Speeches
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Oct. 22, 2010, 08:00
More medical abortion but high secondary intervention rates in an alternative abortion setting in the Netherland
Gunilla Kleiverda, MD, PhD, gynaecologist and Elles Garcia, MD, Flevoziekenhuis, Almere, Netherlands
Abortion clinics provide the vast majority (94%) of abortions in the Netherlands. Of the 11807 first-trimester abortions performed in 2008, 10% were medical abortions, the remaining 90% instrumental procedures.
In Almere, a vast-growing city close to Amsterdam, no traditional abortion clinic is present. The local Flevoziekenhuis started therefore an out-patient abortion clinic as a satellite in 2008. The clinic, not located in the hospital, offers possibilities of medical and instrumental abortion, and anonymous and non-anonymous care. Non-anonymous instrumental abortion up to 12-14 weeks is performed in the Flevoziekenhuis. For anonymous abortion and abortion after 12-14 weeks gestation, women are referred to abortion clinics in Amsterdam.
Women were referred either by their general practitioner or by self-referral. In the first year, 616 patients were seen. 127 did not have a termination of pregnancy, because a decision to keep the pregnancy, because of not being pregnant or a non-viable pregnancy. 56 women were referred to abortion clinics because of the wish to have an anonymous treatment or advanced gestational period.
Of the remaining 435 women, 239 (55 %) had a medical abortion, 196 (45%) had an instrumental first trimester abortion. The percentages of women who requested a medical abortion was high compared to national figures. However, rates of secondary aspiration were high as well, 35 (14.6%) in the medical abortion group, 5 (2.6%) in the primary aspiration group. Patient and health-care characteristics related to this high curettage risk will be presented and discussed.
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Oct. 2, 2014, 12:00
MYA study: Observational study on cervical preparation prior to surgical abortion in real life conditions
Aubert Agostini1, Philippe David2, Virginie Rondeau3 1Assistance Publique Hôpitaux de Marseille, Service Gynécologie, Hôpital de la Conception, Marseille, France, 2Service Gynécologie Obstétrique, Clinique Jules Verne, Nantes, France, 3INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France - aubert.agostini@ap-hm.fr
Background: More than 200,000 abortions are performed yearly in France. Guidelines are available for medical and surgical abortion. However, clinical practices on surgical abortion and particularly on cervical preparation are not well known and not sufficiently documented. Study objectives: The main objective is to describe the different surgical abortion procedures especially the methods used for cervical preparation prior to surgical abortion including mechanical dilatation, therapeutic regimen, prescribed medications and conditions of administration. The secondary objectives assess the investigator's satisfaction with cervaical preparation, patient's feedback on surgery and identify associated factors with the chosen method of cervical preparation. Design: MYA is an observational, prospective study set up, in real-life conditions, in centres with at least 50% of their activity in surgical abortions and with a high number of abortions per year (N >500). In total, 132 centres were invited and 40 centres agreed to take part in the study from December 2013. A cohort of 600 women (older than 18 years) undergoing a surgical abortion at less than 14 weeks’ gestation, is expected. Women are enrolled during the visit prior the surgery after giving their oral consent. Data collection and outcome measures: Data will be collected by the investigator on 3 occasions: enrollment visit, during surgery and at the follow-up visit usually planned 3 weeks after surgery, including safety data. Patients will be asked to complete a questionnaire on acceptability one week after surgery. Cervical preparation will be described by the method used: medication prescribed or not, dosage and type of administration, interval between the medication administration and surgery and the rationale of this therapeutic regimen. Descriptive statistics of all variables will be performed to analyze the results. Conclusion: This study aims to provide additional information on the procedures of cervical preparation particularly for Western countries where these medical practices are poorly documented.
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Oct. 25, 2008, 04:00
New developments in medical abortion care at 9-13 weeks
Alan Templeton (Scotland)
University of Aberdeen, Scotland
allan.templeton@abdn.ac.uk
After considerable experience of a mifepristone-misoprostol regimen for induced abortion in the early first trimester, pilot studies indicated the feasibility of using a similar regimen in the late first trimester. A randomised study was then carried out which demonstrated efficacy and acceptability compared with surgical abortion, and indicated that medical regimen was an effective alternative, acceptable to the majority of women. Subsequent review of experience indicated that approximately half of women will opt for medical abortion at 9-13 weeks gestation, if offered the choice. However acceptability is less than surgery, and decreases with gestation. Similarly the ongoing pregnancy rate is higher at higher gestations. Further randomised study has indicated the efficacy and acceptability of sublingually administered misoprostol at all first trimester gestations, even though the frequency of prostaglandin related side affects is higher. Further developments using the regimen will be reported at the meeting.
