Expanding medical abortion: can medical abortion be effectively provided without the routine use of ultrasound?

Telemedicine for the provision of medication abortion to pregnant people at up to twelve weeks of pregnancy: a systematic literature review and meta-analysis

BACKGROUND

Telemedicine represents an important strategy to facilitate access to medication abortion (MAB) procedures, reduces distance barriers and expands coverage to underserved communities. The aim is evaluating the self-managed MAB (provided through telemedicine as the sole intervention or in comparison to in-person care) in pregnant people at up to 12 weeks of pregnancy.

METHODS

A literature search was conducted using electronic databases: MEDLINE, Embase, Cochrane (Central Register of Controlled Trials and Database of Systematic Reviews), LILACS, SciELO, and Google Scholar. The search was based on the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework, and was not restricted to any years of publication, and studies could be published in English or Spanish. Study screening and selection, risk of bias assessment, and data extraction were performed by peer reviewers. Risk of bias was evaluated with RoB 2.0 and ROBIS-I. A narrative and descriptive synthesis of the results was conducted. Meta-analyses with random-effects models were performed using Review Manager version 5.4 to calculate pooled risk differences, along with their individual 95% confidence intervals. The rate of evidence certainty was based on GRADE recommendations.

RESULTS

21 articles published between 2011 and 2022 met the inclusion criteria. Among them, 20 were observational studies, and 1 was a randomized clinical trial. Regarding the risk of bias, 5 studies had a serious risk, 15 had a moderate risk, and 1 had an undetermined risk. In terms of the type of intervention, 7 compared telemedicine to standard care. The meta-analysis of effectiveness revealed no statistically significant differences between the two modalities of care (RD = 0.01; 95%CI 0.00, 0.02). Our meta-analyses show that there were no significant differences in the occurrence of adverse events or in patient satisfaction when comparing the two methods of healthcare delivery.

CONCLUSION

Telemedicine is an effective and viable alternative for MAB, similar to standard care. The occurrence of complications was low in both forms of healthcare delivery. Telemedicine services are an opportunity to expand access to safe abortion services.

Trend of serum beta-human chorionic gonadotropin levels after medical abortion in the early first trimester of pregnancy

AIM

This study aimed to study serum beta-human chorionic gonadotropin level trends after medical abortion using mifepristone and misoprostol in the early first trimester.

METHODS

We enrolled women at ≤63 days of gestation who were indicated for pregnancy termination. We excluded women with incomplete abortions, nonviable pregnancies, extrauterine pregnancies, and contraindications for mifepristone/misoprostol use. Women received oral mifepristone (200 mg), followed by vaginal misoprostol (800 mcg) after 48 h. Serum beta-human chorionic gonadotropin levels were monitored pre-mifepristone administration (day 1); 48 h post-mifepristone, pre-misoprostol administration (day 3); day 10; and weekly after day 10, until negative beta-human chorionic gonadotropin levels (<25 mIU/mL) were achieved.

RESULTS

Among 39 enrolled women, 36 (92.3%) who underwent complete abortion without further interventions were included. The median gestational age was 51 (32-61) days. Three phases of beta-human chorionic gonadotropin levels were observed: an increase of up to 5.1% within 48 h of taking mifepristone, before misoprostol administration; a rapid decline on day 10 (by 98.5% compared with initial levels); and a slow decline after day 10 until negative results were attained within 7 weeks.

CONCLUSION

Serum beta-human chorionic gonadotropin levels minimally increased 48 h after taking mifepristone, rapidly declined within 1 week of misoprostol administration, and slowly declined until negative within 7 weeks post-abortion.

Cost Analysis of Surgical and Medical Uterine Evacuation Methods for First-Trimester Abortion Used in Public Hospitals in Mexico

Background:

Data on abortion procedures costs are scarce in low- and middle-income countries. In Mexico, the only known study was conducted more than a decade ago, with data from years before the abortion legislation. This study estimated the costs, from the health system’s perspective, of surgical and medical abortion methods commonly used by women who undergo first-trimester abortion in Mexico.

