A review of evidence for safe abortion care

The potential prophylactic and therapeutic efficacy of progesterone and mifepristone on experimental trichinellosis with ultra-structural studies

Right up to now, there has not been an effective or safe therapy for trichinellosis. Thus, this study aimed to determine the efficacy of prophylactic and therapeutic regimens of progesterone and mifepristone on the intestinal and muscular phases of experimental Trichinella spiralis infection compared to albendazole. Seven distinct groups of mice were divided as follows: negative, positive, and drug control groups, as well as prophylactic and treatment groups using mifepristone and progesterone. Mice were sacrificed on the 7th and 37th days after infection. Treatment efficacy was evaluated using parasitological techniques, histopathological examination, immunohistochemical staining, and ultrastructural morphological analysis of adult worms by scanning electron microscopy. The mice groups received progesterone (300 ng/ml) and mifepristone (100 ng/ml). They demonstrated a significant improvement in intestinal and muscular inflammation and a statistically significant decline in the adult worm burden and encysted larvae (P< 0.001). Moreover, immunohistochemical staining of vascular endothelial growth factor and mucosal mast cell analyses were coincided with the obtained parasitological results. There was notable destruction and degeneration of the adult worm tegument by using both drugs. The current study pointed out that progesterone and mifepristone may provide new insights regarding the development of vaccines and drug protocols to treat trichinellosis through their combined action in reducing the inflammation, affecting the intestinal immune cell, and decreasing the adult worm burden, and larval capsule development.

“Out of This World”: Norwegian Women’s Experiences of Medical Abortion Pain

Introduction

Medical abortion has rapidly become the dominant abortion method in western countries. Pain is a known adverse effect; however, few studies have explored women's subjective experience of medical abortion pain.

Purpose

To explore Norwegian women's experiences of pain when performing a medical abortion at home.

Material and Methods

We recruited 24 women through an advertisement on Facebook and conducted semi-structured, face-to-face interviews. The interviews were transcribed verbatim and the data were analyzed using a phenomenological hermeneutical method.

Results

Our findings consisted of two main themes: 1) Being in pain or becoming pain, and 2) Being caught off guard and struggling to cope. Participants described undergoing severe pain, comparable to giving birth, during the medical abortion. Unprepared for the type and intensity of the pain, they felt anxious and insecure. Pain is physical, but it also has important psychological, social, and existential dimensions. Our culture (in)forms our thoughts and feelings about our pain, affecting our ability to endure suffering. The participants' experiences of abortion pain prompt timely questions concerning gendered socio-cultural and existential meanings connected to pain, specifically in relation to female reproductive functions.

Conclusion

Women need realistic information about the type and intensity of abortion pain, as well as evidence-based pain medication. Psychological factors may affect the experience of abortion pain and should therefore be taken into account in abortion care.

Advancing Reproductive Health through Policy-Engaged Research in Abortion Care

Mifepristone medication abortion was first approved in China and France more than 30 years ago and is now used in more than 60 countries worldwide. It is a highly safe and effective method that has the potential to increase population access to abortion in early pregnancy, closer to home. In both Canada and the United States, the initial regulations for distribution, prescribing, and dispensing of mifepristone were highly restricted. However, in Canada, where mifepristone was made available in 2017, most restrictions on the medication were removed in the first year of its availability. The Canadian regulation of mifepristone as a normal prescription makes access possible in community primary care through a physician or nurse practitioner prescription, which any pharmacist can dispense. In this approach, people decide when and where to take their medication. We explore how policy-maker-engaged research advanced reproductive health policy and facilitated this rapid change in Canada. We discuss the implications of these policy advances for self-management of abortion and demonstrate how in Canada patients "self-manage" components of the abortion process within a supportive health care system.

[Interruption of pregnancy between 12 and 16 weeks of gestation: Complications depending on term and method]

OBJECTIVE

Analyze the complication rate of pregnancy termination between 12 and 16 weeks of gestation, depending on the method and the exact term.

