Speeches
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Oct. 19, 2012, 02:00
Review of telephone follow-up of women having
early medical termination of pregnancy
Michie, L1,2; Cameron, S1,2; Johnstone, A1,2;
Dewart, H1,2
1 NHS Lothian; 2 University of Edinburgh, UK
Introduction: Telephone follow-up2 weeksaftermedical
terminationofpregnancy(TOP)(£9 weeksofgestation)withaself-
performedlowsensitivityurinepregnancy(LSUP)test,was
introducedatahospitalTOPserviceinEdinburgh.Womenwho
screened‘positive’attelephonefollow-up(ongoingpregnancy
symptoms,scantbleeding,orLSUPresult)subsequentlyattended
foranultrasound.Apreviousserviceevaluationconfirmedthatthis
waseffectivefordetectingongoingpregnancyandhadgoodfollow-
uprates.Wesoughttodetermineifthismethodoffollow-up
continuedtobesuccessfulduringtheyearfollowingitsintroductionMethods: Retrospective computerised database review of outcome
of telephone follow-up of women having a medical TOP
(£9 weeks of gestation) over 12 months (March 2011–February
2012).
Results: One thousand and eighty-four women of mean age
25 years had a medical TOP during this period. One hundred and
twelve women were scheduled to attend the clinic for follow-up
and three women did not require follow-up as complete TOP was
confirmed on the day of treatment. Ten women (out of 969)
attended hospital before the planned telephone contact (1%). Of
the 959 requiring telephone follow-up, 656 (68%) were
successfully contacted. Two of those who were not contactable
had ongoing pregnancies. Five hundred and seventy-three (87%)
of those contacted, screened ‘negative’ with no false negatives
occurring. Of the 83 (13%) who screened ‘positive’, three had
ongoing pregnancies. The sensitivity of follow-up was 100% and
specificity was 88% (95% CI 84.9–90.1).
Conclusion: Although slightly lower follow-up rates were obtained
in the 12 months following initial introduction, telephone follow-
up with LSUP was shown to be effective for detecting ongoing
pregnancy. -
Oct. 14, 2006, 02:00
Risk factors for failure in medical abortion
Marie Duriez, MD, Philippe Lefebvre, MD
Service d’Orthogénie (Hospital Family Planning Service), Roubaix, France
Aim: To identify potential risk factors of inefficiency for elective medical termination of
pregnancy based on records of failures of this technique in a hospital environment.
Patients and methods: A retrospective study was conducted on elective medical
pregnancy terminations performed up to 49 days post amenorrhoea in the Family Planning
Service of Roubaix hospital between January 1st 2001 and December 31st 2005. The
service's termination protocol consists in an oral dose of 600mg mifepristone, followed by
an oral dose of 400µg misoprostol 48 hours later. A 2nd oral dose of misoprostol (400µg) is
given 3 hours later if there has been no expulsion.
Every patient is required to return 15 days later to check their βHCG levels.
Failure is defined as ongoing pregnancies, total or partial retentions, and cases requiring
emergency surgery. Success is defined as complete abortion requiring no additional
surgical or medical treatment.
Five items were analysed: patient age, patient parity, duration of pregnancy, βHCG levels
on the day mifepristone (D1) was given, and the dose of misoprostol received.
Results: 1,975 medical terminations were performed during this period. 125 (6.33%) of
these patients did not return to be checked and have been excluded from the study. The
analysis was thus performed on 1,850 patients.
The method was a success in 97.08% of cases (1,796/1,850). 54 failures (2.92%) were
recorded, including 7 ongoing pregnancies (0.38%) .
Patients for whom the method resulted in a success compared to patients who had failures
have a significantly lower age.The duration of pregnancy was not different for the two
groups.
Nulliparous (873/1,850) patients had significantly fewer failures (12/873: 1.37%) than
multiparous patients (42/977: 4.30%).
Age is significantly higher for failures amongst the nulliparous patients. Conversely, for
patients who have had at least one child, age is not a determining factor.
28 patients did not receive any misoprostol because they expulsed prior to the 48th hour
(1.51%). Amongst the 673 patients who received only a single dose of misoprostol, 11
(1.63%) required additional actions including one emergency admission for haemorrhage.
