Speeches
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Oct. 22, 2010, 08:00
Early post abortion insertion of Mirena IUS
Ingrid Sääv, MD and Kristina Gemzell Danielsson, Professor, MD, PhD, Dept of Woman & Child Health,
Div of Obstetrics & Gynaecology, Karolinska University. Hospital / Karolinska Institutet, Sweden
Background: Today a majority of early abortions are conducted medically, in accordance to the woman’s choice. When opting for an IUS/IUD as contraception method, the insertion routinely takes place at the check up visit 3-4 weeks after the abortion. This means an obvious risk of a new pregnancy.
Objectives: We wanted to study if early post abortion insertion of Mirena IUS could be conducted in a safe way and without increased risk of expulsion or infection. Furthermore, we wished to investigate however early insertion would have an impact on the bleeding patterns during the first 4 weeks, and if Mirena use during the first year is comparable between the two groups.
Material and methods: 65 women undergoing elective early medical abortion up to 9 weeks gestation and opting for a Mirena IUS were included. They were randomized to either early insertion on day 5-9 (34 women), or routine insertion at 3-4 weeks (day 21-31) (31 women). The medical termination was performed according to clinical routine. Antibiotic prophylaxis was not administered routinely, but a screening test for Chlamydia infection and bacterial vaginosis was performed. An ultrasound examination was performed before Mirena insertion. Hb and S-hcg was determined on day 1 and at the day of insertion. The patients were scheduled for control visit 4 weeks after Mirena insertion and complications such as infection and expulsion was recorded, and a diary of the bleeding pattern was collected from the patient. Hb was determined, and a urine pregnancy test was performed.
Results: 34 women were randomized to early insertion (day 5-9). 4 women were excluded, of these one was diagnosed with missed abortion and scheduled for vacuum aspiration, one was booked to late by mistake, one did not show up and one woman had regrets and requested a cupper IUD instead. 31 women were randomized to routine insertion (day 21-31). 3 women were excluded, one was diagnosed with a viable pregnancy and was scheduled for a vacuum aspiration and two did not show up for insertion. There were no infections in either group. There were 5 expulsions (17%) in the early group, compared to 3 (11%) in the late group. The bleeding pattern post IUS insertion did not differ between the groups; neither did the acceptability of the patient regarding insertion of the IUS or further use.
Conclusion: There was no difference in safety between the groups. There was no case of endometritis or pelvic infection. Acceptability and bleeding patterns did not differ between the groups. The expulsion rate was substantially elevated in both groups, compared to routine insertion in a non-pregnant woman. We conclude that all women undergoing post-abortion insertion should be scheduled for a control visit
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Oct. 25, 2008, 09:00
Eastern Europe: Turning back the wheel?
Rodica Comendant, Galina Maistruk, Irina Savelyeva (Moldavia)
Reproductive Health Training Center, Moldavia
comendantrodica@yahoo.com
Despite the widespread availability of abortion on legal grounds for more than 50 years, unsafe abortions account for 24% of maternal deaths in Eastern European (EE) region (WHO, 1998). Abortion rates remain high. Abortion is commonly used as a primary means to regulate fertility; the use of modern contraception methods remains low. Access to abortion services in EE has been challenged in recent years. Concerns about declining birth rates, pressure from religious groups have reduced support for family planning and abortion. The low quality of services is influenced by the lack of quality of care standards and quality control.
In this context, the recent registration of Mifepristone in many of EE countries, hasn’t much contributed to the improvement of the quality of abortion care. Medical abortion is still inaccessible for general population and remains an “elite” method for most of the women. The analysis of the access to medical abortion in several EE countries has showed the following common trends:
- Cost of the pills is prohibitive;
- statistic is virtually inexistent;
- low level of the awareness about the method in the population, low demand for comprehensive abortion care services, many existing myths;
- lack of providers motivation to use a new method, the misuse, low efficacy;
- unwillingness of the public health systems to take the necessary steps for the implementation of the medical abortion services, and unnecessary barriers imposed by their regulations.
Recently launched by the leading abortion professionals and women advocates from 10 EE countries network „European Alliance for Reproductive Choice“ , supported by ICMA, among other objectives, has decided to focus on developing strategies, to make MA technology accessible in practice in EE countries. Experience-sharing, information, education, communication (IEC) activities, targeting potential users, to increase the demand for better and affordable services among women, advocacy for women rights to the access to the fruits of modern science, the improvement of providers knowledge among providers, transforming them in women advocates, advocacy events to register and utilize medical abortion are some of the listed strategies to consider.