MATERIAL AND METHODS

Retrospective study focuses on patients who were going through a pregnancy termination between January 2015 and December 2020 at the Necker Universitary hospital in Paris. Two methods were applied: surgical abortion or medical evacuation. We compared 4 groups of patients depending on methods and term (12-14 or 14-16 weeks of gestation). The main complications such as hemorrhage, infection, need for surgery were collected.

RESULTS

414 patients were included. Blood loss and hemorrhage rate>500cc were higher for surgical abortion (3.5 vs 55% P<0.001), but the medical evacuation lead to an important rate of secondary aspiration for trophoblastic retention (14.7% vs 1.5% P<0.001). We didn't observe any difference regarding the complication rate for medical evacuation depending on the term. However, in case of surgical abortion the increase of term from 12-14 to 14-16 weeks of gestation leads to a tiny increment of the transfusion rate (0.6% vs 4.4% P=0.04), even if the hemorrhage rate >500cc didn't significantly differ (50,3 vs 57,9% P=0,2).

CONCLUSION

Surgical abortion between 12 and 16 weeks of gestation exposed the patients to an increased hemorrhagic risk, while the medical evacuation required more secondary aspiration for trophoblastic retention. The term of the abortion didn't affect the complication rate, beside a tiny increase in transfusion rate for surgical abortion.

Characterization of Membrane-Associated Progesterone Receptor Component-2 (MAPRC2) from Trichinella spiralis and Its Interaction with Progesterone and Mifepristone

Trichinellosis is a foodborne zoonotic disease caused by Trichinella spp., including Trichinella spiralis. In the present study, T. spiralis membrane-associated progesterone receptor component-2 (Ts-MAPRC2) gene was cloned and characterized using protein sequencing analysis. Furthermore, the expression, purification, immunoblot assay, binding ability with progesterone antibody, and immunofluorescence assay were performed. A direct effect of progesterone (P4) and mifepristone (RU486) on the Ts-MAPRC2 gene was determined using in vitro cell culture that showed different expression levels at all developmental stages (muscle larvae (ML), female adult worm (F-AL), male adult worm (M-AL), and newborn larvae (NBL)). Subsequently, the in vitro phenotypic effects of P4, RU486, and rTs-MAPRC2-Ab on F-AL and ML stages were measured. Later, the in vivo phenotypic effect and relative mRNA expression of mifepristone on the F-AL stage were studied. Our results revealed that the Ts-MAPRC2 gene is critical to maintaining pregnancy in the female adult worm (F-AL) of T. spiralis. The 300 ng/mL of P4 and 100 ng/mL of RU486 showed downregulation of the Ts-MAPRC2 gene in F-AL (p ≤ 0.05). This plays an important role in abortion and possibly decreases the worm burden of T. spiralis in the host. Only 30 ng/mL P4 showed significant upregulation in F-AL (p ≤ 0.05). The current study provides new insights regarding the antihormone (P4 and RU486) drug design and vaccine therapy of recombinant (rTs-MAPRC2) protein as well as their combined effects to control T. spiralis infection.

First Trimester Abortion Care in Low- and Middle-Income Countries

Access to first trimester abortions has increased significantly in the past few decades in low and middle-income countries. Manual vacuum aspiration is now standard of care for procedural abortion and postabortion care. Medication abortion has shifted abortions to being performed earlier in pregnancy and is becoming more widely available with new service delivery strategies to broaden access. Widespread availability of misoprostol has made abortions induced outside of the formal medical sector overall safer. In both legally restrictive and supportive environments, there is increased interested in self-managed abortions as part of a shift towards demedicalizing abortion through task-sharing.

Medical abortion at 13 or more weeks gestation provided through telemedicine: A retrospective review of services

Objectives

To evaluate medical abortion effectiveness and safety in women at 13 or more weeks gestation provided care through Women on Web's telemedicine service.

Study Design

We conducted a retrospective case study of abortions at 13 or more weeks gestation provided by Women on Web between 2016 and 2019. Women received mifepristone and misoprostol or misoprostol alone for abortion. We extracted demographic characteristics and outcome data for cases with pregnancy continuation outcomes.

