Cervical priming before surgical abortion
Aubert Agostini, Alexandra Ohannessian
La Conception Hospital, Marseille, France
Legal abortions are an international public health issue, with one in five pregnancies worldwide resulting in the decision to terminate. Accordingly, in 2008, 43.8 million elective abortions were performed, for a mean of 28 per 1000 women aged 15 to 44 years, with nearly 8.5 million complications. These complications can be life-threatening and are responsible for 13% of the annual international maternal mortality.
Surgical abortion requires mechanical dilatation of the cervix. This cervical dilatation is the source of the principal complications of abortions including cervical laceration, uterine perforation with a risk of wounding adjoining organs, haemorrhage and, finally, the long term risks of cervical incompetence, late miscarriage and preterm delivery.On the other hand, when cervical dilatation is not adequate at the moment of aspiration, it can also cause other short-term complications: ongoing pregnancy and infection that can affect fertility. Cervical preparation has shown benefits in terms of cervical dilatation and reduction of intraoperative bleeding as well as a reduction in the incidence of complications. Misoprostol and mifepristone are the two substances recommended for cervical preparation during the first trimester.
MYA study: Observational study on cervical preparation prior to surgical abortion in real life conditions
Aubert Agostini1, Philippe David2, Virginie Rondeau3 1Assistance Publique Hôpitaux de Marseille, Service Gynécologie, Hôpital de la Conception, Marseille, France, 2Service Gynécologie Obstétrique, Clinique Jules Verne, Nantes, France, 3INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France - firstname.lastname@example.org
Background: More than 200,000 abortions are performed yearly in France. Guidelines are available for medical and surgical abortion. However, clinical practices on surgical abortion and particularly on cervical preparation are not well known and not sufficiently documented. Study objectives: The main objective is to describe the different surgical abortion procedures especially the methods used for cervical preparation prior to surgical abortion including mechanical dilatation, therapeutic regimen, prescribed medications and conditions of administration. The secondary objectives assess the investigator's satisfaction with cervaical preparation, patient's feedback on surgery and identify associated factors with the chosen method of cervical preparation. Design: MYA is an observational, prospective study set up, in real-life conditions, in centres with at least 50% of their activity in surgical abortions and with a high number of abortions per year (N >500). In total, 132 centres were invited and 40 centres agreed to take part in the study from December 2013. A cohort of 600 women (older than 18 years) undergoing a surgical abortion at less than 14 weeks’ gestation, is expected. Women are enrolled during the visit prior the surgery after giving their oral consent. Data collection and outcome measures: Data will be collected by the investigator on 3 occasions: enrollment visit, during surgery and at the follow-up visit usually planned 3 weeks after surgery, including safety data. Patients will be asked to complete a questionnaire on acceptability one week after surgery. Cervical preparation will be described by the method used: medication prescribed or not, dosage and type of administration, interval between the medication administration and surgery and the rationale of this therapeutic regimen. Descriptive statistics of all variables will be performed to analyze the results. Conclusion: This study aims to provide additional information on the procedures of cervical preparation particularly for Western countries where these medical practices are poorly documented.
Mifepristone and misoprostol for cervical ripening in surgical abortion between 12 and 14 weeks of gestation: a randomised controlled trial
Alexandra Ohannessian1, Karine Baumstarck2, Julia Maruani1, Emmanuelle Cohen-Solal1, Pascal Auquier2, Aubert Agostini1
1Department of Gynecology and Obstetrics, La Conception Hospital, Marseille, France, 2Department of Public Health, Self-perceived Health Assessment Research Unit, Aix-Marseille University, Marseille, France
Objective: Misoprostol and mifepristone are the two substances recommended for cervical preparation during first-trimester surgical abortions to decrease intraoperative bleeding and complications. The objective of the study was to evaluate whether the combination of mifepristone and misoprostol for cervical preparation in an elective surgical abortion between 12 and 14 weeks of gestation can reduce blood loss in comparison to misoprostol or mifepristone alone.
Method: A randomised controlled trial was performed in Marseille, France between May 2013 and May 2014. Women requesting a surgical abortion under general anesthesia between 12 and 14 weeks of gestation numbered 198, randomised into three groups: one group received 400 mcg oral misoprostol three hours before surgery; one 200 mg oral mifepristone 36 hours before surgery; and the other both treatments. The main outcome was the quantity of intraoperative bleeding. Secondary outcomes were duration of intervention, ease of dilatation and complications.
Results: The quantity of intraoperative bleeding differed significantly between the groups (p=0.001): 222 mL+/-64 in the combination group, 329 mL+/-129 in the misoprostol group, and 276 mL+/-119 in the mifepristone group. The combination was associated with a shorter operative duration (p=0.001): 5 minutes +/-2 in the combination group, 7+/-5 in the misoprostol group, 7+/-3 in the mifepristone group. A hemorrhage was observed for 5 of 55 women (9%) in the combination group, 13 of 51 (25%) in the misoprostol group, and 9 of 56 (16%) in the mifepristone group (p=0.08). No cervical laceration or uterine perforation was reported.
Conclusion: The combination of mifepristone and misoprostol in cervical preparation for elective surgical abortions between 12 and 14 weeks of gestation significantly reduced blood loss in comparison to misoprostol or mifepristone alone.