Speeches
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Oct. 19, 2012, 09:00
Termination of pregnancy among teenagers – why
more surgical terminations?
Dufey-Liengme, C; Coquillat, F; Demierre, M;
Renteria, S-C
Centre for Sexual Health and Planned Parenthood, Unit for Psycho-
social gynaecology and obstetrics, ObGyn Department, Centre
Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Introduction: In 2012, a study by K. Chatziioannidou and S-C.
Renteria showed that teenagers chose to undergo a surgical
termination of pregnancy (TOP) more often than a medical TOP
(mifepristone followed by misoprostol) when they decided to
terminate a pregnancy. It also showed that the teenagers’ choice
for a medical versus surgical method is inversely proportional to
the adults’ choice although the efficiency of the medical method
showed even better results for teenagers than for adults.Accordingtothehypothesismade,thereasonsforthischoice
mightbeinfluencedbythefollowingfacts:(i)thebelatedcalltomake
anappointment,themedicalprocedurenotbeingavailableafter
9 weeksofgestation;(ii)theimperativerequestforconfidentiality;
(iii)thebeliefsandsubjectiveappreciationofthemedicalstaff.
Objectives: The aim of this retrospective and qualitative study is
to analyse the reasons why, in case of a TOP, teenagers chose the
surgical method more often than their adult counterparts.
Material: (i) All teenagers who were admitted for an abortive
procedure during 2011 in the in- or outpatient ward.
(ii) The professional team (midwives and sexual and
reproductive counsellors) in charge in the case of a TOP request.
Methods: The information about the patient’s history and the bio-
psycho-social data was retrieved from thepatient files filled out by
midwives and sexual and reproductive healthcounsellors during the
first appointment for a TOP request orduring its process.
The professionals’ appreciation was evaluated by means of a
semi-structured questionnaire.
Results: Concerning the choice of the method for a pregnancy
termination, the results of our research show that:
(i) Out of 47 teenagers, 27 chose the surgical method and 17
the medical method.
(ii) Three had a second trimester abortion (which includes use
of the medical method).
(iii) Fifteen teenagers out of the 27 who chose a surgical
method consulted between the 9th and 14th weeks of
amenorrhoea and therefore did not have any other choice.
The reasons for their ‘late arrival’ will be explained in detail.
The 12 teenagers who arrived before the 8th week of
amenorrhoea and chose to undertake abortion by suction &
curettage under general anaesthesia did it for the following
reasons:
(i) Four were afraid of bleeding and pain.
(ii) Five thought that the organisation of the surgical procedure
was easier.
(iii) Two did not trust the abortion pill.
(iv) One was taken to her mother’s gynaecologist where she
had a D&C.
Confidentiality was requested nine times out of 27 whenchoosing the surgical method, and six times out of 17 when
choosing the medical method.
Therefore, although confidentiality concerns a third of the
teenagers’ pregnancy termination requests, it does not seem to be
a significant element for the choice of the method.
As for the subjective appreciation of the professionals, the first
results of the discussions seem to show that teenagers were
reluctant or resistant towards the medical method.
Conclusion: This study shows that the reasons why teenagers still
prefer the use of the surgical over the medical method compared
to adults, seem to include the late request for an appointment,
fear of pain and bleeding and organisational issues.
Confidentiality does not seem to greatly influence the teenagers’
choice. Nonetheless, medical professionals seem to favour the
suction curettage procedure performed under anesthesia because
they associate young age with vulnerability and psychological
frailty and consequently diminished ability to cope with pain and
emotional distress during the medical procedures. -
Oct. 19, 2012, 09:00
Termination of pregnancy at women’s request in
Portugal – data from the national registry
2008–2011
Vicente, L; Henriques, A; Almeida, T; Freire, A;
Nogueira, P; Ramos, M
Directorate General of Health, Portugal
Termination of pregnancy (TOP) at women’s request was legalised
in Portugal up to 10 weeks of gestation, in June, 2007. All public
and private services that deliver TOP care are recorded in a
national web-based database. It is a record of episodes of TOP
and not a register of users, in which anonymity and
confidentiality is guaranteed, to be used for statistical purposes of
public health. Induced TOP at a woman’s request represent 97%
of all legal induced TOPs. Sociodemographic charactristics of the
users, distribuition by time of the procedure and contraception
after TOP, will be presented and analysed. In Portugal more than
65% of terminations are performed within the National Health
Service (NHS), where medical TOP is mainly used (96%). Annual
variation of the induced TOP at women’s request: the largest
annual growth occurred between the years 2008 and 2009 – with
an increase of 6.7%. Between 2009 and 2010, the variation was
1.8% and 1.2% between 2010 and 2011. -
Oct. 19, 2012, 09:00
Termination of pregnancy in Lothian: a health
needs assessment
Cochrane, R; Milne, D; Cameron, S
NHS Lothian, UK
Introduction: The rate of termination of pregnancy (TOP) in
Scotland remains high, with 12 681 TOPs performed in Scotland
in 2010.
