Speeches
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Sept. 15, 2018, 11:00
Increasingly, women are obtaining abortifacient medicines through pharmacies, drug sellers, and online or telemedicine services – particularly where abortion services are restricted or access is difficult. Many of these women are using medical abortion drugs safely on their own, although data on their clinical outcomes are limited. Many clinicians consider the self-use of medical abortion to be dangerous; however, from a strictly medical perspective, mifepristone and misoprostol meet many of the FDA criteria for being available over- the- counter (OTC): an acceptable toxicity profile, unlikely to be addictive, and a low abuse potential.
To demonstrate that medical abortion is appropriate for OTC distribution, a series of investigations would be required by the FDA. This research would need to establish that individuals can understand a Drug Facts Label for medical abortion, assess gestational age as eligible and rule out other contraindications for medical abortion, self-administer the medications according to instructions, and identify complications or need to seek medical care, including for ongoing pregnancy. In the short term, these efforts will help support a wide variety of efforts aimed at improving access to clinic-based medical abortion, and in the long-term, support regulatory approval for an OTC product. -
Oct. 14, 2016, 02:00
FC01
A randomised controlled trial of immediate initiation of contraception by levonorgestrel-releasing intrauterine system (LNG-IUS) after medical abortion - one year continuation rates
Riina Korjamo1 ,2, Maarit Mentula1, Oskari Heikinheimo1 ,2
1Helsinki University Hospital/ Obsterics and Gynecology, Helsinki, Finland, 2University of Helsinki, Helsinki, FinlandObjectives: Immediate insertion of intrauterine device at the time of the surgical abortion results into higher uptake of effective contraception and prevent unintended pregnancies. We performed a randomised controlled trial comparing immediate (≤3 days) vs. delayed (within 2-4 weeks) insertion of the LNG-IUS after medical abortion.
Method: Women ≥18 years requesting medical abortion and desiring LNG-IUS contraception were eligible to enter the trial, which was conducted at Helsinki University Hospital between Jan 30nd 2013 and Dec 31st 2014. Trial has registered to www.clinicaltrials.com, NCT01755715. The primary outcome was the LNG-IUS use at 1 year after abortion. Secondary outcomes were expulsions, further pregnancies and abortions.
Results: Altogether 267 women were randomised to immediate (134) and delayed (133) insertion groups, of which 264 (133 and 131, respectively) were analysed. LNG-IUS was inserted in 127 (95.5%) women in the immediate and 111 (84.7%) women in the delayed insertion groups (OR3.81, 95%CI 1.48-9.83, p=0.004). The verified numbers of women continuing the LNG-IUS use at 1 year were 83 (62.4%) and 52 (39.7%), respectively (OR2.52, 95%CI 1.54-4.14, p=0.001). In the best case scenario (the use of LNG-IUS verified or LNG-IUS inserted) 113 (85.0%) women in the immediate, and 88 (67.2%) women in the delayed insertion group continued LNG-IUS use at 1 year (OR2.76, 95%CI 1.52-5.03, p=0.001). Numbers of total expulsions were 3 (2.3%) vs. 3 (2.3%) (OR0.98, 95%CI 0.20-4.97, p=1.00), partial expulsions 26 (19.5%) vs. 9 (6.9%) (OR3.29 95%CI 1.48-7.34, p=0.003), new pregnancies 6 (4.5%) vs. 16 (12.2%) (OR0.34 95%CI 0.13-0.90,p=0.027) and further abortions 4 (3.0%) vs. 5 (3.8%) (OR0.78 95%CI 0.21-2.98, p=0.75), respectively.
Conclusions: Immediate insertion of the LNG-IUS after medical abortion resulted in a higher uptake and continuation rates of intrauterine contraception compared to delayed insertion, despite higher partial expulsion rates of LNG-IUS. Immediate insertion of the LNG-IUS decreased the 1-year pregnancy rates but did not affect the rate of further abortions. -
Sept. 15, 2018, 11:00
Wondering how to manage second trimester medical abortion or dilation & evacuation in the setting of an abnormally implanted placenta?
