Speeches

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    Oct. 22, 2010, 08:00

    Medical abortion between 9 and 12 weeks gestation: experiences from a nursing perspective

    Linda Grung Ertzeid, RN, Ingrid Økland, RN, Line Bjørge, MD, Ragnhild Tveit Sekse, RN, Mette Løkeland, MD

    Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway

    Background: Worldwide most late first trimester abortions are achieved surgically by vacuum aspiration. As the first hospital in Norway, medical abortion between 9 and 12 weeks of gestation was introduced at the Department of Obstetrics and Genecology, Haukeland University hospital, Bergen, Norway. in October 2005.  Data from the implementation period has been analysed in detail, and shows that it is an effective and acceptable method for this gestational age (1). When the procedure was introduced women were given the choice between medical or surgical methods for termination of pregnancy. In June 2007 the medical abortion procedure became the method of choice for late first trimester abortions at the Department. The treatment and follow-up requires a close collaboration between different groups of health care providers. The nurses play a central role in treatment and follow-up of this patient group by administrating the medications, monitoring the patients clinically, confirming the terminations and

    providing mental support as well as giving information about the procedure.

    Method: A multi-competence team consisting of nurses and doctors with special interest was established. Its role was to develop treatment protocols and information materials and to enlighten and motivate the health care providergroups to use the new treatment alternative. At the first consultation at the outpatient clinic the doctor determined the gestational age and the choice of method were decided. The nurses informed the women about the treatment procedures, administrate mifepristone medication, governed misoprostol and pain killers, monitored bleeding, provided mental support and confirmed the termination by visual inspection. They were also responsible for contacting the women if further follow-up were needed. To build nursing competence structured training was made compulsory and given to all the nurses. They needed more knowledge about why conservative treatment should be preferred to surgical, and also be acquainted with the new procedures so they could be able to give a proper information and support to women.

    Results: From October 2005 to April 2007 55% (254) of the women requesting abortion with gestational age 63 to 90 days chose medical termination. Initially many nurses found it hard to handle the new procedures, especially to verify the abortion by visual inspection to see that both fetus and placenta had been passed. To master this it was essential and important to give the nurses time for debriefing and for discussions, - like how to motivate each other and how to cope with different emotional reactions. Routines have also been made for new nurses. They were never left alone with this patient group until they felt secure with the procedures. This was important for a successful outcome of the implement of the new method.

    Conclusion: Late first trimester medical abortion is an effective and acceptable method for termination of pregnancies. During the study period the numbers of procedures performed has increased and today more than 75% of all the abortions performed at this gestational age are performed medically. The key factors for the successful implementation were planning, delegation of treatment responsibility and motivation and follow-up of the nurses. Interdisciplinary cooperation on procedures and methods and increased knowledge has given the nurses professional confidence, competence and more responsibility for patient care provided for the women who choose abortion.

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    Sept. 11, 2004, 09:00

    Medical abortion, early treatment

     

    Peter Safar   MD, Head of Department of Obstetrics and Gynaecology

    Humanis-Klinikum Korneuburg, Austria,

    Board member of the Regional Executive Commitee of the IPPF/EN

    Most women are faced with unnecessary obstacles in access to termination of a very early pregnancy, even when their decision for termination is clear.

    Frequently the treatment of medical abortion is delayed until a foetal cardiac activity can be seen on ultrasound. Additionally women are sometimes subject to several ß-hCG tests in the serum. Treatment is delayed until a viable intrauterine pregnancy can be diagnosed, usually around 6 1/2 weeks LMP.

     

    Our experience is presented with medical abortion in very early pregnancy. We also follow patients and repeat ß-hCG in these cases, but we start medical abortion immediately. Patients are counselled about the possibility of an ectopic pregnancy or a missed abortion in cases where no foetal cardiac activity or even no gestational sac can be seen on ultrasound.

