Speeches
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Oct. 22, 2010, 02:00
Diagnosing gestational age, viability and location
Christian Fiala, MD, PhD, Gynmed clinic, Vienna, Austria
The best method to diagnose a pregnancy depends on gestational age and on the setting.
hCG in serum or urine is highly reliable in diagnosing a pregnancy and the only way of doing so in very early gestation. But it gives very little information about gestational age and tells us nothing about viability or location of the pregnancy. In very early pregnancy, before it can be seen on ultrasound, it is useful to have a baseline serum hCG for comparison at follow-up.
Ultrasound examination (abdominal is sufficient in most cases) is very fast and gives a very reliable result about gestational age and location. But it can only be done in pregnancies over 6 weeks gestation. It also needs a trained provider and the machine might be expensive in some settings. Bi-manual examination is cheap and easy to do but unreliable in early pregnancy.
Therefore a combination of ultrasound and hCG testing is most reliable.
Blood grouping (Rhesus)
This is done in most places in Europe and North America because we want to find those women who are rhesus negative and give them an Rh-immunoprophylaxis. Rhesus negativity is a Kaukasian trait usually not found elsewhere. However there is no evidence for the need of Rhesus-prophylaxis for a first trimester abortion. Foeto-maternal blood transfusion seems unlikely given the small amount of fetal blood, especially in very early pregnancy.
So far only the health authorities in Sweden (Board of Health and Welfare) have issued a recommendation not to give Rh-prophylaxis in medical and spontaneous abortion.
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Oct. 20, 2012, 02:00
FC1.01
Our love affair with misoprostol over the last
20 years
Herbert, WY
The Queen Elizabeth Hospital Pregnancy Advisory Centre, Australia
TheQueen Elizabeth Hospital Pregnancy Advisory Centre in
Adelaide, South Australia is agovernment-funded clinic established
in 1992,providing over 2500 surgical terminations eachyear.
Four papers published over the last 20 years document our
implementation of misoprostol use, showing significant
improvements in service delivery, as well as reduction in
complication rates.
Our first study published in 1999 showed that adding
misoprostol to osmotic dilators at 17–20 weeks of gestation to
increase passive dilatation of the cervix, markedly reduces the risk
of perforation of the uterus.
Our second study published in 2009 compared the outcomes
of four different peri-operative misoprostol regimens for first
trimester surgical terminations. Compared to no misoprostol
regimen, the regimen of 200 lg of oral misoprostol 3 hours
pre-operatively plus 200 lg of misoprostol vaginally at the end of
the surgical procedure showed: 90% reduction in difficult cervical
dilatations, 60% reduction in rate of D&C treatment of retained
products of conception and 71% reduction in incidence of
women requiring post-operative contact for concerns.
In 2011, our third study demonstrated that adding 200 lg of
oral misoprostol 3 hours before two tablets sublingually every
half-hour for three doses at 13–16 weeks of gestation further
reduced difficulty of the operation.
In 2002, we adopted medical management with misoprostol,
as first-line treatment for retained products following surgical
termination. Our study published in 2009 showed that the
regimen of 200 lg of misoprostol orally or sublingually three
times a day for six doses was 93% effective, and reduced the
D&C rate by 79.6% from 1.18% to 0.24%. -
Oct. 19, 2012, 09:00
Outcomes of very early medical termination of
pregnancy at ££6 weeks of gestation
Heller, R; Cameron, S
NHS Lothian, UK
Background and methods: In 2010 the termination of pregnancy
(TOP) service at The Royal Infirmary of Edinburgh, Scotland, UK
introduced a protocol that allowed women at very early gestation
without ultrasonic evidence of an ongoing intrauterine pregnancy,
but who fulfilled certain criteria (£6 weeks of gestation by dates,
eccentric placed intrauterine gestational sac of £3 mm, decidual
reaction, no risk factors for ectopic) to proceed directly
with medical TOP, without the need for further investigations
or ultrasound scans. Follow up consisted of routine
telephone follow up with home low sensitivity urine pregnancy
(LSUP) test.
