Authors
A B C D E F G H I J K LRaquel Maciel
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The effectiveness of ultrasound and s-βhCG measurement in predicting failure after medical abortion
Raquel Maciel, Maria Céu Rodrigues, Teresa Oliveira, Fátima Sousa, Lurdes Lima, Paulo Sarmento (Portugal)
Centro Hospitalar do Porto - Maternidade Júlio Dinis, Porto, Portugal
raquelmaciel@gmail.com
Objective. Diagnostic tests’ effectiveness in predicting failure after medical abortion has been subject of discussion in some studies. We compared ultrasound findings and β-hCG levels and tried to determine its cut-off value that would allow us to excuse a routine ultrasound examination as follow-up.
Methods.In 49 women who had opted to interrupt the pregnancy, with a mean gestacional age of 50 days, ultrasound examination and serum β-hCG were performed prior and around the 20th day after medical treatment. On the follow-up we considered as ultrasound findings the endometrial thickness – virtual or with heterogeneous content – the presence of an empty gestacional sac or an embryo arrest, and compared them with their corresponding s-hCG levels – its decrease %, its initial level % and its absolute final value.
Results.Treatment was successful in 92%. There was evidence of a close relation between ultrasound images and their β-hCG levels. The sensitivity of the ultrasound examination was 100% and its specificity was 49%. Despite the ratio of β-hCG initial level’s sensitivity, with a 1,3% cut-off, was the same as the one with a 0,8% cut-off (75%), the specificity of the first revealed to be more favorable (93,3% vs 86,6%).
Conclusion.The percentage of β-hCG initial level determination, combined with clinical examination, can be an effective method in predicting the success of the medical treatment, as an initial procedure. Therefore, ultrasonography should only be considered in prompt cases.
Eva Macun
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Analysis of medical abortion in first trimester in a small regional hospital in Slovenia
Eva Macun, General Hospital Jesenice, Slovenia
Introduction: Medical abortions have been performed in General Hospital Jesenice since 2005. The first attempts were made during our participation in the WHO supported study which was coordinated by Gynecological Department of the University Medical Center in Ljubljana. Both drugs that are used regularly for medical abortions (mifepriston and misoprostol) are not register at the Agency for Medicinal Products and Medical Devices of Slovenia. Therefore a special approval is needed for their import. Our doctors needed time to accept the method but since 2009 two thirds of all abortions have been performed using this method. One step forward has been made and a clinical pathway for medical abortion is being prepared. Our final goal is to make the method widely available, to educate all the involved professionals and to make it possible for home use.
Methods: In the current presentation an analysis of all performed medical abortions from 2005 to 2009 is shown. All data were collected by hand. A WHO protocol was used for medical abortions under 9th week of pregnancy. Women were given 200mg of mifepriston orally and after 36-48 hours 800µg of misoprostol vaginally. For women, who were pregnant 9 to 12 weeks, the protocol was adjusted for every single pregnancy.
Criteria for successful abortion that we used after 14 days were: no gestational sac, endometrial lining thinner than 15 mm, if there were hiper- and hipoechogenic areals in the endometrial lining from 15 to 20 mm, we prescribed uterotonic and antibiotic therapy and ultrasound control after menstrual period. In case of prolonged bleeding we did a curettage.
In other cases we took this as unsuccessful abortion and completed it with a curettage.
Results:We performed 124 medical abortions in this time. Till 49 days of amenorrhea we performed 75 abortions: 3 patients needed curettage, because there remnants of trophoblast in the endometrial lining after 14 days. Success rate of the method in our department was 96%.
Between 7th and 9th week we performed 39 abortions. Two needed additional curettage (5%).
We also performed 10 abortions between 9th and 12th weeks. All were successful.
All together the success rate was 93.4%. for abortions performed in women who were pregnant less than 12 weeks. We found no complications (heavy bleeding, infection).
Conclusions:In our department the method is very successful. We see a lot of potentials in promoting medical abortion in Slovenia, because we have really good experience with it, our patients prefer medical over surgical abortion, we need less professionals, we will make a clinical pathway for hospital use. But our goal is to perform medical abortion at home, because the method is safe. In this project good cooperation would be achieved with local gynecologists who will follow the patients at home.
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Medical abortion in Slovenia: where are we?
Eva Macun General hospital Jesenice, Jesenica, Slovenia - eva.macun@sb-je.si
Introduction: In Slovenia abortion is legal on demand up to 10 weeks of pregnancy. Later abortion can be done after approval of the Commission for abortion. It can be performed in 14 gynaecological departments. Slovenia has a national register of fetal death up to 500g. Institutions that perform abortions are obliged to report all known fetal deaths, with demographic data and procedure. Methods: We checked the fetal death database for method of abortion on demand for Slovenia for the years 2007-2011. We interviewed doctors in all Ob/Gyn departments. We asked them how many percent of abortion were medical in the year 2014. Possible answers were: <50%, >50% and >90%. We asked them also if women can be given misoprostol for home use. Results: In the year 2007 there were 5176 abortions on demand in Slovenia; 4660 (90%) were surgical and 123 (2.4%) were medical abortion and some other methods. In the following years the rate of medical abortions increased (Table 1). In year 2011 there were 4263 abortions ; 2153 (50.5%) were surgical and 1602 (37.6%) were medical abortions.
Table 1: The rates of medical and surgical abortions in Slovenia, 2007 - 2011
Year 2007 2008 2009 2010 2011
Surgical
Abortion number 4660 4099 3560 2604 2153 % 90.0 82.8 76.5 60.2 50.5
Medical number 123 434 734 1345 1602
Abortion % 2.4 8.8 15.8 31.1 37.6
Results of interviews show that in year 2014 four Ob/Gyn departments use medical abortion in 50% or less. Four departments use it in more than 50% and less than 90%. Six departments use medical abortion in more than 90%. Three of the latter give misoprostol to women for home use. Conclusions: Use of medical abortion is increasing in Slovenia. There are departments that give misoprostol for home use.
