Speeches
-
Oct. 13, 2006, 02:00
For the doctor
Sophie Eyraud, MD; Sophie Gaudu, MD, seyraud@wanadoo.fr
Hôpital Antoine Béclère, Centre de régulation des naissances, Clamart, France
The doctor must make sure it is the best solution and the right time for the patient, not
only from a medical, but also from a psychological point of view.
Therefore we should check :
- The intra-uterine location of the pregnancy
- The length of the pregnancy
- The advisability of the treatment
- The treatment of pain
We also must be able to weigh the advantages and disadvantages in terms of the patient’s
perceptions :
Women tend to see the method as less agresive given the absence of surgical intervention
and the possibility to „do their own abortion“ in a familiar environment.
The fact that it takes place rather early in the pregnancy also makes it safer.
But it requires for the woman undergoing the abortion to be actively involved.
We must explain carefully that, unlike aspiration, the procedure takes place over several
days and is statistically less efficient (the failure rate is approximately 2-3%).
As long as the doctor is assured that the method is medically and psychologically
appropriate, medical abortion makes an excellent option for a well-informed woman. -
Oct. 20, 2012, 05:30
Future perspectivesThe current situation in abortion care should be
improved on two levels: medical and social. On
both levels the focus needs to be the pregnant
woman rather than external factors.
On the medical level we need to give more
autonomy to the woman coming for an abortion.
The procedure still is very much controlled by
the medical system and women are forced to
follow the rules. There is a huge potential for
more autonomy especially in medical abortion,
which will be done at home in the future, only
the drug needs to be bought in the pharmacy
or drugstore, just like the pregnancy test. This is
already reality for example in India.
Also we urgently need better means to effectively
control pain associated with the medical and
surgical procedure and for medical abortion we
need to reduce duration of bleeding.
Equally important are improvements on a social
level: real self-determination. Women and couples
need the legal framework to freely decide on a
pregnancy and as well all necessary means to
execute their decision. We have made a huge
progress from archaic interdiction of abortion to the
current legal status. However there still are many
paternalistic remnants when it comes to abortion. -
Oct. 24, 2008, 09:00
High failure rates of medical termination of pregnancy after the introduction to a large teaching hospital
D. Vitner, R. Machtinger, M. Baum, M. Goldenberg, E. Schiff, D.S. Seidman (Israel)
Department of Ob. & Gyn., Sheba Medical Center, Tel-Hashomer, affiliated to Sackler School of Med., Tel-Aviv University, Tel-Aviv, Israel
dseidman@tau.ac.il
Background. The outcome of all 349 women who chose to undergo medical termination of pregnancy in a tertiary medical center during 2000-2003 was studied.
Methods. The success rates in two time periods (2000-2001 and 2002-2003) were compared in order to assess the effectiveness of medical abortion with mifepristone and misoprostol after its introduction to a large academic tertiary medical center.
Results. The success rates were overall disappointing and significantly declined over time (87.0% vs. 79.3%, p=0.029).
Conclusions. The continuing relatively high failure rate is probably due to the difficulty in defining clear sonographic criteria for treatment failure, and the complexity of a follow-up program implemented at a large teaching hospital by a broad staff with widely varying experience and knowledge of the new procedure.
-
Sept. 10, 2004, 09:15
Historical background of abortion with an emphasis on medical abortion
Marc Bygdeman, Department of Obstetrics and Gynecology, Karolinska Hospital,
Stockholm, Sweden.
Marc Bygdeman is since 1978 professor of Obstetrics and Gynecology at the Karolinska hospital in Stockholm, Sweden. M. Bygdeman has previously been Head of the department, Medical Director of the hospital as well as President of the Swedish Association of Obstetrics and Gynecology. M. Bygdeman is honorary member of the Royal College of Obstetrics and Gynecology and the American College of Obstetricians and Gynecologists and has been awarded the King of Sweden gold medal for outstanding achievements in education and research. M. Bygdeman has published more than 400 scientific articles mainly concerning infertility, contraception and abortion.
