Speeches
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Sept. 14, 2018, 04:00
Medical and surgical methods of abortion are highly effective, safe, and acceptable to women. Women value being offered a choice of methods and receiving a preferred method is a strong predictor of satisfaction with care. For women who do not have a strong preference for a particular method, clinical trial evidence suggests that randomisation to a surgical abortion results in higher satisfaction rates than randomisation to a medical abortion.
While providers may wish to optimise women’s abortion experience by offering a choice of methods, this can be challenging with the increasing shift toward medical methods and the very early gestational ages at which women now present for abortion care. Surgical abortion under general anaesthesia may be cost-prohibitive and the predominance of medical abortion in some settings can reduce opportunities for obtaining surgical skills. Providers may be uncertain of whether or how to offer surgical abortion in the earliest weeks of pregnancy.
This talk will address the evidence supporting the offer of a choice of abortion methods and will discuss less resource intensive models of outpatient surgical abortion care as well as a protocol for providing surgical abortion before a gestational sac is visible on ultrasound. -
Sept. 15, 2018, 01:00
The scientific community emphasizes the evident need to utilize an effective contraceptive method as rapidly as possible following an abortion. After surgical procedure: There is no question in regards to the convenience of inserting intrauterine contraceptives immediately after a surgical termination, if the woman so desires. Like many other groups we offer this presentation with 250 IUD inserted immediately after a surgical termination, at the end of the procedure through out 2015 and 2016. The results after a year of follow up, are equivalent to others that are usually published on the the subject of continuation, expulsion, failure and satisfaction of the IUD. When shall the IUD be inserted following a MToP? In our opinion, as soon as possible, that is, in the first follow up visit after the procedure. There is no benefit in delaying the insertion. Therefore we refuse the notion of delayed insertion (3-4 weeks after the abortion) and we recommend an early insertion (between 5 and 14 days after the MFP intake.) Often, the follow up visit is the only opportunity for the patient to begin using an adequate contraceptive. The benefits of LARC over SARC are evident. We will present a study of the early insertion of 115 IUD after MToP through out 2015 and 2016. The results, as we will prove, are similar to in IUD users in general.
Our recommendation:
-Insert the IUD as soon as possible
-Take advantage of the opportunity of follow up visit
-Let none leave the follow up visit without an adequate contraceptive.
References:
1.-Heikinheimo O, Gissler M,Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. contraception. 2008;78:149-154
2.-Cameron ST, Berugoda N,Johnstone A, et al.Assesment of a “fast track” referral service for intrauterine contraception following early medical abortion. J Fam Plann Reproductiva Health Care. 2012;38:175-178
3.-National Institut for health and Welfare. official Statistics from Finland. Induced abortion 2015 (Internet). Published Oct 2016. Available from: http/urn.fi/URN:NBN:fife2016102025429 -
Sept. 15, 2018, 02:00
Australia is a prosperous country which endeavours to provide equitable access to high-quality healthcare. Yet this is not the case for abortion.
With the introduction of government-subsidised medical abortion in 2013 it was envisaged that women would be able to access affordable abortions, medical or surgical, across the country. Unfortunately, this promise has not been met, especially for those who are financially disadvantaged or who live in rural and remote areas.
Australia has a complex patchwork of abortion laws across its 8 states and territories, ranging from legal abortion available on request up to 24-weeks with potential supply of early medical abortion drugs by nurses in Victoria, to abortion provision still residing in the Crimes Act of 1900 in the most populous state of New South Wales. While decriminalisation has not always led to improved access, the risk of prosecution serves as a barrier to service provision, particularly in the public setting. Publically-funded hospital services, except for fetal abnormality, are difficult to access or non-existent in most states and territories and costs for private medical and surgical abortion services vary widely and can be substantial and unaffordable. While General Practitioners are potentially able to provide low cost medical abortion to their patients only a very small number do so due to perceived stigma, poor remuneration and concerns about managing complications in the absence of clear referral pathways into local hospitals. Australia’s innovative telemedicine service has the potential to overcome barriers to access but reports of obstruction and psychological abuse of women by health care providers providing radiology and other necessary support services highlights that abortion is far from stigma-free in Australia. Despite these challenges key steps are being taken by professional colleges and other leading health organisations to integrate abortion care within their training pathways and in calling for policy reform focussing on reducing costs and enhancing early access. -
Oct. 4, 2014, 02:00
Alternative schemes for follow-up, including use of a semi-quantitative pregnancy test
Wendy Sheldon Gynuity Health Projects, New York, USA - wsheldon@gynuity.org
Semi-quantitative urine pregnancy tests are a recent innovation with the potential to revolutionize abortion care worldwide. Sequential use of such tests enables women to monitor the success of their abortion procedures in the privacy of their own homes and can be an effective replacement for serum hCG and/or transvaginal ultrasound, thus reducing overall abortion-related costs and, for many women, the need to return for clinic-based follow-up. This presentation will summarize data from multiple studies conducted in the United States, Mexico, Tunisia and Vietnam using a semi-quantitative test with five bracketed hCG ranges (25-99, 100-499, 500-1,999, 2000-9,999, and 10,000 mIU/ml). The studies explore the effectiveness, feasibility and acceptability of using a semi-quantitative pregnancy test for at-home medical abortion follow-up at various points in time up until 14 days after initiation of the abortion procedure.
