Speeches
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Oct. 15, 2016, 02:00
FC27
European transnational survey related to medical abortion in the first trimester of pregnancy
Filipa Mendes Coutinho1, Teresa Bombas1 ,2, Paulo Moura1
1Serviço de Obstetrícia A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 2On behalf of Expert Group on abortion, European Society of Contraception and Reproductive Health (ESC), Coimbra, PortugalBackground: Currently most European countries allow abortion upon women's request in the early weeks of pregnancy. Despite WHO's recommendations, the definitions and methods used in clinical practice are not well established. The knowledge of the different attitudes regarding abortion would be beneficial.
Methods: We conducted a survey via mail involving 20 centres from 19 countries in which abortion is legal, to understand the differences in clinical practice regarding medical abortion. We performed a statistical analysis assessing a number of variables, including: number of abortions per year; rate of medical abortion; availability of national guidelines; methods of follow-up; among others.
Results: Nineteen centres responded (95%) and most of these (84%) perform medical abortion. A large number do not use it as a first-line method. Thus, from an estimated 21,925 abortions registered in the past year, only 39% were performed by medical protocol. In spite of the lack of guidelines all the institutions use a combination of mifepristone and misoprostol to terminate pregnancy. The differences lie in the dosage used as well as the route of administration. Concerning follow-up, 52% of the institutions agree on a two week interval and almost 65% perform an hCG blood level as well as an ultrasound scan after this period. Similar percentages (63%) repeat medical treatment in case of ongoing pregnancy after a first cycle of medication and 68% in case of incomplete abortion. When asked if having more precise definitions for success of medical/surgical abortion would be beneficial, nearly 77% responded affirmatively.
Conclusions: In late years we have witnessed an increase in the number of medical abortions performed in European countries. Despite the WHO recommendations the access to abortion methods are quite different. The majority of the surveyed institutions agree this would be an important step towards improving management of the procedure. -
Oct. 4, 2014, 02:00
How do women manage antibiotic pills after medical abortion?
Laura Frye, Erica Chong, Beverly Winikoff Gynuity Health Projects, New York, USA - bwinikoff@gynuity.org
Is it time to move away from routinely giving doxycycline to medical abortion patients? Objectives: Routine provision of antibiotics following medical abortion is common, yet practitioners and professional societies differ on the utility of this practice. Our study compares the side-effects experienced by women who were prescribed doxycycline following medical abortion to those who were not and assesses the adherence to one regimen. Methods: 581 women seeking medical abortion were enrolled in this prospective, observational study in nine study sites. They were recruited from 1) clinics that routinely prescribe a seven-day course of doxycycline (Doxy Arm) and 2) clinics that do not routinely prescribe any antibiotics (No Doxy Arm). Seven to fourteen days following the administration of mifepristone, women were asked to self-administer a computer-based survey. The survey asked about side effects experienced (both arms) and adherence to the regimen (Doxy Arm only). Results: Self-reported adherence to the doxycycline regimen was moderate: 44% reported missing at least one dose and 34% stopped taking the doxycycline before 7 days. There was a trend toward increased nausea in the Doxy Arm (48% vs. 41%; p=.06) and a statistically significant difference in vomiting (25% vs. 19%; p=.03). A small but noteworthy number of women were confused about various aspects of the different medicines they received or were prescribed, including misunderstanding the purpose of a medicine, claiming to not have received a drug despite medical chart confirmation and noting costs of filling prescriptions that were not received. Implications: In the absence of robust evidence that prescribing 7 days of doxycycline following medical abortion is effective at reducing serious infections, these data can assist in deciding whether routine provision is the most appropriate strategy. Given the limits of any patients' ability to follow multiple and varied instructions, it is worth considering the impact of adding doxycycline, especially when it is frequently advised to be taken with an anti-emetic.