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Oct. 25, 2008, 02:00
Effectiveness of intracardiac potassium chloride for feticide prior to termination of pregnancy between 20 and 24 weeks
Emeka Oloto (Great Britain)
emeka.oloto@btinternet.com
Background.There is a rising trend in the number of abortions carried out for England and Wales residents and the total was 193737 in 20061. Only 1.5% (2948) of these was carried out at 20 weeks and over of which 34% (1002) were reported as involving feticide. In United Kingdom, termination of pregnancy (TOP) can only be carried out in a National Health Service (NHS) hospital or in a place approved for the purpose by the Secretary of State for Health (non-NHS setting). In 2006, 75328 (39%) of all abortions were performed in the NHS hospitals of which 679 (<1%) were at gestations of 20 weeks and above. The distribution of the feticide procedures between the two settings was not obvious from the published data1.
Objective. This study was conducted to assess the effectiveness and safety of intracardiac Potassium Chloride administration in inducing fetal demise prior to second trimester pregnancy termination in a non-NHS setting.
Patients and Methods.Data regarding the age, parity, gestation, dose of KCl required to achieve asystole, presence or absence of cardiac activity at delivery or immediately before surgery, duration of procedure (from entering to leaving the theatre) and complications were prospectively collected in an excel spreadsheet from February 2007 till date. The feticide was carried out in theatre under general anaesthesia, aseptic conditions and continuous ultrasound guidance. A 16 cm 17-G Chiba needle (Cook Ob/Gyn, Spencer, Indiana, USA) was inserted into the fetal heart and a concentrated KCl (15% , 20mM/10ml ; B-Braun Melsungen AG, Germany) was injected 1 ml at a time until fetal asystole was achieved. A minimum of 5 mls of KCl was given in each case but the dose required to achieve asystole was recorded. Fetal cardiac activity was then observed for about 1-2 minutes to confirm that asystole persisted, but scan was not repeated thereafter. Anti-D immunoglobulin (500 iu) prophylaxis was given to all RhD-negative women. Following feticide, labour was induced for those undergoing medical TOP and surgery the following day for the rest.
Results.Till date241 feticide procedures have been carried out for women between 20 and 24 weeks gestation (mean gestational age of 22 weeks) of which 2 (0.8%) failed to achieve fetal demise. Fifty women (21%) had medical TOP while the rest had surgery. The average age of the patients was 22 years (range 13 – 42 years) and the average parity was 1 (range 0 – 5). 48% of the women were teenagers. The average duration of procedure was 12 minutes (range 5 – 40 minutes) and the average dose of KCl required to achieve asystole was 3 mls (range 1 – 15 mls). No live birth occurred and no maternal complication. The two cases where feticide failed were for planned surgery which was carried out successfully.
Discussion.The Royal College of Obstetrician and Gynaecologists (RCOG) recommended that the method chosen for all terminations at gestational age of more than 21 weeks and 6 days should ensure that the fetus is burn dead. Feticide prior to TOP at late gestation is necessary to avoid resuscitation dilemma for patients, nurses and doctors2; to avoid medico-legal and economic consequences of live birth that survives3; to shorten the mean ‘initiation-expulsion interval4; to reduce the prostaglandin requirement for mid-trimester medical abortion5; and to soften fetal cortical bones which aids surgery and minimises risk to the patients4. Of the available methods for feticide6, intracardiac injection of potassium Chloride (KCl) appears to be the most effective. The average dose of KCl required in this study (3mls) is similar to that reported recently7, but much less than the amount reported by Bhide et al.8
Conclusion.This is, to my knowledge, the first report of the experience of using intracardiac KCl for feticide prior to mid-trimester abortion in non-NHS setting in United Kingdom. It is an effective and safe procedure in non-NHS settings with appropriately trained team and should not be limited to tertiary fetal medicine unit as suggested by Pasquini et al.7
References.
1. Department of Health Abortion Statistics, England and Wales: 2006, Statistical Bulletin 2007/xx. London: Department of Health 2007.
2. Royal College of Obstetricians and Gynaecologists. Further Issues Relating to Late Abortion, Fetal Viability and Registration of Births and Deaths. RCOG Statement London; RCOG Press; 2001.
3. Clark et al. An Infant who survived Abortion and Neonatal Intensive Care. Blumenthal PD et al. Abortion by Labour Induction. A Clinician’s guide to Medical and Surgical Abortion.
5. Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol 1999;94:139-41.
6. National Abortion Federation – Clinical Practice Bulletin: Digoxin Administration. May 2, 2007.
7. Pasquini L, Pontello V, Kumar S. Intracardiac injection of potassium chloride as Method for feticide: experience from a single UK tertiary centre. BJOG 2008;115(4):528-531.
8. Bhide A, Sairam S, Hollis B et al. Comparison of feticide carried out by cordocentesis versus cardiac puncture. Ulrasound Obstet Gyncol 2002;20:230-2.
