Speeches
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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. 4, 2014, 11:00
Task sharing in delivering safe abortion services: experience from Africa
Chilanga Asmani1, Karthik Srinivasan2 1International Planned Parenthood Federation, Africa Regional Office, Nairobi, Kenya, 2International Planned Parenthood Federation, Central Office, London, UK - casmani@ippfaro.org
Globally, Africa is hardest hit by the current healthcare worker crisis with a shortage of over 800,000 staff primarily among physicians and specialists. As an effort to overcome this shortage and expand access to critical health services, task sharing and task shifting has been promoted in the different health sectors by governments and civil society organizations. This approach has been adopted by IPPF to ensure universal access to sexual and reproductive health services. In many of its Member Associations (MA), IPPF has utilized this approach to expand access to safe and comprehensive abortion care and contraceptive services. A range of health workers comprising non-physicians, clinical officers, nurses and midwives currently provide pre and post abortion counselling, induced medical and surgical abortion and contraceptive services. As a result of these efforts, provision of abortion services by IPPF in the Africa region has increased by 42% between 2012 and 2013. Among the five MAs implementing the Global Abortion Care Initiative in Burkina Faso, Cameroon, Ethiopia, Ghana and Kenya, safe abortion service provision has increased from 6,477 to 14,653; treatment of incomplete abortion services has increased from 1,709 to 2,125 between 2011 and 2013. Although community awareness and acceptance for abortion services has increased and assessments indicate high level of quality of care and satisfied clients, the challenge of abortion stigma and staff attrition still persist. Task shifting and sharing the provision of safe abortion and contraceptive services has proven to be an extremely safe, well-accepted and feasible strategy to expand access to safe abortion care and contraception even in low-resource settings. Looking ahead, IPPF aims to conduct pre-service and in-service trainings and updates for midlevel providers, conduct operational research and develop strategies to increase access to safe abortion and contraceptive services in a stigma-free environment.
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Oct. 4, 2014, 02:00
Telemedicine for abortion care: the Highlands experience
Lucy Caird1, Sharon Cameron2, Tracy Hough1 1Raigmore Hospital, Inverness, UK, 23 Department of Reproductive and Developmental Sciences, University of Edinburgh,, Edinburgh, UK - lucy.caird@gmail.com
In NHS Highland we provide an abortion service in a geographically challenging environment especially in terms of providing care within the context of the UK Abortion Act. Travel time to and from our service will be a consistent barrier to providing early medical discharge with those excluded consistently at around 35%. Our aim was to improve care by streamlining care with fewer visits and thus remove some inequity in providing abortion care in our remote and rural area. To reduce visits we offer a telephone consultation option with information sharing that affords women the chance to reflect on their choices and for us to 'one stop' their visit especially where flights or ferries are involved. Women from further away have to choose either day case medical or surgical abortion in hospital and this has resource implications for the gynaecology service. Manual vacuum aspiration can offer women the advantages of same-day treatment and as with all surgical abortion the easy insertion of intrauterine contraception chosen by 55% of the women having MVA. In this paper we discuss how we have developed new ways to deliver this service remotely and have aimed to make it as streamlined as possible for women.
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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.