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Oct. 4, 2014, 04:00
Medical methods at later gestations
Allan Templeton University of Aberdeen, Aberdeen, UK - allan.templeton@abdn.ac.uk
Induced abortion is one of the most common medical interventions. Most abortions are carried out in the first trimester, but there is a continuing need to provide services for those presenting later, about 10% of the total, and including most abortions carried out for fetal abnormality and for medical reasons. Medical, rather than surgical, methods became safe and effective with the advent of prostaglandins and this approach was greatly facilitated with the introduction of mifepristone around thirty years ago. Regimens employing mifepristone and a prostaglandin, usually misoprostol given vaginally or sublingually, are now available at all gestations. From about nine weeks onwards it will be necessary to repeat the misoprostol dosage perhaps two or three times or more, usually at three hourly intervals. Misprostol alone can be used in this way, where mifepristone is unavailable, but the efficacy is much reduced, a higher total dose is needed, the abortion interval is increased and there are more side effects. With the combined regimen the overall incomplete abortion rate is around 5%, necessitating the removal of the placenta (usually) surgically. Trials comparing medical and surgical approaches are few, but point to a greater preference among women for surgical approaches, although a good number choose medical. Pain and bleeding is higher with medical abortion, but the risk of serious injury, although rare, may be higher following surgery. Infection screening and antibiotic policies should be as for early abortion, as should the offer of immediate long-acting contraception.
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Oct. 14, 2016, 02:00
FC03
Pain management for up to 9 weeks medical abortion – An international survey among providers
Christian Fiala1 ,8, Sharon Cameron2, Teresa Bombas3, Mirella Parachini4, Aubert Agostini5, Roberto Lertxundi6, Laurence Saya7, Kristina Gemzell-Danielsson8
1Gynmed Clinic, Vienna, Austria, 2Chalmers Centre, NHS Lothian, Edinburgh, UK, 3Obstetric Service A, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 4San Filippo Neri Hospital, Rome, Italy, 5Obstetric and Gynecology Department, La Conception hospital, Marseille, France, 6Clinica Euskalduna, Bilbao, Spain, 7Altius Pharma CS, Paris, France, 8Department of Women’s and Children’s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, SwedenIntroduction: There is no consensus about pain management for medical abortion (MToP) and evidence based guidelines give different recommendations. A survey among providers was done to analyse regimens being used in clinical routine.
Methods: A questionnaire on details of pain management for first trimester MToP was developed by a group of experts. Health care providers all over the world offering MToP were invited to complete it through a FIAPAC dedicated website.
Results: 283 health care professionals from all regions of the world completed the questionnaire: Europe 59%, North America 21%, Asia 8%, Australia and New Zealand 6%, Africa 4%, Latin America 2%. Most respondents (n= 267, 94%) reported analgesic prescription/provision for all women, either prophylactic for 82% (n=233) or upon request for 12% (n=34). WHO Step I analgesics (NSAIDs, paracetamol) were the most often used in both cases. A total of 16 (6%) respondents indicated that they never provided analgesics (or prescriptions for them). Only 24 providers (10%) started pain treatment after mifepristone. Female providers of abortion care were significantly more likely to prescribe systematic analgesia for patients than male providers (85% vs 74%, p<0.04). Most practitioners did not adapt the analgesic treatment to gestational age or according to place of intake of misoprostol (home or at the clinic/hospital). The majority of respondents (69%, n=195) did not conduct formal assessments of women’s pain.
Conclusion: There is widespread variation in the assessment and management of pain during MToP, reflecting the lack of evidence based guidelines. This is a clear indication for improvement of using available and effective pain treatment to avoid unnecessary pain by women. -
Oct. 3, 2014, 02:00
UK Faculty programme
Katherine Guthrie City Health Care Partnership CIC, Hull, UK - k.guthrie@nhs.net
Training in abortion provision is within the postgraduate specialty training programmes of the Faculty of Sexual and Reproductive Healthcare (FSRH) and the Royal College of Obstetricians and Gynaecologists (RCOG). These cover medical abortion and 1st trimester surgical abortion. The RCOG programme does not cover local anaesthetic procedures. The College has an optional advanced programme to cover local anaesthetic procedures and later gestations for surgery. The Faculty also has a training programme accessible to doctors and nurses who wish to undertake further training in this field. Conscientious objection within the National Health Service plus the shift in the provision of care to non-NHS providers has created a challenge in accessing training.
