Silvio Viale
Speeches:
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Conscientious objection in Italy: is a ban the solution?
Silvio Viale Sant'Anna Hospital, Turin, Italy - silvioviale@libero.it
In Italy abortion can be performed only in public hospitals and only by gynaecologists working in public hospitals. In Italy you cannot obtain an abortion at outpatient clinics. So conscientious objection is the bottleneck of the service. According to the latest available data, in 2011 the number of public gynaecologists was 5,036 of which 3,490 were objectors (69.7%) and 1,546 were non-objectors (30.7%). Given that in 2011 there were 111,415 abortions, we can say that the mean annual number of abortion for each non-objector gynaecologist was 72. For comparison it is to be observed that the average annual number of deliveries for each gynaecologist was 110. The actual situation varies greatly by region, with the mean ratio of 60 abortions for gynaecologists in northern regions and 112 in southern regions, but in general has changed little over the last few years. In 1998 total gynaecologists were 5,285, of which 3,338 were objectors (64%) and 1897 non-objectors (36%), with 138,357 abortions and 73 for each non-objector. Both the number of abortions and the number of non-objectors have gone down together. Since we cannot expect a change in the law in order to allow abortions at outpatient clinics and by other categories of doctors, we must ask ourselves if 1,546 is a sufficient number for the needs. There is one non-objector gynaecologist for every 7,189 women aged 15-44 years, with an abortion rate of 9.4 per 1,000. Probably the answer lies in reducing the number of departments of obstetrics, that in Italy are nearly 600, and deciding to perform abortion in the biggest ones. The answer is to establish an annual threshold of at least 1,000 abortions with more then 50% of non-objectors in these departments. The author does not think that the answer is to ban conscientious objection.
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Death after medical abortion not linked to mifepristone
Silvio Viale Sant'Anna Hospital, Turin, Italy - silvioviale@libero.it
The death of a woman of 36 years with no previous known medical condtions after a medical abortion in Turin last April 9 attracted great attention in the media, . The headlines were "death after RU486", but the first report of the medical examiner appointed by the coroner said that RU486 was not responsible for the death . The protocol was mifepristone 600 mg on the first day and gemeprost 1 mg on the third day. On the third day ketorolac 30 mg IM for pain was also administered together with methylergometrine maleate 0.2 mg IM to reduce blood loss. Shortly after the expulsion the woman developed shortness of breath and loss of consciousness followed by cardiac arrest. The first cardiac arrest occurred at around 12:30 and the woman died at 22:45 in the ICU. From the first evidence the autopsy did not reveal any relevant items. Unfortunately, this is not the only death that has occurred in Italy in 2014 after an abortion. Two other women died recently after an abortion. One woman died in Nocera Inferiore, near Salerno, from abdominal bleeding after surgical abortion in a woman with myomas and previous caesarean section. The other woman died in Turin from acute liver failure two days after a surgical procedure for missed miscarriage. In the first case the media interest was mostly local. In the second case the media didn't known about it. These three deaths remind us that there is no zero-risk in pregnancy and that, though rare, it is possible to die during an abortion procedure even in countries with advanced health care systems. Regarding the death after medical abortion that occurred in Turin, we can say that mifepristone is not responsible in any way.
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Medical treatment of abortion and missed miscarriage: what's the difference in results?
Silvio Viale San'Anna Hospital, Turin, Italy - silvioviale@libero.it
Objectives: We have compared the efficacy of medical treatment for abortions in women with missed miscarriages. The protocol was mifepristone 600 mg orally + gemeprost 1 mg vaginally two days after, eventually repeated once. Women didn't stay in hospital between mifepristone and gemeprost. Methods: Since April 2011, when mifepristone became available in Italy, until April 2014 we have performed 3545 medical abortions up to 7 weeks. Later we started to offer medical treatment also for blighted ovum and missed miscarriage up to eight weeks of development, regardless of the true gestational age. As at April 2014 we have performed 423 medical treatments of missed miscarriages and blighted ovum. Results: The overall success rate of medical management of abortion and missed miscarriage was 96.3%, with 147 surgical procedures out of 3968. For abortion the success rate was 96.5%, with 125 surgical procedures out of 3545. For missed miscarriage the success rate was 94.8%, a little less, with 22 surgical procedures out of 423. If we keep out the 32 cases in which the curettage occurred for failure in expulsion, 22 abortion and 10 missed miscarriage, the overall success rate rises from 96.3% to 97.1%. By doing the same for abortions and missed miscarriages we found that the success rate rise in both cases, from 96.5% to 97.1% for abortions and from 94.8% to 97.1% for missed miscarriage. Consequently, the rate of curettage drops from 3.5 to 2.9% for abortions and from 5.2 to 2.9% for missed miscarriages. Conclusions: The only significant difference is that medical treatment of missed miscarriage has a fourfold risk of failed expulsion compared to medical treatment of abortion, 2.4% versus 0.6%. With a success rate of 94.8% the medical regimen with mifepristone and gemeprost can be a routine alternative to surgical management of early fetal demise.