Results

We identified 144 women who used medical abortion at 13 or more weeks; 131 (91%) provided abortion outcome data. Almost all, 118 (90%) received mifepristone and misoprostol. The population had an average age of 26 ± 5.8 years, 102 (78%) reported a gestational age of 13 to 15 weeks, 114 (87%) had experienced prior pregnancy, and represented all world regions. Overall, 13 (10%) women reported a continuing pregnancy, with 5 (5%) among women 13 to 15 weeks and 8 (28%) among those ≥16 weeks (p = 0.001); 38 (29%) reported adverse events (heavy bleeding, fever), 53 (43%) sought additional care from a health provider, and 18% of all cases received treatment with D&C/aspiration.

Conclusions

Efficacy of self-administered medical abortion decreases as gestational age increases, risking continuation of pregnancy. Provision through telemedicine at 13 to 15 weeks appears safe and effective.

Implications

Limited data suggest that medical abortion through telemedicine services may be a safe option through 15 weeks gestation in settings where there is ready access to the formal health system. More research with adequate sample sizes and high rates of follow-up is needed to inform on the safety of telemedicine for pregnancies 13 weeks and greater.

Barriers in Accessing Care for Consequence of Unsafe Abortion by Black Women: Evidence of Institutional Racism in Brazil

Women face difficulties in accessing post-abortion care, as hierarchical care operates under discrimination mechanisms that condemn women in abortion. In addition, it is the Black and Brown women who are more subject to unsafe abortions and need hospitalization to complete the termination of pregnancy or treat associated complications. This study aimed at identifying factors associated with the institutional barriers in access to health services for women who underwent abortion by race/color. The survey encompassed 2640 users admitted to public hospitals in Salvador, Recife, and São Luís. Differences among covariables according to race/color (Black, Brown, and White women) were analyzed and tested for statistical significance using Pearson's χ² test. The regression analysis initially included variables that may express the technical criteria of priority in care (time of pregnancy when abortion occurred and conditions of arrival), then the sociodemographic characteristics, and, lastly, the type of abortion declared. Black women faced more institutional difficulties (27.7% vs 19.5% in White women and 18.7% in Brown women), such as waiting to be attended and getting a bed. The association between being Black women and institutional barriers remained, even after adjustments in the regression model. Institutional racism limits access to health services and timely care for Black women, acting as a performative mechanism, legitimizing and generating exclusionary behaviors. The results demonstrate that the intersection between racial discrimination and abortion stigma redouble institutional barriers that are denominated intersectional discrimination.

A Retrospective Cost-Effectiveness Analysis of Mifepristone-Misoprostol Medical Abortions in the First Year at the Regina General Hospital

Objective

In July 2017, mifepristone–misoprostol (mife/miso) became available for medical abortion at the Regina General Hospital's Women's Health Centre (RGH WHC). We investigated whether the proportion of abortions performed medically changed as a result of the introduction of mife/miso, whether using mife/miso instead of the surgical alternative would result in cost savings to the health care system, and whether abortion type differed between patients residing in and outside of Regina.

Methods

We conducted a retrospective chart review of all 306 medical abortions from the RGH WHC between July 1, 2017 and June 30, 2018. We obtained medical and surgical abortion information from that year and the preceding one from an administrative database. Statistical methods were used to calculate the costs of mife/miso, methotrexate-misoprostol (MTX/miso) and surgical abortion, as well as cost-effectiveness ratios.

Results

The proportion of medical abortions increased from 15.4% in 2016/2017 to 28.7% in 2017/2018 (χ²₁ = 54.629; P < 0.001). Calculated costs for mife/miso, with and without complications were CAD $1173.70 and CAD $1708.90, respectively, versus CAD $871.10 and CAD $1204.10, respectively, for MTX/miso, and CAD $1445.95 and CAD $2261.95, respectively, for hospital-based vacuum aspiration. At a willingness-to-pay threshold of CAD $318 (the cost of mife/miso), statistical modelling showed a 61.3% chance that mife/miso was more cost-effective than surgical abortion and a 90.8% chance that it was more cost-effective than MTX/miso. Patients from Regina were significantly more likely (χ²₁ = 29.406; P < 0.001) to receive a medical abortion (34.9% of abortions) than those living outside of Regina (19.6% of abortions).