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Oct. 3, 2014, 02:00
Using research to increase access to medical abortion in Uzbekistan
Diffuza Kurbanbekova Women's Wellness Center, Tashkent, Uzbekistan - dilfuzabegim@yahoo.com
The Republic of Uzbekistan, located in Central Asia, is the most populous country in the region with 28 million people. More than a quarter of the population are women of reproductive age. Abortion in Uzbekistan has been legal for over 50 years and abortion services are available without restriction in the first 12 weeks of gestation. Abortion in the second trimester (up to 24 weeks) is available only on broad medical and select socioeconomic grounds. Until recently, the prevailing methods for termination of pregnancy were manual vacuum aspiration (MVA) using outdated equipment and dilatation and curettage (D&C) under local anaesthesia. Although mifepristone has been registered in the country since 2005, there were no national guidelines on medical abortion provision. In addition, the lack of trained providers and absence of an established distribution system for mifepristone inhibited its use on a wide scale. In 2007, Gynuity Health Projects launched a series of collaborative activities in Uzbekistan with the goal of increasing access to medical abortion services in the country. Through its clinical research projects and trainings, Gynuity introduced an evidence-based regimen, trained providers in provision of early medical abortion and expanded access to medical abortion services by conducting a study on an alternative method of follow-up. Additional collaborative activities included dissemination meetings to present study findings and assistance in developing national protocols. This presentation will describe how clinical research has contributed to increased access to medical abortion in Uzbekistan.
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Oct. 3, 2014, 09:45
Women on Web
Rebecca Gomperts Women on Waves, Amsterdam, The Netherlands - gomperts@womenonwaves.org
Women on Web is a telemedical abortion service for women with an unwanted pregnancy up to 9 weeks living in countries without safe abortion care. Three studies looked at the outcome and factors influencing the surgical intervention rate after the medical abortion provided to women through telemedicine. One retrospective study analyzed information from 484 women who received a medical abortion at their home addresses in 2006 and 2007. Sixteen of the 265 (6.0%) women who provided follow-up information reported that they did not use the medication. Of the remaining 249 women who did the medical abortion at home, 13.6% reported having a surgical intervention afterwards and 1.6% reported a continuing pregnancy. After the follow-up rate increased from 54.8% to 77.6% of the cases, 12.6% of the women reported they did not take the medication and only 6.8% of the women having the medical abortion at home underwent a surgical intervention afterwards. Another study analyzed the influence of geographical location on the outcome of the 2323 women. High rates were found in Eastern Europe (14.8%), Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%; p=0.000). The third study evaluated the data from women living in Brazil.. Of the 370 women who used the medicines, 307 women provided follow-up information about the outcome of the medical abortion. Of this group, 207 (67.4%) of the women were up to 9 weeks pregnant, 71 (23.1%) were 10, 11 or 12 weeks pregnant, and 29 (9.5%) of the women were at least 13 weeks pregnant. There was a significant difference in surgical intervention rates after the medical abortion at the different gestations (19.3% at <9 weeks, 15.5% at 10-12 weeks and 44.8% at >13 weeks, p=0.06). However, 42.2% of the women who had received a surgical intervention afterwards did not have any symptoms of a complication. This research shows that medical abortion can be safely and effectively provided to women themselves through telemedicine. Surgical intervention rates after the medical abortion provided via telemedicine reflect local medical practices. The risk of surgical intervention and ongoing pregnancy after home medical abortion only tends to increase after 12 weeks of pregnancy.
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Sept. 14, 2018, 02:00
Context: The method of abortion has rapidly changed from surgical to medical termination of pregnancy (MToP) in several countries; today 95% of abortions are MToP in Finland.
Objective: Intensity of pain, need of analgesics, evaluation the adequacy of ibuprofein and paracetamol, and patient satisfaction. Comparison of teenagers vs. adult women. These are the results of an interim analysis of the first 97 patients of the study.
Methods: This prospective study evaluates pain during MToP in early pregnancy (<64 days of gestation). Altogether 120 primigravid women are being recruited. The ratio of teenagers (15-19 year-olds) and adult women (25-35 year-olds) is 1:1.