Methods:

Data were collected on staff time, salaries, medications, consumables, equipment, imaging, and lab studies, at 5 public general hospitals. A bottom-up micro-costing approach was used.

Results:

Surgical abortion costs were US$201 for manual vacuum aspiration and US$298 for sharp curettage. The cost of medical abortion with misoprostol was US$85. The use of cervical ripening increases the costs by up to 18%. Staff comprised up to 72% of total costs in surgical abortions. Hospitalization was the area where most of the spending occurred, due to the staff and post-surgical surveillance required.

Conclusions:

Our estimates reflect the costs of “real-life” implementation and highlight the impact on costs of the overuse of resources not routinely recommended by clinical guidelines, such as cervical ripening for surgical abortion. This information will help decision-makers to generate policies that contribute to more efficient use of resources.

Dutch GPs' views on prescribing mifepristone and misoprostol: a mixed-methods study

BACKGROUND

The World Health Organization has indicated that GPs can safely and effectively provide mifepristone and misoprostol for medical termination of pregnancy (TOP). Dutch GPs are allowed to treat miscarriages with mifepristone and misoprostol, but few do so. Current Dutch abortion law prohibits GPs from prescribing these medications for medical TOP. Medical TOP is limited to the specialised settings of abortion clinics and hospitals. Recently, the House of Representatives debated shifting abortion to the domain of primary care, following the example of France and the Republic of Ireland. This would improve access to sexual and reproductive health care, and increase choices for women. Nevertheless, little is known about GPs' willingness to provide medical TOP and miscarriage management.

AIM

To gain insight into Dutch GPs' willingness to prescribe mifepristone and misoprostol for medical TOP and miscarriages, as well as the anticipated barriers.

DESIGN AND SETTING

Mixed-methods study among Dutch GPs.

METHOD

A questionnaire provided quantitative data that were analysed using descriptive methods. Thematic analyses were performed on qualitative data collected through in-depth interviews.

RESULTS

The questionnaire was sent to 575 GPs; the response rate was 22.1% (n = 127). Of the responders, 84.3% (n = 107) were willing to prescribe mifepristone and misoprostol, with 58.3% (n = 74) willing to provide this medication for both medical TOP and miscarriage management. A total of 57.5% (n = 73) of participants indicated a need for training. The main barriers influencing participants' willingness to provide medical TOP and miscarriage management were lack of experience, lack of knowledge, time constraints, and a restrictive abortion law.

CONCLUSION

Over 80.0% of responders were willing to prescribe mifepristone and misoprostol for medical TOP or miscarriages. Training, (online) education, and a revision of the abortion law are recommended.

Utility of a routine ultrasound for detection of ectopic pregnancies among women requesting abortion: a retrospective review

INTRODUCTION

Routine ultrasound may be used in abortion services to determine gestational age and confirm an intrauterine pregnancy. However, ultrasound adds complexity to care and results may be inconclusive, delaying abortion. We sought to determine the rate of ectopic pregnancy and the utility of routine ultrasound in its detection, in a community abortion service.

METHODS

Retrospective case record review of women requesting abortion over a 5-year period (2015-2019) with an outcome of ectopic pregnancy or pregnancy of unknown location (PUL) at a service (Edinburgh, UK) conducting routine ultrasound on all women. Records were searched for symptoms at presentation, development of symptoms during clinical care, significant risk factors and routine ultrasound findings.

RESULTS

Only 29/11 381 women (0.25%, 95% CI 0.18%, 0.33%) had an ectopic pregnancy or PUL (tubal=18, caesarean scar=1, heterotopic=1, PUL=9). Eleven (38%) cases had either symptoms at presentation (n=8) and/or significant risk factors for ectopic pregnancy (n=4). A further 12 women developed symptoms during their clinical care. Of the remaining six, three were PUL treated with methotrexate and three were ectopic (salpingectomy=2, methotrexate=1). In three cases, the baseline ultrasound indicated a probable early intrauterine pregnancy.