Most TOPs are hospital procedures or early medical
termination. In 2011 a new centre for SRH (Chalmers) opened in
Edinburgh; most provision of early medical termination will be
delivered from here in the future. Some TOPs will continue to be
performed within hospitals.
Whilst much research has concentrated on the efficacy and
acceptability of TOP, little has been written about women’s
experience and the patient pathway.
How the current service is viewed by users and providers, and
the impact of future change to the service, was uncertain.
This health needs assessment aims to:
(i) describe population accessing TOP services in Lothian
(ii) describe current service
(iii) identify areas of delay in service provision
(iv) identify areas of unnecessary complexity in patient’s
journey
(v) elicit stakeholders views
(vi) consider evidence of and recommend effective intervention
to improve termination services
(vii) support planning for change from 2011.
Methods: Women attending TOP services were interviewed and
then telephoned approximately two weeks after TOP and
questioned about their views of the TOP service.
Staff members within the TOP service including management
were interviewed.
Results and conclusions: Seventeen women and 17 staff members
were interviewed. Difficulty with patient recruitment and follow-
up is discussed.
Patients overall were happy with the service; several pertinent
negative points were raised.
Staff have mixed feelings about the service, and useful ideas for
improvement were garnered, and form part of an action plan as
part of the Lothian Sexual Health and HIV Strategy. -
Oct. 19, 2012, 09:00
Termination of second trimester pregnancies with
mifepristone and misoprostol
Rajic, M; Vrhkar, N; Stritar, BS; Tul Mandic, N
Division of Gynaecology and Obstetrics, Department of Perinatology,
University Medical Centre Ljubljana, Ljubljana, Slovenia
Objective: To evaluate the safety and efficacy of termination of
pregnancy (TOP) for medical reasons (structural fetal congenital
anomalies, fetal chromosomal abnormalities, intrauterine fetal
death, early preterm prelabour rupture of membranes) using
mifepristone and misoprostol (MI-MI) between 11 and 22 weeks
of gestation.
Methods: We collected data from all women requiring TOP with
MI-MI for medical reasons. The protocol consisted of 200 mg of
mifepristone orally, 36–48 hours later 800 lg of misoprostol
vaginally, followed by 400 lg buccally every 3 hours until TOP
(maximum of four doses in 24 hours). If the placenta was
retained, uterotonics were adminsitered, and a decision was made
whether to evacuate the uterus surgically. The data were analysed
using the statistical software program SPSS, version 18.
Results: A total of 435 women were enrolled in the study (we
analysed 157 cases, the remainder will be analysed by the
beginning of FIAPAC Conference 2012). The mean gestational age
was 16.5 weeks. For 58 (36.9%) women this was their first
pregnancy. The method was successful in 156 (99.4%) cases. The
average time interval from the beginning of the procedure till
TOP was 47.3 hours (13.8–168 hours). The average duration of
hospital stay was 39.3 hours (25.0–167 hours). In 40 (25.5%)
cases surgical evacuation of the uterus after TOP was performed.