--------
The methods used at present for termination of early pregnancy is vacuum aspiration and the antiprogestin, Mifepristone, in combination with an suitable analogue, either misoprostol or gemeprost. Vacuum aspiration was first described in China in 1958 and started to be introduced in Europe shortly thereafter. It replaced the surgical procedure dilatation ond curettage (D&C). The development of a medical method started when prostaglandin analogues became available. In late 1970 and early 1980 it could be demonstrated that repeated administration of e.g. gemeprost by the vaginal route was highly effective resulting in a frequency of complete abortion of 95% or higher. However, effective dose schedules were associated with a high incidence of side effects such as vomiting and diarrhoea. Even home treatment was shown to be a possibility
In 1982 Herrman and co-workers (Herrman et al. Comptes Rendus 1882; 294;933-940) demonstrated that treatment with mifepristone could terminate early pregnancy. Although mifepristone induced a bleeding in almost all early pregnant patients the frequency of complete abortion, 60 to 85% depending on duration of pregnancy at treatment, was not sufficient for clinical use. Treatment with mifepristone converts the quite early pregnant uterus into an organ of spontaneous activity, ripens the cervix and very importantly increases the sensitivity of the myometrium to prostaglandin by around 5 times. The increased sensitivity and contractility of the uterus can be demonstrated after 24 hours and is fully developed 36 to 48 hours after the administration of mifepristone. We could also demonstrate that the treatment with mifepristone followed 36 to 48 hours later by a prostaglandin analogue was a very effective method to terminate early pregnancy (Bygdeman and Swahn, Contraception 1985; 32:45-51). The high sensitivity of the uterus allowed a low dose of prostaglandin to be used and the prostaglandin related side effects to be significantly reduced. After extensive clinical trials, mifepristone in combination with a prostaglandin analogue, initially sulprostone or gemeprost later mainly misoprostol, was licensed 1988 in France and China for induction of abortion up to 7 weeks, followed in the United Kingdom in 1991 and in Sweden in 1992 up to 9 weeks. Today the procedure is licensed in around 30 countries in different parts of the world including a number of countries in Europe and in the United States. In most of these countries the upper limit for the procedure is 7 weeks.
Mifepristone alone is also used to soften the cervix prior to vacuum aspiration and to induce labour in case of intrauterine foetal death and in combination with a prostaglandin analogue for termination of second trimester pregnancy.
-
Oct. 24, 2008, 09:00
Home abortion. Experiences of women and their partners
Marianne Wulff, Anneli Kero, Katarina Bergström, Ann Lalos (Sweden)
Department of Clinical sciences, obstetrics and gynecology, Umeå University, 901 87 Umeå, Sweden
marianne.wulff@vll.se
Background.At Umeå university hospital in Sweden 34% (2007) of all medical abortions were homeabortions. A team of counsellor, nurse as well as a gynaecologist will take care of the abortion seeking woman/couple and offer the opportunity to choose between medical abortion (when early in pregnancy) or surgical abortion. If medical abortion is preferred by the woman, she can do it at home if she wants to and if she fulfils certain criteria (not being too young or immature, not suffering from heavy dysmenorrhoea, not being alone at the time for abortion and not living too far from the hospital). The aim of the study was to gain deeper knowledge about experiences, opinions and reactions among women who choose homeabortions and among their partners present when the abortion took place.
Subjects and methods.Telephone interview by the counsellor in the abortion team using a semi-structured questionnaire with 41 questions, most of these being open-ended. Interviewed were: 100 women and 25 partners. Most women were interviewed one week after the abortion. Quantitative data were analysed using SPSS -programme and the open-ended qualitative data were analyzed using content analysis.
