Authors by program from Rome 2006
Speeches:
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Pain treatment during second trimester abortion
Inga-Maj Andersson, K. Gemzell-Danielsson, O. Stephansson, K. Christensson,
Dept of Woman & Child Health, Karolinska University Hospital,/Institutet
Stockholm, Sweden,Objectives To assess pain intensity, methods of pain treatment and predictors for the
need of analgesia in women undergoing second trimester abortion.
Design Descriptive study with consecutive inclusion of patients.
Material and methods A combined treatment with mifepristone and misoprostol was used
for the termination of pregnancy. From February 2002 to June 2003 data from 122 women,
undergoing second trimester abortion, was collected into a protocol to describe pain-
intensity measured by Visual Analoge Scale (VAS) and methods of pain treatment.
Demographic data such as age, gestational duration and reproductive history were
collected. The indication for the termination of pregnancy was noted as well as the
presence or absence of a partner or friend during the abortion.
Results The age of the women varied from 14 years to 46 years and the length of
gestation between 86 and 153 days. Indication for the abortion was socio-economic in
66% of the women. Young women, women with no previous birth and women with higher
gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
treatment was higher for these women during second trimester medical abortion. Pain-
intensity VAS >7 (severe pain) was reported by 63% of the women at some time during
the abortion. Intavenous morfine was given to 80% of the women. Paracervical blockade
(PCB) was given to 21% of the women. There was no significant difference in pain-
intensity, morphine- or PCB-requirements related to the presence of a partner, parent or
friend during the abortion nor to the indication for the termination of the pregnancy
(unwanted pregnancy or foetal malformation).Univariat analyses, Chi2-test (p=0.05) and
Mann-Whitney´s test were used for the data analyses.
Discussion Management of pain during second trimester abortion must be focused on the
women’s need. Individual care is crucial for optimal pain treatment. To reduce the high
frequency of severe pain one step is early active pain treatment to women with known
predictors for higher pain experience. Different methods of pain treatment should also beavailable (i.ex. NSAID, PCB). Education of the staff in pain management and caring is
needed to make the abortion care more focused on pain treatment and create a high
quality and non-judgemental atmosphere. Further research is needed to improve the care
of women undergoing second trimester abortion.
Conclusions Young women, women with no previous birth and women with higher
gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
treatment was higher for these women during second trimester medical abortion.
Speeches:
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How to Think About the Fetus
Joyce Arthur, Abortion Rights Coalition of Canada, Vancouver, BC
Should providers and the pro-choice movement acknowledge the "moral value" of the
fetus? This philosophical presentation explains that judging what a fetus is, and any value
it may have, is entirely subjective and personal. Only the individual pregnant woman can
decide what her fetus means to her, and our role is to respect her opinion.
Speeches:
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The midwife’s role in care of abortion patients
Axelsson Monika. RNM, Holmqvist Liselott. RNM, abortion clinic, Göteborg, Sweden
In Sweden, abortion has been legal since 1975. The law stipulates that termination of
pregnancy is the woman’s own choice until week 18. After this gestational age, an
application must be made to the National Board of Health and Welfare. This application is
made jointly by the gynaecologist, who makes a medical assessment, and a social
worker/counsellor, who makes a socio-psychological assessment. The Board approves or
denies the application, based on the special conditions pertinent to the case.
Counselling with a social worker/counsellor is offered to all women until pregnancy week
18; after week 18 counselling is compulsory.
34 800 abortions are performed every year in Sweden. This corresponds to 20.1 abortions
per 1000 women. The most common age group is 20 – 24.The statistics for 2003 show a
decrease in abortions among teenagers for the first time since 1995.
The woman can choose the medical or surgical method surgery until the ninth week of
pregnancy. At the abortion clinic at Sahlgrenska University Hospital/Östra(SUÖ), the staff
consists of four midwives and two auxiliary nurses. Two doctors work at the clinic. Social
workers/counsellors are available when required for consultations. Midwives work in
abortion clinics in Sweden. In many clinics, midwifes are employed, and together with
gynaecologists, social workers/counsellors and auxiliary nurses run the organisation.