A retrospective audit of the management of this group of
women attending in 2011 was conducted. Hospital computerised
records and case notes were used to determine the number of
visits made, investigations performed and outcome of the
pregnancy.
Results: Five hundred and eighty women attended over the audit
period requesting a TOP at £6 weeks of gestation. Of these
women 3.7% (n = 21) had a serum hCG performed prior to TOP,
and 2% of women (n = 12) had more than one ultrasound before
TOP. Seventy-three percent of women (n = 414) had routine
follow up (telephone follow-up with LSUP) only, 24.4% (n = 138)
had one post-TOP ultrasound, and 1.5%, (n = 9) returned for
more than one post-TOP ultrasound. At follow up ultrasound,
two women were found to have ongoing pregnancies (0.3%).
There were no ectopic pregnancies.
Discussion and conclusions: Most women at early gestation
(£6 weeks) without definite evidence of a viable intrauterine
pregnancy can proceed to medical TOP without the need for
additional pre-TOP or post-TOP ultrasonography -
Oct. 25, 2008, 02:00
Outpatient use of mifepristone and misoprostol before and after 8 weeks gestation
Marisa Moreira, Renato Martins, Teresa Bombas, Teresa Sousa Fernandes, Manuel Pitorra, Maria Céu Almeida, Paulo Moura (Portugal)
Genetics, Reproductions and Fetal Maternal Medicine Department, Coimbra University Hospitals, and Bissaya Barreto Maternity, Coimbra Hospital Center, Portugal
renato.alessandre@gmail.com
Introduction. Since 16th of July of 2007, abortion is legal by women request before 10 weeks. The use of medical abortion is associated with lower complications. According to OMS protocols, the use of Mifeprostone and Misoprostol for abortion in out patient therapy can be used, for early pregnancies.
Objectives. We analyzed the use of medical therapy in abortions under 10 weeks gestational age comparing two groups – under 8 weeks (Group 1) and between 8 and 10 weeks (Group 2).
Material and Methods. We analyzed the clinical reports of women that came for abortion, during one year of experience, since 16th of July of 2007, in both medical facilities of Coimbra.
Results. We included 600 women. The average age was 28.2 ± 7.6 years. Most women are Portuguese (about 90%) and lived in Coimbra. More than half of these women are married and live with their partner. The authors split these women into 2 different groups: Group 1 (before 8 weeks gestacional age) with 450 women, and Group 2 (between 8 and 10 weeks) - 150. Both groups showed no statistical difference in all demographic aspects analysed. In terms of abortion method, correlation between the 2 groups revealed no statistical difference. Both groups revealed 5% complications, mainly due to failure of medical therapy. Between the two groups no statistical difference was found in terms of complications.
Conclusions.The use of medical abortion in out patient regimen can be safely used. The authors showed in this study that results between two different groups had no statistical significance. Moreover, when questioned, patients showed a high level of satisfaction with this protocol.
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Oct. 22, 2010, 09:00
An overview from Asia
Nongluk Boonthai, Bureau of Reproductive Health, Department of Health, Ministry of Public Health, Thailand - Co-author: Kamheang Chaturachinda, Women’s Health and Reproductive Rights Foundation
of Thailand
With the largest population of any region of the world, Asia has the largest absolute number of abortion
around 26 million per year Nearly half of the world’s unsafe abortion take place in Asia and almost one third in South Asia alone. Unsafe abortion accounts for 12% of maternal death in Asia worldwide there is a declining trend in abortion between 1995 to 2003. Asia is no exception the rate of abortion declined from 33 to 29/1000 women of reproductive age. At the same time contraceptive use (CPR) in Asia, as estimated by UN, climbed from an estimate of 65.6 percent in 2000 to an estimate of 68.2 in 2010 and a further estimated climb to 70 percent in 2020.This climb in CPR is hand in hand with the reduction in UN estimate of Asia’s total fertility rate( TFR )from 2.6 in 2000 to 2.4 in 2010 and to 2.2 in 2020.
