Medical abortion - clinical aspects Gynmed Clinic Vienna, Austria www.gynmed.at Karolinska University Hospital Department of Women and Child Health Stockholm/Sweden Christian Fiala, MD, PhD International Association of Abortion and Contraception Associates www.fiapac.org Conférence sur l’avortement par médicament- 16 Septembre 2014 - FQPN www.mifegyne.info www.misoprostol.org Museum of Contraception and Abortion Vienna, www.muvs.org
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Medical abortion - clinical aspects Gynmed Clinic Vienna, Austria Karolinska University Hospital Department of Women and Child Health Stockholm/Sweden.
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Medical abortion - clinical aspects
Gynmed Clinic
Vienna, Austria
www.gynmed.atKarolinska University Hospital
Department of Women and Child Health
Stockholm/Sweden
Christian Fiala, MD, PhD
International Association of Abortion and Contraception Associates
• Priming of the cervix prior to surgical abortion
• Medical abortion for medical indications in the 2. +
3. Trimester
• Induction of labour in intrauterine foetal death
Mifepristone: approved indications in Europe
Medical abortion - clinical aspects, C. Fiala
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Website: - information (www.gynmed.org)
First contact /telephone: - Is pregnancy confirmed?- Has the patient been able to talk to someone close?- Has the decision for the abortion been taken?- Answer questions or refer to the website- Exclude contra indications- Make appointment
Day 1: - Ultrasound, hCG (gynaecological examination) - Blood group- Counselling: abortion only if the decision is clear otherwise give an appointment one week later- 1 or 3 tab mifepristone
Day 3: - <49 days LMP = 2 tab misoprostol (Cytotec®) orally 50-63 days LMP = 4 tab misoprostol vaginaly- Option for up to 3 hours in the institution (rarely used)- Make sure patient has sufficient analgesics- Start oral contraception the next day
Day 8 -14: - ultrasound and/or hCG
The procedure up to 63 days LMP
Medical abortion - clinical aspects, C. Fiala
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When does the abortion take place?
Phase of psychological confrontation -Phase of coming to a decision
Mifepristone
Prostaglandin
• Detachment of the gestational sac
• Bleeding may start• Expulsion may take place
• Bleeding becomes heavy• Expulsion takes place
• Beginning of a new cycle/fertility
The abortion/Point of no return
Expulsion ≠ Abortion
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Medical abortion: impact of the interval
Mifepristone Misoprostol
36-48 hours
Reducing the interval needs a higher dose of prostaglandin > more side effects
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1 2 3 4 5 6 7 8 9 10 11
5
10
15
12 13 14 15 16 17 18 19 20 21
20
22 23 24
in %
(hours after misoprostol)
Time to expulsion of the sac in 1720 women with successfull termination of pregnancy. The women took mifeprostone on day 1 and misoprostol 48 hours later. Uncertain means expulsion at some point during 24 hours following misoprostol. Unknown means expulsion at some point later than 24 after misoprostol.
Source: The New England Journal of Medicine, 1998; 338 (18): 1244
Befor
e m
iso
Mor
e th
an 2
4 h
late
run
know
n
unce
rtain
When does the expulsion take place?
Medical abortion - clinical aspects, C. Fiala
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D 1: CRL 10 mmhCG 83.439
D 8: E 8 mmhCG 312
The procedure
Medical abortion - clinical aspects, C. Fiala
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Day 1: hCG 32.000yolk sac visible
Day 8: E 12 mmhCG 837
Day 3: Gestational sac
The procedure
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Day 7: hCG 7Day 3: Gestational sac
Day 1: Gestational sac5 mmhCG 862
The procedure
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Day 1: ß-hCG 269 mIU/ml Day 9: ß-hCG 20
The procedure
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D 28: hCG 100D 10: E 20 mm, hCG 16.841
D 17: OC exD 21: Withdrawl-bleeding
D 1: CRL 6 mmhCG 104.900
D 3: Start OC
The procedure
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D 1: Gestational + yolk sachCG 13.300
D 3: Start OC
D 19: E 8 mmhCG 718
D 9: missed ABhCG 10.819
D 16: OC exD 18: Withdrawl-bleeding
The procedure
Medical abortion - clinical aspects, C. Fiala
23hCG before and after an abortion
Top curve: women after vacuum aspiration for elective abortionMiddle curve: women with spontaneous abortions uterine aspirationLower curve: women with ectopic removed surgically
,
,
,
,
,
,
,
Montagnana et al., Clinica Chimica Acta, 2011
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Mean 3,8% (0,1-44); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 25 patients, Fiala et al., 2003
0
5
10
15
20
0 2 4 6 8 10 12 14 16 18 20
%
days
Serum hCG at follow-up in % of the initial value
3 cs of successful abortion were at 27,32 and 44%,2 cs of missed abortion at 91 and 159%, 1 cs of continued pregnancy 7.900 %
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Thickness of the uterine cavity at follow upAverage: 10mm (1-24mm) after successful medical abortion