Speeches
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Oct. 3, 2014, 04:00
Pain and abortion: women’s perspective, including cultural aspects
Anne Verougstraete1 1-Sjerp-Dilemma-VUB: Family Planning and Abortion Centre: Vrije Universiteit Brussel, Brussels, Belgium, 2-Hôpital Erasme: Université Libre de Bruxelles (Obstetrics), Brussels, Belgium - ann.verougstraete@telenet.be
Surgical abortion: Surgical abortion is a very safe procedure and with local anaesthesia it is even safer than with general anaesthesia. In Europe, there are huge regional differences in the anaesthesia used for surgical abortion, and in a given region, some institutions perform the procedure only under local anaesthesia and others only under general anaesthesia. It seems very unlikely that these differences reflect the choice of women! A growing number of women choose "not to be there" at the moment of the abortion, while others prefer to be in control even if this means they will feel some pain.
Given the choice, many women appreciate emotional support during the surgical abortion procedure; some may want respect for a desired scheme (silence, music etc). Recently hypnotic techniques have been introduced in medical care: it is now used in emergency medicine, during interventional radiology, diagnostic procedures and surgical treatments. In some hospitals breast cancer operations and thyroid operations are performed under local anaesthesia and hypnosis so that general anaesthesia is not needed. There is growing interest in also using hypnosis during abortion procedures to reduce anxiety and pain, in women who desire it.
Medical abortion: Most women prefer home use of misoprostol but it is important to maintain the option to reside in the medical setting for those who wish. At home, women appreciate the possibility to have personal phone support or support by mobile phone messages in order to better manage pain and bleeding by reducing anxiety and stress. Conclusion: Woman-centred care should respect pain management and some rituals women wish for their abortion. In a lot of settings, women do not have this choice!
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Sept. 15, 2018, 11:00
Increasingly, women are obtaining abortifacient medicines through pharmacies, drug sellers, and online or telemedicine services – particularly where abortion services are restricted or access is difficult. Many of these women are using medical abortion drugs safely on their own, although data on their clinical outcomes are limited. Many clinicians consider the self-use of medical abortion to be dangerous; however, from a strictly medical perspective, mifepristone and misoprostol meet many of the FDA criteria for being available over- the- counter (OTC): an acceptable toxicity profile, unlikely to be addictive, and a low abuse potential.
To demonstrate that medical abortion is appropriate for OTC distribution, a series of investigations would be required by the FDA. This research would need to establish that individuals can understand a Drug Facts Label for medical abortion, assess gestational age as eligible and rule out other contraindications for medical abortion, self-administer the medications according to instructions, and identify complications or need to seek medical care, including for ongoing pregnancy. In the short term, these efforts will help support a wide variety of efforts aimed at improving access to clinic-based medical abortion, and in the long-term, support regulatory approval for an OTC product. -
Oct. 14, 2016, 02:00
FC01
A randomised controlled trial of immediate initiation of contraception by levonorgestrel-releasing intrauterine system (LNG-IUS) after medical abortion - one year continuation rates
Riina Korjamo1 ,2, Maarit Mentula1, Oskari Heikinheimo1 ,2
1Helsinki University Hospital/ Obsterics and Gynecology, Helsinki, Finland, 2University of Helsinki, Helsinki, FinlandObjectives: Immediate insertion of intrauterine device at the time of the surgical abortion results into higher uptake of effective contraception and prevent unintended pregnancies. We performed a randomised controlled trial comparing immediate (≤3 days) vs. delayed (within 2-4 weeks) insertion of the LNG-IUS after medical abortion.
Method: Women ≥18 years requesting medical abortion and desiring LNG-IUS contraception were eligible to enter the trial, which was conducted at Helsinki University Hospital between Jan 30nd 2013 and Dec 31st 2014. Trial has registered to www.clinicaltrials.com, NCT01755715. The primary outcome was the LNG-IUS use at 1 year after abortion. Secondary outcomes were expulsions, further pregnancies and abortions.