Conclusions: The use of MI-MI is safe, effective and non-invasive
regimen for TOP for medical reasons between 11 and 22 weeks of
gestation. -
Oct. 23, 2010, 09:00
The campaign to liberise the law in Spain : ACAI´s mark on a new act
Eva Rodriguez, Spain
Twenty-three years since the enacting of the 1965 Abortion Bill, Virginia’s right to decide, like that of
thousands of other women, was once again called into question in Spain, with the outbreak of an unprecedented crisis. Following a report by the Catholic organisation E-Christians on illegal abortions, on the 26th November 2007 the Civil Guard searched the clinics of Dr. Carlos Morín, arresting seven people and seizing the medical records of 2,780 women. The Morín case, still pending a court ruling, burst into the scene, reinstating the dichotomy: abortion yes, abortion no, which the political elite of the Transition had tried to resolve.
The abortion indications law, which legalised abortion in three possible cases: foetal pathology, rape, and in the interests of the pregnant woman's health, allowed professionals to work with the same perspective on health as that of the WHO, which comprehends not only the absence of illnesses but also physical, psychological and social well-being. This professional decision made it possible for 90% of Spanish women to have the option to interrupt their pregnancies during the last 25 years.
If the ambiguity of the Law permitted the standardisation of abortion in Spain, this very same ambiguity has aided the anti-abortion groups which have played the leading role in one of the fiercest battles against this women's right; the politically-instigated inspections, the reporting to the police, the attacks and the circulation of distorted information have diminished the legal and personal safety of medical professionals and women over the last three years.
One of the most serious violations took place in January 2008, when agents of SEPRONA Unit of the Civil Guard appeared at the homes of 25 women, urging them to give evidence. These facts were used in the case against the Isadora Clinic, opened by Judge Sierra, who for a year and a half has been proceeding with criminal charges against three doctors of this Clinic, on suspicion of carrying out illegal abortions and irregular treatment of the remains.
In the same week in which 25 women were investigated for having illegal abortions, 40 clinics - more than half of those in Spain - suspended activity because it was no longer possible for them to guarantee the provision of their services, nor safety. The 2,000 abortions that were not carried out between 7th and 13th January 2008 prove that it is the private clinics that undertake a provision of a service that is technically covered, but not provided, by the Spanish National Health System.
The suspension of activity ended on the 13th January with the publication of a manifesto in the newspaper El País. In it, 66 national and international organisations joined forces with the clinics, to call for respect and personal and legal safety for both women and medical professionals, but above all, to call for a change in the law.
The pressure served to speed up the action and the dialogue between the clinics and the political parties. Also during those days, came the reactions of the Spanish Government and also of an Executive in
charge of delegating mediation with the clinics to its Ministers of Health and Justice.
During those days, the feminist movement, along with civil, legal, trade union and health platforms, took the debate to the streets, with rallies and protests in favour of the right to abortion taking place all over Spain. Instigated by the Alcerín Women’s Association, a campaign was started in Vigo, which would present to different courts all over Spain more than 15,000 voluntary pleas of guilty to having an abortion, while at the port of Valencia the boat of the organisation “Woman on Waves” arrived. On 9th March 2008, the Socialist Party (PSOE) won the election. The electoral victory cleared the way for reformation of the Abortion Law. The Ministry of Equality, headed by Bibiana Aído, was the body commissioned to tackle this reform, for which purpose it would create a committee made up of experts, whose deliberations would be made public to the groups and platforms both for and against the legislative change, among them, the Association of Authorised Clinics.
While the ministerial work was under way, a parliamentary sub-commission, in which would appear experts and spokespersons for both supporters and opponents of a new law, was created. The President of the Association of Authorised Clinics, Santiago Barambio, would participate, at the suggestion of the party in government, in the said sub-commission on 25th November 2008.
The action taken by the Catalan Family Planning Association, coordinated and led by its Vice-president, Isabel Iserte, and the State Family Planning Federation, proved to be essential in the incorporation of some of the historic demands of these Platforms.
As the bill overcame the obstacles involved in its processing, on the streets the position between supporters and opponents of the right to abortion becomes increasingly heated with the approach of the final reading,which took place in the Senate on the 24th February 2010. The bill was carried with 132 votes in favour and 126 votes against and the Sexual and Reproductive Health and Voluntary Termination of Pregnancy Act became law.