Looking for advice on advancing the gestational age at which you and your team provide? Have questions about cervical preparation, offering a choice of method, managing prolonged inductions, or anything else related to medical or surgical methods of abortion after the first trimester? Bring your questions along to this panel of five leading experts in second trimester abortion care. Experienced, new and curious providers are all welcome to contribute to what should be a lively and wide-ranging discussion. -
Oct. 3, 2014, 02:00
Barriers in access to contraception for minors
Katarina Sedlecky Institute for Mother and Child Health Care of Serbia, Belgrade, Serbia - ksedlecki@gmail.com
Use of effective contraception is one of the crucial issues in the sexual and reproductive health care for minors. However, far too many adolescents are at a risk of unplanned pregnancy, due to the many and varied factors that hinder them from recognizing and fulfilling their needs in the field of safe sexual behavior. The barriers can be grouped into macro and micro determinants. Among macro determinants the most significant are the sexual and reproductive health (SRH) legislative framework, socio-cultural environment, economic conditions, public awareness of the rights and needs of minors in relation to SRH, sexuality education, availability of appropriate healthcare services and access to modern contraceptive choice. The general and individual biological and psychosocial characteristics of adolescents, the influence of the family and peers, as well as school performance and aspirations comprise the major micro determinants of the access of contraception for minors. Due to different historical, sociocultural, political, and economical conditions, a diversity exists across Europe in means and motives of teenagers to use reliable contraception, societal acceptance of sexual activity among teenagers, commitment of different European countries to prevent teenage pregnancy, prevalence of health risk behaviours among teenagers, as well as in sexual and reproductive health care for migrant population and vulnerable groups. Recognition of SRH needs of minors, easy access of contraception, reimbursement of contraceptive methods and higher prevalence rates for medical contraceptive methods usually result in low teenage pregnancy rates.
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Oct. 15, 2016, 02:00
FC25
Buccal versus sublingual misoprostol alone for early pregnancy termination in legally restricted Latin American settings: A randomised trial
Wendy Sheldon1, Ilana Dzuba1, Heather Sayette2, Jill Durocher1, Beverly Winikoff1
1Gynuity Health Projects, New York, NY, USA, 2PP Global, New York, NY, USAObjectives: To examine the efficacy and acceptability of two misoprostol only regimens that are commonly used for medical abortion in legally restrictive settings; as well as the feasibility of a multi-level pregnancy test (MLPT) for at-home follow-up.
Methods: This randomised open-label trial is ongoing at six clinics in two Latin American countries where abortion is highly restricted.* A total of 382 eligible, consenting women with gestations of ≤ 70 days who request medical abortion is required to show an expected difference of 8% in efficacy between the two study arms. Participants are randomised to three doses of buccal or sublingual administration of 800 mcg misoprostol every three hours. Study providers are blinded to group allocation. All women receive two MLPTs to administer and interpret abortion status: the first is taken in-clinic on the day of enrolment and the second at-home on the day of follow-up.
Results: Data collection should be completed before October 2016. To date, the overall rate of successful, non-surgical abortion is 93.4% (183/196) and rate of ongoing pregnancy is 1.0% (2/196). Among those with no ongoing pregnancy, the MLPT successfully identified this outcome in 83.5% (162/194) of cases; it also identified need for follow-up among all those with ongoing pregnancy (2/2). More than 80% (160/195) of participants stated they would select medical abortion in the future and 87.6% (170/194) felt they could use an MLPT on their own.
Conclusion: The efficacy of misoprostol alone is higher than expected based on published literature. Study findings will provide important evidence on the efficacy of a three-dose buccal misoprostol alone regimen. In addition, multi-level pregnancy tests appear to be a feasible and potentially useful tool for abortion service delivery in legally restrictive settings.