The midwife has a unique position, she has a broader view of both the woman’s and man’s
sexual health. She can thus provide information to the patient/woman and give advice and
support prior to the abortion decision. The midwife provides contraceptive information and,
according to Swedish law, prescribes hormonal contraceptives and inserts IUDs and
implants. Cooperation with the social workers/counsellors with their greater knowledge and
education about abortion issues, is positive.
In order to improve our care of and approach to our patients, we performed a study to
evaluate our work in 2001.With the help of a questionnaire, 50 women were questioned
during their follow-up visit. They answered 21 questions concerning clinic environment,
staff availability, information, competence, confidentiality, approach and pain relief.
Most patients were satisfied with the information, with the exception of that regarding pain.
Some patients felt that experiencing labour-like pains/contractions was unpleasant.
Bleeding was also an area, which surprised some of our patients, who had expected tobleed less. The majority of women were satisfied with their care, but thought that the
appointment with the gynaecologist was stressful. We will proceed to improve our
organisation, based on the results of our study.
It is our ambition that a midwife is the first person the patient meets when she requires an
abortion, because the midwife has a unique knowledge of women and their sexual health.
This knowledge should lead to the midwife being responsible for making appointments and
providing advice by telephone, including information on abortion and contraception
methods, so that the woman is well prepared when she comes for her gynaecologist’s
appointment. In our opinion, it is important that women be offered a follow-up appointment
with the midwife after the abortion, regardless of whether it is medical or surgical. Offeringbleed less. The majority of women were satisfied with their care, but thought that the
appointment with the gynaecologist was stressful. We will proceed to improve our
organisation, based on the results of our study.
It is our ambition that a midwife is the first person the patient meets when she requires an
abortion, because the midwife has a unique knowledge of women and their sexual health.
This knowledge should lead to the midwife being responsible for making appointments and
providing advice by telephone, including information on abortion and contraception
methods, so that the woman is well prepared when she comes for her gynaecologist’s
appointment. In our opinion, it is important that women be offered a follow-up appointment
with the midwife after the abortion, regardless of whether it is medical or surgical. Offeringbleed less. The majority of women were satisfied with their care, but thought that the
appointment with the gynaecologist was stressful. We will proceed to improve our
organisation, based on the results of our study.
It is our ambition that a midwife is the first person the patient meets when she requires an
abortion, because the midwife has a unique knowledge of women and their sexual health.
This knowledge should lead to the midwife being responsible for making appointments and
providing advice by telephone, including information on abortion and contraception
methods, so that the woman is well prepared when she comes for her gynaecologist’s
appointment. In our opinion, it is important that women be offered a follow-up appointment
with the midwife after the abortion, regardless of whether it is medical or surgical. Offeringbleed less. The majority of women were satisfied with their care, but thought that the
appointment with the gynaecologist was stressful. We will proceed to improve our
organisation, based on the results of our study.
It is our ambition that a midwife is the first person the patient meets when she requires an
abortion, because the midwife has a unique knowledge of women and their sexual health.
This knowledge should lead to the midwife being responsible for making appointments and
providing advice by telephone, including information on abortion and contraception
methods, so that the woman is well prepared when she comes for her gynaecologist’s
appointment. In our opinion, it is important that women be offered a follow-up appointment
with the midwife after the abortion, regardless of whether it is medical or surgical. Offeringthis service is our ambition, albeit a long-term goal, since it currently depends on the
economical situation in the hospitals. Unfortunately, these women are not a high priority.
Speeches:
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Mifepristone 10 mg for emergency contraception up to 144 hours after an
unprotected intercourse
Carbonell JL,* García R,† Breto A,† Llorente M,* Marí JM,* Sánchez E,* Salvador I,*
Guillén S.*
†Eusebio Hernández Gyneco-Obstetric Teaching Hospital, Havana, Cuba.
*Mediterrania Medica Clinic, Valencia, Spain.