Galina Maistruk
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Improved access to safe abortion in Ukraine: Comprehensive Care for Unwanted Pregnancies project results, 2009-2013
Anastasiya Dumcheva1, Galina Maistruk2 1World Health Organization, Kyiv, Ukraine, 2Charitable Foundation "Women Health and Family Planning", Kyiv, Ukraine - ada@euro.who.int
Introduction: Before 2009, most of the pregnancy terminations in Ukraine were unsafe, which contributed from 8.5% to 16.0% to the maternal mortality in Ukraine over the period from 2003 to 2009. To address this issue, Comprehensive Care for Unwanted Pregnancies (CCUP) project was introduced in 2009 in partnership with Swiss Agency for Development and Cooperation, MoH Ukraine, NGO "Women Health and Family Planning", and WHO. Objective: The project goal was to improve availability, accessibility and quality of safe abortion in Ukraine. Methods: The project included activities at the national - improving legislation, monitoring and evaluation system, and regional levels - strengthening capacity of health care professionals, improving quality of abortion services and enhancing communication in five pilot regions of Ukraine. Results: Over the period from 2009 to 2012, the contribution of unsafe abortions into overall maternal mortality in Ukraine has steadily decreased from 9.2% (12 cases) to 4.6% (3 cases). The main reason for the overall decrease was the development and endorsement of new national legislation documents - organizational and clinical protocols, which adapted WHO recommendations on safe abortion. The percentage of women undergoing safe abortion methods in the first trimester (medical abortion, manual or electrical vacuum aspiration) vs unsafe (dilatation and curettage) has increased in pilot regions from 25-32% in 2011 to 53-75% in 2013 (variability is due to the regional context and time of project start in the region). The percentage of women who received local vs general anaesthesia has increased from 11% in 2011 to 29-37% in 2013. By the end of 2013, most of the women received pre- and post-abortion counselling sessions (82-95% compared 59-62% in 2011). Conclusion: The project interventions contributed to the overall decrease of abortion-related maternal mortality in Ukraine. Interventions piloted at the regional level are acceptable for healthcare professionals and women and can be disseminated nationwide.
A. Manaj
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Misoprostol-only compared with solution of NaCl 20%for induction of second trimester abortion
A. Manaj, A. Musta (Albania)
Obsetric Gynecological Hospital Mbreteresha Xheraldine, Tirana, Albania
amusta@acpd-al.org
Objective. The effect of Misoprostol in induced abortions of second trimester as treatment of choice.
Design & Method. In our country, the main method to terminate the second trimester pregnancies was the solution of NaCl 20%. These five last years this method is being replaced with misoprostol-only regimen. This was a comperative study. During a 12-month period, were selected and voluntary involved, two groups of healthy pregnant women (13-24 weeks) wishing to terminate their pregnancy due to medical reasons. A total of 80 patients, treated with misoprostol (experiment group) were compared with 77 patients treated with NaCl 20% (control group). Chi Square test for comparison of these proportions was used.
In the first group of 80 women the abortion was induced by misoprostol (Cytotec) 400 mcg vaginally 3-hourly (x5). The abortion time varied from 18 hours and 20 (pluripara) to 25 hours and 5 minutes (primigravida) hours. In the second group of 77 women abortion induced by intramniotic transabdominal instillation of 20 % NaCl, amounting to 250 ml. The shortest abortion-instillation time was 28 hours and 10 minutes (pluripara), while the longest was 36 hours and 8 minutes (primipara). 2 cases pertaining the first group and 8 cases pertaining to the second one, experienced haemorrhage due to partial retention of the placenta which were subsequently removed by curettage. In the second group we experienced two cases of distacco placenta.
Results. From data analyses resulted that patients treated with misoprostol have a much lower rate of haemorrhage P=0.01, cramps P=0.02 and curettage after misoprostol/ NaCl administration P=0.3.
There is no statistically significant difference in the rates of infections P=0.6, pelvic pain P=0.7, diarrhoea P=0.67, and the difference in the amniotic fluid embolism P=0.7 and distacco placenta P=0.7.
Jaana Männistö
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Cunha José Manuel et al.
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Abortion in Portuguese Health Primary Care
Cunha José Manuel, C. Ribeiro, R. Aguiar, C. Lomba, A. Mateus, F. Fonseca, A. Simões, L. Campos, C. Silva (Portugal)
Administração Regional de Saúde do Norte, Porto, Portugal
jmscunha@gmail.com
Introduction. The fulfilment of the new Portuguese legislation on the interruption of pregnancy by woman’s free option made it necessary the creation of a public care rendering net that involved Hospitals and Health Care Centres. The Centres were attributed the generic function of women reference to the hospitals where if it carried the medical and surgical interruption takes place. The availability of some professionals allowed to organise in three Centres a consultation of medical interruption of the pregnancy by option of the woman until 10 weeks. There is a protocol of joint with the nearby hospitals that answer to the complications and the situations of medical abortion failure.
Objectives. Description of medical abortion practice by the woman’s option, done by general practitioners in family health services.
Method. The women appeal to the consultation voluntarily or referred by other institutions. The process consists of previous consultation where dating of pregnancy is confirmed by ultrasonographic scan. The law imposes three days of reflection, followed by a 2nd consultation where the therapeutic with Mifepristone starts; 36 - 48 hours later the process is completed with Misoprostol. Pregnancy termination is confirmed 2- 3 weeks later by ultrasonographic scan.
Results. Since October 2007 until May 2008, 118 abortions had been carried through. There were 4 medical abortion failures which required surgical termination and 1 case of hemorrhagic complication that needed curettage.
The study of the evaluation of the women’s satisfaction confirms a high level of satisfaction.
Conclusions. The results of abortions by the woman’s option done in these family Health Services are similar to the published ones in literature.
Lena Marions
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Mode of action
Lena Marions MD PhD,
Dep of Ob/Gyn, Karolinska University Hospital Stockholm Sweden
Emergency contraception is a method that is used after sexual intercourse to prevent unwanted pregnancy. Available methods are combined contraceptive pills (the Yuzpe method), levonorgestrel only, the antiprogesteron mifepristone and the insertion of a copper IUD.
Levonorgestrel has become the drug of choice in many countries because it is effective and well tolerated. However due to lack of knowledge, about the mechanism of action, millions of women have no access to postcoital contraception because of religious and/or political reasons. The sensitive question is whether the mode of action is exerted before or after fertilization. The only method that has shown to exert an inhibitory effect on the implantation process is the copper IUD, the EC pills act by postponing or prevention of ovulation and can not be regarded upon as abortifacient.