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Oct. 14, 2016, 12:45
LS01.3
A tailored pregnancy test offers new possibilities to women for follow-up after medical abortion
Kristina Gemzell Danielsson
Karolinska Institutet, Stockholm, SwedenOne reason for limited access to medical abortion is that women are required to make multiple visits to the clinic. The purpose of a follow-up visit after medical abortion has been to ensure that pregnancy has successfully terminated, to detect complications and to start contraceptives. However, in case of complications women should not wait until a routine follow-up visit and, importantly, to help women start contraception after the abortion contraceptive counselling and provision should be done at the first visit to the abortion clinic and should not be postponed to the follow-up. Hence the main purpose of a routine follow-up visit after medical abortion is to detect an on-going pregnancy. Most service delivery guidelines recommend that women return at 2-3 weeks for a follow-up visit. However, an increasing number of women choose not to return for follow-up after their medical abortion.
Recently, studies have assessed alternative methods of follow-up after medical abortion, such as using a low-sensitivity urine pregnancy test, semi-quantitative urine pregnancy test or a high sensitivity pregnancy test followed by a telephone follow-up or through text message or online. A few studies have also investigated women’s experiences and perceptions of self-assessment and safety and effectiveness of self-assessment in low resource settings, including women who reside in rural areas, have low literacy levels and limited access to telephone and transport facilities.
Overall there is no increased risk of complications in women who self-assessed their treatment outcome compared with women who attend clinical follow-up. Self-assessment of treatment success after early medical abortion has a resource-saving potential. Women need to be counselled about the risk of continuing pregnancy and any strategy for self-assessment will need to be carefully assessed for test and user performance before introduction.
A simple, reliable test for self assessment allows a one-stop clinic for medical abortion. -
Oct. 15, 2016, 11:00
FC11
Evaluation of two low sensitivity urine pregnancy tests (1000 IU) used for self assessment following early medical abortion
Sarah Millar, Sharon Cameron
Chalmers Centre, Edinburgh, UKIntroduction: The majority of women who have early medical abortion (EMA) at our service choose to confirm the success of the procedure by “self assessment” (a self-performed low sensitivity urinary pregnancy (LSUP) test at home two weeks after EMA). Women contact the abortion service if they have an invalid or positive result or symptoms of ongoing pregnancy. In 2014 we changed from a double cassette LSUP (Babyduo) to a single window LSUP (Check4) (both Quadratech diagnostics, UK). We predicted the Check4 test would be easier for women to use and interpret.
Aims: To determine if the Check4 test improves the detection of ongoing pregnancies when compared with Babyduo and if there are any differences in reported invalid or positive results between the two tests.
Methods: A retrospective database review identified women who had EMA “self assessment” in the 10 months before and 10 months after the introduction of the Check4 test. Fishers exact test and descriptive statistics were used for data analysis.
Results: 1047 women were identified (n=492 Babyduo group and n=555 Check4 group). There were 2 ongoing pregnancies in the Babyduo group and 3 in the Check4 group. Significantly more invalid tests were reported in the Babyduo (n=18, 3.6%) than the Check4 group (n=6, 1.1%) (p=0.0064). Significantly more positive tests tests were reported in the Check4 (n=19, 3.4%) than the Babyduo group (6, 1.2%) (p=0.0244).