Background: Mifepristone 10 mg has proved to be an effective emergency contraceptive
when administered up to 120 hours after unprotected coitus. We assessed whether the
same effectiveness can be achieved if mifepristone is administered in a longer postcoital
interval (144 hours). Methods: Between May 2003 and February 2005, in the Eusebio
Hernández Gyneco-Obstetric Teaching Hospital in Havana, Cuba, we conducted a single-arm trial to evaluate the effectiveness of 10 mg mifepristone for emergency contraception
up to 144 hours (6 days) after unprotected coitus, A total of 635 women who requested
emergency contraception after a single act of unprotected intercourse were included in the
study. Results: After treatment there was a total of 7/635 (1.1%) pregnancies, 95% CI 0.4
– 2.3%. The prevented pregnancy fraction was 88.0% with 95% CI 77.1 – 95.1%. The
most common side effects reported by subjects were dizziness (6.1%) and nausea (4.9%);
vomiting was only reported by 0.6%. In 38/635 (6.0%) women menstruation was delayed >
7 days. Conclusions: Mifepristone 10 mg administered after unprotected sex can be an
effective method in emergency contraception with an acceptable profile of side effects, but
bigger studies are necessary to verify that it could be administered up to 6 days (144
hours) after an unprotected intercourse. -
Sublingual versus vaginal misoprostol 400 µg for cervical priming
Josep Lluis Carbonell1, J. Marí1, F. Valero2, M. Llorente1, I Salvador1, L Varela1, P Leal1,
A. Candel1, A Tudela1, M Serrano1, E Muñoz1,1Clinica “Mediterrania Medica”, Valencia, Castelló, Spain. 2Clínica “Ginemur”, Murcia,
Murcia Capital, Spain.
Objective: To compare the sublingual and vaginal administration of misoprostol for
cervical priming before first trimester surgical abortion. Design: Open, multicenter,
randomized trial. Locations: Four clinics in Spain: Valencia, Castelló, Murcia and Murcia
Capital. Participants: 1424 healthy pregnant women with amenorrhea ≤ 84 days who
voluntarily decided to terminate their pregnancies. Methods: Women were randomly
assigned to receive a single dose of 400-µg misoprostol sublingually or vaginally 1 to 3
hours before aspiration. Outcomes assessed: The cervix dilation before surgery and
surgical time needed for aspiration. They were also evaluated the incidence of side effects
such as nausea, vomiting, diarrhea, fever/chill and parestheses. Results: The mean
cervical dilation achieved was 6.8 ± 0.8 mm and 6.7 ± 0.9 for sublingual and vaginal
groups, respectively. Mean surgical time for the sublingual group was 7.0 ± 2.8 minutes
and 7.4 ± 2.5 for the vaginal group. Nausea, vomiting and diarrhea were more frequent in
the sublingual group. Conclusions: Both regimens had similar efficacy; however, the
sublingual route caused more side effects.
Speeches:
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Quinacrine Sterilization
George C Denniston MD MPH, President, Doctors Opposing Circumcision, Clinical Asst
Professor, (retir) Dept of Family Medicine, University of Washington, Seattle, WA US
Inserting 7 Quinacrine (Atabrine) pellets into the uterine cavity via an IUD inserter two
times one month apart provides effective permanent sterilization. Already 200,000 women
in 50 countries have benefited from this procedure, developed by Dr Jaime Zipper of
Santiago Chile. The procedure is quick and comfortable, and can be provided by health
care professionals, with fully informed consent. Abortion providers are ideally suited to
offer this procedure.
Speeches:
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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.
Speeches:
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Medical abortion in the hospital or at home - Let the woman chose
Monica Johansson and Marianne Racke, midwifes, Karolinska University Hospital, Division
of Gynecology and Obstetrics Stockholm, Sweden
Introduction: The Board of Healt and Welfare approved medical abortion up to 9 weeks gestation in Sweden in September 1992. Today a majority of induced abortions are performed before 8 weeks and more than 50% of first trimester abortions are medical. The percetage varies between 30 to 90% between different hospitals. Hme-user of misoprostol is approvided since September 2004.
Procedure: Woman with a pregnancy length up to 63 days of amenorrhea, requesting medical abortion, are given the choice between the standard protocol of administration of misoprostol at the hospital and possibility of taken it at home.Information is given by a midwife at the first telephone contact, At the visit in the abortion clinic (day 1) the gestational age is established by menstrual history and confirmed by physical examination and endovaginal ultrasound examination. Whomen are counseled by gynecologist, as well as by a trained and experienced nurse-midwife.