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Oct. 22, 2010, 08:00
Efficacy and Acceptability of Home-Based Medical Abortion: A Systematic Review
Thoai D. Ngo, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Research and Metrics Team, Health System Department, Marie Stopes International,
London, UK
Background: Home-use of misoprostol can reduce the number of clinic visits required and improve access to medical abortion. We conducted a systematic review to assess the efficacy, safety, and acceptability of medical abortion administered at home versus at clinic.
Methods: The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched for randomized and non-randomized prospective studies of medical abortion at home versus clinic. The main outcomes of interest were failure to achieve complete abortion, side effects, and acceptability. We calculated relative risks (95% CIs), and pooled estimates using a random-effects model.
Findings: Nine studies met the inclusion criteria (n=4,522 participants). All studies used a mifepristone-misoprostol combination for medical abortion. The proportion of women who had a complete abortion in home-based groups (n=3,478) ranged from 86% in India to 97% in Albania, with average success of 89.7%. Complete abortion in clinic-based groups (n=1,044) ranged from 80% in Turkey to 99% in France, with average success of 93.1%. Pooled analyses indicate that there is no difference in complete abortion between home-based (n=3,215) and clinic-based (n=593) intervention groups (OR=1.11; 95% CI: 0.65, 1.91). Serious complications of abortion were rare. Acceptability data indicate that women using self-administered medical abortion at home were more likely to be satisfied, to choose the method again, and to recommend medical abortion to a friend than women who opted for medical abortion at the clinic.
Interpretations: Evidence from prospective cohort studies suggests that the option of home-use of misoprostol for medical abortion is efficacious, safe, and acceptable to women living in both resource-limited and resource-rich settings. This option allows women greater flexibility and privacy in the abortion process, and could increase access to and acceptability of medical abortion.
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Oct. 20, 2012, 02:00
Examples from Italy
ABSTRACT TEXT
The Italian law no.194 approved in 1978, is often considered one of the most advanced inWestern Europe. An abortion may only be carried out in a public hospital and there are no special abortion clinics inItaly. The conscience clause is partially responsible for many of the difficulties in availability of services. The Article 9 provides for the non-participation of staff of any level who work in hospitals and do not want to participate in abortions for reasons of conscience. The objectors are freed from activity specifically directed to the interruption of pregnancy but not from assistance before or after the abortion. It is the responsibility of the hospital to ensure the procedure is efficient and the Region is responsible for the to the provision of the services. This brings to remarkable differences from one region of the country to another. For example the Region of Emilia Romagna, where social and medical facilities are easily available, offers better services with access to medical abortion. Conscientious objection is a major limiting factor in the implementation of the law. According to the Secretary for Health’s last report, at a national level nearly 71 % of the gynaecologists are conscientious objectors and in some regions this percentage reaches 80-85%. Medical abortion has been approved since 2009, but only within 49 days of amenorrhea, in spite of the European mutual recognition procedure. In all cases, with only two regional exceptions , a compulsory hospitalization is requested. So far the medical procedure is not readily accessible in all localities. Restrictions in access to abortion and lack of having the choice between a medical or a surgical procedure are currently the major problems.
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Oct. 3, 2014, 02:00
Objectives: The purpose of this pilot study was to ensure that the insertions and early expulsion rates were acceptable in order to plan a larger trial with the IUB.
Methods: This was an observational pilot case series. The inclusion/exclusion criteria were similar to those for non-study patients receiving IUDs. Women aged 18-50 requesting intrauterine contraception were enrolled. Exclusions included recent pelvic inflammatory disease, genital malignancy and anaemia. The main outcome measure was expulsion by the 6-8 week follow-up visit. Ease and pain of insertion as well as complications and side-effects were also recorded.
Results: 50 women had IUBs inserted between January and April 2014 by a single clinician in Canada. Only 6 (12%) had had a previous birth and 16 had had previous IUDs. There were no failed insertions and 43 (86%) insertions were found to be "easy". The mean pain score for insertion was 5.3/10. There were 32 follow-up visits 6-8 weeks post-insertion by May 2014. There were 8 expulsions (one post medical abortion and accompanied by a "gush of blood"), there was one removal for pain and bleeding and no other complications.
Conclusions: Including the first study of 15 women, there are now data on 65 insertions with no problems, so the insertion technique and equipment for IUBs can be considered acceptable. The early expulsion rate appears too high and may require some change in design. The lack of other complications warrants further studies with this innovative product.
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Sept. 14, 2018, 02:00
Objectives: We examined experiences of women who travel from the Republic of Ireland to the UK for abortion care. Irish women’s experiences are poorly understood. Publically shared stories tend to highlight cases of tragic circumstances (e.g., foetal anomalies, minors), eclipsing more ordinary circumstances for seeking abortion. We collected data about experiences of the latter group by using a systematic qualitative research approach.
