Annet Jansen

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    Is there a lower limit in gestational age?


    Annet Jansen MD, 1979-1984 Curaçao (Dutch Antilles), 2 years department gynaecology and obstetrics, 1984 rehabilitation outpatient department university hospital Groningen, 1985-1998 primary health center baby and child care (prevention), 1993-          medical supervisor center for sexual and reproductive health Amsterdam


    It is acceptable to perform an abortion from 2.5- 3 weeks  gestation if the pregnancy test is positive and the pregnancy is detected intra uterine by ultrasound examination.

    In the Netherlands there is quite a lot of experience with early first trimester surgical abortions with good results. The percentage of failures is 2-5%, comparable with failures by use of the abortion pill.

    The failures are usually not on going pregnancies, but retained placentaparts.

    A higher risk of failed abortion is seen by uterine anomalies, by twin pregnancies, extreme position of the uterus, retroflexion or anteflexion.

    The follow up after 3 weeks is offered to each woman. It includes a laboratory test and if positive an ultrasound examination will follow to exclude an on going pregnancy.

    Depending on the complaints of the failed curettage there is required a repeat curettage.

Izabella Jawad

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    Etonogestrel subdermal implant (Implanon) and overweight/obesity- does it work?
    Izabella Jawad, Ingrid Östlund
    Department of Obstetrics and Gynaecology, University Hospital in Örebro, Sweden
    Background: Overweight and obesity are the cumulative problems in many countries.
    Overweight and obesity have special implications on contraception. Hormonal methods
    supposed to be less effective in women with overweight/obesity. Combined oral
    contraception in women with overweight /obesity are associated with elevated risks for
    DVT. The objective of this study was to evaluate etonogestrel subdermal contraceptive
    implant’s (Implanon) tolerability, efficacy, adverse effects and user continuation rate in
    women with overweight and obesity.
    Material and methods: A prospective cohort study of 75 women with overweight (BMI 25-
    29) and obesity ( BMI >30) who got Implanon insert under period the 01/01/2001 –
    07/08/2002. Reasons for discontinuation and lifetime for Implanon were registrated.
    Results: Mean age of women was 27,5 years (15-44 years). 34 women (45%) were
    overweight and 41 women (55 %) were obese. Compliance under 3 years period in
    overweight group was 50% and in obese group 56%. Totally 40 women (53%) completed
    usage of Implanon and 23 of them (30%) changed to a new one.
    Lifetime for Implanon at 12 months was 75 %, at 24 months 53% and at 35 months 53%.
    None unintended pregnancy was noted.
    Most common reason for discontinuation was menstrual disorders – 17 women (22,5%)
    Other adverse effects (acne, headache and moodchanges), which lead to discontinuation,
    were at cumulative rate of 16%.
    Conclusion: Efficacy and tolerability in users of etonogestrel subdermal implant
    (Implanon) with overweight/obesity are high and doesn’t differ in those groups of women
    compared to women with normal BMI as well as adverse effects rate.
    Almost 60% of women could have a reliable contraceptive method under a period of two
    years and more than a half could use it under three years period.

Monica Johansson et al.

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    A pilot study on women’s experiences with misoprostol at home or in the hospital in medical abortion up to 63 days of pregnancy.

    Monica Johansson, Eneli Salomonsson and Helena Ekberg, Dept of Woman and Child Health,

    Division of Obstetrics and Gynecology, Karolinska Institutet / Karolinska University Hospital, Sweden

    Background: Home-use of misoprostol in medical abortion up to 63 days of pregnancy was approved in Sweden in 2004. It is now an increasingly popular option for women undergoing first trimester induced abortion. The experiences with misoprostol at home or in the hospital were explored among abortion seeking women.

    Methods: Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 800 g and advised to take them vaginally 36–48 hours later either at home or in the hospital. A follow-up visit was performed a few weeks after the misoprostol treatment.

    The main outcome measures were:

    1) acceptability assesses as satisfaction with the choosen method.

    2) feasibility, assessed through successful completion of abortion at home without the need for hospital admission.

    In addition contraceptive choice and uptake was investigated.

    Results: A total of 53 women participated in this pilot study. Of these, 29 women aborted at home and 24 in the hospital. The majority of women were satisfied with their choice of method and place of treatment. Two women per group reported not being satisfied. No surgical interventions were reported but two women per group had unscheduled visits to the clinic before the Follow-up (FU).

    Follow-up was performed after a mean of 24 or 20 days among women who administered misoprostol at home or in the clinic, respectively. At that time all women except two per group reported that they considered it highly important to avoid another pregnancy at the moment. Six or 7 women per group had had sex before the FU. Among them 6 and 4 women, respectively, had not started any contraceptive method. In the first group (home-use of misoprostol) 6 women had started contraception before the FU and 12 started at the FU while in the second group 9 women started before the FU and 7 at FU.

    Conclusions: This study supports that women should be free to choose their preferred location of the induced medical abortion. The reason why so many women postpone post abortion contraception despite stressing the importance to avoid a pregnancy needs to be further explored.

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    Medical abortion at  9+1 to 12+0 weeks of gestation - a pilot studyon efficacy, bleeding and women´s experiences

    Monica Johansson, Department of Women´s and Children´s Health, Division of Obstetrics

    and Gynecology, Karolinska Institutet/Karolinska University Hospital, Sweden

    Background:Medical abortion up to 9+0 weeks gestation was approved in Sweden in 1992.  Today a majority of induced abortions are medically induced and performed before the eight’s week of gestation. The standard method for termination of pregnancy in the late first trimester is still surgical using vacuum aspiration. However, more recently medical abortion has become increasingly used also beyond 63 days of gestation.