Results.The mean age was 32 years and the majority was married or cohabiting. Pregnant for the first time were 18 women and almost half (45) had had an abortion earlier. The women wanted to do the abortion at home because of a wish of: “control and integrity”, “not having to respond to other people”, “becoming more peaceful when in your own environment”, “not making the process so dramatic”. The overall experience of the homeabortion was that it was “as expected or easier than expected”. The day of mifepristone however, was for many women filled of strong emotions, often paradoxical feelings, and a waiting to the day of prostaglandin and the expulsion of the fetus. That day were dominated by physical symptoms such as nausea, pain and bleeding. Women expressed with emphasis that they would recommend homeabortion to other women. Regarding the partners present during the day of the abortion, they were present because: “it felt natural” or “because she asked for it . Theirreflexions included feelings of “contribution”, “involvement” and “I had a greater role than I would have had at the hospital”.
Conclusions.When having the opportunity to choose homeabortions, the vast majority of women 26-45 years who chose this type of care felt healthier, freer and more empowered having done the abortion at home. They experienced the abortion “as expected or easier than expected” and would strongly recommend it to other women. Their partners were satisfied too, mostly due to the opportunity to be involved to a greater extent than if being at the hospital.
-
Oct. 23, 2010, 02:00
Home abortions
Anneli Kero, (co-authors: Marianne Wulff and Ann Lalos), Department of Clinical Sciences, Obstetrics
and Gynaecology, and Department of Social Work, Umea University, Umea, Sweden
Home abortion implies radical changes for women
Objective: To gain knowledge about women’s experiences, views and reactions regarding having a home abortion (medical abortion with the use of misoprostol at home).
Methods: One hundred women were interviewed one week post-abortion; this yielded both quantitative and qualitative data.
Results: The overwhelming majority of the women experienced wellbeing and were satisfied with their choice of abortion method. They appreciated the privacy and the comfort of being at home which also allowed the presence of a partner. The intake of mifepristone at the clinic was described by many in existential terms as an emotionally charged act, experienced by some as more difficult than expulsion at home. However, relief was the predominant emotional feeling during the expulsion day. Most women did not find it especially dramatic to see and handle the products of conception although some felt uncomfortable at the sight.
Conclusion: Given that they choose this method themselves and are well informed, women are able to handle the abortion process by themselves outside a clinical setting. The option to choose home abortion implies a radical change in empowerment for women. Also allowing them the possibility to take mifepristone at home would increase their privacy and personal integrity even more.
Home abortion - experiences of male involvement
Objective: To gain knowledge about the male partner’s experiences of being present during induced home abortion.
Methods: Twenty-three couples, whose male partner had been present when the woman aborted at home, were interviewed one to two weeks post-abortion.
Results: All mengavesupport to their partner’s decision to have a home abortion, as this gave them the possibility of being near and of caring for her needs on theexpulsion day. In fact, all men took the opportunity to be present and all their partnersconfirmed that they had been supportive. Half the men had been anxious prior to the expulsion, but most considered that their experiences during the expulsion had been ‘easier than expected’ and their dominant feeling was one of relief.
Conclusions: Abortion is an important life event. When taking place at home, it increases the possibility for the couple to share the experience. Sharing an abortion may have a positive impact on those males who lack a sense of responsibility regarding reproductive issues, such as contraceptive use. This could facilitate society’s efforts to involve men as a target group in this field. Designing an abortion policy that caters for the needs of both partners is a challenge.
-
Oct. 23, 2010, 04:00
Home use of misoprostol in medical abortion uo to 63 days gestation
Helena Kopp-Kallner, Karolinska Institute, Sweden
In 1997 home administration of misoprostol was shown to be a safe option up to 56 days gestation (Schaff et al J Fam Pract, 1997. 44(4): p. 353-60) and studies of efficacy of home administration of vaginal administration of misoprostol at home for medical abortion have recently included women with pregnancies up to 63 days gestation (Westhoff et al Analgesia during at-home use of misoprostol as part of a medical abortion regimen. Contraception, 2000. 62(6): p. 311-4, Creinin et al Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol, 2007. 109(4): p. 885-94, Kopp Kallner et al Home self-administration of vaginal misoprostol for medical abortion at 50-63 days compared with gestation of below 50 days. Hum Repr 2010 May;25(5):1153-7).