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Sept. 10, 2004, 11:00
New frontiers in contraception research
Regine Sitruk-Ware USA
Regine L. Sitruk-Ware is a reproductive endocrinologist and holds the position of executive director of product research and development at the Population Council’s Center of Biomedical Research. She organizes pre-clinical research and clinical development of new molecules designed for reproductive healthcare in men and women suitable for use in developing countries. She is a program director for a cooperative contraceptive research center of the NICHD. Prior to joining the Council, Sitruk-Ware had successively an Academic career and then a career in Industry in Research and Development. She taught and conducted clinical research in reproductive endocrinology at the University of Paris for ten years. She was a member of the International Committee for Contraceptive Research, which was established by the Population Council in 1970. She is a member of several national and international medical societies.
Sitruk-Ware has written eight books and over 200 articles and reviews, mostly dealing with women’s healthcare issues. She served as adviser in several ad hoc committees of the WHO and the NIH. She received her medical doctorate at the University of Paris and is currently an Adjunct Professor at Rockefeller University.
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Estimates predict that by 2015, the population growth rate will decline but that the total world population will reach the 6 billion mark, a 25% increase above the present day population. More than 26 million new couples will need contraceptives. Although a steady increase in contraceptive use has been observed both in developed and less-developed countries, the contraceptive needs of a significant percent of couples have not yet been met, and the number of unplanned pregnancies continue to increase. The actual usage of contraception differs from region to region. Although no new methods were registered for many years, several new products have reached the market during the last 2 years. Among these are new implants, medicated intrauterine systems, contraceptive vaginal rings, transdermal patches, and several new combined oral contraceptives.
New methods have been developed to meet the objectives of expanding contraceptive choices for both women and men and, of answering an unmet need for contraceptives with long-term action that meet the expectations of consumers. When interviewed, women request affordable methods that are highly effective and reversible, easy to use, and under their own control. Preference is given to methods that do not interfere with sexual intercourse and that result in regular withdrawal bleeding or, at least, no unpredictable bleeding. Men now tend to accept the concept of taking responsibility for the control of the couple’s fertility, leading to a growth in requests for male contraceptives, an emerging area of research. Simplicity, reversibility, and effectiveness are the desired features of a male contraceptive but no method is yet available.
New areas of basic research include studies of genes, proteins, and enzymes involved in the reproductive system. Identifying specific genes and the proteins induced by these genes and finding molecules that specifically antagonize gene action will open new avenues for the development of contraceptives that do not modify the hormonal profile of the individual. The new methods will be targeted to specific interactions within the reproductive system at the level of the ovary and testis, as well as between spermatozoa and the ovum.
Genes involved in the regulation of human reproduction are explored first in animal models but these models must then be validated by studies in humans. As an example, spermatogenesis requires a complex interaction between various cellular compartments of
the testis, and proteins involved in these interactions are now targets for contraceptive methods. These new approaches also require the engineering of original drug-delivery methods that reach the target very specifically but do not interact with other tissues in the body.
This futuristic approach still keeps in mind the need for better access to existing contraceptive methods, as well as the discovery of new contraceptives that are simple to use, safe, reversible and inexpensive. In the future, contraceptives may be combined with other medicinal agents to provide dual protection against both pregnancy and another preventable condition, such as sexually transmitted infections. Some preliminary studies suggests that certain contraceptive methods, given alone, may not only prevent pregnancy but may also prevent common disorders of the female reproductive system, such as menorrhagia and the anemia it causes. When a contraceptive method provides dual benefits, women may have a greater motivation to use a contraceptive method, reducing contraceptive failures and unwanted pregnancies.
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Oct. 23, 2010, 02:00
NGO providing support to improve the quality of abortion services
in a government clinic: case study from Armenia
Meri Khachikyan, “For Family and Health” Pan-Armenian Association, Yerevan, Armenia
Co-author: Ruzanna Abrahamyan
In Armenia, as in all former Soviet countries, induced abortion was the primary means of fertility control
for many years. The most frequently used methods for pregnancy termination are Dilatation and Curettage (D&C) and Electrical Vacuum Aspiration (EVA). More modern methods like medical abortion and Manual Vacuum Aspiration (MVA) are not commonly used. In 2002 the Parliament of Armenia adopted a new law on “Human Reproductive Rights and Reproductive Health” that legalizes induced abortion on request up to 12 weeks of gestation and legalizes induced abortion up to 22 weeks for medical or social reasons. According to official data from the Ministry of Health of Armenia, induced abortions before 22 weeks of gestation constituted 33 percent of all maternal deaths in 2002. In 2005 this had been reduced to 7% of all maternal deaths. Among women that have an abortion, the average number of abortions per lifetime is 2.6 (the survey reached 14-24 year old male and female respondents). Repeat abortions are common due to the lack of post-abortion contraception.