    Objectives: The objectives of this pilot study were to evaluate women´s experiences with late first trimester abortion and to collect data on efficacy, bleeding and side effects.

    Methods: All women received mifepristone 200 mg orally under nursing  supervision, followed by 800 micrograms misoprostol self administered vaginally 48 hours later. Misoprostol was repeated every 3 hours orally, to a maximum of five doses if needed. A clinical examination including ultrasonography if needed was performed prior to discharge If expulsion had not occurred women were kept in hospital over night and vacuumaspiration performed the following day. Follow-up was performed 3 weeks after treatment. Bleeding and side effects were reported two times from the intake of mifepristone until follow-up.

    Results: A total of 14 pregnant women with gestational age 9+1 to 12+0 weeks were included. The successful termination rate was 85,7 %. Surgical evacuation was carried out in 2 (14,2 %) women and only 3 (21,4 %) estimated bleeding more than a regular period. Most women 13 (92,8 %) found the method of treatment highly acceptable.

    Conclusion: Medical abortion is a highly acceptable method for termination of pregnancy also in late first trimester and could safely be offered to more women.

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    Training: ultrasound for midwives involved in abortion care

    Monica Johansson, Eneli Salomonsson Karolinska Universitetssjukhuset Sesam gyn dagvård, Stockholm, Solna, Sweden -

    Background: The aim of the course was to teach both theoretical and practical aspects of ultrasound diagnostics to those who are active in the field of abortion care. Material and Methods: The target audience was midwives and OBGYN residents active in the field of abortion care who had completed a 3-day theoretical course on induced abortion. The curriculum included two half days of lectures and two afternoon sessions with practical training involving simulators or patients at the abortion care unit at Karolinska University Hospital. The theoretical parts included lectures on ultrasound technique, ultrasound devices, ethics, the legal situation, communicating with patients, ultrasound findings in normal and pathological early pregnancies (until week 9+0) and an update on medical abortion care. After having completed the course and a written exam, participants continued practical training under supervision of a local mentor. A minimum of 50 supervised and 50 independent examinations should be documented and approved by the course leaders. 18 midwives and 1 doctor took part in the ultrasound course in 2013. Of the midwives 14 are now certified and work independently. Results: Introduction of midwifery- led abortion clinics has resulted in: shortened waiting times, time saved for patients and staff, better continuity and reduced costs for the clinic. Significance: Training midwives in medical abortion care will help to shorten waiting times, reduce costs and help to better allocate healthcare resources.

Ronald Johnson

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    The Global Abortion Policies Project: a WHO-United Nations Population Division initiative to strengthen transparency of laws and policies and accountability for women’s health and human rights

    Brooke Ronald Johnson1, Bela Ganatra1, Rajat Khosla1, Vinod Mishra2
    1World Health Organisation, Geneva, Switzerland, 2United Nations, New York, USA

    Prevention of unsafe abortion is a core component of the WHO Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets. To facilitate policy work towards preventing unsafe abortions, the WHO Safe Abortion technical and policy guidance for health systems (2012) recommends that:

    • Laws and policies on abortion should protect women's health and their human rights; 
    • Regulatory, policy and programmematic barriers that hinder access to and timely provision of safe abortion care should be removed;
    • An enabling regulatory and policy environment is needed to ensure that every woman who is legally eligible has ready access to safe abortion care; and,
    • Policies should be geared to respecting, protecting and fulfilling the human rights of women, to achieving positive health outcomes for women, to providing good-quality contraceptive information and services, and to meeting the particular needs of poor women, adolescents, rape survivors and women living with HIV.

    The Global Abortion Policies Project is designed to further strengthen global efforts to eliminate unsafe abortion by producing an open-access, interactive database and repository of current abortion laws, policies, and national standards and guidelines for all countries in the world.  The Project aims to increase the transparency of abortion laws and policies and accountability for implementation and protection of women's health and human rights.  The database and repository will facilitate comparisons of national laws and policies with WHO guidelines and international human rights standards related to safe abortion.  
    The first of three presentations will provide details on the methodology used to retrieve official legal and policy documents, extract selected information for the database and conduct independent validation and country review.  Plans for updating the database/repository, producing a second edition of Abortion policies: a global review, and working with international human rights bodies and intergovernmental organisations will also be presented.

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    WHO tools and activities addressing unsafe abortion

    R.Johnson, WHO, Switzerland

    This presentation will provide an overview of global experience implementing the WHO’s ‘Safe abortion: technical and policy guidance for health systems’*, using the WHO’s ‘Strategic Approach to strengthening sexual and reproductive health policies and programmes’** and ‘Using human rights to advance sexual and reproductive health: a tool for examining laws, regulations and policies’.

    The WHO safe abortion technical and policy guidance was first published in 2003.  The second edition is scheduled for publication in 2011 in addition to new WHO clinical guidelines on comprehensive abortion care.  The WHO Strategic Approach is a three-stage process that includes;

    1) a strategic assessment to identify and prioritize sexual and reproductive health needs;

    2) implementation of policy and programme interventions to address those needs;

    3) scaling up interventions so their benefits can have broader impact.

    It has been applied to prevention of unsafe abortion in 13 countries to date.  The WHO human rights tool (still in draft form, but piloted in several countries) is an instrument that can be used to document and examine laws, regulations and policies related to a broad range of sexual and reproductive health issues.  In June 2009, it was incorporated for the first time into a strategic assessment on unsafe abortion, conducted in Malawi.



J. Joseph Speidel


Bojan Jovanovski