Speeches
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Oct. 25, 2008, 02:00
Challenges in post-abortion contraception
Oskari Heikinheimo (Finland)
Department of Obstetrics and Gynecology, Helsinki University Central Hospital, POBox 140, 00029-HUS, Helsinki, Finland
oskari.heikinheimo@helsinki.fi
The influence of contraceptive use and counseling on the risk of repeated abortion is unclear. In a recent prospective study, specialist counseling and provision of contraceptives did not have an effect on the rate of repeated abortion (Schunmann and Glasier, Human Reproduction, 2006). However, in randomized clinical trials the use of intrauterine contraception, initiated at the time of surgical abortion, has been effective in reducing further unintended pregnancies (Pakarinen et al., Contraception, 2003).
We analyzed recently risk factors for repeat abortion among a cohort of 1269 women undergoing medical abortion between August 2000 and December 2002 (Heikinheimo et al., Contraception, 2008). Contraceptive use was assessed at the time of follow-up performed at 2-3 weeks following the abortion; intrauterine contraception was initiated at the clinic at the time of follow-up, or within 2 months. The subjects were followed prospectively via the Finnish Registry of Induced Abortions until December 2005, the follow-up time (mean ± SD) being 49.2 ± 8.0 months.
In comparison with combined oral contraceptives, use of intrauterine contraception was most efficacious in reducing the risk of another pregnancy termination. In multivariate analyses the hazard ratios (95% Cl) of repeat abortion were 0.33 (0.16 to 0.70) among Cu-IUD users and 0.39 (0.18 to 0.83) among LNG-IUS users when compared to users of combined oral contraceptives. The incidence of repeat abortion was highest among women the postponing initiation of contraceptive use.
Contraceptive choices made at the time of abortion have an important effect on the rate of re-abortion. Use of intrauterine contraceptives for post-abortal contraception is most efficacious in decreasing the risk of repeat abortion.
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Sept. 11, 2004, 02:00
Choice between medical and surgical abortion,
Philippe Lefèbvre MD, Président de l’ Association Nationale des Centres d’Interruption de grossesse et de Contraception, Chef du Service d’Orthogènie – Hôpital La Fraternité, Roubaix, France
Interrupting her pregnancy is a decision which belongs to the woman and only to her. However, once this decision is made, since a medical environment is required to guarantee her safety, the choice of a technique will take place whereas medical power is potentially at risk of being overbearing. The purpose of this paper is to evaluate if the objective and subjective elements of choice are the sole factors to intervene in the choice of the TOP method.
The duty of informing the patient about the various available options , their respective efficiency, and their potential risks, allows in theory , the woman to make an informed choice.
However, the medical practices are subject to numerous contingencies such as : access time, availability of mifepristone, presence of an anesthesist practitioner, economical viability of the medical act, implementation of the hospital-city network, lack of training, and sometimes , the difficulty for a doctor to challenge himself his own practices or habbits.
The litterature about good practices and clinical guidelines states that the type of technique , medical TOP or chirurgical TOP, is defined by the gestationnel age. But working by this sole criteria is obviously not enough, while the choice of a technique should be reached through a good medical consultancy , establishing a dialog between the patient and the professional (counsellers, nurses, doctors,) developping appropriate proposals.
The buy-in of the patient to the chosen method plays an essential role in the physical as well as psychical acceptance of the TOP.
Experience in the field shows that the TOP method will be all the more accepted by the patient that her buy-in shall have been seeked and reached.
Despite the ongoing upgrades of the techniques for the last 30 years , it is a shame that making a true choice available to the patient remains so highly dependant on some practitioners good will.
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Oct. 22, 2010, 08:00
Combined oral contraception and weight changes
Medard Lech, Fertility and Sterility Research Center Warsaw and L.Ostrowska, Medical University of
Białystok, Poland
Obesity is associated with a host of medical conditions, including diabetes mellitus, osteoarthritis, cardiovascular diseases, sleep apnea, breast, colon and uterine cancer, pregnancy and reproductive disorders. Last but not least, overweight [and obesity] is of great concern to most women in today’s world.
There are many, complex, inter-related reasons for overweight and obesity in women, a phenomenon which is related to genetic, endocrine, social and other factors. The most common reason for obesity is high food intake and low levels of physical activity. Some pharmaceutical products may also affect the energy balance in women and thus lead to overweight and obesity. The list of such pharmaceuticals is not fully defined, but steroids (and most commonly, hormonal contraceptives) are often included here.
As combined oral contraception [COC] is the most popular method of hormonal contraception, there is a large number of publications discussing the unwanted side-effects of COC. Generally the discussion focuses on cardiovascular problems, whereas the most common concerns of patients concentrate on weight gain and cancer risk, especially the risk of breast cancer. This discrepancy between scientific concerns and the problems arising in clinical settings is even greater due to the long list of possible unwanted side-effects mentioned in COC pack inserts.
