Speeches
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Sept. 11, 2004, 02:00
Beyond the first trimester: Medical methods
Kristina Gemzell Danielsson MD, PhD, Dept of Obstetrics and Gynecology,
Karolinska University Hospital/ Institute, Stockholm, Sweden
Second trimester abortion constitute 10-15% of all induced abortions but are responsible for two thirds of all major complications. The non-surgical methods to terminate 2nd trimester abortion have shown a considerable development during the last 30 years. In the beginning of the 70ies prostaglandins become available on this indication. The non-invasive mode of administration has certainly facilitated the treatment and reduced the risk for complications. With the introduction of mifepristone the method could be further improved.
Mifepristone has been registered in Sweden since 1992 for termination of early pregnancy until 63 days and from 1994 for termination of second trimester pregnancy in combination with gemeprost. With the approved regimen 600 mg mifepristone followed by 1 mg gemeprost vaginally every 6 hours the median prostaglandin to abortion interval was shown to be 9.0 (1.4-40.5) hours for primigravidae and 7.2 (0-152.5) hours for multigravidae. The medium number of gemeprost pessaries to induce abortion was 2. Our data confirms the efficacy and safety of mifepristone combined with gemeprost for termination of second trimester pregnancy when used on a routine basis in the clinic. Today, another prostaglandin analogue, misoprostol, has been shown to be an attractive alternative to gemeprost with higher efficacy and a lower rate of side effects. Various regimens of misoprostol with or without mifepristone have been investigated. Recently it has been shown that sublingual administration of misoprostol is also an effective alternative for second trimester abortion.
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Oct. 24, 2008, 04:00
Medical methods: Advantages and disadvantages
Kristina Gemzell (Sweden)
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/Karolinska Institutet, Stockholm, Sweden
kristina.gemzell@ki.se
Delayed diagnosis of fetal anomalies, logistic and financial difficulties in obtaining abortion services, and failure to recognize an undesired pregnancy in the first trimester all contribute to the continuing need for late abortions. Second trimester abortion constitutes 10–15% of all induced abortions worldwide but is responsible for two-thirds of all major abortion-related complications. During the last decade, medical methods for second trimester induced abortion have shown a considerable development and have become safe and more accessible.
Today, in most cases, safe and efficient medical abortion services can be offered or improved by minor changes in existing health care facilities. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of second trimester pregnancy. In some places medical abortion has become the recommended method for second trimester abortion leading to increased access. In countries where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective, although a higher total dose is needed and efficacy is lower than for the combined regimen. Therefore, whenever possible the combined regimen should be used. Efforts should be done to reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus and future studies should focus on improving pain management. More studies are also needed to explore the safety of medical abortion regimens in women with a previous caesarean section or uterine scar. Advantages and possible disadvantages with medically induced abortion in the second trimester will be discussed.
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Oct. 2, 2014, 12:00
Medical students' attitudes and perceptions on abortion: a cross-sectional survey among medical interns in Maharastra, India
Susanne Sjöström1 ,2, Birgitta Essén2, Filip Sydén2, Kristina Gemzell-Danielsson1, Marie Klingberg-Allvin3 ,1 1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden - susanne.sjostrom@ki.se
Introduction: Although abortion care as a procedure to prevent maternal death has been an established routine for decades in India, eight per cent of maternal mortality is attributed to unsafe abortion. Increased knowledge and improved attitudes among healthcare providers have a potential to reduce barriers to safe abortion care by reducing stigma and reluctance to provide abortion. Previous research has shown that medical students’ attitudes can predict whether they will perform abortions. The objective of our study was to explore attitudes toward abortion among medical interns in Maharastra, India. Study Design: A cross-sectional survey was carried out among 1,996 medical interns in Maharastra, India. Descriptive and analytical statistics interpreted the study instrument and significant results were presented with a 95% confidence interval. Results: A majority of the respondents rated their knowledge of sexual and reproductive health as good, but only 13% had any clinical practice in abortion care services. Most participants agreed that unsafe abortion is a serious health problem in India. However, many considered abortion to be morally wrong, one fifth did not find abortions for unmarried women acceptable, and one quarter falsely believed that a woman needs her partner or spouse’s approval to have an abortion. Conclusion: Despite good self-assessed knowledge of reproductive health, disallowing attitudes toward abortion and misconceptions about the legal regulations were common. Knowledge and attitudes toward abortion among future physicians could be improved by amendments to medical education, potentially increasing the number of future providers delivering safe and legal abortion services.
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Oct. 19, 2012, 09:00
Medical termination of pregnancy by mifepristone
and sublingual misoprostol: preliminary results of
their use in reproductive health centre of Nabeul
in Tunisia
Halleb, D1; Temimi, F2; Belcaid, A1; Ben Khedija,
W1; Wahbi, H1
1 Centre de la Sante´ de la Reproduction, Nabeul, Tunisia; 2 Office
National de la Famille et de la Population, Tunis, Tunisia
Introduction: Medical termination of pregnancy (TOP) is a
method increasingly used worldwide. It was introduced in Tunisia
by the National Office of Family and Population, since 1994 as
part of research. Then it was extended in 22 of the 24
reproductive health centres. Medical TOP was introduced in the
Nabeul Centre since November 2002. We used three different
protocols; the third protocol was introduced since March 2010.
The aim of the study was to describe the effects of this protocol
on medical TOP effectiveness; frequency of side effects, and
frequency of TOP failure.
Methods: We conducted a retrospective observational study
performed in the reproductive health centre of Nabeul from April
2010 to June 2010 about women who chose medical TOP.
For all women consulting for TOP, the medical staff explained
the interest of medical TOP and the risks of this method
compared to the surgical one.
