Early, liberal provision of intrauterine contraception after first trimester abortion is not associated with an increased risk of postabortal adverse events or complications
Elina Pohjoranta, Maarit Mentula, Satu Suhonen, Oskari Heikinheimo Helsinki University Central Hospital, Helsinki, Finland - email@example.com
Objectives: We carried out a randomized prospective study to assess the effects of early provision of intrauterine contraception (either LNG-IUS or Cu-IUD) vs. routine practice of starting contraception following first trimester induced abortion. This is a secondary analysis comparing early (i.e. within 3 months) adverse events/complications in the two groups. Method: Altogether 756 women undergoing an induced abortion were randomized into two groups (378 in the intervention and 372 in the control group). In the intervention group, 70 (19%) women chose surgical abortion; 68 (97%) of them received an IUS/IUD at the time of abortion. Of the 308 women choosing medical abortion, 290 (83%) received the IUS/IUD at the follow-up visit 2-3 weeks after abortion, the remaining 61 (17%) later. The women in the intervention group had an appointment with the study nurse at 3 months after the abortion. For the control group, a follow-up and future contraceptive counselling was scheduled in primary health care, which is the normal practice. All women were advised to contact the hospital should complications arise. The hospital charts were reviewed for postabortal complications (i.e. bleeding, residual tissue, ongoing pregnancy or infection requiring treatment) within 3 months. Results: 58 (15%) women in the intervention group and 45 (12%) women in the control group were treated for an adverse event (p=0.196). The rate of complications among all women choosing medical abortion was 82 (13%) and 21 (15%) among those choosing surgical abortion. In the intervention group, 24 (41%) patients' complications were detected before the follow-up, 31 (53%) at the follow-up visit, and 3 (5%) at 3 months. Altogether 20 (5.3%) IUS/IUD expulsions occurred by 3 months, 7 (35%) of which were before 2-3 weeks. Conclusions: The early insertion of an IUD after first trimester abortion does not increase the overall risk of adverse events/complications nor cause extra visits to the clinic.
Perception of pain during misoprostol-induced medical abortion
Marja Tikka, Satu Suhonen, Timo Kauppila, Seppo Kivinen (Finland)
Helsinki University Central Hospital, Finland
Counselling, information about the process of medical abortion as well as sufficient pain relief are important factors when a woman chooses medical abortion. Menstrual pain, parity and woman’s age may influence pain perception and satisfaction with the chosen method of abortion. Medical abortion can be performed with misoprostol administered in home. How painful the abortion experience is, and can this pain be predicted would be useful to know when medical abortion is chosen and especially when home-use of misoprostol is planned.
Fifty-six women who had chosen medical abortion were allocated in this study. Their mean age was 26.2 years (SD 6.2, range 15-43). On the day the medical abortion was started, the median length of pregnancy evaluated by transvaginal ultrasound was 47 days (range 32-63). This was the first pregnancy for 4 women. Altogether 29 women (51.7 %) were nulliparous.
The women were asked to describe their menstrual pain by describing how intense (sensory discriminative component of pain) and unpleasant (affective-motivational component) the pain was. Visual analogue scale (VAS) and a pain drawing of the body area where the pain was felt were applied. When the participants were at the ward after receiving misoprostol, they were asked to describe similarly the pain they felt during the abortion. Afterwards, the type of pain at home, its duration and need for painkillers were recorded, too. At the control visit after medical abortion, their willingness to have gone through the abortion at home was also asked.
The intensity of menstrual pain correlated significantly with the intensity of pain perceived during medical abortion. Both intensity and unpleasantness of menstrual pain correlated with the affective-motivational component of pain perception during medical abortion, too. Older and parous women reported less pain. In these women the area where pain was felt was also smaller. At the time of control visit, 55 % women were willing to choose home administration of misoprostol as a method of choice for abortion. Their VAS scores for pain during abortion were lower than in women who would not prefer home administration of misoprostol (12 vs 68 mm, median). Most of the women who were willing for home-administration were parous. However, neither the length of pregnancy at the time of abortion nor the age of the woman had an influence on her view.
In nulliparous women, dysmenorrhea predicts the pain perceived during medical misoprostol-induced abortion. Sufficient pain relief is important to all women, but especially if home-administration of misoprostol is planned during medical abortion.
Contraceptive failure - unprotected sex or failure
in use of the chosen contraceptive method or use
of an ineffective method - leads to unintended
pregnancy. Most women choose abortion in this
situation. Avoiding the same incident in future, that is
reducing the risk of repeat abortion, is in the interest
of the woman and also the society both medically,
psychologically, socially and economically. Including
contraceptive counselling in post-abortion care is
important and emphasized also in recent guidelines
(WHO, RCOG). However, counselling itself has not
been shown to have a beneficial long-term effect on
contraceptive use and risk of repeat abortion.
Recovery of ovarian function after abortion is
rapid, ovulation occurs within the first month after
abortion in most women. Thus contraception
should be started as early as possible after
abortion. Immediate start of both hormonal
(pill, patch, ring) and also long-acting reversible
(LARC) methods (implant, injection, intrauterine
contraception) is recommended in the above
mentioned guidelines. After medical abortion
LARC using implants, injections can be started on
the day of abortion, intrauterine contraception as
soon as an on-going pregnancy is excluded. There
is evidence that if after abortion a LARC method
is chosen, the risk of repeat abortion is reduced.
Well-functioning, easy-access contraceptive
services are important in the follow-up.