuumaspiration performed the following day. Follow-up was performed 3 weeks after treatment. Bleeding and side effects were reported two times from the intake of mifepristone until follow-up.
Results: A total of 14 pregnant women with gestational age 9+1 to 12+0 weeks were included. The successful termination rate was 85,7 %. Surgical evacuation was carried out in 2 (14,2 %) women and only 3 (21,4 %) estimated bleeding more than a regular period. Most women 13 (92,8 %) found the method of treatment highly acceptable.
Conclusion: Medical abortion is a highly acceptable method for termination of pregnancy also in late first trimester and could safely be offered to more women.