CONCLUSIONS

Ectopic pregnancies are uncommon among women presenting for abortion. The value of routine ultrasound in excluding ectopic pregnancy in symptom-free women without significant risk factors is questionable as it may aid detection of some cases but may provide false reassurance that a pregnancy is intrauterine.

Early termination of pregnancy: differences in gestational age estimation using last menstrual period and ultrasound in Mexico

Background

Gestational age estimation is key to the provision of abortion, to ensure safety and successful termination of pregnancy. We compared gestational age based on reported last menstrual period and ultrasonography among a large sample of women in Mexico City’s public first trimester abortion program, Interrupcion Legal de Embarazo (ILE).

Methods

We conducted a retrospective study of 43,219 clinical records of women seeking abortion services in the public abortion program from 2007 to 2015. We extracted gestational age estimates in days based on last menstrual period and ultrasonography. We calculated the proportion of under- and over-estimation of gestational age based on last menstrual period versus ultrasonography. We compared overall differences in estimates and focused on discrepancies at two relevant cut-offs points (70 days for medication abortion eligibility and 90 days for ILE program eligibility).

Results

On average, ultrasonography estimation was nearly 1 (− 0.97) days less than the last menstrual period estimation (SD = 13.9), indicating women tended to overestimate the duration of their pregnancy based on recall of date of last menstrual period. Overall, 51.4% of women overestimated and 38.5% underestimated their gestations based on last menstrual period. Using a 70-day limit, 93.8% of women who were eligible for medication abortion based on ultrasonography would have been correctly classified using last menstrual period estimation alone. Using the 90-day limit for ILE program eligibility, 96.0% would have been eligible for first trimester abortion based on last menstrual period estimation alone.

Conclusions

The majority of women can estimate gestational age using last menstrual period date. Where available, ultrasonography can be used, but it should not be a barrier to providing care.

El ultrasonido anterior al aborto en contexto de ilegalidad: un estudio sobre las prácticas discursivas de profesionales desde la experiencia de las mujeres

Resumen En este artículo, indagamos en la situación de examen ultrasonográfico preaborto en un contexto de ilegalidad, atendiendo a las prácticas discursivas de los profesionales que median las experiencias de visualización, desde la perspectiva de las experiencias y repertorios interpretativos de mujeres jóvenes que se realizan dicho examen. Para ello, se realizaron entrevistas en profundidad a 25 mujeres que hicieron un aborto en el periodo universitario y que hicieron una ecografía preaborto. El material fue transcrito y analizado desde el paradigma interpretativo. El aborto es clausurado en la situación de examen mediante una particular práctica discursiva de los profesionales en torno a la personificación del feto y la naturalización del lazo materno-fetal. En el examen se produce una incitación sobre la mujer a ver y saber sobre el feto, mientras ella rehúsa la incitación a participar de la visualización. Las jóvenes no producen el enlazamiento dominante o hegemónico entre imágenes, lenguajes y emociones, que las convertiría en madres, pero tampoco producen un enlazamiento alternativo que les permita experimentar el ultrasonido de un modo compatible con la decisión de interrumpir. De este modo, la situación de ecografía se traduce en una experiencia de violencia normativa para las mujeres.