Even though the use of EC pills has significantly increased during the last years, the number of induced abortions has not decreased as expected. Studies indicate however that both women and providers have a tendency to underestimate the risk for pregnancy. It is important to recommend treatment after every unprotected intercourse at any time during the menstrual cycle.
Marie-Jeanne Martin
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Pain treatment in local anaesthesia
Marie Jeanne Martin MD, Hopital d’Armentières – Armentières - France
I represent a team from an abortion centre, in the North of France. In this region, most abortions are practiced in public hospitals. We are a small team and I want to lay stress on the presence of counsellors fully fledged in the team.
A modification in the law, in 2001, has authorized abortions until 14 weeks since last periods. This modification has generated a lot of discussions and debates, sometimes very severe between professionals, but not at all in the public opinion. During these discussions, some of our colleagues were very surprised to learn what we practiced all abortions with local anesthesia (whatever the term). They considered that general anesthesia was always indicated for pregnancy which were above 12 weeks since last periods because of pain.
So, we asked ourselves on our « evaluation » of the pain felt and also on our method of local anesthesia. We asked us few questions:
- Are surgical abortions more painful after 12 weeks since last periods?
- What adequacy can be found between the level of pain felt by a woman and the evaluation of this pain by the practitioner of the aspiration ?
- It should be noted that during our current study, we have modified technique of anesthesia. Also we have introduced an additional question:
- Is this technique more effective on the level of pain felt ?
The study deals with all the women having a chirurgical abortion whatever the term of the pregnancy. This study was made over a period of 4 months (from March 4 to July 11, 2003). This is an analysis of a subjective evaluation of the pain collected by means of the analogical visual scale, the scale being held vertically. The collection of these feelings was made during the hospitalization at 6 different periods. The presentation and the collection of the scale were made by the same nurse all along the study. Just after the aspiration, at the same time as his report, the doctor notes from 0 to 10 his own evaluation of the pain felt by the lady during the aspiration.
We will present our work with the help of a short film. (see technical drawings in attached)
Principles which are important are:
- Using medicines to dilate cervix, to calm down anxiety, to calm pain in advance.
- A warmth atmosphere, with attention, where we could be close.
- A technique, always looking for improving.
We collected 188 exploitable cards (55 aspirations took place without addition of bicarbonate, that is to say approximately a third, 133 took place with bicarbonate which is to say two thirds of the total). Half of abortions were done between 9 and 11 weeks since last periods which is a representation of the French national statistics.
It’s a modest study:
- by the number of “exploited” files since we have only 188 files
- and by the realization of the study itself and the results obtained since we are not accustomed a realization of studies.
With the impression that the aspirations are felt by woman as more painful for the most advanced terms (superior with 12 weeks since last periods) we could answer : no
and than on the contrary the aspirations of the smaller pregnancies hurt the most.
With the search of the reliability of the evaluation of the pain, by the practitioner, one sees that whatever the doctor, there are errors in undercutting and on quotation, with tendency to on quotation. So this study gives us the opportunity of staying on our place and of committing us to remain vigilant not to plate our impressions like single truth..
With the search for an improvement of the local anesthesia, it appears clearly that our new way of making (with addition of bicarbonate to the lidocaïne in order to plug acidity off it, and with multiple microinjections in the cervix) is much more effective and decreases pains to a significant degree.
Our objectives are always to improve the accompanying of the women and the couples. The alleviation of this moment of their lives forms part of our objectives and this alleviation helps to reduce the painful. This is why we should seek the greater comfort for the lady (who is not the same think as greatest comfort for the doctor). And for this reason the presence in the team of full-time counselors, and this throughout the experience of the women and couples, is a paramount element in this alleviation of the procedure and thus in the pain felt.
Renato Martins et al.
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Sociologic Aspects of Legalized Abortion in Portugal. 1 Year Experience
Renato Martins, Marisa Moreira, Teresa Bombas, Teresa Sousa Fernandes, Paulo Moura (Portugal)
Genetics, Reproduction and Fetal Maternal Medicine Department, Coimbra University Hospitals, Portugal
renato.alessandre@gmail.com
Introduction. According to United Nations, about 13% of maternal deaths in world were attributed to complications after non safe abortions. In Portugal, in last decades, ten maternal deaths occurred per year due to complications of illegal abortion. Since, July 16th of 2007 abortion is legal before ten weeks.
Objectives. Characterization of the female population that came to our Service for abortion.
Material and Methods. We analysed the clinical files of medical abortion appointment during the period of 1 year from 16th July 2007.
Results. We included 298 females. Average age 28,2±7,6 years.(11,8% adolescents and 20,1% more than 35 years). We reported a 10% of non Portuguese women in our sample. Almost 52% were married. In this sample the authors report an average of 27% of women that had no contraceptive method in use before the abortion. In 90% of the cases this was the first abortion, and the majority of women pointed out economics reasons to justify it. Nearly 90% had a medical interruption, with few cases of complications associated to the method.
Conclusions. The great group of women that come for abortion are not adolescents as it was firstly expected. The majority are Portuguese and live with their partner. A great number of women are not users of Family Planning Services.
Bernadette Mattauer
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The dynamic of meaning in requested legal abortion
Bernadette Mattauer (F)
I worked as a psychologist in the birth control centre of the hospital in Montpellier, France, for 15 years. A unique clinical experiment has been led by three psychologists working together in this area.
The counselling process sets the memory in motion, even though at first the person remains immersed in the immediacy of her request.The counselling process opens a space within which the complexity of the circumstances and of a frequently ambivalent decision can be questioned.
The situations that stand out as sources of unwanted pregnancies are periods of change, in which relationships are being modified and sometimes disturbed:
-emotional changes : teenage, pre-menopause, couples in the process of joining or splitting). Changes due to a series of failures or more or less recent experiences of loss, of whatever kind.
-professional changes, which result in a reorganization of tasks and social relations.
In the process towards womanhood, it seems that abortion is frequently associated with the shaping of one’s identity, together with the problematics of castration.
Abortion would be an ideational representative as it were, being both addition and cut, assertion and separation. The abortion often works as the ‘representation’ of an unsuccessful separation process in the route towards womanhood. The present act of separation, the actual experience of loss, sometimes act as a symbolic way of re-enacting a previously unsolved bereavement. Thus refusing a pregnancy has a parting function. Being pregnant can stand for the part-object of ‘completeness’, a phantasy whose function it to repair and/or to fill in.