Conclusion

The proportion of abortions completed medically increased significantly over the period studied. Patients from Regina were more likely to receive medical abortion during both time periods. Mife/miso had a >50% probability of cost-effectiveness over both surgical and MTX/miso options.

Could implementation of mifepristone address Canada's urban-rural abortion access disparity: a mixed-methods implementation study protocol

INTRODUCTION

In January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada, (2) assess the impact of a 'community of practice' clinical and health service support platform and (3) engage in and assess the impact of integrated knowledge translation (iKT) activities aimed to improve health policy, systems and service delivery issues to enhance patient access to mifepristone.

METHODS AND ANALYSIS

This prospective mixed-methods implementation study will involve a national sample of physicians and pharmacists recruited via an online training programme, professional networks and a purpose-built community of practice website. Surveys that explore constructs related to diffusion of innovation and Godin's behaviour change frameworks will be conducted at baseline and at 6 months, and qualitative data will be collected from electronic interactions on the website. Survey participants and a purposeful sample of decision-makers will be invited to participate in in-depth interviews. Descriptive analyses will be conducted for quantitative data. Thematic analysis guided by the theoretical frameworks will guide interpretation of qualitative data. We will conduct and assess iKT activities involving Canada's leading health system and health professional leaders, including evidence briefs, Geographical Information System (GIS)maps, face-to-face meetings and regular electronic exchanges. Findings will contribute to understanding the mechanisms of iKT relationships and activities that have a meaningful effect on uptake of evidence into policy and practice.

ETHICS AND DISSEMINATION

Ethical approval was received from the University of British Columbia Children's and Women's Hospital Ethics Review Board (H16-01006). Full publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to research participants through newsletters and media interviews, and to policy-makers through invited evidence briefs and face-to-face presentations.

The Modified Bushen Antai Recipe Upregulates Estrogen and Progesterone Receptors at the Maternal-Fetal Interface in Pregnant Rats with Mifepristone-Induced Pregnancy Loss

Background

The modified Bushen Antai recipe (BSAT) is a centuries-old traditional Chinese medicine that we use in our center as a therapy against pregnancy loss. Our study aimed to explore the potential benefit and mechanism of BSAT in pregnant rats with mifepristone-induced pregnancy loss.

Materials and Methods

The signature compounds of the eight BSAT ingredients were analyzed by high-performance liquid chromatography (HPLC). The BSAT group (n = 8) was treated daily with 6.3 ml/kg BSAT from gestation day (D) 0.5 to 10.5 and once with 1.25 mg/kg mifepristone on D 10.5. Normal saline replaced BSAT in the model group (n = 8), and both BSAT and mifepristone in the control group (n = 8). Morphological and histological analyses were performed on D 13.5.

Results

BSAT contains eight medicinal ingredients including Cuscuta chinensis and Dipsacus asperoides. The HPLC analysis detected the signature compounds of seven medicinal ingredients in the extract. Embryo resorption rate in the BSAT group was significantly lower than that in the model group, although the number of surviving embryos was similar between the two groups. Hematoxylin and eosin (HE) staining suggested that the maximum cross-sectional area of the placenta and the area ratio of the placental labyrinth in the BSAT group were higher than those in the model group. Immunohistochemical (IHC) staining indicated that the expression of ki67, estrogen receptor alpha (ERα), and progesterone receptor (PR) in the placental labyrinth of the BSAT group was higher than that of the model group. Furthermore, the protein levels of ERα, PR, phospho-Akt/Akt, and phospho-Erk1/2/Erk1/2 in the BSAT group were higher than those in the control group. The mRNA levels of ERα and PR in the BSAT group were higher than those in the control group.