*Note: To protect study providers and their clinics, we are not disclosing country locations at this time. -
Oct. 15, 2016, 09:00
PS04.2
Cervical priming made easy
Ingrid Sääv1 ,2, Kristina Gemzell Danielsson1 ,3
1Karolinska Institutet, Stockholm, Sweden, 2Norrtälje Hospital, Norrtälje, Sweden, 3Karolinska University Hospital, Stockholm, SwedenBefore the development of medical priming agents, mechanical methods were used to dilate and soften the cervix before surgical intervention. Different roots, screws and dilators were used and later intracervical tents that were allowed to swell and slowly dilate.
Misoprostol induces a softening, "priming" effect on the cervix making mechanical dilatation less difficult. The action seems mainly to affect the collagen tissue of the cervix causing disintegration and dissolution. Compared with osmotic dilators misoprostol gives equal cervical dilatation in a shorter time, is easier to administer and is more convenient to the patient.
Misoprostol reduces the rate of complications after surgical abortion when administered as a medical priming agent prior to vacuum aspiration, both in nulliparous and parous women. Prostaglandins have been proven to reduce blood loss associated with vacuum aspiration.
Misoprostol is also used in non-pregnant women to facilitate IUS insertion or dilatation prior to hysteroscopy. However, studies indicate that no effect is achieved in postmenopausal women.
Misoprostol can be administered orally, sublingually or vaginally. Its plasma concentration and half-life, and subsequently effect, differ greatly depending on the route of administration. This gives great opportunity to choose the most convenient, effective and practical way of administration. Plasma half-life after oral administration is only 20-40 minutes, whereas it has a lower plasma peak level but much prolonged duration after vaginal administration. After sublingual administration, the plasma peak is the highest, combined with a prolonged half-life, giving the most rapid effect on cervical priming - but also more side-effects comparing to vaginal administration.
When administered to achieve cervical ripening misoprostol can be administered sublingually, only one hour prior to surgery, or if preferred vaginally with 3 hours interval. This gives great opportunities to choose the most convenient regimen depending on patient preference and practical aspects. -
Oct. 14, 2016, 12:45
LS01.2
Comprehensive pain management in early medical abortion – A follow up
Christian Fiala
Gynmed Clinic, Vienna, AustriaIntroduction: Medical abortion is increasingly used. But most women will experience some pain that requires intervention, while satisfaction with medical abortion may be limited by differences between women’s expectations of pain and their actual symptoms. Pain is still a neglected issue in many settings and even studies. So far, no evidence-based comprehensive pain management protocol has been published. Therefore, a group of experts has developed recommendations based on the following principles: avoidance of pain, non-pharmacological strategies and medical pain treatment.
Background: Pain usually starts following administration of misoprostol. It is caused by contractions, with a peak around expulsion decreasing thereafter. Several associations between various factors and pain can be found. However, the predictive value of these factors is insufficient to define pain management for an individual woman.
Avoidance of pain and non-pharmacological strategies are a cornerstone, including:
· Facilitating access so that women can have the abortion at an early gestational age
· Giving detailed information to women on what to expect during the procedure
· Using the lowest effective dose of misoprostol
· Taking misoprostol at home in a relaxing environment with a support person present
Medical pain treatment: Treatment for pain in first trimester MToP should be systematic and women should have easy access to additional stepwise pain treatment. The limited data do not show prophylactic treatment to be superior compared with curative administration. However, experts’ recommendation is to give prophylactic analgesia using NSAIDs like ibuprofen. Pain treatment should be given stepwise using
· 1st line,: ibuprofen 400 to 800 mg
· Use of Paracetamol alone is not recommended.
· In addition, 2nd line analgesia for break through pain should be offered and be accessible easily and without delay, consisting of opioids like codeine, dihydrocodeine, or morphine. -
Sept. 14, 2018, 02:00
How will we be able to secure the right for abortion? Around the world, in a lot of countries where abortion is legal, women have great difficulties to have access to abortion. A few countries have regulations that state CO is not permitted for health care providers working in the field of reproductive health (Sweden, Finland, Iceland).