    Serum ß-hCG is done prior to treatment and repeated at follow-up after one week. There is a marked decline below 20% of the initial value when the abortion has been successful. Sometimes the combination with the serum level of progesteron could be precise the diagnosis.

    So far we have not had one persistent ectopic pregnancy in more than 5 years and over 2.000 cases. If an ectopic pregnancy would be detected at follow up the treatment option with MTX or laparoscopy can be discussed in time.

     

    Medical abortion with mifepristone and misoprostol in the early and very early pregnancy is safe and very well accepted by women. The success rate is high and side effects of strong bleeding or pain are infrequent. 

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    Oct. 24, 2008, 09:00

    Medical abortion efficacy at 8 and 9 weeks

    Ana Rita Pinto, Inês Vaz, Alfredo Gouveia, Rute Magarinho, Paulo Sarmento (Portugal)

    Centro Hospitalar do Porto – Unidade Maternidade Júlio Dinis, Portugal

    Objective. Abortion by request is allowed in Portugal if carried out within the first 10 weeks since April 17 2007. It implicates a minimum of a 3-day introspection period and the availability of psychological counselling, as well as support from social services technicians and women are given the choice between medical and surgical procedures. This law is a response to illegal abortions and to the need of eradicating its practice, as they are often carried out without the required conditions and with high risks to the sexual and reproductive health of the women involved. Most studies carried out on this subject are related to medical abortions within the first 49 days. This study, however, aims at evaluating the efficacy of medical treatment in abortions after the first 7 weeks.

    Design and Methods. Retrospective study reviewing 380 cases related to abortion by request between July 1 2007 and February 29 2008. The variables analysed were gestational age, treatment methods (medical vs. surgical), dosage administered, treatment efficacy, need of additional intervention as a follow up to protocol and the need for curettage as an aid to uterus emptying completion.

    Results. From the 380 women who underwent abortion, the gestational age in 151 (39,7%) was over 49 days; 7 (4,6%) underwent surgical procedure and 144 (95,4%) medical procedure. Initially, 46 women were administered 200 mg of Mifepristone orally and 800 µg misoprostol orally 36 hours later. From October 1 2007 protocol was changed and in 98 (68,1%) women were administered 600 mg Mifepristone orally and 800 µg misoprostol orally 36 hours later. In the initial procedure, 69,6% (n=32) had a complete abortion although 4,3% (n=2) failed to appear for follow-up. 4 (8,7%) were evolutional pregnancies, 1 (2,2%) had a missed abortion and in 7 cases (15,2%) emptying was considered incomplete, 3 (6,5%) of which needed curettage to aid uterus emptying. In the following procedure, 61,2% (n=60) had a complete abortion although 7,1% (n=7) failed to appear for follow-up. 14 (14,3%) were evolutional pregnancies, 3 (3,1%) were missed abortions and in 14 (14,3) cases emptying was considered incomplete, 1 (1,0) of which needed curettage. Overall, medical treatment was administered to 144 women. Abortion was complete in 92 (63,9%) cases, 18 (12,5%) were evolutional gestations and 25 (17,4%) were incomplete abortions. Defining the presence of live embryo after medical cycle as medical abortion failure, it is calculated as 12,5%.

    Conclusions. Medical abortion had an 87,5% efficacy rate for the absence of live embryo at the time of ultrasound control. In our service the efficacy rate in the same period of time of medical treatment for any gestational age was 91,9%. Although scientific evidence of efficacy of medical treatment relates mainly to pregnancies within the first 49 days, the authors conclude that its use in cases of higher gestational ages is highly efficient, thus contributing to a lower number of surgical abortions.

