Immediate Complications After Medical Compared With Surgical Termination of Pregnancy

Obstetric infections and clinical characteristics of maternal sepsis: a hospital-based retrospective cohort study

Sepsis is responsible for 50% of intrahospital maternal deaths worldwide. Incidence is increasing in both low and middle-, and high-income countries. There is little data on incidence and clinical outcomes of obstetric infections including maternal sepsis in the Nordic countries. The aims of this study are to give estimates of the occurrence of obstetric infections and maternal sepsis in a Norwegian hospital cohort, assess the quality of management of maternal sepsis cases, and evaluate the usefulness of diagnostic codes to identify maternal sepsis retrospectively. We conducted a retrospective cohort study of pregnant, labouring, post-abortion, and postpartum women. We assessed the accuracy of the diagnostic code most frequently applied for maternal sepsis, O85. We found 7.8% (95% confidence interval 7.1-8.5) infection amongst pregnant, labouring, and postpartum women. The incidence of maternal sepsis was 0.3% (95% confidence interval 0.2-0.5), and the majority of sepsis cases were recorded in the postpartum period. Two thirds of women were given broad-spectrum antibiotics at the time sepsis was diagnosed, but only 15.4% of women with puerperal sepsis were given antimicrobials in accordance with national guidelines. When used retrospectively, obstetric infection codes are insufficient in identifying both maternal and puerperal sepsis, with only 20.3% positive predictive value for both conditions. In conclusion, obstetric infections contribute significantly to maternal morbidity in Norway's second largest maternity hospital. This study provides incidences of maternal infections for hospitalised patients in temporal relation to pregnancy, labour, abortion and the postpartum period, knowledge which is valuable for planning of health care services and allocation of resources. In addition, the study highlights areas where improvement is needed in clinical handling of maternal sepsis. There is need for studies on the management quality and use of correct diagnostic codes in this patient category.

Self-Managed Medication Abortion: Implications for Clinical Practice

Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women.

Summary

Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.

Short-Term Adverse Outcomes After Mifepristone-Misoprostol Versus Procedural Induced Abortion : A Population-Based Propensity-Weighted Study

BACKGROUND

Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada.

OBJECTIVE

To compare short-term risk for adverse outcomes after early IA by mifepristone-misoprostol versus by procedural IA.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PATIENTS

All women who had first-trimester IA.

MEASUREMENTS

A total of 39 856 women dispensed mifepristone-misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone-misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups.

RESULTS

Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone-misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]).

LIMITATION

A woman prescribed mifepristone-misoprostol may not have taken the medication, and the exact gestational age at IA was not always known.

CONCLUSION

Although rare, short-term adverse events are more likely after mifepristone-misoprostol IA than procedural IA, especially for less serious adverse outcomes.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research.

Language policy at an abortion clinic: linguistic capital and agency in treatment decision-making

This paper investigates an abortion clinic's procedural choices regarding the management of linguistic diversity. It focuses in particular on how language serves as capital for clients' agency in decision-making regarding their abortion treatment. Based on linguistic-ethnographic fieldwork in a Flemish abortion clinic, we analyse the clinic's institutional language policy, which states that clients should be able to speak Dutch, English or French in order to be eligible for a medical abortion-the alternative to a surgical abortion. We show how direct and smooth communication is considered a condition to ensure safety during the medical abortion treatment. We also discuss how, against the backdrop of the COVID-19 pandemic, the practical reorganisation of the clinic has led to more autonomy and empowerment for some clients, while it reinforced the already existing inequality for others. Finally, we discuss the clinic's struggles with and lack of reflection on language support services. We conclude that the case of the abortion clinic can be considered as one of exclusive inclusion, and suggest that a higher awareness of language support and a critical rethinking of the safety procedure could strengthen this clinic further in its endeavour to help women confronted with an unwanted pregnancy.

The risk of venous thromboembolism in early pregnancy loss: Review of the literature and current guidelines and the need for guidance - Communication from the SSC on Women's Health Issues for thrombosis and haemostasis

BACKGROUND

Thromboembolic disease is one of the major causes of mortality and morbidity in pregnancy and the puerperium, with 1 death per 100 000 births attributed to venous thromboembolism (VTE). Factors associated with development of thrombosis are all present in pregnancy, with some of these changes seen from conception.

OBJECTIVE

Given how common early pregnancy loss is, the aim of this review is to evaluate the uncertainty surrounding the risk of VTE following early pregnancy loss and termination of pregnancy.

METHODS

A structured literature search was conducted to identify existing evidence as well as international pregnancy-specific guidelines regarding assessment and prevention of VTE risk in pregnant women. This review was reviewed, critiqued, and approved by all members of the International Society on Thrombosis and Haemostasis subcommittee for Women's Health Issues in Thrombosis and Haemostasis.

