Speeches
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Oct. 3, 2014, 04:00
Pain management
Nathalie Kapp HRA Pharma, Paris, France - n.kapp@hra-pharma.com Background: Pain is a predictable feature of induced abortion in both the first and the second trimester, but pain control regimens available to women vary considerably.
Methods: We searched the PubMed and Cochrane databases for publications of trials comparing methods of pain control during induced abortion.
Results: Few rigorously conducted studies of pain control regimens for medical abortion have been conducted. Five studies conducted in women with pregnancies <9 weeks' gestation found that prophylactic analgesia did not reduce medical abortion pain, including the most recent rigorous trial where prophylactic ibuprofen was administered and dosing was repeated through the abortion process. In second-trimester medical abortion, one study found more pain relief with higher doses of fentanyl delivered through PCA than lower doses; the only adjuvant therapy shown to be associated with decreased opioid use has been diclofenac. During first trimester surgical abortion, more than 40 randomized controlled trials are available. Paracervical block, conscious sedation, general anesthesia and non-pharmacologic interventions decreased procedural and postoperative pain during first trimester abortion. Second trimester surgical procedures generally use conscious sedation or general anesthesia which have not been the subject of comparative trials. The severity of pain experienced by a woman varies considerably, but appears to be influenced by the age of the woman, parity, history of dysmenorrhea, and fearfulness/ anxiety. Prior vaginal delivery and a shorter procedure time are associated with lower levels of pain.
Conclusion: As pain associated with the process of abortion should be expected, medication for pain management should always be offered to women who desire it, and may be combined with non-pharmacologic techniques. Further research is needed to determine the optimal analgesia regimens for first-trimester and second-trimester medical termination of pregnancy. To facilitate comparability of data, researchers should use contemporary medical abortion regimens, outcomes and study instruments to measure pain.
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Oct. 4, 2014, 02:00
Using mobile phones to strengthen medical abortion provision: opportunities and dangers identified from the South African experience.
Deborah Constant1, Katherine de Tolly2, Marijke Alblas3,4 1University of Cape Town, Cape Town, South Africa, 2Cell-Life, Cape Town, South Africa, 3Association des sages femmes, Douala, Cameroon, 4CSU/CNRS, Paris, France - deborah.constant@uct.ac.za
Objective: To report the South African experience using text systems on mobile phones to provide support and a self-assessment of completion of their procedure to women undergoing medical abortion. Methods: A randomized controlled trial during 2011-2012 recruited 469 women seeking medical abortion at clinics in South Africa. All women received standard abortion care with mifepristone and home administration of misoprostol and were asked to return to the clinic to assess completion 14 - 21 days later. Consenting women were randomized to standard-of-care or intervention groups. The intervention group received timed SMSs over the period between their clinic visits, with reminders on what to expect, alerts to complications and encouragement to complete the self-assessment. They were also prompted to access a contraception mobisite. Interviews were conducted at both clinic visits and one month later by telephone. Results: Most found the SMSs helped them manage the abortion symptoms and would recommend them to a friend; however 20% of recipients had concerns around phone privacy. The intervention group were significantly better prepared (p<0.05) for the pain, bleeding and side effects of the abortion. Of the 5471 messages sent, there was only a 5% failure rate. Seventy-eight percent completed the self-assessment and of these, 93% found it easy to do, however the questions did not predict all cases requiring further surgical management or additional misoprostol. More in the intervention group chose long-acting reversible contraception at their follow-up clinic visit. Conclusions: Support SMSs were effective in assisting women manage their abortion symptoms between clinic visits. Most could conduct a self-assessment of abortion completion on their mobile phones and promotion of contraception can succeed using mobile text systems. The self-assessment showed promise but was not sufficiently accurate; problems with privacy can be of concern for some women and a mechanism for stopping the SMSs is required.
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Oct. 14, 2016, 02:00
CS04.3
Quickstarting implants after medical abortion
Helena Kopp Kallner
Karolinska Institutet, Stockholm, SwedenGiven the choice, the majority of women in the first trimester choose medical rather than surgical abortion. In Europe, and globally, a significant proportion of women having an abortion have had one or more previous abortions. Long acting reversible contraception reduces subsequent abortions in women. In studies, women resumed sexual intercourse quickly and are thus at risk for unintended pregnancy if effective contraception is not provided. Immediate postabortion initiation of long acting reversible contraception is therefore desirable and recommended by guidelines.
Implants are the only long acting contraception which can be provided at the same time as the initial abortion medication. However, theoretically treatment with a progestin could affect the binding of mifepristone to the progesterone receptor.
Several pilot studies have reported implant insertion at the time of mifepristone in medical abortion. In addition, there is one randomised study performed in Mexico and the United States and one randomised study performed in Sweden and Scotland. Women were randomised to implant insertion at the time of mifepristone ingestion or at follow up. These studies show that implant insertion at the time of the mifepristone is safe and acceptable for women. In addition, the efficacy of the medical abortion is not affected. In the study from Mexico and the United States insertion rates differed between countries and no difference could be shown in unintended pregnancy at the 6 month follow up. The study from Sweden and Scotland had similar insertion rates to women recruited in the United States. There was a significant difference in unintended pregnancy at the 6 month follow up between the immediate and delayed insertion group.