Clinical practice during the 60’s and 70’s showed that COC use was linked to estrogen related nausea, vomiting, headache and breast tenderness. Since that time, the estrogen dose in COC has been markedly diminished, largely to reduce the rate of unwanted, cardiovascular effects, but also as the method of lowering the number of side effects related to quality of life [headache, breast tenderness, nausea and vomiting]. Most controlled clinical trials found neither a correlation between COC use and body weight nor any possible mechanisms affecting body weight in COC users.
Although there is no - scientifically-proved - relationship between COC use and weight gain, many women have discontinued their use of hormonal contraceptives due to “weight gain”. More than half of US women believe that COC causes weight gain. Gynecologists from all over the world report that their patients frequently consider COC one of the causes of their “weight gain”, but neither early [with COC containing more than 35 mg ethinyloestradiol] nor recent [with COC containing 20 – 35 mg ethinyloestradiol] placebo-controlled trials confirm this.
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Oct. 2, 2014, 12:00
Community involvement in promotion of safe abortion among vulnerable groups in Kazakhstan
Galina Grebennikova1, Bibigul Alimbekova1 1Kazakhstan Association on Sexual and Reproductive Health (KMPA), Almaty, Kazakhstan, 2International Planned Parenthood Federation EN, Brussels, Belgium - galina.kmpa@gmail.com
Background: The initiative was aimed at improving access to high quality comprehensive abortion care for low-income women, including internal and external migrants, and youth. KMPA established cabinets in community clinical centres of two regions populated by low-income people. KMPA cabinets provided services within a comprehensive package of SRH services in the framework of national legislation to meet high standards of care. Services were oriented and based on client rights and providers needs model. KMPA provided educational workshops on safe abortion techniques, postabortion counselling and quality of care for service providers in respective centres with the following M&E for further dissemination of experience to other community medical centres. Objective: To improve awareness of low-income population, including migrants and the youth on their sexual and reproductive rights and availability of comprehensive abortion care in local healthcare facilities of pilot regions by the end of 2013. Method: Primarily KMPA selected volunteers among women working in the local trade markets to be trained on the following topics: advantages of safe abortion and accessing sites for obtaining of services. Trained volunteers distributed the information materials on safe abortion and contraception among vulnerable groups in the markets. Results: After training 20 volunteers actively working at Black Market and providing information about free safe abortion services and contraceptives in the pilot outpatient clinics, the number of requests for safe abortion at primary healthcare (PHC) level increased by 2.5 times. The outcome indicates an improvement of women's awareness of the available medical abortion services for free. Conclusion: Involvement of local community in education and dissemination of information and knowledge about safe abortion services at PHC level significantly improves the level of awareness and visits of vulnerable population of PHC outpatient clinics.
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Oct. 25, 2008, 02:00
Comparison between local and general anaesthesia
Philippe Lefèbvre, Marie Duriez (France)
Service d’Orthogénie (Hospital Family Planning Service), Roubaix, France
philippe.lefebvre@ch-roubaix.fr
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 400mg misoprostol 48 hours later. A 2nd oral dose of misoprostol (400mg) is given 3 hours later if there has been no expulsion. Every patient is required to return 15 days later to check their bHCG 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, bHCG 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 are 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.
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Oct. 2, 2014, 12:00
Comparison of two methods of late termination of pregnancy for fetal anomalies
Urška Gruden, Barbara Šajina-Stritar, Nataša Vrhkar, Nataša Tul-Mandić Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana, Slovenia - urska.gruden@gmail.com
Objective: To compare results of intra-amniotic injection of carboprost (IA method) with mifepristone-misoprostol oral/vaginal application (MI-MI method) for termination of pregnancy (TOP) for fetal anomalies after 22 weeks. Methods: We collected data from women requiring TOP after 22w for fetal anomalies from January 2011 to December 2012. After the maternal request and ethical committee approval, feticide was performed followed by IA injection of carboprost 4 ml or by application of mifepristone 200 mg orally and misoprostol vaginally 24-36 hours later. Mifepristone was optional. The first dose of misoprostol was 100 mcg vaginally, continued every 3 hours bucally with rising doses 100-400 mcg until labour started. We collected data about gestational age, parity, average time from beginning of procedure to labour and need for surgical evacuation of the placenta after TOP. We analyzed data using the statistical program SPSS. Results: We included 74 women, 24 in the IA group and 50 in the MI-MI group. Mean gestational age was 26w 2/7 (22w 1/7 -36w 2/7). Mifepristone was administered to 29 of 50 women in the MI-MI group TOP was successful in 24 (100 %) cases after IA and in 49 (98 %) cases after MI-MI. The average time from beginning of TOP procedure until labour was 24.8 hours in IA group and 17.4 hours after misoprostol application in the MI-MI group. Surgical evacuation of the uterus was done in 15 cases (65.2 %) in IA group and 13 cases (26 %) in the MI-MI group. In cases where mifepristone was combined with misoprostol the time interval from administration of vaginal misoprostol to labour was 5.5 hours, shorter than in cases where only misoprostol was used. Conclusions: Both methods are safe and effective, but the MI-MI method has more advantages. These are non-invasiveness, less surgical intervention for retained placenta, shorter interval from beginning of procedure to labour and lower costs.