Amongst those who received two doses of misoprostol, 43 failed (3.74%), including 2 re-admitted the same day for haemorrhages and 1 for pelvic pains.
Discussion and conclusion: The overall efficiency results for the method are excellent
despite an exhaustive and detailed analysis of the failures.
The various studied factors have demonstrated that there is an increase in failure rates for
the method with parity and, to a lesser extent, with the patient's age.
High plasma beta HCG levels also seem to be more often associated with failures of the
method. The addition of a second dose of misoprostol is likely to increase the chances of
an expulsion during the hospital stay but, this non-comparative retrospective study can not
conclude on the beneficial effect of a second dose of misoprostol on overall efficiency.
Finally, it should be noted that none of the criteria evaluated in this study can be used as a
diagnosis factor to predict the outcome of an elective termination as none of them has the
sensitivity / specificity that is required to identify 'at risk' patients from amongst other
patients. -
Oct. 14, 2006, 02:00
Risk factors for repeated abortion
Oskari Heikinheimo, MK, Prof., Department of Ob&Gyn, Helsinki University Central
Hospital, Helsinki, Finland
The frequency of repeated abortion varies in different countries and depends greatly on
the overall abortion incidence. In Finland the annual abortion incidence is ~9/1000 fertile
aged women; the proportion of repeated abortion has been ~30% of all abortions for
several years. Low socioeconomic status, parity and older age have emerged as risk
factors for repeat abortion in previous studies.
In order to further characterize the risk factors for repeated abortion we have initiated two
large scale cohort studies employing the national abortion register, where 99% of all
abortions performed in Finland are being reported. Woman’s age, previous pregnancies,
duration of pregnancy, method of pregnancy termination as well as planned future
contraception are reported to the national register.
Helsinki study comprises of ~1400 women chosing medical abortion at our institute
between 2000-2002. At 2-3 weeks following abortion, all women attended the clinic for a
control visit, where the outcome, as well as compliance and initiation of contraception was
assessed. Detailed demographic, life-style and abortion related data of the subjects have
been collected. Also, the contraceptive method and the date when contraception was
initiated have been recorded. The first assessment of repeat abortion until the end of year
2005, and it’s risk factors is being performed. However, the study will continue until 2012.Similarly, a nationwide study employing the national abortion register has been initiated. In
the nationwide study cohorts of ~23.500 women choosing medical abortion and 65.000
women choosing surgical abortion between 2000-2005 are being followed. The first
assessement of repeat abortion will be performed until the end of year 2005. Among other
things, the study allows estimation of the true risk for repeat abortion following different
methods of pregnancy termination.
It is hoped that these register based strategies will be valuable in identifying the incidence
and risk factors for repeat abortion. In addition, true efficacy and cost-benefit ratio of
various contraceptive methods can be assessed. These data are valuable when
developing and designing family planning services aiming to shift from abortion to effective
contraception. -
Oct. 19, 2012, 09:00
Risk factors for repeat termination of pregnancy:
implications for addressing unintended pregnancy
in Vietnam
Ngo, T1; Keogh, S1; Nguyen, T1; Le, H2; Kiet, P2;
Nguyen, Y2
1 Marie Stopes International; 2 Hanoi Medical University, Vietnam
Objective: Vietnam has one of the highest pregnancy termination
rates in the world; 26 terminations of pregnancy (TOPs) per 1000
women. We explored factors associated with having repeat TOPs
in three provinces in Vietnam.
Methods: A cross-sectional survey was conducted from September
to December 2011 among abortion clients at 61 health facilities in
Hanoi, Khanh Hoa and Ho Chi Minh City. After their procedure,
women participated in an exit interview asking about socio-
demographic factors, contraceptive use, and knowledge and
experience of TOP services. The primary outcome was repeat TOP
(‡2 TOPs).