Beyond the arguments uttered and their usual motivations, the analysis of many women’s itineraries has enabled us to grasp and shed light on some unconscious motivations.
These two obviously antagonistic moments: the pregnancy and its termination are yet interconnected.
The dynamic of meaningof those events, whether they are experienced as apparently trivial or felt tragically, never leaves women indifferent. A terminated pregnancy is never a non-event. But that pregnancy was not aimed at giving birth, and is seldom rooted in the desire to have a child. Therefore it is not synonymous with rejecting a child.
The aim of our study is to convey the idea that a terminated pregnancy can at times contribute to reshaping a woman’s identity through symbolic work.
Silja Matthiesen
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When contraception fails: Adolescent contraception practices and teenage pregnancy
Silja Matthiesen (Germany)
Universitätsklinikum Hamburg-Eppendorf, Germany
smatthie@uke.uni-hamburg.de
When young people become pregnant it is usually due to a failed attempt at contraception. The primary question examined here is why these attempts fail. The author conducted a quantitative analysis of a questionnaire distributed to underage pregnant females (n=2278) and a qualitative analysis of interviews with underage females who terminated their pregnancies (n=62). The quantitative data show that approximately two-thirds of the unwanted pregnancies were the result of improperly using birth control pills and condoms. Three particularly vulnerable groups were identified: social disadvantaged teenagers; those involved in relationships in which an egalitarian relationship with the male partner is not present; and those who experience an emotional distance to their partners. On the basis of the interviews information could be gained concerning the problems encountered in using contraceptives in the context of the sexual biography of the participants. Results show that using contraceptives is a learning process on the part of both partners. The failures in contraception use are not primarily due to a lack of information about sexuality, but rather to a lack of competency in managing the relationship dynamics as well as to a lack of knowledge about the proper use of contraceptives.
Christine McCafferty
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Natalie McDonnell
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The Situation in the Republic
of Ireland This presentation will set out the basis of
abortion in law in Ireland and examine recent
developments pertaining to the manner in which
Ireland’s constitutionally enshrined ban on
abortion operates. The application of international
human rights norms and standards reveal the
manner in which the ban – and the failure to
attain legal clarity in relation to its operation –
provides real opportunities for change. One
such opportunity arose in the context of A, B,
C v Ireland, the case taken to the European
Court of Human Rights in which the Grand
Chamber of the Court, in 2010, found a breach
of the Convention in the case of C, due to the
lack of clarity and the illusory nature of the right
to access a termination under Irish law where
there is a real and substantial risk to the life of
a woman. The options available to the State to
ensure compliance with the judgment will also be
explored in this presentation.
Christine McKnight
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Aim: To explore women’s experiences of returning for subsequent abortions and the experiences of staff who provide abortions.
Background: While overall abortion rates are decreasing in the UK, the percentage of women undergoing more than one abortion has increased. Between 2006-2016 there was a 6% increase in the number of women requesting repeat abortions, rising from 32% to 38% despite historical improvements in medical interventions for contraceptive technology. Previous quantitative research has focussed on what is different about women who request multiple abortions and how to get them to uptake and adhere to long acting reversible contraception. Rather than their personal experiences.
Methodology: Qualitative semi structured interviews with 10 women who have had multiple abortions and 12 semi structured interviews with staff who work in an abortion service. All interviews were transcribed verbatim. Interviews were analysed using thematic analysis.
Results: Four overarching themes emerged which were guilt, shame, coping and perfect contraception. Women experience guilt at multiple levels from the legal framework, to service and individual level; whereas staff struggle with their own guilt regarding provision of services. Stigma is expressed in the language used, by both women and staff, surrounding abortion and by the issue of woman returning for multiple procedures. Coping describes the different ways that women coped with their abortions and how they coped differently with each one, examining how patterns of behaviour may emerge. Accounts evidence a sense of deep shame around returning for abortions which links closely with guilt where both women and staff apportion and internalise blame.
Conclusions: Abortion is a stigmatised medical procedure for both women and the staff who provide them. Women and staff use a variety of mechanisms to reduce that stigma some of which may fail to address ongoing problems with contraception. However, women who return for multiple abortions are diverse and so are their experiences, procedural and service issues may need to re-examine implicit attitudes to abortion.
Jim McVicker
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Amani Meaidi
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Objective: To assess the influence of gestational age, maternal age, and reproductive history on the risk for surgical intervention of early medical abortion.
Methods: A nationwide cohort study with eight weeks follow-up of all medical abortions induced at a gestational age <63 days among Danish women through the years 2005-2015. A multiple logistic regression model provided adjusted odds ratios (OR) with 95% confidence intervals (CI) for all the potential risk factors of interest. A division of the data into a training and validation set provided a test of the prediction performance of the model. Reported is the area under the receiver operating characteristic curve (AUC) with 95 % CI.
Results: 86,437 medical abortions were included, 5,320 (6.2%) were surgically intervened. The risk of surgical intervention increased with increasing gestational age (p<0.0001). The risk of surgical intervention peaked among women aged 30-35 years and declined for lower and higher ages (p<0.0001). The OR of surgical intervention among parous women compared to nulliparous was 2.0 (1.7-2.4) for women with a history of failed birth of placenta, 1.5 (1.3-1.6) for women with previous caesarean section, and 1.1 (1.0-1.2) for women with previous vaginal births with spontaneous birth of placenta. A history of early surgical abortion implied an OR of surgical intervention of 1.5 (1.4-1.7), and women with a previous late surgical abortion had an OR of 1.2 (1.1-1.3). Previous medical abortion implied an OR of surgical intervention of 0.84 (0.78-0.90). The AUC was found to be 0.63 (0.62-0.64).
Conclusion: In addition to gestational age, our study shows maternal age, previous delivery, and history of induced abortion to be risk factors for surgical intervention of early medical abortion. However, all these risk factors do not predict surgical intervention well, possibly indicating the subjective nature of the decision to surgically intervene a medical abortion.