In the National Survey and Case Studies on Sexual and Reproductive Health Knowledge, Attitude, Behaviour and Experiences conducted among young people 16% of sexually active young women reported having had an unintended pregnancy in comparison with 19% of young men. The attempt to self-induce abortion is common. The rates of miscarriages and abortion-related complications are quite high. Most of young women were not happy with the quality of abortion care when having had a hospital-based abortion.
“For Family and Health” Pan-Armenian Association NGO (PAFHA), with support of the IPPF/IF and other donors has established its own clinic in Yerevan to provide sexual and reproductive health services, including comprehensive abortion care in response to the needs of young and poor women who cannot access high-quality care due to financial or social barriers. Since January 2009, the PAFHA has been involved in implementation of the IPPF Global Comprehensive Abortion Care Initiative in partnership with tertiary referral level health facility - Institute of Perinatology, Obstetrics and Gynaecology and a regional clinic that provides services for the town of Vayk and five neighbouring villages in Vayots Dzor region of Armenia. The purpose of the project is to reduce the incidence of abortion complications, and enable poor and young women in Armenia to access high-quality abortion services.
The project used different strategies like capacity building, community participation, and advocacy to improve abortion care and access to high quality abortion services. Within the framework of the project the PAFHA established an effective model of public-private partnership that involves introduction of the quality of care approach, improvement of the systems of clinical information management, improving the referral and follow-up systems. Support from decision makers, health professionals, journalists, community leaders, parents and peer-educators were essential in increasing access to comprehensive safe abortion care.
As an outcome of the initiative significant progress was revealed in the improvement of the quality of abortion care at the PAFHA clinic and its two partner clinics. Furthermore, the IPPF GCAC initiative gave a unique opportunity to PAFHA to introduce international approaches towards quality of abortion care nationally. In June 2010, the National guidelines and standards for providing safe abortion services in line with international recommendations were endorsed by the Ministry of Health. The implementation of a national program on monitoring and evaluating the quality of SRH services, including maternal and abortion care has been initiated.
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Oct. 25, 2008, 02:00
No compulsory counselling: The advantages for women
Margot Schaschl (Austria)
Gynmed Clinic, Vienna, Austria
Austrian law only requires counselling by the medical doctor. This is usually no more than a standard medical conversation about informed consent. There are no other regulations, and no requirement for further counselling, nor does the law provide for any compensation for such counselling.
Our experience has shown that more than 90% of the women who come to us for an abortion have already made their decision. In most cases, the decision is made quickly, within a few days, usually with advice and support from a partner, family, or friends. Many women also search the Internet for information. But most women do not need professional counselling to make a decision.
The advantages of the Austrian system for women are:
- The woman does not have to visit a counselling centre, which usually incurs extra effort and financial costs (i.e. taking time off work or school, travel expenses, childcare, etc.)
- For advanced pregnancies, each day counts and the extra time needed for compulsory counselling can put a woman past the legal deadline.
- A rapid appointment is possible. This offers a better possibility to choose between medical and surgical abortion.
- The woman need not justify her decision in front of a stranger, thus respecting her privacy and reducing the psychological pressure.
- Less emotional stress means less problems, pain and fear when the abortion is done.
- Unnecessary concerns are not raised or fuelled.
- The decision remains self-determined by the woman. This helps her “own” it, so she can accept the responsibility and live with her decision more easily.
The basis for the counselling is accepting and respecting the woman’s decision. To challenge her decision is neither fair nor professional. On the contrary, being too investigative can lead to paternalism.
Another key element of the counselling is that each woman knows best about her present life circumstances. Therefore, only she can decide if she needs assistance in her situation.
Professional counselling is good and necessary. Nevertheless it should be voluntary, patient-directed, and individually adapted for each woman.
There are few things that could do more harm than biased counselling that tries to lead the woman to a particular decision. That can lead to indoctrination.
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May 25, 2002, 11:00
Medication After Medical Abortion -
NSAIDs in pain treatment, Rh-immunoglobulin
Christian Fiala
Management of pain during medical abortion has been hampered by recommendations in the product information and guidelines from various sources that non-steroidal anti-inflammatory drugs (NSAIDS) should not be given to women at least until the follow-up visit eight to 12 days after mifepristone administration. Currently the summary of product characteristics for mifepristone includes advice that, ‘A decrease of the efficacy of the method can theoretically occur due to the antiprostaglandin properties of NSAIDS. Use preferably non-NSAI agents.’ The published evidence does not support these recommendations against the use of NSAIDs.