Thus, immediate insertion of implants is safe and acceptable and may prevent subsequent abortions as early as 6 months postabortion. -
Oct. 15, 2016, 09:00
PS04.3
Strengthening autonomy: Mobile technology and self-assessment for medical abortion
Deborah Constant1, Jane Harries1, Caitlin Gertz2
1University of Cape Town, Cape Town, South Africa, 2Ibis Reproductive Health, San Francisco, USAShortages of providers of surgical abortion methods are a significant barrier to safe abortion care across diverse settings where abortion is legal. Early medical abortion using mifepristone and misoprostol requires less provider involvement, is highly effective and can largely be managed by women themselves. Medical methods are highly acceptable to women and can increase women’s autonomy.
Self-determination of gestational age eligibility, self-administration of misoprostol and management of abortion symptoms, self-assessment of abortion outcome and selection of postabortion contraception can be strengthened using mobile phone technology (mhealth). Reliable networks, adequate connectivity, phone ownership and phone privacy are necessary for mhealth to effectively facilitate safe abortion care. These conditions exist in developed but also in many developing countries.
In South Africa studies have shown most women with gestations within 70 days can recall their last menstrual period with sufficient accuracy and use an online gestational age calculator to determine eligibility for medical abortion. Supportive text messages including reminders and information on complications over 14 days following mifepristone significantly improved preparedness and provided effective emotional support during the abortion. Self-assessment using a text questionnaire was feasible, but not accurate, and a low sensitivity pregnancy test was necessary to better detect ongoing pregnancies. Twenty-three percent of women correctly recalled information from the messages on contraceptive methods 4-6 weeks after they had received them. In Colombia a low sensitivity pregnancy test together with text questions for self-assessment was a safe and feasible alternative to in-facility care.
Mhealth, using text messages, shows promise for strengthening women's roles and control with respect to medical abortion. Other approaches include telemedicine consultations, automated text checklists on incomplete abortion symptoms, digital images to verify pregnancy test results and online resources with contraceptive advice. The increasing familiarity with digital technology provides a powerful opportunity to strengthen women’s reproductive autonomy. -
Oct. 3, 2014, 02:00
Sustainability of medical abortion services in the Caucasian region
Tamar Tsereteli Gynuity Health Projects, Tbilisi, Georgia - ttsereteli@gynuity.org
Caucasian women, as residents of former Soviet republics, have had widespread access to legal abortion for almost one hundred years. Abortion rates are high, and many women rely on abortion as their primary means of fertility regulation. Current laws provide for abortions up to 12 weeks’ gestation without restrictions, and up to 22 weeks’ gestation for broad medical and selected socioeconomic grounds. Until recently, surgical abortion was the only option available to women in Caucasian countries. Very few doctors were trained in medical abortion provision, most women did not know what medical abortion was or had an incorrect understanding of the procedure and there were no recommended national protocols doctors could consult if they were interested in providing the service. In addition, mifepristone was not always available: if registered at all, it often was unavailable outside of the capital cities. In 2006, Gynuity Health Projects launched a series of collaborative activities in Armenia, Azerbaijan and Georgia with the goal of increasing the availability of safe abortion services and access to medical abortion. Activities included training for doctors and nurses on medical abortion, clinical research studies, dissemination meetings to present study findings, development of Information, Education and Communication (IEC) materials for women and assistance in developing national protocols. In some cases data generated from the clinical studies supported mifepristone registration and informed national protocols. Between December 2011 and June 2013, Gynuity conducted studies in Armenia and Georgia to assess ongoing provision of medical abortion services and evaluate the quality of care provided at former research sites. This presentation will describe how programme components have contributed to sustainability of medical abortion in the Caucasian region.
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Oct. 15, 2016, 11:00
CS08.3
The Telabourtion Study: Evaluation of a Direct-to-Patient Telemedicine Abortion Service
Erica Chong, Elizabeth Raymond, Philicia Castillo, Beverly Winikoff
Gynuity Health Projects, New York, NY, USAObjectives: Given the difficulties women face in obtaining clinic-based abortion in many parts of the US, provision of medical abortion by telemedicine to women in their homes could be highly beneficial for increasing access. We developed a pilot study to obtain preliminary data on the safety, acceptability and feasibility of direct-to-patient telemedicine abortion.
Methods: This case-series study of 50 women is being conducted in selected US states with no legal restrictions on telemedicine abortion. Women may learn about the study from staff at the collabourating study sites, from referring providers or from the study website. Each woman who is interested in the study will consult with a study investigator by videoconference and then will obtain screening tests at local facilities. If the results indicate that she is eligible, the investigator will send the abortion medications to her by mail. The participant will obtain tests at local facilities to confirm abortion completion and will have a follow-up consultation with the investigator by phone or videoconference. Data will be collected about interest in, and satisfaction with, the service, abortion complications and difficulties encountered by patients and providers in completing the protocol requirements.