Catherine Megill
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Elvira Méndez
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Coresponsibility and equity fairness in abortion services oriented to vulnerable groups of women
Elvira Méndez (Spain)
Asociación Salud y Familia, Via Laietana, 40, 3º 2ª B, 08003 Barcelona, Spain
cherrera@saludyfamilia.es
The Asociación Salud y Familia, a non-profit NGO, has been the leader of a programme aimed at providing abortion services to vulnerable groups of women for the past fifteen years. This programme, called “Safe Motherhood Assistance”, has served more than 41,000 women, 4,693 women during 2007 alone (20% of all abortions in Catalonia). The programme is based on a tripartite scheme, involving collaborations between private abortion clinics, public healthcare services and the association. Among its greatest achievements are: accessibility to a co-payment system for abortions; free post-abortion contraception services (IUD insertion); and the capability to adapt to new social and individual vulnerable situations.
Chun-Xia Meng et al.
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Emergency contraceptive use among 5677 abortion seeking women in Shanghai
Chun-Xia Meng (China), Kristina Gemzell (Sweden), Olof Stephansson (Sweden), Li-Nan Cheng (China)
Woman and Child Health Department, Division of Gynecology and Obstetrics, Karolinska University Hospital / Karolinska Institute, Stockholm, Sweden, and International Peace Maternity and Child Health Hospital / School of Medicine, Shanghai Jiao Tong University, Shanghai, China
chunxia.meng@ki.se
Introduction.Unintended pregnancy is a global reproductive health problem. Emergency contraceptive pill (ECP) provides women with a safe and convenient means of preventing pregnancy following unprotected sexual intercourse. Levonorgestrel only or low dose of mifepristone has recently emerged as the most effective ECP with a low rate of side effect and both are over-the-counter available in China. Discrepancy between the wide-spread use of ECP and large proportion of abortions indicates that how women use ECP may be a strong determinant of its final effect. Lack of understanding of fertility and concerns about its side effects may contribute to the underutilization of emergency contraceptive pill. This study aims to study the use of ECP among women seeking abortions and different demographic factors involved, as well as to explore the possible concerns for not using ECP.
Materials & Methods.A six-month cross-sectional survey was done by using face-to-face questionnaire interview among abortion seeking women in Shanghai, China. Respondents were asked about their experience in using ECP and from which source did they access ECP. The differences between ECP users and non-users regarding various demographic characteristics and their cited reasons for seeking abortion were analysed by using chi-square test. Respondents who had previously used ECP, but did not use it to try to prevent this current pregnancy were asked to state their reasons for non-use.
Results. A total of 5677 abortion seeking women aged between 15 to 48 years were recruited, among whom 48.8% are ECP users and 55.3% had experienced at least one abortion. Young, married, well-educated, nulliparous women were more likely to use ECP. Unawareness of the risk of pregnancy was the main reason for not using any contraceptive methods among abortion applicants who had never used ECP. Among 2773 women who had experience in emergency contraceptive use, 72.7% did not use it to try to prevent this current pregnancy, for which the major reason was not realizing the need to use ECP. Pharmacy was the preferable source to access ECP for the sake of convenience and privacy protection.
Conclusions. The large proportion of repeated abortions necessitates the sexual education to avoid unintended pregnancy. We need to find ways to raise people’s awareness of the high risk of pregnancy associated with non-use, incorrect or inconsistent use of contraception. Women of reproductive age should be well-informed of knowledge about and access to emergency contraceptive pill, which provides a “second-chance” to prevent an unwanted pregnancy. All reproductive health-care providers including pharmacists should be trained for family planning counselling with a special emphasis on emergency contraception.
Maarit Mentula
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Immediate adverse events after second trimester medical termination of pregnancy - results of a nationwide registry study
Maarit J. Mentula, M.D., Maarit Niinimäki, M.D., Ph.D., Satu Suhonen, M.D., Ph.D., Elina Hemmiki, M.D., DrPH., Mika Gissler, M.Soc.Sc., Dr. Phil., Oskari Heikiheimo, M.D., Ph.D.
From the Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, Finland (M.M., O.H.), the Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland (M.N.), the City of Helsinki Health Care Centre Unit for Maternity and Child Health Care and Health Promotion (S.S.), The National Institute for Health and Welfare, Helsinki, Finland (M.G., E.H.),
The Nordic School of Public Health, Gothenburg, Sweden (M.G.).
Objective: To assess the rate of adverse events following medical second trimester termination of pregnancy (TOP) and to compare it to those in the first trimester medical TOP.
Methods: This register based cohort study included 26,053 women, who underwent medical TOP in Finland between 1st January 2000 and 31st December 2006. Women were identified from the Abortion Registry. Adverse events related to medical TOP within 6 weeks were searched from the Hospital Discharge Registry. The rate and risk factors for adverse events were estimated during 2003 to 2006.
Results: The rate of surgical evacuation of second trimester medical TOP decreased during the first three years of the study period and thereafter stabilized at 39.5%.Second trimester TOP increased the risk of surgical evacuation (OR 9.3; 95% CI 8.1 to 10.7), especially immediately after fetal expulsion (OR 41.0; 95% CI 32.9 to 51.0). Also the risk of infection was elevated (OR 2.1; 95% CI 1.5 to 2.9). Increased length of gestation did not influence the risk of surgical evacuation or infection in the second trimester medical TOP.
Conclusions: The medical TOP during second trimester is generally safe. Surgical evacuation because of residual tissue is avoided in more than half of the cases, though it is much more common than in first trimester medical TOP. More wide use of medical TOP decreased the use of surgical evacuation. The risk of surgical evacuation and infection does not increase by gestational weeks in the second trimester TOP.
Gabriele Merki
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Long cycle combined hormonal contraception
Gabriele Merki (Switzerland)
Family planning clinic, University hospital, Zürich, Switzerland
gabriele.merki@usz.ch
Prolonged use of combined pill preparations (COC) has been widely performed to suppress menstruation in women with clinical conditions like premenstrual symptoms, endometriosis, or cyclic headache. At present there is in several European countries a trend to use the long-cycle to suppress normal menstruations for convenience, particularly for women who are already taking COC. Some authors medicalize and pathologize the natural event of menstruation and declare normal cycles as unnecessary annoyance and as possibly health risk. We intend to discuss open questions concerning the safety of the long-cycle and long-term health risks specially on the breast and the endometrium. Furthermore we speculate about the consequences of cycle suppression in healthy adolescents for their later attitude towards menstruation.
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Post-abortion contraception
Gabriele Susanne Merki-Feld, MD, PhD, Universtiy Hospital, Zürich, Switzerland
Contraceptive counseling is an important part of postabortion care and should include accurate and comprehensive information about different contraceptive options. Surprisingly not all studies provide evidence for a higher acceptance and lower rate of repeat abortions in women after extensive postabortion counseling. Other studies investigate preabortion counseling in comparison to postabortion counseling.