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    Oct. 13, 2006, 11:15

    Medical abortion general recommendations
    Kristina Gemzell, MD, PhD, Professor
    Dept. of OB/Gyn, Karolinska University Hospital/Institutet, Stockholm, Sweden

    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. Today medical abortion is available in
    around 30 countries. Since the introduction of the method research has focused mainly on
    the following issues: To find the optimal dose of mifepristone, the optimal type, dose and
    route of administration of a prostaglandin analogue, to increase acceptability of the method
    and to define the duration of pregnancy for which it can be used.
    During this time it has been shown that the dose of mifepristone can be reduced without
    affecting its priming effect on the myometrium and cervix. Misoprostol has emerged as the
    most optimal prostaglandin analogue with its effect being dependent on the duration of
    pregnancy, and on the dose and route of administration. Based on pharmacokinetics and
    effect on uterine contractility, it could be hypothesised that a newly developed slow-release
    form of misoprostol may offer an alternative to conventional misoprostol. Our studies
    further confirm the safety, efficacy and high acceptability of home-use of misoprostol.
    Home-use of misoprostol allows women more flexibility, privacy and control in their
    abortions.
    With the introduction of mifepristone the non-surgical, non-invasive methods for 2nd
    trimester abortion could be dramatically improved and has become the recommended
    method in many centres. More recently medical abortion has also become increasingly
    used in the interval 9 to 13 weeks.
    In conclusion the combined treatment with mifepristone and misoprostol is a highly
    effective and safe method to terminate pregnancy provided that the dose and route of
    misoprostol is adjusted to the pregnancy length. Detailed counseling, adequate pain
    management and information and the possibility of getting advice on the telephone are
    likely to increase acceptability.

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    Oct. 23, 2010, 04:00

    Medical abortion in adolescents

    Maarit Niinimäki, MD PhD, Department of O&G, University Hospital of Oulu, Finland

    Pregnancies among teenagers, mostly unplanned, offer a special challenge to family planning. Vast majority, about 80%, of teenage pregnancies are unintended (Guttmacher Institute Report 2010). In 2009 9.5% of all abortions were performed for girls <18 years in UK. Also in Finland teenage abortions are relatively common. In the youngest age group (15-19 years) the abortion rates were higher than in the whole population (12.8 vs. 8.8/1000 women in the same age) in 2009.

    Despite the widespread use of medical abortion, data concerning the safety and feasibility of medical abortion among adolescents is scarce. A small prospective study found medical abortion to be highly effective and well tolerated among minors aged 14 to 17 years in duration of gestation 56 days maximum (Phelps 2001).

    The present study aimed to compare the incidence and risk factors for adverse events among adolescents and adult women.  The study was based on the national registry-based cohort in which all the medical abortions during 2000-2006, 27.030 women, were included. The duration of gestation was 5 to 20 weeks. The cohort was divided into two subgroups; adolescent < 18 years (n=3024) and adults ≥ 18 years of age (n=24.006). The categories for adverse events were: I hemorrhage, II post-abortal infections, III incomplete abortions, IV injuries or other reasons for surgical operation, V thromboembolic disease, VI psychiatric morbidity and VII death. The classification was based on that reported in the Joint Study of the Royal College of General Practitioners and the Royal College of Obstetricians and Gynaecologists and modified for the present study. Codes for interventions and diagnoses (ICD-10) found in a national Hospital Registry were linked with the abortion registry. For 2004-2006, individual data on STDs (Chlamydia trachomatis and gonorrhea) in this cohort was also available. The screening for Chlamydia infections has been recommended in the national guidelines for termination of pregnancy.

    The overall number of adverse events was higher in adult cohort. Also the incidence of hemorrhage, incomplete abortion and surgical evacuation was significantly higher among adults. The incidence of infections was similar in the cohorts. However, adolescents had more psychiatric morbidity. In subanalysis of primigravid women, the overall rate of adverse events and hemorrhage was higher in cohort of adult women. The risk factors for adverse events (e.g. age, duration of gestation) were mostly similar in the two cohorts.

    In 2004-2006, the incidence of STD was significantly higher among adolescents (5.7% vs. 3.7%). No difference in the rate of post-abortal infections emerged between the two cohorts among women positive in the preabortal STD-screening. Also, positive preabortal STD screening had no effect on rate of postaboral infections when compared to STD-negative women in the whole cohort.