Results: We will review key legal issues that impact this model and challenges in designing the service to conform to expected standards of care for clinic-based abortion. We will also present data obtained in the project to date.
Conclusions: In states with no legal restrictions, direct-to-consumer telemedicine abortion has great potential to increase women's access to abortion care in a safe and acceptable manner. -
Sept. 15, 2018, 09:00
Today many women are reluctant to use any of the existing contraceptive methods due to side effects or fear of experiencing such effects. Unsafe abortion is a major contributor to maternal mortality. Therefore effective methods for contraception and safe and acceptable methods for termination of unwanted pregnancies are prerequisites for reproductive health, for gender equality and for the empowerment of women. New methods for contraception are also needed including improved methods for emergency contraception and new mechanisms of action as well as mode of delivery. Additional health benefits of contraceptive methods such as protection against various cancers, and a wide range of other benefits need to be better recognized. Based on their mechanisms of action Progesterone receptor modulators (PRMs) can be used for emergency contraception as well as regular contraception by various modes of delivery. Progesterone receptor modulators have been shown to be effective when used on demand post coital, as daily pills, once-weekly or once-a-month and is a well establish method for medical first and second trimester abortion. The use of progesterone receptor modulators for contraception and positive health benefits such as the possible protection against breast cancer as well as prevention of uterine leiomyomas and endometriosis deserves to be further explored. Progesterone receptor modulators have also been studied for “late emergency contraception” and for menstrual induction. Very early medical abortion (VEMA) before an intrauterine pregnancy can be visualized by ultrasound has been shown to be acceptable, safe and effective. Medical abortion is also highly effective later in the first trimester and can be self administered by women. Thus PRMs such as mifepristone if offered in a suitable dosage provides a model for a woman centred contraceptive continuum with added health benefits and increased autonomy for women.
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Oct. 3, 2014, 12:45
Comprehensive pain management in medical abortion
Christian Fiala
Gynmed Clinic, Vienna, Austria - christian.fiala@aon.at
Management of pain during medical abortion has been given insufficient attention in clinical practice as well as in research. For example neither pain nor its treatment are systematically reported in clinical trials: a literature research on Pubmed revealed 1 459 publications on medical abortion from 1988 until 2011, but only 18 trials reported pain when comparing different treatment regimens using mifepristone and misoprostol in first trimester. This shortcoming reflects a neglect of the individual pain perception, yet pain remains a decisive factor for women in the decision making process of abortion. Comprehensive pain management in medical abortion should be based on the principles of general pain management:
Avoidance of pain
As a first step, measures should be taken to avoid pain as far as possible:
* Unrestricted access to abortion would enable women to come as early as possible. Studies show that women’s experience of pain increases with gestational age. Reducing restrictions in access are therefore an important pain reduction measure.
* Induction of contractions should be limited as far as possible. Therefore the lowest effective dosage of the prostaglandin should be given.
* Free choice of the method is important because women report less pain when the choice of early medical abortion has been their own decision.
* Full and accurate information should be given on what to expect and what to do in case of pain.
* Women should feel relaxed and safe. Taking misoprostol at home is a pain reducing measure for many women.
Non-medical pain treatment
Classical hot water bottle, choosing the preferred body position and activity are effective aspect.
Medical pain treatment
* NSAIDs such as ibuprofen or diclofenac should be an integral part of pain management. They do not interfere with medical abortion treatment.
* Codein or tramadol should be available as backup.
Medication should be started as early as possible or even be given as prophylaxis before intake of misoprostol. (absorption of misoprostol is very fast and the first contractions can occur already within 15 minutes.) Providers should also make sure that patients have analgesics at home.
Reference: Pain during medical abortion, the impact of the regimen: A neglected issue? A review.
Fiala C, Cameron S, Bombas T, Parachini M, Saya L, Gemzell-Danielsson K.
Eur J Contracept Reprod Health Care. 2014 Sep 2:1-17.
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Oct. 2, 2014, 08:00
Dilatation and evacuation (D&E) is one of the World Health Organization's recommend methods for abortion in the second trimester. In addition to its safety and effectiveness, advantages of D&E are that the procedure can be scheduled as a day case and operating times are short (about 10-15 minutes), as opposed to the unpredictable duration of a medical abortion (MA), which may require hospitalisation. The efficiency and predictability of D&E is also beneficial where women require an abortion for maternal medical conditions or complications of pregnancy which could deteriorate during the course of a lengthy labour induction. Lastly, D&E is an important back-up for failed second trimester MA. In many parts of the world multiple barriers prevent access to D&E. One important barrier is a lack of trained providers. Using a mixture of didactic and adult learning methods, this day long workshop will cover the practical requirements of D&E including pre-operative assessment and planning, instruments, cervical preparation, pain control, procedural steps, immediate post-abortion care, and identification and management of complications. We will also cover the next steps in developing a D&E service such as preparation of clinical teams, training, waste management, and infrastructure requirements.