The patients received 200 mg mifepristone orally at the hospital on day 1. The women are also given 4 tablets of misoprostol ( 200µg per tablet) to take vaginally at home 24-48h after mifepristone together with pain prophylaxis. The first follow –up to assess the outcome of treatment is performed by a thelephone call by the midwife within a few days after the treatment.
Follow-up: Is performed on day 14 after the medical abortion.Outcome is evaluated using a urinary HCG test with cut-off value of 500 IU/ml. If necessary, a gynecological examination, an ultrasound examination and seum HCG is performed.Follow-up is mandatory following medical abortion and also includes contraceptive counseling.
Discussion: Home-user of misoprostol reduce the number of visit and improve access to medical abortion. Our data shows a high acceptabilly among women and their partners and confirms the safety and efficacy of home-use of mosoprostol. Women should be pffered this choice to allow more flexibility and privacy in their abortions.
Speeches:
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Advantages of the Implementation of a Quality Control System in a Abortion Clinic
Rodríguez, E.; Gómez, M.; Serrano, J.; González, M.; Martin, M. Rubio, C.
Clínica El Sur, Sevilla, Spain
Quality control programs are being used more often to promote business . Since they have
been proved to be very effective we believe that they could also be implemented in the
medical sector, specifically in interruption of pregnancy. After four years of quality control
program which we have implemented in our clinic it has been succesfull. In colabaration
with other specialist we have brought this poster so that it might encourage others to
introduce this program in their clinics.
The supervision, and certification of a quality control program by an international
enterprise which specialises in QUALITY CONTROL means describing, documenting and
making protocols with regards to all the practices in that business, establishing a
consensus on the standards at all levels.
The main objective of our quality management program is client satisfaction. It involves
establishing mechanisms in order to obtain a continuos improvement in the service which
we offer i.e. performing abortions. It also involves monitoring the results of these
standards. In order to achieve this we plan the objectives of organization, formation of our
personal, control and analize our desviations that occur so that we can rectify them and
hence securely value the most important areas of our enterprise, suppliers, products,
maintance of our equipment, infrastucture, the satisfaction of our clients etc.
Speeches:
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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,
Stockholm, Sweden,
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
IUD.
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
insertion.
Our preliminary results show that sublingual misoprostol is effective for pre-operative
cervical dilatation in non-pregnant women.
Speeches:
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The song „The Knitting Needle Bill“
Carol Shand, MD New Zealand
Explanatory notes for the song by Dr Carol Shand & Dr Margaret Sparrow
This song* was written in 1976 at the height of the abortion debate in New Zealand (NZ).
In the 19th Century, abortion laws in NZ and Australia (based on UK law) were restrictive.
A test case occurred in June 1938 when Dr Aleck Bourne, London, carried out an abortion
on a 14 year old girl who had been raped. Mr Justice Macnaghten directed the jury that an
abortion was not unlawful if carried out on the grounds of preserving the health (as
opposed to the life) of the woman. In 1967 a more liberal law was passed in the UK but NZ
and Australian did not follow suit. Most abortions were clandestine acts. NZ women with
money could travel to the UK or Japan for a legal abortion. Poor women relied on do-it-
yourself techniques, backstreet abortionists or doctors acting covertly within NZ.
Each State in Australia has different abortion laws. In 1969 a Melbourne court case
exposed police corruption and political interference but the result was an acquittal,
liberalising the law in the State of Victoria. In Sydney in 1971 the jury in another trial
involving an abortion “clinic” again failed to convict, effectively liberalising the law in the
State of New South Wales. After this, clinics in these two States operated more openly and
the trans-Tasman traffic increased greatly. (Auckland to Sydney is 2146 km)
In May 1974 a private abortion clinic opened in Auckland to test whether NZ would also
accept a more liberal interpretation of the law. Rich or poor now had access to a safe NZ
service. The police raided the clinic in September 1974 and one of the operating doctorswas brought to trial. Fearing that a NZ jury might not convict (as had happened in
Melbourne and Sydney) anti-abortionists lobbied for parliamentary change.