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Oct. 13, 2006, 04:00
Comprehensive pain treatment in abortion care
Inga-May Andersson, Midwife Msc
Karolinska University Hospital, Stockholm
Background: Pain during abortion is a complex condition with many aspects to pay
attention to in the nursing care of women undergoing abortion. Management of pain during
abortion has been given insufficient attention.
Materials and Methods: Review of the current literature.
Results: The abortion methods have been given a lot of attention in different research
projects. Several studies focus on the regimen of medical abortion. The methods for
surgical abortion are also well evaluated.
Studies show that women’s experience of pain varies with gestational age, maternal age
and parity. Visceral pain, as abortion pain belongs to, is deep and poorly localised often
with high intensity score. Systematically given opioids are not optimal treatment in pain
from urogenithal region; regional blockades are more effective. Early treatment of pain
reduces the pain intensity.
Anxiety is related to pain in a number of procedures and situations. Anxiety combined with
physical (nociceptive) pain makes the total experience of pain more intensive. To reduce
stress related to the physical and emotional aspects of the abortion information is helpful.
It is important for the women to have accurate information before the procedure and high
quality care throughout. The information and care should be as effective as possible in
meeting the needs for the individual woman.
Other non-medical pain management strategies should also be given the necessary
attention. The woman should be offered a choice of abortion methods because women
report less pain if the choice of early abortion has been their own decision. The importanceof positive staff attitudes and a non-judgemental atmosphere in the quality of care is
emphasised.
Conclusions: Pain treatment in abortion care is a complex challenge. Correct information,
positive attitudes together witn non-judgemental atmosphere are important parts to reduce
stress for the women. Medical pain management during abortion should be mixed with
drugs acting both central- and periphere. Paracetamol, kodein and NSAID is
recommended. Local anaesthetic by paracervical blockade is an effective method if
needed. Prophylactic pain treatment should be considered. -
Sept. 11, 2004, 11:00
Concerning abortion
Irina Savelieva, MD, Russia
The growing economic difficulties have made it hard to implement universal access to health in Russia. Significant cuts in the public health care budget have resulted in a decrease of state-guaranteed health services for women and children. Due to the lack of appropriate contraceptives and counseling services, abortion was and still remains the principal means of fertility regulation in Russia, sometimes exceeding the number of live births by two or three times. Though the number of abortions performed annually has declined drastically over the past decade (the abortion rate was 100.3 per 1,000 in 1991 compared with 47.7 per 1.000 women of reproductive age in 2001) abortion remains to be an important cause of preventable morbidity and mortality among women of reproductive age. In 2001, abortion accounted for 27,7% of maternal deaths in Russia, as compared with an estimated 13% of maternal deaths attributable to abortion globally. At the same time the number of post-abortion complications remains high, and according to some research can reach 40-60% with high level of incomplete medical abortions, of which nearly half (46.2%) required hospitalization. There are also several safety issues (abortion in nulliparous women, multiple pregnancy terminations, second trimester abortion) which have not be addressed adequately and need special attention, not to mention the psycho-social effects of multiple abortions and possible secondary infertility, and the growing interest and practice of assisted reproduction techniques, such as in vitro fertilization (IVF). These data demonstrated that quality abortion care in Russia does not satisfy world standards and WHO recommendations.
Abortions are more common among women ages 20 to 34 (approximately 70%), with 15.3% women who were pregnant for the first time; the mean number of abortions is 2.8-3.07. Almost 40% of abortion clients had already terminated a pregnancy by abortion during the previous 12 month. About half (43%) were using contraception at the time of their last pregnancy (39% were using condoms, 20% - natural family planning, 12% - spermicides and 11% - pills). The principal reasons for abortions (62,3%) were indicated as socioeconomic reasons; and 20,0% did not want more children. Only 36,9% of abortion clients, including young adults and primigravidae, what is of a crucial importance, received family planning counseling prior to the discharge and only 22,0% left medical facility with a contraceptive method of their choice. Since many women who are terminating an unwanted pregnancy intend to have a child later, it is extremely important to identify high level of post-abortion complications on subsequent reproductive function. The entire population is covered by a national health insurance, but abortion as a procedure has not been included. The country has adopted the Essential Drug Policy but has not included contraceptives in the Essential Drug List.