Is this an actual solution for other countries? In most countries, individual CO is written in the abortion law and in medical law, and in Belgium, abortion providers agree to this.
Which woman wants to be treated by a team that has a negative feelings towards abortion? Anti-choice health care workers obliged to work in the field of abortion could make it a traumatic experience!
In countries where CO is permitted, our actual fight should focus on the following:
The state should ensure that abortion services are available in each region (in hospitals or in outpatient facilities) and make sure women know where to go. Public hospitals should offer an abortion service if they want to keep their state funding. Public hospitals should not have the “right” of conscience. Objector status of doctors should be public and quick referral to an abortion service mandatory. Providers, who work in abortion services, should choose to do so (conscientious commitment) so that women are treated with respect and empathy.
Doctors performing abortions should not be discriminated and should be dismissed from other tasks who need to be taken over by conscientious objectors. Women’s rights movements should encourage feminists to become doctors and young doctors to perform abortion and be proud to do so. We need to do a charm offensive to show that working in abortion care permits rich human encounters with women grateful to be able to decide about their future life. -
Oct. 14, 2016, 04:00
PS03.2
Expanding providers and task sharing
Helena Kopp Kallner
Karolinska Institutet, Stockholm, SwedenIn many countries the access to medical doctors in abortion care is limited either by a general shortage of medical doctors or by the unwillingness of medical doctors to be involved in abortion care. Specially trained, midlevel providers can often perform services generally performed by physicians. In abortion care the evidence in support of midlevel provision of surgical and medical abortion and postabortion care is increasing.
In some countries midlevel providers perform primary vacuum aspiration for surgical abortion and in low resource settings midlevel providers supply medication and information and thereby perform medical abortions. Medical abortion provided by midlevel providers in a low resource setting has been evaluated in a large randomised trial in Nepal and was found to be safe and effective.
In high resource settings abortion is usually provided after an ultrasound provided by a trained physician. However, access to appointments for ultrasound may, in fact, increase the waiting time to have an abortion. In a large randomised trial it has been shown that trained midlevel providers can perform early medical abortion including the ultrasound as part of standard care as effectively and safely as physicians.
Women in countries where abortion is illegal often self induce abortions surgically or medically. Denied health care due to complications contributes to maternal morbidity and mortality. Midlevel providers who supply postabortion care including manual vacuum aspiration for incomplete abortion have been shown to be safe and effective. In a large randomised trial it has been shown that trained, midlevel providers can perform postabortion care as effectively and safely as physicians in rural as well as in urban settings in Africa. -
Sept. 14, 2018, 02:00
Background: The failures of medical termination of pregnancy (MToP) can have serious consequences such as exceeding the legal age of abortion and the occurrence of fetal malformations related to the teratogenic action of misoprostol.
Objective: To study the correlation between a low-sensitivity urine pregnancy (LSUP) test associated to a self-performed questionnaire and the standard patient follow-up after MToP, consisting of a clinical examination, a blood hCG test and ultrasonography when needed. Methods: Prospective cohort study included women who came to their post abortion visit after MToP from March to August 2017. They performed a LSUP test and a self-performed questionnaire to assess their opinion on the completion of the abortion. Then a standard follow up was done by a doctor. A successful MToP was defined as a complete uterine abortion, with no the need for surgical intervention or for new abortive medication. Results: 133 women have been included in this study. The rate of successful MToP was 94.0%. Regarding failures there were two ongoing pregnancies (1.5%) and six retained products of conception (4.5%) treated either by a surgical procedure or with a new oral administration of misoprostol. Sensitivity of the womens opinion combined to the LSUP test was 100%, specificity was 89.6%, positive predictive value 38.1%, negative predictive value 100%, a Youden index of 0.89 and a kappa coefficient of 0.51. Conclusion: Given the extremely high efficacy of MToP, most women do not need a clinical follow-up to confirm pregnancy termination. Our data show that most women can ascertain their abortion outcome using a simple self-administrated questionnaire and a LSUP test.