Conclusions

BSAT may induce estrogen and progesterone receptors by phosphorylation via the classic Akt and Erk1/2 signaling pathways in the maternal-fetal interface of pregnant rats, thereby reducing the pregnancy loss rate and improving the live birth rate.

Low-dose mifepristone increased angiogenesis in a manner involving AQP1

PURPOSE

To investigate the molecular mechanisms governing aquaporin-1 (AQP1)-mediated, mifepristone-induced angiogenesis and improve the understanding of low-dose mifepristone serving as an anti-implantation contraceptive drug.

METHODS

Human umbilical vein endothelial cells (HUVECs) were used to explore the effects of different concentrations of mifepristone (0, 65, and 200 nmol/L) on the activity of angiogenesis. Forty-five pregnant mice during the "window of implantation" were treated with different concentrations of mifepristone. HUVECs' proliferation was examined using a methyl thiazolyl tetrazolium (MTT) assay. The microvessel density (MVD) and the expression of AQP1 in endometrium were determined with immunohistochemical methods.

RESULTS

The MVD and the expression of AQP1 were significantly higher than controls. Mifepristone at 200 nmol/L significantly affected HUVECs' proliferation during culture over 12 h, and pretreatment with AQP1-specific siRNA significantly inhibited the mifepristone-enhanced cell proliferation.

CONCLUSIONS

Low-dose mifepristone increased angiogenesis in a manner involving AQP1. This affords a new insight into the molecular mechanism underpinning the angiogenic effects of low-dose mifepristone.

Abortion-related care and the role of the midwife: a global perspective

Introduction

The International Confederation of Midwives (ICM) represents 132 midwifery associations in 113 countries. The ICM disseminates the Essential Competencies for Basic Midwifery Practice (EC) that describes the global scope of midwifery practice. The basic (core) and expanded (additional or optional) role of midwives in providing abortion-related care services was first described in 2010. A literature review about three items that are particularly critical to access to abortion services was conducted. Findings that emerged in the recent 2016-2017 update study about these three items are presented.

Methods

A modified Delphi study was administered via the Internet in a series of three rounds. Thirty-seven statements of abortion-related knowledge and skill were presented.

Results

A total of 895 individuals participated. The total of respondents across all three rounds represented 90 of the 105 member countries at the time of the study. The role of midwives in providing comprehensive abortion care, including referral for abortion and provision of postabortion family planning, achieved the necessary 85% agreement to be designated as essential (basic) knowledge or skill for the global scope of midwifery practice. The provision of medication abortion and performance of manual vacuum aspiration abortion were designated as optional for midwives who wished to provide these services. Endorsement of these latter practices was highest in both Francophone and Anglophone regions of Africa, Asian Pacific countries, and countries at a lower state of economic development.

Conclusion

The role of midwives in provision of abortion-related care services was reaffirmed in the recent Delphi study to inform the update to the EC. The role of midwives as direct providers of medical and vacuum aspiration abortions was reaffirmed for those individual midwives who wish to obtain the requisite competency to provide those services, in jurisdictions where these services are legally authorized.

Abortion among Adolescents in Israel: Intervention and Health Behavior Outcomes

The current study investigated the post-abortion health behaviors of adolescents. Authors assessed the association between pre-abortion interventions and receiving post-abortion checkups and uptake of effective contraceptives. Participants were 172 adolescents under 19 years of age who were recruited pre-abortion at 10 hospitals in Israel and followed up by phone one and two months post-abortion. Results indicate that a quarter of participants did not receive a post-abortion checkup. The reported reasons for this were mostly personal, with very few cases attributed to accessibility issues. Rates of effective contraceptive use increased from the pre- to post-abortion periods but were still not high. Longer duration of pre-abortion counseling with a social worker, having the checkup where the abortion took place, and parental involvement increased the odds of having a post-abortion checkup. Getting a prescription for oral contraceptive pills at the time of abortion increased the odds of uptake one month post-abortion. Nonadherence to post-abortion recommendations is a problem with the potential to cause health risks and more unintended pregnancies. Effective social work interventions to promote behavioral change are needed, especially those based on theory and evidence.

