When is a backup aspiration needed? hCG and ultrasound for verification of successful expulsion Christian Fiala Gynmed Ambulatorium Vienna, Austria Karolinska Institute Department of Woman and Child Health Stockholm/Sweden www.fiapac.org International Association of Abortion and Contraception Associates Abortion, Contraception and Women’s Health International Seminar of FIAPAC, RSOG, RC Ob/Gyn &P , 27/28 October 2005
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When is a backup aspiration needed? hCG and ultrasound for verification of successful expulsion
Abortion, Contraception and Women’s Health International Seminar of FIAPAC , RSOG, RC Ob/Gyn &P , 27/28 October 2005. When is a backup aspiration needed? hCG and ultrasound for verification of successful expulsion. Christian Fiala. www.fiapac.org - PowerPoint PPT Presentation
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When is a backup aspiration needed?
hCG and ultrasound for verification of
successful expulsion
Christian Fiala
Gynmed Ambulatorium
Vienna, Austria
Karolinska Institute
Department of Woman and Child Health
Stockholm/Sweden
www.fiapac.org
International Association of Abortion and Contraception Associates
Abortion, Contraception and Women’s Health
International Seminar of FIAPAC, RSOG, RC Ob/Gyn &P , 27/28 October 2005
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
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an 2
4 h
late
run
know
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unce
rtain
hCG and US in medical abortion, C. Fiala
Day 1: hCG 269 mIU/ml Day 9: hCG 20
Treatment
hCG and US in medical abortion, C. Fiala
Day 7: hCG 7Day 3: GestationalSac
Day 1: Gestational sac 5 mmhCG 862
Treatment
hCG and US in medical abortion, C. Fiala
D 1: hCG 32.000 D 8: E 12 mmhCG 837
D 3: Gestationalsac
Treatment
hCG and US in medical abortion, C. Fiala
D 1: CRL 10 mmhCG 83.439
D 8: E 8 mmhCG 312
Treatment
hCG and US in medical abortion, C. Fiala
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
Treatment
hCG and US in medical abortion, C. Fiala
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
Treatment
hCG and US in medical abortion, C. Fiala
Methods
– 217 women with
– an unwanted pregnancy
– <49 days of amenorrhea
– received:
• 600mg of Mifepristone orally
• 400µg of Misoprostol orally 2 days later
• hCG was performed at all visits
• US was performed before Mifepristone and at follow-up
hCG and US in medical abortion, C. Fiala
Results
• Curettage:– 1 continued pregnancy– 1 missed abortion– 1 haemorrhage
• One missed abortion was expelled after withdrawal bleeding
hCG and US in medical abortion, C. Fiala
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 patients3 cases of successful abortion (27,32 and 44%)2 cases of missed abortion (91 and 159%), 1 case of continued pregnancy (7,900 %)
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
Fiala et al., 2003
hCG and US in medical abortion, C. Fiala
Mean 10mm (1-24mm); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 10 patients
0
5
10
15
20
25
30
0 2 4 6 8 10 12 14 16 18 20
Days
mm
Endometrium thickness at follow-up
Fiala et al., 2003
hCG and US in medical abortion, C. Fiala
First trimester surgical abortion:
– Urinary test (cut off 1,000mIU/ml) at two weeks (Paul et al., 2000)
Medication abortion <9 weeks:
– Urinary test, cut off 500mIU/ml at 3 weeks
(Karolinska University Hospital, Sweden)
– Urinary test, cut off 1,000mIU/ml at >1 week
(Gynmed Clinic, Vienna)
– Decline in serum hCG at follow up in % of the initial value:
• 30% on day 10 (Jourdan and van den Bossche 1991)
• 40% at 1 week (Legarth et al. 1991)
• 60-70.5% 24 hours following misoprostol
• 99.4% on day 14 (Walker et al., 2001, Honkanen et al., 2002)
• 20% after day 6 (Fiala et al., 2003)
hCG for verification of expulsion
hCG and US in medical abortion, C. Fiala
Retained products of conception (RPC)
• Commonly present with sharp or crampy lower abdominal pain and bleeding
• No difference to haematomata
• Presence of sparse villi alone after successful surgical abortion is a normal finding and not diagnostic of RPC
• After abortion, small amounts of retained products may pass spontaneousely, avoiding the need for backup curettage
hCG and US in medical abortion, C. Fiala
Verification of expulsion
• Ultrasound
– Gives reliable results in most cases when the yolk sac or CRL can be visualised before treatment
– It is not reliable in very early pregnancy
– Endometrium is thick in many patients at follow up
• hCG
– Has to be used in early pregnancy
– Is very reliable in most cases > cut off at 20% of initial value after day 6
– Follow-up can be done at a different laboratory
hCG and US in medical abortion, C. Fiala
Rapid hCG test
Duo rapid test (urine)
5 mIU/ml and 1.000 mIU/mlwww.VedaLab.com
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Objects (IUDs, Cervical caps etc.),
reports, posters, publications
www.contraceptive-museum.at
The museum will be in Vienna, at conferences and online