Today most abortions are performed with medical procedures. Use of combined contraceptive pills is recommended to start already on day 3 of abortion ( day of misoprostol administration). After abortion 80% of all women ovulate before the first menstrual period and many of them ovulate within 22 days. Thus providing the pill before leaving the hospital is of importance. Immediate IUD insertion after surgical abortion is effective and safe, even if some studies suggest a slightly increased rate of partial or complete expulsions. Since medical abortion takes longer than surgical abortion, IUD insertion is recommended during the first menstrual cycle after medical abortion. This procedure is of course associated with a small risk for another pregnancy. Progestagen-only methods can be started immediately after medical abortion. The implant in an important alternative for women with desire for longterm contraception.
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Abortion in minors
Gabriele Merki-Feld University Hospital, Zürich, Switzerland - gabriele.merki@usz.ch
Teenage pregnancies must be viewed in the context of sexual and reproductive health (SRH) and rights, with the understanding that the social environment ha a major influence. Most teenage pregnancies in Europe occur unplanned. Therefore access to effective contraceptive methods is a critical point in the prevention of abortions in minors.The decision to pursue or end an unintended pregnancy is based on factors like cultural and religious background, access to safe and legal abortion, access to confidential counselling and support from partners, friends and parents. The availability of legal abortion, the covering of costs and the question of parental consent varies across Europe. Very little is known about factors asscociated with coping afterwards. Across Europe there are countries with very high abortion rate in teenagers, especially in some Northern and Eastern European countries. The majority of southern European and western European countries report numbers below the EU mean of 12.2/1000. Interestingly there is in contrast to other countries a balance between teenage live birth and teenage legally-induced abortions in the UK. Also there are differences between countries. There is a clear trend to decreasing number of abortions in minors in most European countries.
Eddie Mhlanga
Lucy Michie
Speeches:
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Asurvey of attitudes of staff working within a
sexual and reproductive health centre, towards
undertaking early medical termination of
pregnancy
Michie, L1,2; Cameron, S1,2
1 Chalmers Sexual Health Centre, Edinburgh, UK; 2 University of
Edinburgh,UK
Introduction: In Scotland, most termination of pregnancy (TOPs)
are provided in hospital departments of Obstetrics and
Gynaecology. Since high quality contraceptive provision should be
integral to TOP, this raises the question of whether TOP services
would be better provided by clinicians in community sexual and
reproductive health services (SRH). We aimed to determine views
of these clinicians about potentially offering TOP servicesMethods: An anonymous internet questionnaire of staff working
in a large SRH service in Edinburgh (Chalmers) was conducted
between January and March 2012. The questionnaire consisted
mainly of ‘drop-down’ list options with additional free text
response to some questions.
Results: A 69% response rate was obtained. (62 out of 90;
doctor = 22, nurses = 25, admin staff = 15). The majority of
responders (69%) felt that provision of abortion services would be
a natural extension to existing services and the majority, (69%)
would be personally willing to provide abortion care. Only 11%
stated that they would refuse to be involved in TOP care due to
moral objections. Respondents agreed that TOP care from this
setting would offer advantages for women including better
provision of contraception (71%) and better management of
sexual infection (53%), amongst others. Only 23% of responders
(n = 14) felt there would be some disadvantage to offering
abortion services from this setting.
Conclusion: Most staff felt that providing TOP services within a
community SRH service is a natural extension to existing services
and that this would offer improved contraception and sexual
health care to women undergoing TOP. -
Asurvey of professionals in sexual and
reproductive health in the United Kingdom, about
attitudes towards provision of termination of
pregnancy care within community sexual and
reproductive health (SRH) clinics
Michie, L1,2; Cameron, S1,2
1 Chalmers Sexual Health Centre, Edinburgh, UK; 2 University of
Edinburgh, UK
Introduction: In the UK, termination of pregnancy (TOP) services
are predominantly based within National Health Service hospitals.
However, community based sexual and reproductive health (SRH)
clinics that provide specialist contraceptive services could offer an
alternative setting and may provide high quality on-going
contraception. We sought to determine the attitudes of those
working within SRH towards participating in TOP and views on
which setting is most appropriate for TOP care.
Methods: A questionnaire was distributed to attendees at a large
UK sexual and reproductive health scientific meeting in April
2012. Information obtained included demographics, respondents
current experience of TOP care and their response to a series of
statements concerning, attitude and willingness to participate in
and location of TOP care.
Results: An 82% response rate was obtained (165 of 200). Eighty-
eight percent (n = 146) of respondents were female. Ninety-five
percent (157) were doctors and 4% (6) were nurses. Almost all
responders already had some involvement in TOP care (97%
n = 160); 78% (29) refer patients on to hospital TOP services,
64% (106) assess patients and provide information, 62% (103)
sign documents authorising TOP and 14% (24) undertake the
procedure or administer medication. Whilst 78% (128) agree TOP
care services (for 1st trimester, uncomplicated cases) would be
best suited to community SRH, 51% (83) believe it should be
divided across community, hospital and charity services.Conclusion: The overwhelming majority of doctors and nurses in
SRH agreed that abortion services would be best delivered from a
community SRH setting and would be willing to participate in
providing this service. -
Review of telephone follow-up of women having
early medical termination of pregnancy
Michie, L1,2; Cameron, S1,2; Johnstone, A1,2;
Dewart, H1,2
1 NHS Lothian; 2 University of Edinburgh, UK
Introduction: Telephone follow-up2 weeksaftermedical
terminationofpregnancy(TOP)(£9 weeksofgestation)withaself-
performedlowsensitivityurinepregnancy(LSUP)test,was
introducedatahospitalTOPserviceinEdinburgh.Womenwho
screened‘positive’attelephonefollow-up(ongoingpregnancy
symptoms,scantbleeding,orLSUPresult)subsequentlyattended
foranultrasound.Apreviousserviceevaluationconfirmedthatthis
waseffectivefordetectingongoingpregnancyandhadgoodfollow-
uprates.Wesoughttodetermineifthismethodoffollow-up
continuedtobesuccessfulduringtheyearfollowingitsintroductionMethods: Retrospective computerised database review of outcome
of telephone follow-up of women having a medical TOP
(£9 weeks of gestation) over 12 months (March 2011–February
2012).