RESULTS

Four published original research studies, one clinical comment paper, and six guidelines were reviewed. Despite clear evidence of the increased risk of VTE in pregnancy, there is a lack of guidance regarding evaluation and management after early pregnancy loss.

CONCLUSION

International collaborative research to determine the risk of VTE and its prevention in women undergoing surgical termination of pregnancy or following surgical management of early pregnancy loss is urgently needed. Pregnancy-specific risk assessment taking into account preexisting risk factors is advocated. Education of health care professionals involved in early pregnancy care and guidance on management, albeit based on limited existing evidence, are necessary to highlight the need for individualized care.

Mifepristone-Misoprostol Use for Second and Third Trimester Medical Termination of Pregnancy in a Canadian Tertiary Care Centre

OBJECTIVE

This study aims to evaluate the impact of the implementation a mifepristone-misoprostol protocol (MIFE/MISO) on the induction-to-expulsion interval in the context of second- and third-trimester pregnancy termination or intrauterine fetal death (IUFD) compared with misoprostol alone (MISO), and to share the experience of a Canadian tertiary hospital concerning the feasibility and safety of such a protocol.

METHODS

This is a single-centre retrospective pre-post cohort study carried out at the Centre Hospitalier Universitaire (CHU) Sainte-Justine between 2017 and 2019. Women in the MIFE/MISO group were instructed to take mifepristone 24-48 hours before induction. Induction in the MIFE/MISO group was performed with misoprostol dosages adjusted to gestational age and the presence of previous uterine scars, while, in the MISO group, all patients received 400 μg of misoprostol vaginally every 4 hours.

RESULTS

Ninety-four patients were included in the MIFE/MISO group and 103 patients, in the MISO group. Median time to expulsion was significantly lower in the MIFE/MISO group than the MISO group (13.5 and 19.5 h respectively; P < 0.001). The total dose of misoprostol administered was significantly lower in the MIFE/MISO group than the MISO group, and adverse effects were reported in 60% and 82% of patient records, respectively (P < 0.001). Complication rates were similar between the two groups.

CONCLUSION

The MIFE/MISO protocol is highly effective for second- and third-trimester induction for pregnancy termination or IUFD, without increasing complication rates and with fewer reported adverse effects. Its implementation is safe and feasible in a tertiary medical centre.

Pregnancy termination in patients with rheumatic diseases

Rheumatic diseases affect women during their reproductive years. Many women with rheumatic diseases become pregnant; some undergo pregnancy termination. However, there are no official guidelines on pregnancy termination in patients with rheumatic diseases. This paper provides an overview of considerations that healthcare professionals must take into account. We highlight areas that require further studies and the importance of pregnancy planning and contraception counseling. Patients with rheumatic diseases need to be informed of adverse maternal and fetal outcomes of pregnancy to make informed reproductive decisions and reduce the need for pregnancy terminations. This article is protected by copyright. All rights reserved.

Maternal Mortality from Induced Abortion in Malawi: What Does the Latest Evidence Suggest?

It is commonly claimed that thousands of women die every year from unsafe abortion in Malawi. This commentary critically assesses those claims, demonstrating that these estimates are not supported by the evidence. On the contrary, the latest evidence—itself from 15 to 20 years ago—suggests that 6–7% of maternal deaths in Malawi are attributable to induced and spontaneous abortion combined, totalling approximately 70–150 deaths per year. I then offer some evidence suggesting that a substantial proportion of these are attributable to spontaneous abortion. To reduce maternal mortality by large margins, emergency obstetric care should be prioritised, which will also save women from complications of induced and spontaneous abortion.

Association of Traumatic Injury With Adverse Pregnancy Outcomes in Taiwan, 2004 to 2014

IMPORTANCE

Literature has suggested that trauma among pregnant women is associated with an increased risk of adverse pregnancy outcomes. However, limited research has investigated the association of trauma with adverse pregnancy outcomes by using a national data set.

OBJECTIVE

To investigate the association between traumatic injury and adverse pregnancy outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study of pregnant women in Taiwan linked 3 data sets, the Taiwan Birth Registry, Household Registration Information, and National Health Insurance Research Database, from January 1, 2004, through December 31, 2014. Data, including the characteristics of pregnant women and infants, were extracted from the Taiwan Birth Registry data set; to obtain trauma data, this data set and the Household Registration Information data set were collectively linked to National Health Insurance Research Database data. The combined data set was analyzed from January to July 2019. Adverse pregnancy outcomes and premature delivery were defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes.

EXPOSURES

The primary exposures of this study were 2 clinical variables related to injury during pregnancy: medical treatment in the emergency department (yes or no) and hospitalization (yes or no).