Results: Altogether 267 women were randomised to immediate (134) and delayed (133) insertion groups, of which 264 (133 and 131, respectively) were analysed. LNG-IUS was inserted in 127 (95.5%) women in the immediate and 111 (84.7%) women in the delayed insertion groups (OR3.81, 95%CI 1.48-9.83, p=0.004). The verified numbers of women continuing the LNG-IUS use at 1 year were 83 (62.4%) and 52 (39.7%), respectively (OR2.52, 95%CI 1.54-4.14, p=0.001). In the best case scenario (the use of LNG-IUS verified or LNG-IUS inserted) 113 (85.0%) women in the immediate, and 88 (67.2%) women in the delayed insertion group continued LNG-IUS use at 1 year (OR2.76, 95%CI 1.52-5.03, p=0.001). Numbers of total expulsions were 3 (2.3%) vs. 3 (2.3%) (OR0.98, 95%CI 0.20-4.97, p=1.00), partial expulsions 26 (19.5%) vs. 9 (6.9%) (OR3.29 95%CI 1.48-7.34, p=0.003), new pregnancies 6 (4.5%) vs. 16 (12.2%) (OR0.34 95%CI 0.13-0.90,p=0.027) and further abortions 4 (3.0%) vs. 5 (3.8%) (OR0.78 95%CI 0.21-2.98, p=0.75), respectively.
Conclusions: Immediate insertion of the LNG-IUS after medical abortion resulted in a higher uptake and continuation rates of intrauterine contraception compared to delayed insertion, despite higher partial expulsion rates of LNG-IUS. Immediate insertion of the LNG-IUS decreased the 1-year pregnancy rates but did not affect the rate of further abortions. -
Sept. 15, 2018, 11:00
Wondering how to manage second trimester medical abortion or dilation & evacuation in the setting of an abnormally implanted placenta?
Looking for advice on advancing the gestational age at which you and your team provide? Have questions about cervical preparation, offering a choice of method, managing prolonged inductions, or anything else related to medical or surgical methods of abortion after the first trimester? Bring your questions along to this panel of five leading experts in second trimester abortion care. Experienced, new and curious providers are all welcome to contribute to what should be a lively and wide-ranging discussion. -
Oct. 15, 2016, 02:00
FC25
Buccal versus sublingual misoprostol alone for early pregnancy termination in legally restricted Latin American settings: A randomised trial
Wendy Sheldon1, Ilana Dzuba1, Heather Sayette2, Jill Durocher1, Beverly Winikoff1
1Gynuity Health Projects, New York, NY, USA, 2PP Global, New York, NY, USAObjectives: To examine the efficacy and acceptability of two misoprostol only regimens that are commonly used for medical abortion in legally restrictive settings; as well as the feasibility of a multi-level pregnancy test (MLPT) for at-home follow-up.
Methods: This randomised open-label trial is ongoing at six clinics in two Latin American countries where abortion is highly restricted.* A total of 382 eligible, consenting women with gestations of ≤ 70 days who request medical abortion is required to show an expected difference of 8% in efficacy between the two study arms. Participants are randomised to three doses of buccal or sublingual administration of 800 mcg misoprostol every three hours. Study providers are blinded to group allocation. All women receive two MLPTs to administer and interpret abortion status: the first is taken in-clinic on the day of enrolment and the second at-home on the day of follow-up.
Results: Data collection should be completed before October 2016. To date, the overall rate of successful, non-surgical abortion is 93.4% (183/196) and rate of ongoing pregnancy is 1.0% (2/196). Among those with no ongoing pregnancy, the MLPT successfully identified this outcome in 83.5% (162/194) of cases; it also identified need for follow-up among all those with ongoing pregnancy (2/2). More than 80% (160/195) of participants stated they would select medical abortion in the future and 87.6% (170/194) felt they could use an MLPT on their own.
Conclusion: The efficacy of misoprostol alone is higher than expected based on published literature. Study findings will provide important evidence on the efficacy of a three-dose buccal misoprostol alone regimen. In addition, multi-level pregnancy tests appear to be a feasible and potentially useful tool for abortion service delivery in legally restrictive settings.