Results: One thousand and eighty-four women of mean age
25 years had a medical TOP during this period. One hundred and
twelve women were scheduled to attend the clinic for follow-up
and three women did not require follow-up as complete TOP was
confirmed on the day of treatment. Ten women (out of 969)
attended hospital before the planned telephone contact (1%). Of
the 959 requiring telephone follow-up, 656 (68%) were
successfully contacted. Two of those who were not contactable
had ongoing pregnancies. Five hundred and seventy-three (87%)
of those contacted, screened ‘negative’ with no false negatives
occurring. Of the 83 (13%) who screened ‘positive’, three had
ongoing pregnancies. The sensitivity of follow-up was 100% and
specificity was 88% (95% CI 84.9–90.1).
Conclusion: Although slightly lower follow-up rates were obtained
in the 12 months following initial introduction, telephone follow-
up with LSUP was shown to be effective for detecting ongoing
pregnancy. -
Objectives: In October 2017, The Scottish Government approved a patient’s place of residence as a place where treatment for abortion can occur. Women up to 9+6 weeks gestation, can be administered mifepristone in a medical facility and given misoprostol to take home and self-administer 24-48 hours later. The option of early medical abortion at home (EMAH) has been available in our service since April 2018. Following ultrasound assessment of gestation, women who are under 9 weeks are offered the options of EMAH, medical abortion in hospital or surgical abortion. We aim to identify any demographic characteristics which may determine if a woman is more likely to choose EMAH, as opposed to hospital management.
Methods: A prospective review of the records of all women who attend over 4 months from April to July, who are 9 weeks or less and choose medical abortion. To be eligible for EMAH they must live in Scotland, be 16 years or over, have an adult with them on the day of abortion, not require an interpreter and have no significant medical conditions. We will analyse demographic data for those who choose EMAH and those who have medical abortion in hospital.
Results: In the first four weeks of offering EMAH to eligible patients, 184 women have been less than 9 weeks gestation and chosen medical abortion. 92 of them were booked to have medical abortion in hospital, and 92 EMAH. Upon completion of data analysis for the first 4 months, we will present the proportion of women who wished medical abortion that were eligible for EMAH, the proportion who chose EMAH and any demographic differences that exist between those choosing home and hospital management.
Conclusions: We will determine if any demographic differences exist between women who opt for home or hospital management of medical abortion.
Anne Miek Richters
Speeches:
Elizabeth Miller
Speeches:
Joanna Mishtal
Speeches:
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Objectives: We examined experiences of women who travel from the Republic of Ireland to the UK for abortion care. Irish women’s experiences are poorly understood. Publically shared stories tend to highlight cases of tragic circumstances (e.g., foetal anomalies, minors), eclipsing more ordinary circumstances for seeking abortion. We collected data about experiences of the latter group by using a systematic qualitative research approach.
Methods: Qualitative data were collected using In-Depth Interviews (IDIs) with 25 Irish women who traveled to Liverpool and London for abortion care between February and June 2017. Participants were Irish citizens or permanent residents and received surgical or medical abortion. We excluded minors and foetal anomaly cases. Participants’ age ranged from 19 to 43 years old; 18 of 25 participants were in their 20s. Their reported gestational age was between 6 and 19 weeks. IDIs followed a 13-item Interview Guide with semistructured probes. Topics included: arranging travel, challenges, support network, delays, and privacy.
Results: Data reveal significant hardships in women’s experiences traveling abroad for abortion care, including difficulties arranging travel in an “environment of secrecy” despite readily available information online, maintaining privacy in social and professional circles while waiting to travel, financial constraints, getting time off work, and securing overnight childcare. Financial barriers may lead women to intentionally schedule later appointments to allow time to organize money. Women who borrowed money reported getting bank loans of 900-1500 Euro. Additionally, the use and location tracking capabilities of social media (Facebook, Snapchat, etc.) may generate added stress about retaining privacy in abortion travel.
Conclusion: Irish women who travel for abortion care to the UK overcome significant financial, social, and employment difficulties in a burdensome environment of secrecy in order to pursue abortion services abroad. This study highlights the need to liberalize access to abortion care in Ireland.
Pierre Moonens
Speeches:
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A good law is not enough
Pierre Moonens MD, Member of the Board of the “Fédération de Centres de Planning Familiaux”, member of the Board of “Gacehpa”, Belgium. Co-founder and Vice President of Fiapac
In my daily work at a southern family planning of Belgium, a third of our clients are coming from Luxemburg. They do not find an opportunity to be aborted in their own country. This situation is very surprising: the Luxemburg’s law is very similar to the Belgian one, and any way those women should find the possibility to be helped by their own medical structures, but it does not work.
Why is it so?
Which “bad reasons» do give the possibility to those medical structures not to apply their law?
Even in Belgium, we do not use all the potentialities of our so said “good law”.
What did we loose in Belgium with the introduction of our so said “good law”, in comparison with the previous so said “bad obsolete law”?
How has it be possible in Spain, with such a weak law, to develop a so “liberal” situation for women asking for abortion?
Some tactical and ethical reflections when the opportunity appears to improve a national
law about abortion.
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Termination has been legal since 1990.
It is authorised on the demand of the woman and on medical grounds up to 14
weeks of amenorrhoea.
The woman has to declare that she is in a situation of distress, and must make
her request in written form.
Beyond 14 weeks of amenorrhoea, termination is possible only after the
consent of two doctors, provided that there is a serious health risk to the
woman, or if there is an abnormality of the foetus.
There is a mandatory waiting period after the first counselling of 6 days. -
Why do we need medical abortion when surgical abortion works so well?
Pierre Moonens, MD, Boardmember of the “Fédération de Centres de Planning Familiaux” and of “Gacehpa”, Belgium. Co-founder and Vice President of Fiapac
In the French spoken part of Belgium, we have a 25 years old experience of performing abortions in family planning clinics, using the aspiration’s technique under local anaesthesia. We are very pleased with this way of working. Description of disadvantages and advantages of this technique.
- How did we introduce the medical abortion technique in our Centres?
- Which protocol are we following for medical abortions?
- Which are the changes introduced in our daily work by this new technique?
- In which particular situations are preferring one method or the other?
