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
Sublingual misoprostol for cervical dilatation prior to insertion of an IUD
Sääv I, MD. Aronsson A, MD, Marions L, MD.PhD, Gemzell Danielsson K. MD, PhD,
Dept. of Obstetrics &.Gynecology, Karolinska University Hospital/ Karolinska Institutet,
The IUD is highly effective contraceptive method also in young nulliparous women. The
cupper-IUD is the most effective emergency contraceptive method available.
Complications at insertion are not more common postcoitally at any time during the
menstrual cycle than routine insertion. However, a disadvantage in nulliparous women is
that insertion of an IUD through a narrow cervix may be technically difficult and painful.
Failed insertion, complications and side effects are significantly more common among
women who have no previous delivery. The fear of painful insertion may make women to
hesitate to use an IUD.
Misoprostol (Cytotec) is a prostaglandin (PG) E1 analogue commercially widely available
and used to decrease the ulcerogenic effects of non-steroidal anti-inflammatory drugs.
Misoprostol is used for termination of first and second trimester abortion, and cervical
dilatation prior to surgical abortion.
Another possible indication for use of misoprostol is cervical priming prior to insertion of an
The aim of this study is to compare the route of sublingual misoprostol and diclofenac with
only diclofenac treatment and to evaluate the effect on cervical dilatation, side effects,
pain, bleeding and acceptability.
We randomise 80 healthy nulliparous women requesting IUD insertion to 400 microgram
of misoprostol and pain medication to only pain medication one hour to prior to IUD
Our preliminary results show that sublingual misoprostol is effective for pre-operative
cervical dilatation in non-pregnant women.
Sublingual versus vaginal misoprostol for cervical dilatation, 1 or 3 hours prior to surgical abortion, a placebo-controlled, double-blind study
Ingrid Sääv1 ,2, Helena Kopp Kallner1, Majken Ullmark2, Madelaine Dahlin2, Eva Broberg1, Kristina Gemzell-Danielsson1 ,2 1Dept of Women & Child Health, Karolinska Institutet, Stockholm, Sweden, 2Div of Obstetrics & Gynaecology, Karolinska University Hospital, Stockholm, Sweden - firstname.lastname@example.org
Background: Woman undergoing surgical abortion are treated routinely with misoprostol, administered 3 hours before surgical termination of pregnancy. Many women complain of side-effects, and some have bleeding and expulsion before the abortion. Shorter priming time would make it possible to treat women in clinic. Misoprostol reduces the risk of surgical damage, heavy bleeding and incomplete abortion. Vaginal administration has been shown to induce less side-effects. Objective: We wanted to study if a reduction of priming time from 3 to 1 hour could give equal priming effect. We also compared vaginal to sublingual administration. Material and methods: 186 nulliparous women undergoing surgical abortion during the first trimester were recruited. They were randomized to 4 groups, in which they received misoprostol vaginal or sublingual, 1 or 3 hours prior to the abortion. The study was performed in a double-blind fashion. The resistance of the cervical os was measured objectively using a tonometer during the dilatation. The amount of bleeding was noted, and the patients were asked if they had experienced any side-effects, and which administration route they preferred. Results: There was no difference in priming effect between 1 and 3 hours when given sublingually (p=0.62). However, when given vaginally, there was a significant difference with higher force needed in the group with 1 hour priming time (p=0.028). Fewer women started bleeding when the priming time was reduced to one hour. Most women preferred vaginal treatment, in most cases due to bad taste in the mouth for a long time when taken sublingually. Conclusion: It is safe to reduce the priming time to one hour with misoprostol prior to surgical termination of pregnancy. When the priming time is reduced to one hour, sublingual treatment should be used. Shorter priming time induces less side-effects, and fewer women experience bleeding and expulsion prior to the abortion.
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.
Cervical priming made easy
Ingrid Sääv1 ,2, Kristina Gemzell Danielsson1 ,3
1Karolinska Institutet, Stockholm, Sweden, 2Norrtälje Hospital, Norrtälje, Sweden, 3Karolinska University Hospital, Stockholm, Sweden
Before 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.
Intrauterine contraception after medical abortion
Ingrid Sääv1 ,2, Kristina Gemzell Danielsson1
1Karolinska Institutet, Stockholm, Sweden, 2Norrtälje Hospital, Norrtälje, Sweden
Background: Today a large proportion of early abortions are medical terminations, in accordance with the woman's choice. Intrauterine contraceptives (IUC) provide highly effective, reversible, long-acting contraception but the effects of timing of IUC insertion after medical abortion are not well known. Routine insertion after the first menstruation means an obvious risk of a new pregnancy.
Methods: Women undergoing early medical abortion with mifepristone and misoprostol up to 63 days gestation and opting for IUC were randomised to early insertion (day 5-9 after mifepristone) or delayed (routine) insertion (at 3-4 weeks after mifepristone). The primary outcome was the rate of IUC expulsion six months after IUC insertion. Secondary outcomes were rate of insertion, use at 6 and 12 months, and adverse events.
Results: A total of 129 women were randomised and 116 women had a successful IUC insertion. There was no difference in expulsion rate between the groups (p=0.65) with 6 expulsions in the early insertion group (9.7%) compared to 4 in the late insertion group (7.4%). Significantly more women returned for insertion in the intervention group (p=0.03) and more women (41%) had unprotected intercourse prior to insertion in the delayed group (p=0.015). Adverse events were rare in both groups.
At the follow ups no differences could be found in regard to bleeding patterns, menstrual pain or compliance with the IUC.
Conclusions: Early insertion of IUC after medical abortion is safe and well tolerated with no increased incidence for expulsions or complications. Women are more likely to return for the IUC insertion if scheduled early after the abortion and less likely to have had an unprotected intercourse prior to insertion. Early insertion should be offered as a routine for women undergoing first trimester medical abortion.
Key words: IUC, medical abortion, insertion, intrauterine contraception