Conclusion: The introduction of the Check4 LSUP has not altered the detection rates, or time to detection, of ongoing pregnancies. It has, however, been associated with fewer attendances for ‘invalid’ results and more for positive results. These findings may reflect that the single window Check4 test gives less margin for error in interpretation than the former double window test. We will continue to use the Check4 LSUP for EMA “self assessment” for this reason. -
Sept. 15, 2018, 11:00
Objectives: To determine whether prophylactic administration of ibuprofen and metoclopramide or tramadol alone provides superior pain relief compared to analgesia when pain begins with mifepristone and misoprostol medical abortion through 63 days gestation. Methods: We conducted a multi-center randomized, placebo-controlled trial in Nepal, South Africa and Vietnam. Participants were randomized 1:1:1 to: (1) ibuprofen 400 mg and metoclopramide 10 mg ; (2) tramadol 50 mg and a placebo; or (3) two placebo, taken immediately before misoprostol and repeated four hours later. All women had supplementary analgesia to use as needed. Our primary outcome was maximum pain within 8 h of misoprostol administration. Secondary outcomes included maximum pain within 24 h, additional analgesia use, and medical abortion effectiveness. 86 women were required in each arm for 90% power to detect a 1.5 point reduction in maximal pain score using an 11-point visual analogue scale (VAS) compared to placebo; the sample size doubled to examine the effect of parity on the primary outcome. Results: 563 women (nulliparous n=275; parous n= 288) were randomized between June 2016 and October 2017. Women in both treatment arms reported lower pain scores compared to placebo (1: 6.43 (95% CI 6.10, 6.75); 2: 6.78 (95% CI 6.10, 6.75); 3: 7.42 (95% CI 7.10, 7.74). Ibuprofen and metoclopramide reduced scores more than tramadol compared to placebo (D mean 1: -0.99 (95% CI -1.45, -0.54); 2: -0.64 (95% CI -1.09, - 0.18); similar results were noted within 24 hours. Nulliparous women reported higher overall pain scores compared to parous women; but, treatment effect was similar. Women receiving prophylactic treatment generally used less additional analgesia. There was no difference in medical abortion effectiveness. Conclusion: Prophylactic ibuprofen and metoclopramide or tramadol reduced pain with medical abortion compared to placebo; ibuprofen and metoclopramide appears to offer better pain control compared to tramadol.
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Oct. 14, 2016, 09:30
PS01.3
Improving women´s journey through abortion in Portugal
Lisa Vicente
Directorate of General of Health, Lisbon, PortugalAbortion, according to the Portuguese penal code, is considered a crime against intrauterine life. Over the years Portuguese law has incorporated reasons that preclude the illicit use of abortion.
Serious maternal illness, foetal malformation and rape constitute grounds for termination of pregnancy. These motives are accepted for 32 years in Portuguese health care.
It was just in 2007, after a national referendum, that the practice of abortion at women´s request up to10 weeks gestation was recognised. Since then it has been performed within the National Health Service (NHS) or in officially recognised, private clinics.
The implementation of abortion services was made possible within the NHS through a national network, along with the availability of mifepristone and misoprostol, the publication of national guidelines and the creation of a national online registry, mandatory for all health care units.
Nowadays 67% of all the abortions are performed in the NHS, where 95-97% of interventions are medical abortions. In private units the majority of the interventions are still performed using the surgical method (98%).
It is unknown what was the absolute number of illegal abortions before 2007, although 20 000 was the estimated number. We only have data on the complications caused by these abortions because women came to health services looking for treatment. Serious complications included deaths, uterine perforations and sepsis. Many women travelled abroad to seek a safe abortion – a number never known.
National reports show a significant decrease in the number and seriousness of complications caused by illegal abortions since 2008. With legal abortions complications remain low but in 2010 there was one fatal case of Clostridium Sordellii associated with medical abortion. -
Oct. 15, 2016, 02:00
CS15.3
Identifying and managing on-going pregnancy after medical abortion
Patricia Lohr
British Pregnancy Advisory Service, Stratford Upon Avon, UKThe incidence of on-going pregnancy after early medical abortion with mifepristone and misoprostol is about 1%. Early detection is important so that further management can occur within the skill-set of the provider and any country-specific gestational age limits for abortion. A common method of identifying the success or failure of medical abortion is to undertake an ultrasound scan during an in-clinic visit. However increasing evidence supports the effectiveness and acceptability of remote methods of follow-up, typically using a single or multi-level urine pregnancy test and a symptom checklist.
This talk will review how on-going pregnancy after early medical abortion may be detected, surgical and medical management of failure and the risk of continuing a pregnancy that has been exposed to mifepristone and misoprostol.