Medication abortion: Potential for improved patient access through pharmacies

OBJECTIVES

To discuss the potential for improving access to early abortion care through pharmacies in the United States.

SUMMARY

Despite the growing use of medications to induce termination of early pregnancy, pharmacist involvement in abortion care is currently limited. The Food and Drug Administration's Risk Evaluation and Mitigation Strategy (REMS) for Mifeprex® (mifepristone 200 mg), the principal drug used in early medication abortion, prohibits the dispensing of the drug by prescription at pharmacies. This commentary reviews the pharmacology of medication abortion with the use of mifepristone and misoprostol, as well as aspects of service delivery and data on safety, efficacy, and acceptability. Given its safety record, mifepristone no longer fits the profile of a drug that requires an REMS. The recent implementation of pharmacy dispensing of mifepristone in community pharmacies in Australia and some provinces of Canada has improved access to medication abortion by increasing the number of medication abortion providers, particularly in rural areas.

CONCLUSION

Provision of mifepristone in pharmacies, which involves dispensing and patient counseling, would likely improve access to early abortion in the United States without increasing risks to women.

The immunological effect of Galectin-9/TIM-3 pathway after low dose Mifepristone treatment in mice at 14.5 day of pregnancy

The abortifacient Mifepristone (RU486) has proven to be a safe, effective, acceptable option for millions of women seeking abortion during the first and second trimester of pregnancy although its precise mechanism of action is not well understood. The main objective of this study was to investigate the impact of low dose Mifepristone administration on placental Galectin-9 (Gal-9) expression, as well as its effect on the cell surface expression of Gal-9, TIM-3 and CD107a molecules by different T and NK cell subsets. A model of Mifepristone-induced immunological changes was established in syngeneic pregnant BALB/c mice. RU486-induced alteration in placental Gal-9 expression was determined by immunohistochemistry. For immunophenotypic analysis, mid-pregnancy decidual lymphocytes and peripheral mononuclear cells were obtained from Mifepristone treated and control mice at the 14.5 day of gestation. TIM-3 and Gal-9 expression by peripheral and decidual immune cells were examined by flow cytometry. Our results revealed a dramatically decreased intracellular Gal-9 expression in the spongiotrophoblast layer of the haemochorial placenta in Mifepristone treated pregnant mice. Although low dose RU486 treatment did not cause considerable change in the phenotypic distribution of decidual and peripheral immune cells, it altered the Gal-9 and TIM-3 expression by different NK and T cell subsets. In addition, the treatment significantly decreased the CD107a expression by decidual TIM-3+ NK cells, but increased its expression by decidual NKT cell compared to the peripheral counterparts. These findings suggest that low dose Mifepristone administration might induce immune alterations in both progesterone dependent and independent way.

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

BACKGROUND

Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation.

METHODS

An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country's abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships.

RESULTS

After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides.

CONCLUSIONS

These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.