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Oct. 24, 2008, 09:00
The effectiveness of ultrasound and s-βhCG measurement in predicting failure after medical abortion
Raquel Maciel, Maria Céu Rodrigues, Teresa Oliveira, Fátima Sousa, Lurdes Lima, Paulo Sarmento (Portugal)
Centro Hospitalar do Porto - Maternidade Júlio Dinis, Porto, Portugal
raquelmaciel@gmail.com
Objective. Diagnostic tests’ effectiveness in predicting failure after medical abortion has been subject of discussion in some studies. We compared ultrasound findings and β-hCG levels and tried to determine its cut-off value that would allow us to excuse a routine ultrasound examination as follow-up.
Methods.In 49 women who had opted to interrupt the pregnancy, with a mean gestacional age of 50 days, ultrasound examination and serum β-hCG were performed prior and around the 20th day after medical treatment. On the follow-up we considered as ultrasound findings the endometrial thickness – virtual or with heterogeneous content – the presence of an empty gestacional sac or an embryo arrest, and compared them with their corresponding s-hCG levels – its decrease %, its initial level % and its absolute final value.
Results.Treatment was successful in 92%. There was evidence of a close relation between ultrasound images and their β-hCG levels. The sensitivity of the ultrasound examination was 100% and its specificity was 49%. Despite the ratio of β-hCG initial level’s sensitivity, with a 1,3% cut-off, was the same as the one with a 0,8% cut-off (75%), the specificity of the first revealed to be more favorable (93,3% vs 86,6%).
Conclusion.The percentage of β-hCG initial level determination, combined with clinical examination, can be an effective method in predicting the success of the medical treatment, as an initial procedure. Therefore, ultrasonography should only be considered in prompt cases.
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Oct. 19, 2012, 09:00
The effects of bad storage conditions on the
quality and the related effectiveness of Cytotec﷿﷿
Be´rard, V1; Fiala, C2
1 University of Bourgogne, France; 2 Gynmed Ambulatorium, Vienna,
Austria
Cytotec﷿ (Misoprostol 200 lg tablet) has been extensively studied
in reproductive health, and is widely used for various indications
including induction of pregnancy termination (MToP).Misoprostol, a PEG1 is chemically unstable except under very
specific conditions. This is due to susceptibility to relative
humidity and temperature factors. If these factors are not strictly
respected until the moment of intake, misoprostol turns into three
main degradation products: A-form and B-form prostaglandin
and 8-epimer.
Whenusedduringmedicalabortions,thecliniciangivesthe
patient2ormore200 lgtabletsofCytotec﷿ totake24–48 hours
aftertakingmifepristone.Cytotec﷿ tabletsarepackagedinboxesof
50or60tabletsof200 lgeach.Thetabletsarepackagedinheat-
sealedaluminumblisterpacks,eachcontaining10tablets.Each
tabletisseparatelysealedinanalveolusandtheblisterisnotpre-cut.
Thedoctorwillgiveapatient2ormoretablets,whichhavetobecut
fromthisaluminiumblister.Howeverthetabletsarearrangedin
suchawaythatitisalmostimpossibletocuttabletsfromablister
withoutinadvertentlydamaging/openingoneormorealveoli.
The aim of this research is to study the effect on the stability of
misoprostol if a tablet has been exposed to normal air/humidity if
the alveoli has inadvertently been opened when 2 or more tablets
have been cut from the blister. A possible instability would have a
potential negative effect on the treatment of MToP.
Methods: To study the changes of Cytotec﷿ tablets from a
technical-pharmaceutical and analytical viewpoint, once they have
been taken out of their blister pack, they are stored over a period
of time (a few hours to 1 month) at 25 ﷿C and 60% RH
(standard condition of ambient air in Europe),
After the time elapsed, the pharmaco-technical characteristics of
Cytotec﷿ tablets were studied according to the European
Pharmacopeia i.e. Mass uniformity, friability, disintegrating time,
dissolution time (by HPLC). The dimensional measure of tablets
were also measured.
Furthermore Cytotec﷿ tablets were analysed to determine the
uniformity of dosage units of misoprostol (by HPLC),
decomposition products dosage (by HPLC): A-form misoprostol
(Pharm. Eur. impurity C), B-form misoprostol (Pharm. Eur.
Impurity D) and 8-epi misoprostol (Pharm. Eur. impurity A).