MToP was carried out according to the Finnish national guideline. The medication consists of 200mg of mifepristone administered at the outpatient policlinic followed by 0,8mg of misoprostol vaginally or orally at 24-72 hours primarily at home. Ibuprofein (600mg) and paracetamol (1g), both up to three times/day were used for pain management. First doses are taken simultaneously with misoprostol and thereafter whenever needed. Pain is measured by visual analogue scale (VAS), which is reported in a diary each time patient needs analgesics.
Results: The highest pain reported by VAS was 78±18 (mean±SD) among teenagers and 66±27 among adult women (p=0,005, VAS 70-100mm); 48% vs. 19% of the patients reported severe pain. Nevertheless 77% of teenagers and 65% of adults evaluated the analgesia as adequate and the overall satisfaction with the care received was high in both groups (VAS 85±12 vs. 85±15; p=0,311).
Altogether 88% vs. 93% would choose MToP again.
Conclusions: Women and especially teenagers undergoing MToP experience strong pain already in early pregnancy. Even though teenagers experience more pain they more often estimate that the combination of ibuprofein and paracetamol is adequate. -
Oct. 3, 2014, 02:00
The time of an abortion is a window of opportunity for contraceptive counselling. Clinical practice shows us that we can and must provide contraceptive counselling at the first abortion appointment and not leave it for follow-up. There were some concerns that during the time of an abortion the women will be too distressed with the information regarding the abortion decision and abortion method and so will not able to consider the information about contraception. The women and the couples must be informed that fertility returns rapidly after first trimester abortion. Well informed women were able and motived to choose and start a contraception method at the time of the abortion. Starting a contraceptive method at the time of the abortion is safe and good practice. For medical abortion, combined hormonal contraception, oral progestogen, injectable and implant could be start or inserted on the day of misoprostol administration. For surgical abortion these methods could be started or inserted on the day of the procedure. For surgical abortion, an intrauterine device could be inserted at the time as the operation.
Immediate insertion of an IUD/IUS is safe, results in higher method uptake compared to interval insertion but the expulsion rate seems to be marginally higher. A randomized trial showed that IUD/IUS insertion as early as one week after medical abortion is safe and results in high method uptake and no difference in expulsion rate compared to the insertion at 3-4 weeks. Providing information, updated practices and access to contraception at the time of the abortion will contribute to an immediate start of a contraceptive method and to a lower risk of repeated abortion.
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Oct. 15, 2016, 11:00
FC13
Paracervical block (PCB) as pain treatment during second-trimester medical termination of pregnancy - a randomised controlled trial with bupivacaine versus sodium chloride.
Inga-Maj Andersson, Lina Benson, Kyllike Christensson, Kristina Gemzell-Danielsson
Södersjukhuset AB, Stockholm, SwedenThe most common side effect of misoprostol is pain, however there are sparse studies of pain and pain treatment during MToP, especially in second-trimester abortion. Pain reported in second-trimester medical abortion is often intense, and peaks when the expulsion occurs.
Objectives: The aim of the present study was to determine if PCB administered before the onset of pain could decrease women´s pain experience during second-trimester MToP.
Method: A double-blinded randomised controlled trial, with 113 participants included, was performed during May 2012 until April 2015. Women who consented to participate were randomly allocated to receive a PCB with either 20 ml local anaesthesia (bupivacaine 2.5 mg/ml) or 20 ml sodium chloride 9mg/ml. The PCB was applied one hour after the first dose of misoprostol as a 2 to 4 millimetre deep paracervical injection into the mucosa at two sites (2 and 8 o´clock). The experience of pain was measured by visual analogue scale (VAS) at the time of administration of the first dose of misoprostol (baseline) and thereafter repeated every half hour during the abortion until the expulsion. The main outcome was the highest pain intensity recorded on the VAS scale. Secondary outcomes were the induction-to-abortion interval measured from the start of misoprostol to expulsion, the total morphine consumption, safety and side effects.
Results: No statistically significant differences were observed between the two groups with regard to the highest and lowest pain intensity and morphine consumption. There was no difference in efficacy between the groups, neither in induction-to-abortion interval and time to placental expulsion nor in the rates of surgical intervention or the need for any additional treatment.
Conclusion: It can be concluded that prophylactic PCB did not lead to a clinically significant reduction in maximal pain scores and the need for additional opiates during second-trimester MToP.