On the first day, counselling was conducted, clinical and
ultrasound examinations were made to identify no exclusion
factors: anaemia, ectopic pregnancy, and pregnancy off the pill,
kidney failure and liver failure. Then 200 mg of mifepristone was
administered by the midwife or the physician.
On the second day, 400 lg of misoprostol was administered by
the sublingual route. On the fifteenth day, a check was performed
by a clinical and ultrasound examination.
We considered as method failure: surgical aspiration for
ongoing pregnancy, a total retention or significant bleeding.
Withdrawals were not recorded as such.
The study analysis was performed by SPSS with statistical
verification by the v2 and ANOVA at a significance level of 5%
(P £ 0.05).Results: We included 562 women (27.48% single and 72.52%
married) who have chosen medical TOP during the study period.
The average age was 32 years, ranging from 18 to 50. Educational
level was illiterate for 5.1%, elementary or secondary for 78.8%
and university for 16%. In 77% of cases women had not had a
medical TOP before, 16.5% of them had one previously, 4.7%
twice and 1.9% three or more times. The age of pregnancy was in
60% of cases <6 weeks of gestation, in 34.7% of cases between 6
and 7 weeks of gestation, and in 6.9% of cases between 8 and
9 weeks. The expulsion occurred in 54.2% of cases before 4 hours
and in 44.4% after 4 hours. Pain was reported in 10.5% of cases
and need appropriate treatment. Surgical abortion was used in
1.2% (ongoing pregnancy in 1% of cases and bleeding 0.2% of
cases).Statistical analysis showed: (i) a significant relationship between
gestational age and the period of expulsion (P = 0.047); no
significant relationship between the gestational age and the failure
of the TOP; no significant relationship between educational level
and gestational age at the time of first consultation (P = 0.243).
Conclusion: The protocol adopted in this study appeared to be
safe, effective and acceptable to women. However we must be
aware and explain to women that the use of medical TOP does
not replace contraception, contrary to popular belief. -
Oct. 19, 2012, 09:00
Medical termination of pregnancy up to the 10th
week: an experience of two obstetric centres in
Portugal
Ce´u Almeida, M; Bombas, T; Silva, I; Ribeiro, S;
Monteiro, J; Fernandes, T; Moura, P
Maternidade Bissaya Barreto – CHUC, Portugal
Since 2007, termination of pregnancy (TOP) on request is legal in
Portugal up to the 10th week of gestation and we perform mainly
medical TOP.
This study investigated the efficacy and the safety of medical
TOP up to the 10th week of gestation in the two major obstetric
services in central Portugal, over 16 months.
A retrospective study was performed of the clinical outcome of
women requesting a TOP, over the previous 16 months. We
considered three groups regarding gestational age: Group 1:
£49 days; Group 2: 50–62 days; Group 3: ‡63 days and studied
the efficacy and the safety.
We included 1276 women who had had a medical TOP. Group
1: 41.5% (529), Group 2: 41.5% (530) and Group 3: 17% (217).
The mean age was 51 days. The global efficacy was 99%. In three
groups, the efficacy of medical TOP was 99.6%, 99.2% and 96.8%
(P < 0.01) in groups 1, 2 and 3. We performed an aspiration per
failed TOP or incomplete TOP in 1.1%, 3.3% and 6.1%
(P < 0.01) of group 1, 2 and 3, respectively. The global rate of
complications was 5.4%. Group 1: 4.2%; Group 2: 5.4% and
Group 3: 8.3% (p=NS), mainly related with an uncompleted TOP
(4.5%), haemorrhagic complications (0.6%) and infection (0.3%).
Medical TOP is a safe method up to the 10th week of gestation
with a low incidence of complications, most of them (80%) due
to incomplete TOP. In the group with a gestational age of 63 days
or more, the efficacy was lower but similar to the efficacy
specified on the labelling. -
Oct. 2, 2014, 12:00
Medical treatment of abortion and missed miscarriage: what's the difference in results?
Silvio Viale San'Anna Hospital, Turin, Italy - silvioviale@libero.it
Objectives: We have compared the efficacy of medical treatment for abortions in women with missed miscarriages. The protocol was mifepristone 600 mg orally + gemeprost 1 mg vaginally two days after, eventually repeated once. Women didn't stay in hospital between mifepristone and gemeprost. Methods: Since April 2011, when mifepristone became available in Italy, until April 2014 we have performed 3545 medical abortions up to 7 weeks. Later we started to offer medical treatment also for blighted ovum and missed miscarriage up to eight weeks of development, regardless of the true gestational age. As at April 2014 we have performed 423 medical treatments of missed miscarriages and blighted ovum. Results: The overall success rate of medical management of abortion and missed miscarriage was 96.3%, with 147 surgical procedures out of 3968. For abortion the success rate was 96.5%, with 125 surgical procedures out of 3545. For missed miscarriage the success rate was 94.8%, a little less, with 22 surgical procedures out of 423. If we keep out the 32 cases in which the curettage occurred for failure in expulsion, 22 abortion and 10 missed miscarriage, the overall success rate rises from 96.3% to 97.1%. By doing the same for abortions and missed miscarriages we found that the success rate rise in both cases, from 96.5% to 97.1% for abortions and from 94.8% to 97.1% for missed miscarriage. Consequently, the rate of curettage drops from 3.5 to 2.9% for abortions and from 5.2 to 2.9% for missed miscarriages. Conclusions: The only significant difference is that medical treatment of missed miscarriage has a fourfold risk of failed expulsion compared to medical treatment of abortion, 2.4% versus 0.6%. With a success rate of 94.8% the medical regimen with mifepristone and gemeprost can be a routine alternative to surgical management of early fetal demise.