    In conclusion, we find that the rate of adverse events and complications following medical abortion in adolescents is similar or lower than that seen among adult women. Thus medical abortion is not to be evaded as a method among adolescents once the decision of termination of pregnancy has made. In addition, based on these data, preabortal screening for STDs (“screen and treat”) seems to be a feasible strategy in all women.

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    Oct. 2, 2014, 12:00

    Medical abortion in Bulgaria: a happy-ending Cinderella story or a Little Match-Seller drama?

    Dimitar Cvetkov1, Svetlozar Stoykov2 1Women's Health Hospital Nadezhda, Sofia, Bulgaria, 2Medical University Pleven, Pleven, Bulgaria - cvetkoff@abv.bg

    Around the world, probably every medicine man possessed an "abortion recipe", and in Bulgaria too, the interruption of an unwanted pregnancy had its common place in traditional medicine. One of famous works of Bulgarian literature, Dimiter Talev's "The Iron Oil Lamp", gives a dramatic description of the terror of a mother who destroyed the life of her daughter by giving her an abortion potion to save her from the shame of unwanted pregnancy. Much has changed in Bulgaria since these times - the country is the sad leader in Europe's statistics on abortion/live birth ratio. When terminating pregnancy up to 12 weeks is in question, the only option regulation allows is surgical abortion. As early as 1994, there were efforts to introduce medical abortion into practice, but no development resulted, due to lack of interest and insecurity on the part of clinicians facing a new method. In 2010, following a symposium on medical abortion, the idea came back to life once more. After an active search for manufacturers and drugs, and even after a period of unregulated import, finally the pharmaceutical companies at last came to see the Bulgarian market as a rightful destination, and shortly after we saw the first registrations. Today, almost 4 years later, the Bulgarian drug market features Exelgyn, Sun Pharma, and Linepharma, in competition for affordable prices and a steady market share. Yet, at the seemingly happy end, we are facing a multitude of questions: regulatory sales regime; minimum age for abortion; reimbursing procedure costs for teenagers; training of clinicians and midwives. If we are not ready to adequately address these challenges and we do not arrive at viable solutions after a discussion among clinicians, the very method may be compromised and rejected, and a happy-ending Cinderella fairy-tale might turn into the Little Match-Seller sad story.

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    Oct. 22, 2010, 04:00

    Second trimester medical sbortion

    Professor Allan Templeton, University of Aberdeen, United Kingdom

    Most current regimens for second trimester medical abortion are based on the administration of sequential doses of the prostaglandin misoprostol  to women pre-treated with mifepristone, where available. Mifepristone given 24-48 hours prior to the administration of the first dose of prostaglandin will shorten the induction-abortion interval, decrease the dose of prostaglandin required and hence reduce side-effects and analgesia use. Most women will abort within 15 hours, but if not,  the regimen can be repeated next day, or surgery undertaken. A dose of mifepristone 200 mgs is sufficient throughout the second trimester.

    The initial prostaglandin dose can be administered vaginally or sublingually and subsequent doses given orally if the uterus is contractile but abortion has not occurred. Completion of the abortion will require surgery (usually removal of placenta) in 5% of cases with experience. Comparison with surgery (D and E) has proven difficult, although minor complications are more frequent with medical abortion and patient preference favours surgery.  On the other hand the risk of infrequent but serious injury is probably higher with surgery.  A number of other issues  pertinent  to late second trimester and early third trimester abortion including feticide and abortion for fetal abnormality  will be discussed in the light of recent RCOG reports.

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    Oct. 24, 2008, 09:00

    Medical abortion in France. The benefits of a complex procedure

    Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)

    University Hospital of Marseille, France

    Objective. Medical abortion in an ambulatory setting is possible in France since 2004. However, many physicians have been reluctant to use this new option at the office because of the complexity of the protocol. Our aim was to evaluate the feasibility of this procedure in a private practice and to show it’s benefit in terms of contraception counselling.