- Which changes could be introduced in the protocol of medical abortion to improve the women’s rights ?
- Some ethical principals that should not be forgotten in our work of “abortion practitioners”.
Caroline Moreau
Speeches:
Marisa Moreira
Speeches:
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Outpatient use of mifepristone and misoprostol before and after 8 weeks gestation
Marisa Moreira, Renato Martins, Teresa Bombas, Teresa Sousa Fernandes, Manuel Pitorra, Maria Céu Almeida, Paulo Moura (Portugal)
Genetics, Reproductions and Fetal Maternal Medicine Department, Coimbra University Hospitals, and Bissaya Barreto Maternity, Coimbra Hospital Center, Portugal
renato.alessandre@gmail.com
Introduction. Since 16th of July of 2007, abortion is legal by women request before 10 weeks. The use of medical abortion is associated with lower complications. According to OMS protocols, the use of Mifeprostone and Misoprostol for abortion in out patient therapy can be used, for early pregnancies.
Objectives. We analyzed the use of medical therapy in abortions under 10 weeks gestational age comparing two groups – under 8 weeks (Group 1) and between 8 and 10 weeks (Group 2).
Material and Methods. We analyzed the clinical reports of women that came for abortion, during one year of experience, since 16th of July of 2007, in both medical facilities of Coimbra.
Results. We included 600 women. The average age was 28.2 ± 7.6 years. Most women are Portuguese (about 90%) and lived in Coimbra. More than half of these women are married and live with their partner. The authors split these women into 2 different groups: Group 1 (before 8 weeks gestacional age) with 450 women, and Group 2 (between 8 and 10 weeks) - 150. Both groups showed no statistical difference in all demographic aspects analysed. In terms of abortion method, correlation between the 2 groups revealed no statistical difference. Both groups revealed 5% complications, mainly due to failure of medical therapy. Between the two groups no statistical difference was found in terms of complications.
Conclusions.The use of medical abortion in out patient regimen can be safely used. The authors showed in this study that results between two different groups had no statistical significance. Moreover, when questioned, patients showed a high level of satisfaction with this protocol.
Raymonde Moullier
Speeches:
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First trimester surgical abortion under local anaesthesia
Raymonde MOULLIER, Vice-President of ANCIC www.ancic.asso.fr; Martine Hatchuel,
Sylvie Osterreicher, Nathalie Trignol
CIVG S. Veil, CHU de Nantes and CIVG C. Vautier, clinique J. Verne, Nantes, France
In France, abortion was legalized in 1975, and suction vacuum aspiration under local
anesthesia (LA) became prevalent especially in non-hospital autonomous clinics. As the
government decided to integrate abortion units within hospitals, surgical abortion under
local anesthesia decreased while the use of general anesthesia increased particularly for
the 12 to 14 weeks of amenorrhea. This trend seems to be occurring throughout Europe.
However, aspiration under LA remains a reliable technique for well trained personnel,
and ideal for the woman who chose LA when it is combined with psychological guidance
and an empathetic staff. This support is of prime importance in patience comfort and
satisfaction.
Moreover, since 1975, improvements have been made in the procedure:
cervical priming with misoprostol 400µg 2 or 3 hours before suction or even better with 200
mg of mifepriston 36 or 48 hours before suction, or with association of mifepriston and
misoprostol, especially for the 12 to 14 weeks of amenorrhea.
local anesthesia with lignocaïne 1% or lignocaïne + adrenalin by local infiltration of the
cervix or paracervical block or both is used routinely.
Treatment with ibuprofen (400 mg) 2 hours before suction helps prevent the pain during
the uterin contraction at the end of the procedure. Consequently, pain is either not
perceived or is tolerable for most women.
As adjunct analgesia, some providers are now using auto – inhalation of nitrous oxide and
some practice acupuncture.
All these improvements coupled with attention and empathy from the staff should give LA
a primary place in abortion practice. LA should be routinely proposed to women, and
medical teams trained in the technique.
Sabine Müller
Speeches:
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Abortion in women after female genital mutilation (FGM)
Sabine Müller (Germany)
wunobln@lsvw.de
Estimated 150 million women underwent the procedure of FGM, 8-10% of them are infibulated. The movie will show a defibulation, so an abortion may be performed.
Classfication of FGM (according to FIGO):
- "small sunna", removal of the preputial skin
- Excision of the clitoris
- Excision of the small lips ( with ot without clitorectomie)
- Infibulation
Clare Murphy
Arjola Musta
Speeches:
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Misoprostol-only compared with solution of NaCl 20%for induction of second trimester abortion
A. Manaj, A. Musta (Albania)
Obsetric Gynecological Hospital Mbreteresha Xheraldine, Tirana, Albania
amusta@acpd-al.org
Objective. The effect of Misoprostol in induced abortions of second trimester as treatment of choice.
Design & Method. In our country, the main method to terminate the second trimester pregnancies was the solution of NaCl 20%. These five last years this method is being replaced with misoprostol-only regimen. This was a comperative study. During a 12-month period, were selected and voluntary involved, two groups of healthy pregnant women (13-24 weeks) wishing to terminate their pregnancy due to medical reasons. A total of 80 patients, treated with misoprostol (experiment group) were compared with 77 patients treated with NaCl 20% (control group). Chi Square test for comparison of these proportions was used.
In the first group of 80 women the abortion was induced by misoprostol (Cytotec) 400 mcg vaginally 3-hourly (x5). The abortion time varied from 18 hours and 20 (pluripara) to 25 hours and 5 minutes (primigravida) hours. In the second group of 77 women abortion induced by intramniotic transabdominal instillation of 20 % NaCl, amounting to 250 ml. The shortest abortion-instillation time was 28 hours and 10 minutes (pluripara), while the longest was 36 hours and 8 minutes (primipara). 2 cases pertaining the first group and 8 cases pertaining to the second one, experienced haemorrhage due to partial retention of the placenta which were subsequently removed by curettage. In the second group we experienced two cases of distacco placenta.
Results. From data analyses resulted that patients treated with misoprostol have a much lower rate of haemorrhage P=0.01, cramps P=0.02 and curettage after misoprostol/ NaCl administration P=0.3.
There is no statistically significant difference in the rates of infections P=0.6, pelvic pain P=0.7, diarrhoea P=0.67, and the difference in the amniotic fluid embolism P=0.7 and distacco placenta P=0.7.