Water content by Karl Fischer determination was also done.
Conclusions: The results of this research clearly show that
Cytotec﷿ tablets suffered from a significant time dependentdecrease in their technical-pharmaceutical characteristics and
effectiveness if they come into contact with normal air because
they were either taken out of their blister or kept in a blister
which was damaged during cutting out some tablets. As early as
the first day of storage, (with a maximum 48 hours after) in
humidity and temperature corresponding to normal conditions in
Europe the mass (+4.3%), the diameter (+1.2%), and the
thickness (+4.8%) of the tablets increases, which is a sign of the
swelling of the HPMC. However the hardness of the tablets
decreases dramatically ()32.0%).
The water dosage by Karl Fischer clearly shows that there is a
rapid increase of water inside each tablet (+78.8% after 48 hours).
This water penetration, associated with a storage temperature
of 25 ﷿C speeds up the process of transforming the misoprostol
into decomposition compounds. This leads to a decrease in
Cytotec﷿’s active ingredient dosage ()5.1% after 48 hours) with
related consequence on effectiveness. It is clear that under the
current conditions of Cytotec﷿ use for MToP, cutting up theblister packs should not be recommended because the risk of
damaging the heat formed alveoli around the tablets is too high
(we have no data to make such a strong statement, even if it is
true). This drastic change is observed in chemical composition
after 6 hours only of storage and reaching a maximum on the 2nd
day, which is the day the patient normally takes the tablet.
If a Cytotec﷿ tablet is kept in a damaged blister (previously cut
to deliver tablets to the previous patient) and stored in normal
environmental conditions, its effectiveness will be likely seriously
decreased for the next patient.
This research concerns all uses of Cytotec﷿ for MToP and even
when used as gastric protection, where the tablets, which can be
divided into equal parts, can be taken by halves, the second half is
stored in the open alveoli for an undetermined period.
In conclusion, special caution must be taken in delivering
Cytotec﷿ tablets. -
Oct. 22, 2010, 02:00
The efficacy, safety and acceptability of medical and surgical second trimester
termination of pregnancy in Cape Town, South Africa
Marijke Alblas, Independent Consultant, South Africa
Co-authors: Kelly Blanchard, Ibis Reproductive and Health SA, Debbie Constant, Women's Health Research Unit University of Cape Town, Daniel Grossman, Ibis Reproductive Health SA, Jane Harries,
Women's Health Research Unit University of Cape Town, Naomi Lince, Ibis Reproductive Health SA
To examine efficacy, safety and acceptability of two 2nd trimester abortion techniques used in South Africa: medical induction (MI) with misoprostol alone and dilation and evacuation (D&E).
In February-July 2008, we enrolled 304 adult women undergoing abortion at 13-20 weeks at 5 hospitals around Cape Town in a cross-sectional, observational study. 220 underwent D&E with misoprostol cervical priming (up to 3 doses) and paracervical block, and 84 underwent MI. Information was obtained about the procedure and immediate complications, and women were interviewed after recovery.Data were analyzed using SPSS v14.
Median age was 25 years, median parity 1, and median education grade 12. Median gestational age was different between D&E and MI clients (16.0 weeks vs. 18.1 weeks, p<0.001). D&E was more effective than MI (99.5% vs. 50.0% of cases completed on-site and without unplanned surgical procedure, p<0.001). Complications were common (43.8% D&E vs. 52.4% MI, p=0.2). Fetus was expelled prior to procedure in 43.3% of D&E cases. In addition to incomplete abortion, there were 3 MI cases with blood transfusion, 1 hemorrhage without transfusion and 1 fever. 98.8% MI and no D&E clients needed overnight stay. Most women were somewhat-very satisfied with their experience (95% D&E vs. 95.9% MI). More D&E clients compared to MI reported moderate-extreme physical pain (75.7% vs. 59.5%, p=0.007) and moderate-extreme emotional discomfort (49.8% vs. 33.8%, p=0.017).
D&E was more effective, required shorter hospital stay and had fewer severe complications. Second trimester abortion services can be improved in South Africa by expanding D&E training, altering the cervical priming protocol for D&E, improving pain management, and introducing mifepristone.