    Patients and methods. A prospective study was realized among 300 consecutive women, with gestational age less than 49 days, choosing a medical abortion at a general practionner’s office. Under the French law, patients had to undergo five supervised visits (V). The first visit (V1) was to inform patients on the procedure and proposition to encounter a social worker for alternatives to abortion. V2 was for medical examination, cervical cytology, screening for IST and counselling on contraception. After a reflection period of seven days, the third visit was for administration of 600mg of mifepristone under the physician’s supervision. The fourth visit was for administration of 400µg of oral misoprostol at the office. Medications were bought by the physician at the pharmacy. Women were not obliged to remain under supervision and could depart within minutes of receiving medications but were not given the possibility to take the medications themselves at home. They had access to a 24-hour hotline and walk-in emergency service. The fifth visit was for post-abortion control at 10 days with HCG and/or sonography.

    Results.Among the 300 patients, 10 (3%) were lost at follow-up. The rate of complete abortion with no major complications among the 115 patients with a known outcome was 97%. Four patients (3,5%) required surgical aspiration : 2 for haemorrhage, 1 for incomplete abortion and 1 for continuation of pregnancy. Seventy-six women (63%) fully adhered to the protocol and came to the 5 scheduled visits. The mean number of visits at the office was 4,1. An unscheduled visit was required in 7 cases (6%) for repeat administration of misoprostol and 19 patients (16%) phoned for advice. The reflection period of seven days was not possible to respect in 55% of cases because of the time limit of 49 days but all patients had at least 48 hours to confirm their decision. None of our patients requested to encounter a social worker. Concerning contraception, 75% had no use of birth control methods and only 2 women used emergency hormonal contraception. At the control visit, 46% opted for oral contraception and 38% for a long term reversible method (IUD or implant). Overall rate of satisfaction for the method was 78%.

    Conclusions.Our findings confirm that medical abortion in a general solo practice is a safe and acceptable procedure. A complex procedure based on five visits at the office may be a shortcoming and considered as a setback in the era of increased patient autonomy. In our view it improves patient-doctor relationship which is essential for counselling in post-abortion contraception.

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    Oct. 2, 2014, 12:00

    Medical abortion in Slovenia: where are we?

    Eva Macun General hospital Jesenice, Jesenica, Slovenia - eva.macun@sb-je.si

    Introduction: In Slovenia abortion is legal on demand up to 10 weeks of pregnancy. Later abortion can be done after approval of the Commission for abortion. It can be performed in 14 gynaecological departments. Slovenia has a national register of fetal death up to 500g. Institutions that perform abortions are obliged to report all known fetal deaths, with demographic data and procedure. Methods: We checked the fetal death database for method of abortion on demand for Slovenia for the years 2007-2011. We interviewed doctors in all Ob/Gyn departments. We asked them how many percent of abortion were medical in the year 2014. Possible answers were: <50%, >50% and >90%. We asked them also if women can be given misoprostol for home use. Results: In the year 2007 there were 5176 abortions on demand in Slovenia; 4660 (90%) were surgical and 123 (2.4%) were medical abortion and some other methods. In the following years the rate of medical abortions increased (Table 1). In year 2011 there were 4263 abortions ; 2153 (50.5%) were surgical and 1602 (37.6%) were medical abortions.

    Table 1: The rates of medical and surgical abortions in Slovenia, 2007 - 2011

    Year 2007 2008 2009 2010 2011

    Surgical

    Abortion number 4660 4099 3560 2604 2153 % 90.0 82.8 76.5 60.2 50.5

    Medical number 123 434 734 1345 1602

    Abortion % 2.4 8.8 15.8 31.1 37.6

    Results of interviews show that in year 2014 four Ob/Gyn departments use medical abortion in 50% or less. Four departments use it in more than 50% and less than 90%. Six departments use medical abortion in more than 90%. Three of the latter give misoprostol to women for home use. Conclusions: Use of medical abortion is increasing in Slovenia. There are departments that give misoprostol for home use.