Oral contraception following abortion: A systematic review and meta-analysis

Oral contraceptives (OCs) following induced abortion offer a reliable method to avoid repeated abortion. However, limited data exist supporting the effective use of OCs postabortion. We conducted this systematic review and meta-analysis in the present study reported immediate administration of OCs or combined OCs postabortion may reduce vaginal bleeding time and amount, shorten the menstruation recovery period, increase endometrial thickness 2 to 3 weeks after abortion, and reduce the risk of complications and unintended pregnancies.A total of 8 major authorized Chinese and English databases were screened from January 1960 to November 2014. Randomized controlled trials in which patients had undergone medical or surgical abortions were included. Chinese studies that met the inclusion criteria were divided into 3 groups: administration of OC postmedical abortion (group I; n = 1712), administration of OC postsurgical abortion (group II; n = 8788), and administration of OC in combination with traditional Chinese medicine postsurgical abortion (group III; n = 19,707).In total, 119 of 6160 publications were included in this analysis. Significant difference was observed in group I for vaginal bleeding time (P = 0.0001), the amount of vaginal bleeding (P = 0.03), and menstruation recovery period (P < 0.00001) compared with the control groups. Group II demonstrated a significant difference in vaginal bleeding time (P < 0.00001), the amount of vaginal bleeding (P = 0.0002), menstruation recovery period (P < 0.00001), and endometrial thickness at 2 (P = 0.003) and 3 (P < 0.00001) weeks postabortion compared with the control group. Similarly, a significant difference was observed in group III for reducing vaginal bleeding time (P < 0.00001) and the amount of vaginal bleeding (P < 0.00001), shortening the menstruation recovery period (P < 0.00001), and increasing endometrial thickness 2 and 3 weeks after surgical abortion (P < 0.00001, all).Immediate administration of OCs postabortion may reduce vaginal bleeding time and amount, shorten the menstruation recovery period, increase endometrial thickness 2 to 3 weeks after abortion, and reduce the risk of complications and unintended pregnancies.

COMPARISON BETWEEN SUBLINGUAL AND VAGINAL ROUTE OF MISOPROSTOL IN MANAGEMENT OF FIRST TRIMESTER MISCARRIAGE MISSING

Background:

Each year, more than forty million abortions are occurred whole of the world. Misoprostol is a prostaglandin analogue with a strong uterotonic effect. The present study aimed to compare the efficacy of Misoprostol in first trimester abortion through two sublingual and vaginal routes of administration.

Methods:

This randomized clinical trial was conducted on 52 consecutive women in first trimester candidate for pregnancy termination because of fetal IUFD or missed abortion in sonography reports. The patients were hospitalized and then randomly assigned to receive sublingual Misoprostol (400 µg, n 27) or vaginal Misoprostol (400 µg placed in posterior fornix, n = 25).

Findings:

None of the pregnant in the sublingual group developed complete abortion at the end of follow-up time, while 36% of women inducted with vaginal misoprostol experienced complete abortion indicating a intergroup significant difference (p = 0.001). Compared with vaginal group, those women in sublingual group experienced more complications including diarrhea (22.2% versus 20.0%), nausea and vomiting (22.2% versus 0.0%), and abdominal pain (3.7% versus 0.0%).

Conclusion:

The use of Misoprostol in vaginal route results in more abortion completeness as well as lower complication rate as compared to sublingual prescription of the drug.

Obesity as a Risk Factor for Complications After Second-Trimester Abortion by Dilation and Evacuation

OBJECTIVE

To evaluate the association between obesity (body mass index [BMI] 30 or higher) and dilation and evacuation (D&E) complications.

METHODS

We conducted a retrospective cohort study of women who underwent D&E abortion from February 2009 to April 2013 at a hospital-based abortion practice in California. We evaluated the association between obesity and risk of complication after D&E using logistic regression. We defined complications a priori as cervical laceration, hemorrhage, uterine atony, anesthesia complications, uterine perforation, disseminated intravascular coagulation, and retained products of conception. We defined major complications as those requiring hospitalization, transfusion, or further surgical intervention.

RESULTS

Complications occurred in 442 of 4,520 D&Es (9.8%), with equal proportions in obese and nonobese women (9.8%). Major complications occurred in 78 (1.7%) patients. After adjustment for age, ethnicity, prior vaginal delivery, prior cesarean delivery, and gestational duration, there was no association between BMI and D&E complications. Any individual complication was associated with each additional week of gestation (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.3-1.4), prior vaginal delivery (OR 1.5, 95% CI 1.2-1.9) and prior cesarean delivery (OR 1.8, 95% CI 1.4-2.3). Major complications were associated with each additional week of gestation (OR 1.3, 95% CI 1.1-1.4) and cesarean delivery (OR 1.8, 95% CI 1.1-3.1).

CONCLUSION

We found no association between obesity and D&E complications. Our findings are consistent with previous studies demonstrating that later gestational duration is associated with an increased risk of complications. Obesity may not warrant referral to a high-risk abortion center, particularly because referral-associated delay might increase the risk of complications.