[Role of ultrasound in elective abortions]

Ultrasound plays a fundamental role in the management of elective abortions. Although it can improve the quality of post-abortion care, it must not be an obstacle to abortion access. We thus studied the role of ultrasound in pregnancy dating and possible alternatives and analyzed the literature to determine the role of ultrasound in post-abortion follow-up. During an ultrasound scan, the date of conception is estimated by measurement of the crown-rump length (CRL), defined by Robinson, or of the biparietal diameter (BPD), as defined by the French Center for Fetal Ultrasound (CFEF) after 11 weeks of gestation (Robinson and CFEF curves) (grade B). Updated curves have been developed in the INTERGROWTH study. In the context of abortion, the literature recommends the application of a safety margin of 5 days, especially when the CRL and/or BPD measurement indicates a term close to 14 weeks (that is equal or below 80 and 27mm, respectively) (best practice agreement). Accordingly, with the ultrasound measurement reliable to±5 days when its performance meets the relevant criteria, an abortion can take place when the CRL measurement is less than 90mm or the BPD less than 30mm (INTERGROWTH curves) (best practice agreement). While a dating ultrasound should be encouraged, its absence is not an obstacle to scheduling an abortion for women who report that they know the date of their last menstrual period and/or of the at-risk sexual relations and for whom a clinical examination by a healthcare professional is possible (best practice agreement). In cases of intrauterine pregnancy of uncertain viability or of a pregnancy of unknown location, without any particular symptoms, the patient must be able to have a transvaginal ultrasound to increase the precision of the diagnosis (grade B). Various reviews of the literature on post-abortion follow-up indicate that the routine use of ultrasound during instrumental abortions should be avoided (best practice agreement). If it becomes clear immediately after the procedure that the endometrial thickness exceeds 8mm, immediate reaspiration is necessary. Ultrasound examination of the endometrium several days after an instrumental elective abortion does not appear to be relevant (grade B). An analysis of the literature similarly shows that routine ultrasound scans after medical abortions should be avoided. If a transvaginal ultrasound is performed after a medical abortion, it should take place at least two weeks afterwards (best practice agreement). The only aim of an ultrasound examination during follow-up should be to determine whether a gestational sac is present (best practice agreement). Finally, if an ultrasound is performed at any point during pre- or post-abortion care, a report should be drafted, specifying any potential gynecologic abnormalities found, but its absence must not delay the scheduling of the abortion (best practice agreement).

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

Comparison of remote and in-clinic follow-up after methotrexate/misoprostol abortion

OBJECTIVE

This study compared adherence to follow-up and clinical outcomes between standard in-clinic and remote follow-up after methotrexate/misoprostol abortion.

STUDY DESIGN

This nonrandomized trial recruited women requesting medical abortion at two sexual health clinics in Toronto, Canada. Women received methotrexate 50 mg/m(2) followed 3-7 days later by 800 mcg of misoprostol self-administered vaginally. For Day 15, follow-up participants could choose standard in-clinic follow-up with ultrasound and assessment or remote telephone follow-up with serum β-hCG performed at a community laboratory and symptom checklist. Standard and remote follow-up groups were compared for adherence, defined as completing follow-up within 7 days of the scheduled time, and clinical outcomes. Characteristics associated with adherence were assessed using multivariable logistic regression.

RESULTS

Of 129 women, 86 (67%) chose remote follow-up. Nonadherence rates for remote (28%) and standard (23%) follow-up groups did not differ in univariate (p=.57) or multivariable analysis (odds ratio: 1.09, 95% confidence interval: 0.39-3.01). Rates of emergency/hospital visits were 3% and 9% for remote and standard groups, respectively (p=.22), and complete loss to follow was 6% and 14% in remote and standard groups (p=.18). Nonadherent women were more likely to be undecided about their contraception (65% vs. 28%; p=.002), and this difference persisted in the multivariable analysis.

CONCLUSION

Given a choice of remote or in-clinic follow-up after methotrexate/misoprostol abortion, most women chose remote follow-up. Rates of adherence to follow-up, adverse outcomes and complete loss to follow-up were similar for women choosing remote and standard follow-up.

IMPLICATIONS STATEMENT

Since standard and remote follow-up after methotrexate/misoprostol abortion are associated with similar adherence to follow-up and similar safety profiles, women should be offered their choice of follow-up method.