In Europe, medical abortion was introduced and used in clinics and most countries have not adapted their legislation or interpretation of legislation to home use of misoprostol for medical abortion. When medical termination of pregnancy was introduced in the U.S. in the year 2000, home administration of misoprostol became the standard treatment.
Home use of misoprostol has so far been studied only after administration of mifepristone. The regimen is identical to that used in medical abortion in clinics and efficacy rates are identical to medical abortion in clinics. The most frequently mentioned reasons for medical abortion are perception of a more natural course and higher safety, avoidance of surgery or general anaesthesia and having more privacy and autonomy. Women often object to the number of visits required for a medical abortion. Women are required to visit the clinic three or four times to have a medical termination performed, depending on mandatory waiting periods and number of follow-up visits (Winikoff, Acceptability of medical abortion in early pregnancy, Fam Plann Perspec 1995, 27(4): p. 142-8, 185).
Home use of misoprostol is therefore an attractive treatment option for many women requesting medical abortion. Acceptability does not depend on gestational age or parity and has been been shown to be high among women and their partners (Kopp Kallner et al Home self-administration of vaginal misoprostol for medical abortion at 50-63 days compared with gestation of below 50 days. Hum Repr 2010 May;25(5):1153-7).
Women should be carefully counselled and given realistic expectations as to pain and bleeding. They should be provided with written and oral instructions for the procedure. Measures should be taken to confirm that the pregnancy has been successfully terminated.
-
Oct. 25, 2008, 11:00
How to diagnose a complete medical abortion
Christian Fiala (Austria)
Gynmed Clinic, Vienna, Austria
christian.fiala@aon.at
The most widely used definition of a successful medical abortion is the avoidance of a surgical intervention.
Treatment will result in complete abortion in the vast majority of patients (³95%). However, a small percentage will experience incomplete abortion, missed abortion or continuing pregnancy.
The following methods are used for evaluating the outcome of treatment at follow-up:
- Visual verification of expulsion following intake of misoprostol,
- history of clinical events (heavy or continuous bleeding and pain),
- gynaecological examination,
- hCG in serum measured quantitatively,
- hCG in urine, using a rapid test with a high cut-off value,
- ultrasound examination.
The gestational age at the beginning of treatment must also be taken into consideration when considering the diagnostic method used at follow-up. This is because an intrauterine pregnancy becomes difficult or even impossible to diagnose prior to 5 weeks gestation.
So far no standard has been described for the evaluation of successful treatment and various methods are used in clinical practice. Also, the time delay between mifepristone intake and the follow-up visit varies widely. There is no consensus about a recommended time delay and different providers offer various delays between a few days to 3 weeks.
-
Oct. 13, 2006, 02:00
How to introduce medical abortion in a country, the example of NZ
Margaret Sparrow; MD, New Zealand
In 1999 New Zealand abortion providers considered that New Zealand women should be
offered the choice of medical abortion. As no pharmaceutical firm was interested in
importing mifepristone, five doctors formed a not-for-profit company Istar Ltd. The name is
derived from Ishtar or Istar, an ancient Babylonian goddess of love, fertility and war.
In May 2000 Istar signed an agreement with the French manufacturer, Exelgyn and
applied to Medsafe, Ministry of Health for approval of a new prescription medicine.
On August 30 2001 Mifegyne 200mg was approved by the Minister of Health Hon Annette
King and gazetted for use in New Zealand for abortion only.
To comply with the law all abortions in New Zealand must be “performed” in a licensed
institution. For fear of prosecution most clinics except the one at Wellington Hospital,
chose not to use Mifegyne. Second trimester abortions in hospitals were not affected and
the first medical abortion using Mifegyne was carried out in Wellington Hospital in October
2001.
In April 2003 Mr Justice Durie in the High Court Wellington ruled that a woman must take
both sets of pills (Mifegyne, followed 48 hours later by prostaglandin) in a licensed
institution, but she does not need to stay on licensed premises between taking the pills,
nor does she need to stay on licensed premises until the abortion is complete. Clinics are
now able to perform early abortions within these limits.
Our experience demonstrates that with persistence, obstacles can be overcome.