Results: A total of 1233 women were interviewed. The median
age was 28 years; 92.5% had secondary education; 77.8% were
married; and 31.9% had no children. Half the respondents were
not using contraception prior to their recent pregnancy. The
prevalence of repeat TOP was 32.9%. A significantly higher
proportion of repeat TOP compared to first time TOP clients
intended to adopt long-acting contraceptive methods, particularly
the IUD (35% vs. 23%, P £ 0.001), in future. In a multivariate
model, individuals living in Hanoi, older women, and those with
two (vs. fewer) children were more likely to have a repeat TOP
(P < 0.001). While women with ‡2 daughters (vs. 1) were more
likely to have a repeat TOP (P = 0.03), women with no sons
(vs. 1) were less likely to have one (P = 0.03).
Conclusions: Repeat TOP remains high in Vietnam. Strengthening
post-TOP family planning interventions is critical to reduce the
high number of repeat unintended pregnancy in Vietnam. -
Oct. 2, 2014, 12:00
RU OK? Provider perspectives on follow-up with remote technologies after early medical abortion
Lesley Hoggart1, Patricia Lohr1, Jeanette Taylor1, Chelsea Morroni1, Hillary Bracken2, Beverly Winikoff2 1bpas, Stratford Upon Avon, UK, 2Gynuity Health Projects, New York, USA - hbracken@gynuity.org Objective: Guidelines from the World Health Organization and Royal College of Obstetricians and Gynaecologists suggest that routine in-clinic follow-up is not required after early medical abortion. New diagnostic and communication technologies promise to allow women to assess their abortion outcome at home. Yet little is known about healthcare providers' attitudes and opinions about the elimination of clinic follow-up. Methods: Providers in 4 clinics in the bpas clinic network in the United Kingdom were interviewed after participating in a randomized clinical trial testing the feasibility of using remote communication technologies for follow-up after early medical abortion. Clinicians and non-clinical staff (N=10) at participating clinics and the bpas call centre participated in 3 focus group discussions guided by a qualitative researcher. Participants were asked about their perspectives on in-clinic follow-up and home follow-up by phone, text message or email. Focus group discussions were recorded, transcribed, and analyzed thematically by the authors. Results: Participants were open to alternative approaches to follow-up after medical abortion. Staff recognized the need to improve follow-up rates but were sceptical improvement was possible, and uncertain about how to balance time management issues with women's needs. Providers described a tension between two imperatives: to respect women's postabortion preferences and to ensure contact and knowledge of postabortion outcomes. Providers felt responsibility for follow-up was part of their duty of care; although some acknowledged that retaining this responsibility clashed with the bpas culture of trusting women to control their own bodies and reproductive lives. Conclusions: Overall, although there was an evident diversity of views, clinic staff felt that they had a responsibility to follow-up women after early medical abortion. Efforts to introduce home follow-up after medical abortion must be accompanied by training that addresses providers' concerns and ambivalence about allowing women to manage the procedure at home.
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Sept. 15, 2018, 02:00
In recent years, conflict, violence and disasters have brought a dramatic rise in the number of displaced people, both within and across national borders. There are an estimated 26 million women and girls of reproductive age living in emergency situations, all of whom need sexual and reproductive health (SRH) information and services. The average length of time an individual now spends displaced is 20 years, and three quarters of countries with the highest maternal mortality ratios are fragile states as defined by the Organisation for Economic Co-operation and Development. Sexual violence is also prevalent. A recent Global Review demonstrated that significant gaps remain in access to safe abortion and reproductive health care in humanitarian settings.
Providers are an essential component of safe abortion care globally. In humanitarian settings providers have unique needs to provide safe, competent care. To support providers in offering safe, evidence-based reproductive health care, the WHO has recently developed a process for adapting reproductive health guidelines to the humanitarian setting, and developing provider tools. This process was developed following a review of the literature, and in consultation with experts in guideline methodology, emergency response, SRH and rights, epidemiology, implementation research, and program managers. The methodology has been applied to the Medical Eligibility Criteria for Contraceptive Use, and a tool of the adapted guidelines developed and field tested. Similar efforts may further provision of safe abortion care in the humanitarian settings. -
Sept. 14, 2018, 04:00
Women are seeking abortion at increasingly earlier gestations, with 41% of first trimester patients in the U.S. receiving an abortion at <6 weeks gestation. The efficacy of medical abortion at <6 weeks gestation is not significantly different than at 6-7 weeks, however, seeking abortion very early in gestation increases the likelihood that providers will have difficulty visualizing the pregnancy on ultrasound, the current standard of care in many clinics.