In September 1974 Dr Gerald Wall MP introduced a Bill (The Knitting Needle Bill) to try
and close down the Auckland clinic, by restricting abortions to hospitals. The Bill was
passed in May 1975 but never enacted due to an error of drafting. The clinic remained
open. Another attempt in August 1976 to restrict abortions to hospitals was made by the
Minister of Health, Air Commodore Gill. Parliament rejected this as they had already
appointed a Royal Commission in June 1975 to review contraception, sterilisation and
abortion. The Commission produced a very conservative report in March 1977. This
resulted in a redrafting of the abortion laws which although still restrictive on paper, in
practice deliver a reasonable although excessively bureaucratic service. The Prime
Minister at the time, Rob Muldoon was also anti-abortion.
The writer of the song, Dr Erich Geiringer (1917-1995), a medical doctor, a refugee from
Vienna, ran a weekly talkback radio session and this song was one of the satirical songs
he wrote and sang on Radio Windy. The illustrations depict from Top left: a rampant
farmer in black wool singlet, and gumboots, smoking heavily. Top centre: Coat of Arms per
Qantas (Australian airline) with NZ icons of rugby, sheep, beer and knitting needles. Top
right: Bernadette. The bottom scenes depict various illegal abortion methods: Higginson
syringe, herbs, potions, hot bath and gin etc. The satire ostensibly mocks the rich young
miss who hopes to enjoy a days shopping, trip to the opera and visit to the famous Bondi
beach after her quick Australian abortion and is cross that liberalised legal practice might
limit her fun. In fact the song was intended to remind the politicians that a repressive law
would oppress only the poor who would be forced to resort again to dangerous backstreet
abortions.
*Tune: Victorian Music Hall song “She was poor but she was honest”
Chorus: “It’s the same the whole world over, it’s the poor wot gets the blame. It’s the rich wot gets the gravy. Ain’t it all a bleeding
shame.”
Speeches:
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Abortion then & now
Margaret Sparrow MD, New Zealand
Abortion has been present throughout history and in all cultures. This historical perspective
is to remind us of what has happened in the past, so that we have a better understanding
of the present which will assist us as we develop good practice guidelines for the future. In
the past women frequently risked their health, their fertility and their lives with unsafe
procedures and in many parts of the world they still do. The use of traditional methods has
been common but many treatments for self-abortion are unsafe or ineffective. Whenever
safe medical services are unavailable illegal abortionists will flourish. Poor women are the
most vulnerable often paying with their lives. In many countries including my own, New
Zealand, abortion is still regarded as a crime rather than as a medical procedure or as a
matter of personal human freedom. Laws in many countries have been a barrier to change
but changes have occurred through public and professional awareness, protest activity,
commissions, petitions, court cases, feminism and by advances in medical technology.
Now, in developed countries where abortion is legal, it is the most common gynaecological
operation and one of the safest.
Speeches:
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Comparing side effects of hormonal contraceptives in East Asian and Caucasian
women
Ellen R Wiebe MD, Konia Trouton MD, Amy Fang,
University of British Columbia, Vancouver BC, Canada
Introduction: Our previous studies in East Asian women have found that they perceive oral
contraceptives to be dangerous and to have too many side effects. The purpose of this
study was to compare side effects and discontinuation rates in East Asian and Caucasian
women.
Method: This was an observational cohort study of usual care. Chinese, Korean and white
Caucasian women were recruited at two urban freestanding abortion clinics. These women
were given one package plus a prescription of Alesse, Tri-Cyclen, Yasmin or Evra.Questionnaires in Chinese and English asked about the side effects and/or reasons for
discontinuation.
Results: Out of the 212 women recruited, there is follow-up data on 161. There were 65
Caucasians and 96 Asians. These two groups of women were similar with respect to age
(mean 25 years), education (mean 14 years) and obstetrical history (mean 0.2 births),
except that the East Asian women had had more abortions than the Caucasian women.
There was a significant difference in the discontinuation rates; more East Asian women did
not start or quit after taking just a few pills in the first month (40% vs 17%). There was
more acne in the Caucasian women (22% vs 7%). There was more nausea in the East
Asian women (20% vs 7%).
Conclusion: In women who decided to use hormonal contraception after an abortion, rates
of discontinuing or not starting hormonal contraception were higher in East Asians
compared to the Caucasians. Side effects were different in the two groups, indicating there
might be different brands that would be more suitable for East Asians than for Caucasians.