Clinical abortions are performed in medical facilities. The services are provided in maternity hospitals, consultancies of obstetrics and gynecology, private practices and Family Planning Centers. According to state regulations and laws all state institutions provide family planning counseling and abortions free of charge, but the present socio-economic situation has triggered a growing habit of charges made for clinical abortions.
Increasing and more human counseling, improved and good quality of services, good technology (including new medications), good facilities, better information through well-trained providers, careful follow-up, offer choices of contraceptive methods to women and help them to avoid unwanted pregnancies and consequent maternal health risks.
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Sept. 11, 2004, 11:00
Concerning contraception
Medard Lech, MD, Director of the Fertility and Sterility Research Center in Warsaw, Poland. He is also a Senior Consultant Gynecologist in ENELMED Medical System in Poland. After earning his medical degree from the Medical University of Warsaw in 1967 he has completed his postgraduate education at Bielanski Teaching Hospital of Warsaw obtaining the Fellowship Diploma of the Obstetrics and Gynecology College of Poland. He is also a specialist in Public Health. He has obtained broad clinical and educational experience during his service in State Postgraduate Medical Education Center of Poland, State University of Maiduguri (Nigeria) and St Luke’s Teaching Hospital of the University of Malta. The author of more than 100 published abstracts, peer-reviewed papers and reviews, he has served as Principal Investigator and Investigator on numerous clinical trials. He is Editor-in-Chief of Polish Quarterly Journal Antykoncepcja – Aktualności. He is a member of the Polish Gynecology Society and Society of Social Medicine and Public Health. He is a member of Board of Directors and the Executive Committee of European Society of Contraception.
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It is important that couples have easy access to a wide range of methods of birth control so they can freely exercise their choice in the matter of procreation. This can be achieved in several ways; sterilization (male or female), effective contraception, or abortion. Abortion should be a “last resort method” of birth control. Wherever the availability of effective methods of contraception is restricted, the rates of induced abortions are high.
51.5% out of 377.5 million of European women live, in Eastern/Central Europe (year 2003). Historically, induced abortion has been a common method of birth control in this part of Europe, mostly due to the lack of modern contraceptives (ie any method other than the rhythm method or coitus interruptus). In these countries in 1994, 43% of women aged 15-44 years used no contraceptive method, 27% relied on withdrawal and 6% the rhythm method. In 1996 the contraceptive prevalence rate was still only 35%. As a consequence of a low usage of modern methods of contraception these countries have high birth rates in very young women (ie. 6% in Czech Republic, 7.4% in Poland, 9.1% in Hungary). The increased use of modern contraceptives is directly correlated with declining abortion rates. As an example, the annual number of abortions in the Czech Republic declined by 65% from 107,100 in 1990 to 37,200 in 1999 as modern contraceptive use increased seven fold in the same period of time. Inverse correlation can be seen between the abortion rate and use of modern contraception in Romania and Bulgaria is very well documented for the years 1950 – 2000.
Prevalence of contraceptive usage in Central/Eastern Europe (in women aged 15-49 years) varies from 20-23% in Lithuania, Moldova and Ukraine to 73-76% in Hungary and Bulgaria, In some countries, modern methods of contraception are unpopular (eg in Romania; use of all methods – 57%, but modern methods only - 14%. Total fertility rates all over Central/Eastern Europe - in recent years - have fallen, and in most countries have reached less than 1.9 (excluding Albania). It seems unlikely that this is due to a decrease in sexual activity of the people; it must be due to increased use of birth control methods, especially the use of modern contraception. The increase availability of modern methods of contraception is a signum temporis for people living in Central/Eastern Europe, but from the other hand quality family planning services are getting less and less available in these countries. In many of these countries there are still barriers to proper information and sexual education of young people
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Oct. 15, 1999, 08:00
In France, Belgium and Holland the teams are made up of multi-skilled staff :
psychologists, social workers, nurses.
A counselling session is compulsory in France and systematic in Belgium.
C. BIRMAN (F) is worried that psychologisation is moving the problem of legal
abortion from a collective one to one concerning the individual and thus bringing
in a sexist attitude.
P. CESBRON (F) would like to see an exchange between professionals and
militants.
Dr FIALA (A) reminds people of the important role of the paramedical team in
drug induced abortion.
Dr GOLSTEIN (DK) emphasises the specificity of abortion and the need for the
paramedical staff to have followed an appropriate training.