Furtheromore NSAIDS are prostaglandin synthetase inhibitors and should have no adverse effect on exogenous prostaglandins. Stated alternatively, NSAIDs don't interfere with misoprostol and there are some good arguments for their use.
The efficacy of medical abortion in Karolinska Institute and in the General Public Hospital in Korneuburg/Austria has been the same when NSAIDS are used
Anti-D immune globulin is given in most places after early abortion, although evidence is lacking for the usefulness of this intervention at this early stage of pregnancy. Evidence-based guidelines for the administration of anti-D immune globulin (anti-D IgG) for women undergoing early spontaneous or induced abortions are missing. This is especially true for medical abortion, which is increasingly used in recent years.
An ongoing study in Sweden is presented.
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Oct. 2, 2014, 12:00
Nurse’s role in medical abortion up to nine weeks of pregnancy in a day hospital unit
Jasmina Kostoski, Sanja Perić, Vlasta Slapničar University Medical Centre Ljubljana, Ljubljana, Slovenia - jasmina.kostoski@gmail.com
Introduction: The Day Hospital is part of a Reproductive Unit which contains an operating room for aseptic interventions and three hospital rooms with 14 bed units. This is the main unit for all kind of abortions and minor operative procedures in gynaecology. The average annual number of patients is between 2500 and 2700. 1,232 abortions up to 10 weeks are performed, of which 766 medical abortions were recorded last year. Organization and workflow: Patients are coming to the Day Hospital with an already signed application for termination of pregnancy up to 10 weeks of gestation. A nurse will interview the patient in order to determine which kind of abortion will be the most appropriate (depending on the level of pregnancy, her expectations and any additional diagnosis). If medical abortion is appropriate, the patient is going back to the nurse who will give her a prescribed tablet of mifepristone. Together, they will make a plan for the further course of pregnancy termination considering the patient’s career and family responsibilities. The patient will not leave the hospital without having received all the needed spoken and written instructions from the nurse. Approximately 36-48 hours after taking the tablet, the patient is returning. After a brief interview in relation with the course of the first part of the medical abortion, the nurse will give the patient a tablet of NSAID and place the patient into the bed unit. After that the nurse or the resident will insert 4 tablets of misoprostol in her vagina. During that time, nurses are taking good care of the patient, helping to alleviate the possible pain and sickness by giving medications and controlling bleeding and pain. After 3 to 4 hours, the nurse is giving further instructions to the patient who will be able to safely leave the hospital.
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Oct. 22, 2010, 11:00
OC without prescription
Ali Kubba MB ChB FRCOG FFSRH, London, United Kingdom
OCs are the most studied drugs of the modern age. Their non-contraceptive benefits are signi-ficant but largely unknown to users. Their adverse effects are uncommon so most women are eligible to use OCs. The EBM tool for prescribing is the WHO Medical Eligibility Criteria. These are highly adaptable to checklists that users themselves or pharmacists/web based providers can use to select safe use.
Self selection or facilitated self selection for OC use, increases access and cuts costs for the user and the healthcare system. I will be discussing models of delivery and the experience from a small project in South London.
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Sept. 11, 2004, 02:00
One-and two day mifepristone-misoprostol intervals are both effective in medical termination of second trimester pregnancy
Oskari Heikinheimo, Satu Suhonen and Maija Haukkamaa, Department of Ob&Gyn, Helsinki University Central Hospital, Finland
Termination of pregnancy because of fetal anomaly requires the utmost clinical sensitivity and individualized patient care. We compared the efficacy of a one-day mifepristone and misoprostol –interval in medical termination of second trimester pregnancy performed because of fetal anomaly with that of the standard two-day interval among the first 100 women in each group. A 200 mg dose of mifepristone was used; 0.4 mg of misoprostol was administered vaginally at three-hour intervals until abortion occurred.
When calculated from ingestion of mifepristone, the time to abortion was 28:25 h (23:10 – 50:40 h) (median (range)) and 52:43 h (45:55 – 83:15 h) (p<0.0001) in the one- and two-day MIFE-MISO groups, respectively. However, following initiation of misoprostol administration the time to abortion (7:25 h (1:00 – 23:15 h)) was longer (p<0.05) in the one-day interval group than in the two-day interval group (6:20 h (0:45 – 36:30 h); by 12 h 82 and 87% (n.s.), respectively, of the subjects had aborted. The proportions of cases undergoing surgical evacuation of the uterus were 64 and 45% (p<0.001), in the one- and two-day interval groups, respectively.
Thus both one- and two-day mifepristone-misoprostol intervals are both valuable in termination of second trimester pregnancy.