Methods: Qualitative data were collected using In-Depth Interviews (IDIs) with 25 Irish women who traveled to Liverpool and London for abortion care between February and June 2017. Participants were Irish citizens or permanent residents and received surgical or medical abortion. We excluded minors and foetal anomaly cases. Participants’ age ranged from 19 to 43 years old; 18 of 25 participants were in their 20s. Their reported gestational age was between 6 and 19 weeks. IDIs followed a 13-item Interview Guide with semistructured probes. Topics included: arranging travel, challenges, support network, delays, and privacy.
Results: Data reveal significant hardships in women’s experiences traveling abroad for abortion care, including difficulties arranging travel in an “environment of secrecy” despite readily available information online, maintaining privacy in social and professional circles while waiting to travel, financial constraints, getting time off work, and securing overnight childcare. Financial barriers may lead women to intentionally schedule later appointments to allow time to organize money. Women who borrowed money reported getting bank loans of 900-1500 Euro. Additionally, the use and location tracking capabilities of social media (Facebook, Snapchat, etc.) may generate added stress about retaining privacy in abortion travel.
Conclusion: Irish women who travel for abortion care to the UK overcome significant financial, social, and employment difficulties in a burdensome environment of secrecy in order to pursue abortion services abroad. This study highlights the need to liberalize access to abortion care in Ireland. -
Oct. 3, 2014, 02:00
Women’s experiences and perceptions of simplified medical abortion: a qualitative study in Rajasthan, India
Kirti Iyengar1 ,2, Birgitta Essen3, Marie Klingberg-Alvin1, Kristina Gemzell-Danielsson1, Sharad Iyengar2, Sunita Soni2 1Karolinska Institutet, Stockholm, Sweden, 2Action Research & Training for Health, Udaipur, India, 3Uppsala University, Uppsala, Sweden - kirtiiyengar@gmail.com
The requirement for repeated clinic visits remains an important barrier to access to medical abortion. Home use of misoprostol and alternatives to routine follow-up have been suggested as interventions to simplify the medical abortion, however there is little evidence on women’s experiences on these from low-resource settings. This qualitative study was conducted in Rajasthan, India, and explored women’s experiences and perceptions of home use of misoprostol and self-assessment of outcome of medical abortion. The reasons for preferring home use included inconvenience of travel, lack of confidentiality and child care commitments. After taking home misoprostol, most women continued with their routine household work, although they didn’t go for work outside the home. Most women experienced no major health problems, while some women made an extra clinic visit because of perceived health problems. A majority said that if they have to undergo another abortion, then they would prefer to use misoprostol at home. On self-assessment of the outcome of abortion, many women were fairly certain that their abortion was complete either because they experienced bleeding or expulsion or because their pregnancy symptoms subsided. Despite this, a majority of women found it reassuring to do the pregnancy test, to confirm that their abortion was complete. According to one woman, “if abortion is not done then we remain in confusion, any problem can arise inside the body, so it’s good to do the test”. Despite low literacy levels, the majority of the women were able to interpret the results of a pregnancy test. They felt that that this saved them a visit to the clinic. The checklist was used by many women, largely as a refresher to see how to do the pregnancy test. Our results indicate that home use of misoprostol and self-assessment using a low sensitivity pregnancy test is feasible in low-resource settings.
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Sept. 15, 2018, 11:00
Objective: To assess the influence of gestational age, maternal age, and reproductive history on the risk for surgical intervention of early medical abortion.
Methods: A nationwide cohort study with eight weeks follow-up of all medical abortions induced at a gestational age <63 days among Danish women through the years 2005-2015. A multiple logistic regression model provided adjusted odds ratios (OR) with 95% confidence intervals (CI) for all the potential risk factors of interest. A division of the data into a training and validation set provided a test of the prediction performance of the model. Reported is the area under the receiver operating characteristic curve (AUC) with 95 % CI.
Results: 86,437 medical abortions were included, 5,320 (6.2%) were surgically intervened. The risk of surgical intervention increased with increasing gestational age (p<0.0001). The risk of surgical intervention peaked among women aged 30-35 years and declined for lower and higher ages (p<0.0001). The OR of surgical intervention among parous women compared to nulliparous was 2.0 (1.7-2.4) for women with a history of failed birth of placenta, 1.5 (1.3-1.6) for women with previous caesarean section, and 1.1 (1.0-1.2) for women with previous vaginal births with spontaneous birth of placenta. A history of early surgical abortion implied an OR of surgical intervention of 1.5 (1.4-1.7), and women with a previous late surgical abortion had an OR of 1.2 (1.1-1.3). Previous medical abortion implied an OR of surgical intervention of 0.84 (0.78-0.90). The AUC was found to be 0.63 (0.62-0.64).
Conclusion: In addition to gestational age, our study shows maternal age, previous delivery, and history of induced abortion to be risk factors for surgical intervention of early medical abortion. However, all these risk factors do not predict surgical intervention well, possibly indicating the subjective nature of the decision to surgically intervene a medical abortion.