Since 1997, 17 countries around the world liberalized their abortion laws, 4 countries in Asia are among them (Bhutan, Nepal, Cambodia, Thailand ). With the population of just over 63 millions, abortion law in Thailand promulgated in 1956 permits abortion if it is done by a physician with the consent of the patient. Grounds for abortion include maternal health as well as pregnancy arising from sexual crimes , pregnan-cy in the young, ages under 15 years old. There is no hard national data on unsafe abortion. It is not officially collected. Moreover, abortion is socially controversial, stigmatized and condemned. Poor women lacked access to the safe service and therefore suffered most from unsafe abortion and its complications including sequelae of secondary infertility.
The number of unsafe abortion is estimated to be somewhere between 300,000-400,000 cases annually, mostly done “underground”, while there are approximately 800,000 births occurring each year. The cost, economically, physically and psychologically to women and to the nation is unacceptable. In spite of legal freedom to safe abortion access to safe abortion is still limited due to negative attitude of the health care provider. Only a hand full of providers in the govern-ment sector and a few private organizations provide out let for safe abortion in large cities, using Vacuum Aspiration. Almost all other Thai providers still use exclusively dilatation and curettage (D&C).
Lack of service providers is another problem. There are only 2,000 OB-GYN. and not all are willing to provide abortion. The myth that abortion is illegal plus negative personal and religious beliefs and their unwillingness to provide the service, resulted in poor access to safe abortion. Abortion seekers went to see quacks instead.
Over the past 50 years many attempts were made to amend the law; all were unsuccessful. The Thai Medical Council and the Royal Thai College of Obstetricians and Gynaecologists (RTCOG) decided to widen the criteria for termination of pregnancy by defining health to include mental aspect. The new regulation was approved in December 2005.
More works still need to be done. The negative attitude of the physicians toward abortion has to be changed. The use of D&C has to be replaced by vacuum aspiration. Therefore, to increase access, trainings on safe abortion using vacuum aspiration are being conducted. The Women’s Health and Reproductive Rights Foundation of Thailand (WHRRF) a non-profit, non-governmental organization. It is established to eliminate unsafe abortion and promoting safe abortion in Thailand through advocacy research, education and training by using the most up to date abortion technology. It has been collaborating with the Department of Health and the RTCOG, have carried out training workshop on prevention of unsafe abortion and use of MVA (Manual Vacuum Aspiration) through our established training centers in the 4 regions of the country. The 3 day- training include conceptual training, socio-economic, legal impacts of unsafe abortion , value clarification manual skill in using MVA on simulated first trimester pregnant uteri model using HAWAIIAN PAPAYA fruit. During the last years we have trained physicians and nurses from provincial and regional hospitals in all regions over Thailand. We have also organized the First International Congress on Women’s Health and Unsafe Abortion in January 2010 (IWAC 2010). There were over 600 attendees from over 62 countries worldwide attended. The second congress is planned for January 2012.
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Oct. 22, 2010, 09:00
The legal framework for abortion in Latin America: going forward and backwards
Monica Roa, Programme Director of Women’s Link Worldwide, Mexico
The legal regulation of abortion continues being a highly debated topic in Latin America. Even though the discussion did not move for years, two milestones in 2006 gave a renewed strength to those that want to promote or restrict access to legal and safe abortion in the region. One of the milestones takes place in Colombia on May 2006, when the Constitutional Court declared that the total criminalization of abortion is a violation of women’s rights to life, health, integrity, dignity and non-discrimination. The Court recognized women have the right to have an abortion performed at the public health system, when the woman’s life or health (physical or mental) is in danger, when pregnancy resulted from rape or incest, and when there is a diagnosis of a malformation incompatible with life outside the uterus.