*Note: To protect study providers and their clinics, we are not disclosing country locations at this time. -
Oct. 14, 2016, 12:45
LS01.2
Comprehensive pain management in early medical abortion – A follow up
Christian Fiala
Gynmed Clinic, Vienna, AustriaIntroduction: Medical abortion is increasingly used. But most women will experience some pain that requires intervention, while satisfaction with medical abortion may be limited by differences between women’s expectations of pain and their actual symptoms. Pain is still a neglected issue in many settings and even studies. So far, no evidence-based comprehensive pain management protocol has been published. Therefore, a group of experts has developed recommendations based on the following principles: avoidance of pain, non-pharmacological strategies and medical pain treatment.
Background: Pain usually starts following administration of misoprostol. It is caused by contractions, with a peak around expulsion decreasing thereafter. Several associations between various factors and pain can be found. However, the predictive value of these factors is insufficient to define pain management for an individual woman.
Avoidance of pain and non-pharmacological strategies are a cornerstone, including:
· Facilitating access so that women can have the abortion at an early gestational age
· Giving detailed information to women on what to expect during the procedure
· Using the lowest effective dose of misoprostol
· Taking misoprostol at home in a relaxing environment with a support person present
Medical pain treatment: Treatment for pain in first trimester MToP should be systematic and women should have easy access to additional stepwise pain treatment. The limited data do not show prophylactic treatment to be superior compared with curative administration. However, experts’ recommendation is to give prophylactic analgesia using NSAIDs like ibuprofen. Pain treatment should be given stepwise using
· 1st line,: ibuprofen 400 to 800 mg
· Use of Paracetamol alone is not recommended.
· In addition, 2nd line analgesia for break through pain should be offered and be accessible easily and without delay, consisting of opioids like codeine, dihydrocodeine, or morphine. -
Oct. 14, 2016, 04:00
PS03.2
Expanding providers and task sharing
Helena Kopp Kallner
Karolinska Institutet, Stockholm, SwedenIn many countries the access to medical doctors in abortion care is limited either by a general shortage of medical doctors or by the unwillingness of medical doctors to be involved in abortion care. Specially trained, midlevel providers can often perform services generally performed by physicians. In abortion care the evidence in support of midlevel provision of surgical and medical abortion and postabortion care is increasing.
In some countries midlevel providers perform primary vacuum aspiration for surgical abortion and in low resource settings midlevel providers supply medication and information and thereby perform medical abortions. Medical abortion provided by midlevel providers in a low resource setting has been evaluated in a large randomised trial in Nepal and was found to be safe and effective.
In high resource settings abortion is usually provided after an ultrasound provided by a trained physician. However, access to appointments for ultrasound may, in fact, increase the waiting time to have an abortion. In a large randomised trial it has been shown that trained midlevel providers can perform early medical abortion including the ultrasound as part of standard care as effectively and safely as physicians.
Women in countries where abortion is illegal often self induce abortions surgically or medically. Denied health care due to complications contributes to maternal morbidity and mortality. Midlevel providers who supply postabortion care including manual vacuum aspiration for incomplete abortion have been shown to be safe and effective. In a large randomised trial it has been shown that trained, midlevel providers can perform postabortion care as effectively and safely as physicians in rural as well as in urban settings in Africa. -
Sept. 14, 2018, 02:00
Background: The failures of medical termination of pregnancy (MToP) can have serious consequences such as exceeding the legal age of abortion and the occurrence of fetal malformations related to the teratogenic action of misoprostol.