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Oct. 22, 2010, 09:00
The Evolution of Abortion Access in Europe: “Where is the 'European standard'
Christian Fiala, MD, PhD, Gynmed clinic, Vienna, Austria
Europe is far from united when it comes to abortion and a ‘European standard’ is not in sight.
The historical timeline of legalizing abortion reveals the reluctance of most countries to do so, even though abortion laws originated centuries ago in monarchies, dictatorships, and war-leading countries. In 1920, the former Soviet Union became the first modern nation to change its laws, with Portugal the most recent in 2007. But abortion remains illegal in Ireland, Poland, and Malta until today.
Huge variations exist in allowable gestational limits (12 to 24 weeks) as well as other access restrictions like waiting periods (from none to 3, 5, or 7 days), written permission from two doctors, obligatory counselling, and more. All such restrictions are rooted in tradition and morality, with no scientific evidence of any benefit. But negative consequences are well-documented, such as women being forced to delay the procedure or travel long distances to find care. Consequently, countries with the easiest access to abortion have the lowest average gestational age at the abortion, and vice versa.
Countries in Western Europe do provide coverage of abortion as part of universal healthcare, with the exception of Austria. However, the regulations vary widely, unlike the straightforward funding of procedures for other medical treatments.
Given these huge underlying differences, it is no surprise that the frequency of abortions also varies widely between countries. The abortion rate is not linked to legal restrictions, but rather mirrors the use of effective contraception. Switzerland, The Netherlands, and Belgium lead the way, while most Eastern European countries, together with Sweden and the UK, sit at the bottom with abortion rates 3 times higher.
Three main reasons explain the persistence of high abortion rates: lack of sexual education, difficulty in accessing contraceptives, and failure to use effective contraceptives regularly. The last aspect is a new phenomenon that explains the high abortion rate in Sweden.
The slow historic process of women and couples gaining reproductive and sexual autonomy continues. Despite religious and conservative forces doing everything possible to prevent it, most people are determined to control their own lives, including their sexuality and reproduction. The most recent step forward was in Spain, where until last year women seeking abortion were intimidated by a requirement to obtain a psychiatric diagnosis, but can now receive an abortion on request.In 2008 the Council of Europe issued a report, requesting all member states not only to "decriminalise abortion" but also to "guarantee women's effective exercise of their right to abortion and lift restrictions which hinder, de jure or de facto, access to safe abortion". This landmark report came decades after most countries had already legalised abortion, although all of them had left some restrictions in access. However for the first time in history a European political body has decided on a common European recommendation. It will be interesting to see how long it takes for all European countries to apply and to put into practice what seems to be a basic human right, self determination about one's own body.
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Oct. 2, 2014, 12:00
The feasibility of offering medical abortions by telemedicine: two years’ experience
Ellen Wiebe1 ,2, Cheryl Couldwell2 1University of BC, Vancouver, Canada, 2Willow Women's Clinic, Vancouver, Canada - ellenwiebe@gmail.com
Objective: To describe the results of our programme of providing medical abortions by telemedicine. Methods: We did a retrospective chart review May 2012 - May 2014. Women saw a physician and counsellor by Skype videoconferencing for screening, information and consent. They went to a local laboratory for hCG tests for initial screening, the day of the medication and one week later. The medications were couriered or a prescription was faxed to a local pharmacy. At the follow-up visit by Skype we discussed her experience and her blood test results. If the hCGs had fallen by 80% in one week, we told her the abortion is completed and she needed no further follow-up. If she needed more medication, surgery or further blood tests, we arranged these. See www.willowclinic.ca. Results: In 24 months we saw 23 women for medical abortions by telemedicine and 65 were seen in clinic for the first visit and booked for telemedicine follow-up. Of the 88 women, three women were lost to follow-up (3.4%), four had surgery (4.5%) and 14 (15.9%) needed another follow up (more misoprostol or just another hCG). During that time, we saw 3757 women for the usual in-clinic medical abortions. Conclusions: This method of providing telemedicine abortions is feasible in our setting and may improve access to abortions. The main innovation in this programme is that the patients were in their own homes using their own technology (a computer or smart phone) and yet we provided the same physician and counseling services as we did in our clinic. Most women prefer to come to the clinic.