The other milestone occurs in Nicaragua in October 2006 when the legislative assembly eliminated therapeutic abortion, leaving a complete ban on abortion in force. Since then, debates in favor and against abortion regained force and paved the road for advances and regressions that could be characterized in the following manner:
Revision of current laws and promotion of the Health exception:
- Case KL vs Peru at the Human Rights Committee
- Abortion on the ground of mental health
Using the health exception already existing in many latin american criminal codes:
-Processes to liberalize abortion on the woman’s demand during the third trimester
- Mexico City – law declared constitutional by the Supreme Court
- Uruguay – President Tabare Vasquez’ vetos a law approved by Congress
- Argentina – currently discussing a law at the national legislative
Processes to give constitutional protection to the right to life from the moment of conception:
- El Salvador: pioneering the movement to legally recognize the fetus as a human person
- Mexican states (18): the conservative reaction to the liberalization in Mexico City
- Republica Dominicana: the constitutional protection of life from the moment of conception
- Kenya: importing the strategy to Africa
- National laws to declare the day of the unborn
Criminal prosecutions:
- El Salvador: women condemned to 30 years for homicide
- Guanajuato: women condemned to 30 years for homicide
- Brasil: process against 10.000 women whose medical records were removed without due process
- Argentina: judges and attorneys working to implement legal abortion are being prosecuted for promoting
the commission of crimes
Disrupting the implementation of legal abortion:
- Colombia: conscientious objection as a weapon to sabotage legal abortion
- Argentina: fetous ombudsmen try to impede the provision of legal abortions
- Peru: not adopting regulations and protocols for the provision of legal services
Interim measures at the Inter American System for HHRR:
- Case X and XX vs Colombia: protection for the physical and mental Health of a minor who was denied a
legal abortion
- Case Amalia vs Nicaragua: protecting the life of a woman who was denied treatment for cáncer due to
her 10 weeks of pregnancy.
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Oct. 13, 2006, 04:00
Pain management in abortion
Ellen Wiebe MD,
University of British Columbia, Vancouver BC, Canada
Adequate pain control during abortion remains an important challenge in abortion practice.
Pain control methods include general anesthesia, conscious sedation using a narcotic
(usually fentanyl) and sedative (usually midazolam), local anesthesia, oral analgesics,
misoprostol and „verbal anesthesia“. A survey of 640 women from a random sampling of
National Abortion Federation clinics found that the average pain score on an 11-point
scale was 4.65 for abortions performed using conscious sedation and 5.2 for abortions
performed under local anesthesia.
There is evidence that a number of specific techniques and drugs reduce the pain of an
abortion procedure including: buffering the pH of the local anesthetic, using a deep
injection technique, injecting slowly, pre-operative ibuprofen and cervical preparation with
misoprostol. Different surgeons have different pain scores using the same medications
and basic techniques indicating that actual surgical technique also affects the pain scores.
Anxiety and depression scores are highly corelated with pain scores and various methods
of reducing anxiety such as music, low lights, distraction, relaxation techniques etc can be
helpful.
One of the greatest challenges facing a medical director of an abortion clinic is changing
the behaviour of the doctors working within that clinic to improve patient care and
specifically to reduce the pain experienced during the abortion procedure. -
Oct. 13, 2006, 09:00
Pain treatment during second trimester abortion
Inga-Maj Andersson, K. Gemzell-Danielsson, O. Stephansson, K. Christensson,
Dept of Woman & Child Health, Karolinska University Hospital,/Institutet
Stockholm, Sweden,Objectives To assess pain intensity, methods of pain treatment and predictors for the
need of analgesia in women undergoing second trimester abortion.
Design Descriptive study with consecutive inclusion of patients.
Material and methods A combined treatment with mifepristone and misoprostol was used
for the termination of pregnancy. From February 2002 to June 2003 data from 122 women,
undergoing second trimester abortion, was collected into a protocol to describe pain-
intensity measured by Visual Analoge Scale (VAS) and methods of pain treatment.