Objective: To study the correlation between a low-sensitivity urine pregnancy (LSUP) test associated to a self-performed questionnaire and the standard patient follow-up after MToP, consisting of a clinical examination, a blood hCG test and ultrasonography when needed. Methods: Prospective cohort study included women who came to their post abortion visit after MToP from March to August 2017. They performed a LSUP test and a self-performed questionnaire to assess their opinion on the completion of the abortion. Then a standard follow up was done by a doctor. A successful MToP was defined as a complete uterine abortion, with no the need for surgical intervention or for new abortive medication. Results: 133 women have been included in this study. The rate of successful MToP was 94.0%. Regarding failures there were two ongoing pregnancies (1.5%) and six retained products of conception (4.5%) treated either by a surgical procedure or with a new oral administration of misoprostol. Sensitivity of the womens opinion combined to the LSUP test was 100%, specificity was 89.6%, positive predictive value 38.1%, negative predictive value 100%, a Youden index of 0.89 and a kappa coefficient of 0.51. Conclusion: Given the extremely high efficacy of MToP, most women do not need a clinical follow-up to confirm pregnancy termination. Our data show that most women can ascertain their abortion outcome using a simple self-administrated questionnaire and a LSUP test. -
Sept. 15, 2018, 02:00
Introduction: In 2015, mifepristone was approved in Canada, making it the 61st country to do so. Prior to mifepristone, there were only 60 physicians providing medical abortion in Canada. In anticipation of the commercial availability of mifepristone in 2017, clinicians prepared clinical practice guidelines and an online medical abortion training course. Health Canada mandated training prior to prescribing or dispensing mifepristone, however, in late 2017, the regulation was relaxed from “mandatory” to “recommended”.
Methods: We present participant data on the first 16 months of medical abortion training to provide an estimate of clinicians who are currently eligible and/or likely to provide mifepristone medical abortion across Canada.
Results: Overall, 167 Obstetrician/Gynaecologists, and 408 Family Physicians (which make up the majority of abortion providers in Canada) have completed the Medical Abortion Training Course. 1346 pharmacists have completed the course and are eligible to dispense the medication. 173 nurses (of which 112 are nurse practitioners with prescribing privileges), 6 midwives, and 151 medical students and residents also have been trained in medical abortion. There is a physician trained in every province and territory, however there is no pharmacist trained in Nunavut, a northern territory.
Conclusion: There is widespread interest and uptake of mifepristone medical abortion in Canada. Within the first year of availability of mifepristone, over 2000 medical professionals have completed the medical abortion training course. In contrast to pre-mifepristone, where very few physicians provided methotrexate-based medical abortion, there are at least 575 physicians currently eligible to prescribe, and 1346 pharmacists eligible to dispense mifepristone. -
Oct. 3, 2014, 12:45
Self-assessment of urine hCG – a novel option in the follow-up after induced abortion?
Oskari Heikinheimo
Helsinki University Central Hospital and University of Helsinki, Department of Obstetrics and Gynecology, Helsinki, Finland - oskari.heikinheimo@helsinki.fi
There is controversy concerning the need for routine follow-up after an uncomplicated abortion. This is also reflected in the various guidelines on induced abortion. The WHO guideline states that following safe, induced abortion, post abortion care may not require follow-up visit, whereas according the Royal College of Obstetricians & Gynaecologists guideline there is no need for routine follow-up after surgical or medical abortion if successful abortion has been confirmed at the time of the procedure. The Finnish guideline states that ‘the follow-up is important’. This controversy is also reflected in women’s compliance with a follow-up: in research studies, up to 50% of the women do not attend the scheduled follow-up visit. Ideally, during follow-up, completeness of the abortion can be verified, possible complications excluded and the use of post-abortion contraception encouraged. In addition, counseling and psychological support could be provided. The completeness of the abortion can be ascertained in several ways. The value of pelvic examination or ultrasonography have been questioned, whereas the use of serum or urine hCG to exclude ongoing pregnancy has been advocated. Recent studies have focused on development of semi-quantitative urine hCG tests as possible self-assessment tools to verify the completeness of an abortion. We have recently completed a randomized multicenter study to compare self-assessment at home using a two-step urinary hCG tests vs. assessment at the clinic following early medical abortion (Oppegaard et al., accepted for publication). The results show that the rate of complete abortion (94% vs. 95%) or the need for surgical evacuation of the uterus did not differ between the groups. Nine in ten of the women found the urine hCG test easy to use, and significantly higher proportion of the women (82% vs. 59%) would prefer the self-assessment should they undergo an other abortion. It is concluded that self-assessment by means of urinary hCG test performed at home might be an important option for many women to verify the completeness of an induced abortion.