The most serious risk of treating women with an undesired pregnancy with mifepristone and misoprostol without first confirming a diagnosis of intrauterine pregnancy is a missed diagnosis of ectopic pregnancy. Studies suggest an incidence of ectopic pregnancy of 0.2-0.3% among women presenting for medical abortion. Data support the practice of providing mifepristone and misoprostol medical abortion in the setting of undesired pregnancy of unknown location (PUL) using serial serum hcg testing to simultaneously exclude ectopic pregnancy and determine the efficacy of the medical abortion. Guidelines that enable provision of medical abortion in the setting of PUL, when the patient is asymptomatic, low-risk for ectopic and when combined with close follow up to exclude ectopic pregnancy exist to support this service development.
This presentation will review the evidence for providing medical abortion at <6 weeks gestation including in the setting of PUL. -
Oct. 20, 2012, 02:00
Safety and effectiveness of termination services
performed by doctors versus midlevel providers: a
systematic analysis
Ngo, T1,2; Park, MH1,2
1 Marie Stopes International; 2 London School of Hygiene & Tropical
Medicine, UK
Objective: We review the evidence that compares the effectiveness
and safety of termination of pregnancy (TOP) procedures
administered by mid-level providers (MLPs) versus doctors.
Methods: We conducted a systematic search of published studies
assessing the effectiveness and/or safety of TOP provided by MLPs
compared to doctors. The Cochrane Central Register of
Controlled Trials, EMBASE, MEDLINE and Popline were searched
for trials and comparison studies. The primary outcomes were:
(i) incomplete or failed TOP and; (ii) measures of safety (adverse
events and complications) of TOP procedures administered by
MLPs and doctors. Odds ratios and their 95% confidence intervals
(CIs) were calculated for each study.Results: Two prospective cohort studies (n = 3821) and two
randomised controlled trials (RCTs) (n = 3821) were included.
Three thousand seven hundred and forty-nine women underwent
a procedure administered by an MLP and 3893 women underwent
a physician-administered procedure. Three studies used surgical
TOP with maximum gestational ages ranging from 12 to 16+
weeks; a medical TOP study had maximum gestational ages up to
9 weeks.
There was no difference in incomplete/failed TOP for
procedures performed by MLPs compared to doctors in RCTs of
surgical (OR: 2.00; 95% CI: 0.85, 4.68) and medical TOP (OR:
0.69; 95% CI: 0.34, 1.37). One prospective cohort study showed
increased odds of incomplete/failed TOP among MLPs versus
physician groups (OR: 4.03; 95% CI 1.07–15.28).
None of the included studies found a difference in the odds of
overall complications between provider groups.
Conclusions: Based on this evidence, there is no indication that
procedures performed by MLPs are less effective or safe than
those provided by physicians. -
Oct. 13, 2006, 11:15
Second trimester abortion: medical or surgical abortion?
Michel Tournaire, M. Bornes, S. Gaudu, F. Lewin
Hopital Saint Vincent de Paul, Paris, France
The methods for second trimester abortion vary according to countries and institutions.
Medical methods using preparation of the cervix and misoprostol are predominant in
Europe. Surgical dilatation and evacuation requires practitioners trained for this technique.
It is used for almost all second trimester abortions in the USA and is available in some
institutions in Australia, England, France and the Netherlands. Complications are more
frequent with medical method : retention of placenta that needs secondary surgical
removal, hemorrhage with transfusions and rupture of the uterus, risk that is increased in
the cases of previous cesarean section. Surgical method can be complicated by
perforation of the uterus and laceration of the cervix. The risk for premature birth in
subsequent pregnancies seems to be low for the two methods. Emotional consequences
have been found identical with both techniques. The choice of the method is not based on
scientific data but on the practitioner’s experience. If the two methods could be available in the same institution, this would allow, well informed women to participate using their choice.