LEVEL OF EVIDENCE

II.

An overview of medical abortion for clinical practice

Medical abortion is a safe, convenient, and effective method for terminating an early unintended pregnancy. Medical abortion can be performed up to 63 days from the last menstrual period and may even be used up to 70 days for women who prefer medical abortion over surgical abortion. Counseling on the adverse effects and expectations for medical abortion is critical to success. Medical abortion can be performed in a clinic without special equipment, and it is perceived as more "natural" than a surgical abortion by many women. Follow-up for medical abortion can be simplified to include only serum human chorionic gonadotropin measurements when necessary, although obtaining an ultrasound remains the criterion standard. Pain associated with medical abortion is best treated with nonsteroidal anti-inflammatory medications, possibly in combination with opioid analgesics. Medical abortion can contribute to continuity of care for women who wish to remain with their primary care providers for management of their abortion.

Usual hospital care versus post-abortion care for women with unsafe abortion: a case control study from Sri Lanka

BACKGROUND

Good quality post-abortion-care (PAC) is essential to prevent death and long-term complications following unsafe abortion, especially in countries with restrictive abortion laws. We assessed the PAC given to women following an unsafe abortion, compared to the routine hospital care following spontaneous abortion or unintended pregnancy carried to term in Sri Lanka.

METHODS

A case-control study was conducted in Sri Lanka among 171 cases following unsafe abortion, 638 controls following spontaneous abortion (SA-controls) and 600 women following delivery of an unintended pregnancy (TUP-controls) admitted to same hospitals during the same period. Care provided was assessed using interviewer-administered-questionnaires and in-depth-interviews at hospital discharge and in a sub-sample, at 6-8 weeks post-discharge. Differences in care were assessed using chi-square tests.

RESULTS

Mean age of cases was 30.6 years (SD = 6.6); 21.1% were primis. 60.8% cases developed sepsis and 12.3% organ failure. Cases received timely, complete and safe emergency treatment with no difference to SA-controls (p > 0.05): removal of retained products of conception medically (14.6% cases versus 19.4% SA-controls) or surgically (73.7% versus 75.1%), within 24 hours of admission (63.5% versus 52.8%), under anaesthesia (84.1% versus 92.3%) and intravenous antibiotics (91.2% versus 31.0%). Despite this equitable treatment, cases were dissatisfied with their overall care during hospital stay, predominantly due to verbal harassment of health-care-providers on their abortion status (57.9% versus 19.3% SA-controls, p < 0.05). Ward doctors provided the best care to cases in all aspects, except compared to SA-controls in explaining women's health status (60.2% versus 77.7%), and compared to TUP-controls in providing information on contraceptive methods (14% versus 24.3%), service availability (13.5% versus 24.7%) and assistance in decision-making on contraception (13.5% versus 21.3%). Ward-midwives contributed none to family-planning care of cases. At 6-8 weeks, 48.9% of cases were on contraceptive methods, predominantly short-term, compared to 85.3% of TUP-controls, predominantly long-term methods (p < 0.01).

CONCLUSIONS

Despite equitable emergency treatment, care following unsafe abortion was deficient in post-abortion counselling, education and family planning services. Engagement of public-health staff for follow-up care was inadequate. Perceived dissatisfaction of overall care was owing to discrimination related to their abortion status.

Updated WHO guidance on safe abortion: health and human rights

Since its first publication in 2003, the World Health Organization's "Safe abortion: technical and policy guidance for health systems" has had an influence on abortion policy, law, and practice worldwide. To reflect significant developments in the clinical, service delivery, and human rights aspects of abortion care, the Guidance was updated in 2012. This article reviews select recommendations of the updated Guidance, highlighting 3 key themes that run throughout its chapters: evidence-based practice and assessment, human rights standards, and a pragmatic orientation to safe and accessible abortion care. These themes not only connect the chapters into a coherent whole. They reflect the research and advocacy efforts of a growing field in women's health and human rights.