Demographic data such as age, gestational duration and reproductive history were
collected. The indication for the termination of pregnancy was noted as well as the
presence or absence of a partner or friend during the abortion.
Results The age of the women varied from 14 years to 46 years and the length of
gestation between 86 and 153 days. Indication for the abortion was socio-economic in
66% of the women. Young women, women with no previous birth and women with higher
gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
treatment was higher for these women during second trimester medical abortion. Pain-
intensity VAS >7 (severe pain) was reported by 63% of the women at some time during
the abortion. Intavenous morfine was given to 80% of the women. Paracervical blockade
(PCB) was given to 21% of the women. There was no significant difference in pain-
intensity, morphine- or PCB-requirements related to the presence of a partner, parent or
friend during the abortion nor to the indication for the termination of the pregnancy
(unwanted pregnancy or foetal malformation).Univariat analyses, Chi2-test (p=0.05) and
Mann-Whitney´s test were used for the data analyses.
Discussion Management of pain during second trimester abortion must be focused on the
women’s need. Individual care is crucial for optimal pain treatment. To reduce the high
frequency of severe pain one step is early active pain treatment to women with known
predictors for higher pain experience. Different methods of pain treatment should also beavailable (i.ex. NSAID, PCB). Education of the staff in pain management and caring is
needed to make the abortion care more focused on pain treatment and create a high
quality and non-judgemental atmosphere. Further research is needed to improve the care
of women undergoing second trimester abortion.
Conclusions Young women, women with no previous birth and women with higher
gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
treatment was higher for these women during second trimester medical abortion. -
Oct. 25, 2008, 02:00
Perception of pain during misoprostol-induced medical abortion
Marja Tikka, Satu Suhonen, Timo Kauppila, Seppo Kivinen (Finland)
Helsinki University Central Hospital, Finland
tikkamar@kolumbus.fi, satu.suhonen@hel.fi
Counselling, information about the process of medical abortion as well as sufficient pain relief are important factors when a woman chooses medical abortion. Menstrual pain, parity and woman’s age may influence pain perception and satisfaction with the chosen method of abortion. Medical abortion can be performed with misoprostol administered in home. How painful the abortion experience is, and can this pain be predicted would be useful to know when medical abortion is chosen and especially when home-use of misoprostol is planned.
Fifty-six women who had chosen medical abortion were allocated in this study. Their mean age was 26.2 years (SD 6.2, range 15-43). On the day the medical abortion was started, the median length of pregnancy evaluated by transvaginal ultrasound was 47 days (range 32-63). This was the first pregnancy for 4 women. Altogether 29 women (51.7 %) were nulliparous.
The women were asked to describe their menstrual pain by describing how intense (sensory discriminative component of pain) and unpleasant (affective-motivational component) the pain was. Visual analogue scale (VAS) and a pain drawing of the body area where the pain was felt were applied. When the participants were at the ward after receiving misoprostol, they were asked to describe similarly the pain they felt during the abortion. Afterwards, the type of pain at home, its duration and need for painkillers were recorded, too. At the control visit after medical abortion, their willingness to have gone through the abortion at home was also asked.
The intensity of menstrual pain correlated significantly with the intensity of pain perceived during medical abortion. Both intensity and unpleasantness of menstrual pain correlated with the affective-motivational component of pain perception during medical abortion, too. Older and parous women reported less pain. In these women the area where pain was felt was also smaller. At the time of control visit, 55 % women were willing to choose home administration of misoprostol as a method of choice for abortion. Their VAS scores for pain during abortion were lower than in women who would not prefer home administration of misoprostol (12 vs 68 mm, median). Most of the women who were willing for home-administration were parous. However, neither the length of pregnancy at the time of abortion nor the age of the woman had an influence on her view.
In nulliparous women, dysmenorrhea predicts the pain perceived during medical misoprostol-induced abortion. Sufficient pain relief is important to all women, but especially if home-administration of misoprostol is planned during medical abortion.