MAIN OUTCOMES AND MEASURES

The main outcome variable was adverse pregnancy outcomes, and the secondary outcome variable was premature delivery. Multivariate logistic regression models were used to investigate the association of injuries with adverse pregnancy outcomes after controlling for demographic characteristics and other pregnancy-related variables.

RESULTS

A total of 2 973 831 pregnant women (2 475 805 [83.3%] aged 20-34 years) were enrolled between 2004 and 2014, of whom 59 681 (2.0%) sought medical treatments due to injuries. Results of multivariate logistic regression models showed that women receiving emergency treatments more than once were 1.08 times as likely (adjusted odds ratio, 1.08; 95% CI, 1.05-1.10) to have adverse pregnancy outcomes than women who received no emergency treatment. Women with injury-related hospitalization were 1.53 times more likely (adjusted odds ratio, 1.53; 95% CI, 1.41-1.65) to have adverse pregnancy outcomes than women who did not sustain injuries. Furthermore, recurrent injuries were associated with a 572% increase in odds of premature delivery (adjusted odds ratio, 6.72; 95% CI, 2.86-15.80).

CONCLUSIONS AND RELEVANCE

In this study, trauma among pregnant women was associated with an increased risk of adverse pregnancy outcomes, as were hospitalization and emergency department visits due to injury.

A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015

INTRODUCTION

Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures.

OBJECTIVE

To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions.

METHODS

A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion.

RESULTS

ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015.

CONCLUSION

The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.

Induced Abortion and the Increased Risk of Maternal Mortality

After years of failure to obtain accurate statistics on maternal mortality, the United States noted a sharp increase in its maternal mortality rate with widening racial and ethnic disparities. The 2016 report shocked the nation by documenting a 26 percent increase in maternal mortality from 18.8/100,000 live births in 2000 to 23.8 in 2014. Suggested etiologies of this increase included artifact as a result of improved maternal death surveillance, incorrect use of ICD-10 codes, healthcare disparities, lack of family support and other social barriers, substance abuse and violence, depression and suicide, inadequate preconception care, patient noncompliance, lack of standardized protocols for handling obstetric emergencies, failure to meet expected standards of care, aging of the pregnant patient cohort with associated increase in chronic diseases and cardiovascular complications, and lack of a comprehensive national plan. While some of the increase in maternal mortality may be a result of improved data collection, pregnancy-related deaths are occurring at a higher rate in the United States than in other developed countries. Some have suggested that the increased maternal mortality is due to limiting women's access to legal abortion. In order to discover effective strategies to improve pregnancy outcomes, maternal mortality must be investigated in an unbiased manner. This review explores the relationship between legal-induced abortion and maternal mortality.

Summary

In Finland, where epidemiologic record linkage has been validated, the risk of death from legal induced abortion is reported to be almost four times greater than the risk of death from childbirth. It is difficult to do this comparison in the United States not only because prior induced abortion history is often not recorded for a pregnancy-related death but also because less than one-quarter of the states require health care providers to report abortion deaths for investigation. These omissions are important because mortality risk in pregnancies subsequent to abortion is increased due to abortion-induced morbidities such as preterm birth and abnormal placentation. Legal induced abortion is a root cause of the racial and ethnic disparity noted in maternal mortality. In the United States, the death rate from legal induced abortion performed at 18 weeks gestation is more than double that observed for women experiencing vaginal delivery.

Induced abortion and future use of IVF treatment; A nationwide register study

OBJECTIVE

In this nationwide study we assessed the use and factors associated with future in vitro fertilization (IVF) treatment after induced abortion.

MATERIALS AND METHODS

The study population was collected by means of record linkage between Finnish national registers. All women who underwent induced abortion between 2000 and 2009 in Finland were identified through the Register of Induced Abortions (n = 88 522). The study group consisted of women who underwent induced abortion and subsequently had an IVF treatment (n = 379); the comparison group were all women who had a spontaneous pregnancy and delivery 12-24 months after the index abortion (n = 7434). Demographic characteristics at the time of index abortion, and factors associated with the abortion (gestational age at abortion, indication and method of abortion, complications after abortion) were compared between the study groups. Logistic regression was used to assess whether some of the demographic characteristics or abortion associated factors increased the use of IVF treatment in the future.

RESULTS

The proportion of women with IVF treatment after induced abortion in the whole cohort was 0.4%. Women needing IVF treatment were older, of a higher socioeconomic status, and had fewer previous induced abortions and deliveries compared to women in the comparison group. No statistically significant differences were observed in the gestational age (≤ 12 weeks or >12 weeks of gestation) at abortion, method or complications of abortion. In multivariable analysis higher age increased, and history of previous deliveries or one or two abortions decreased the use of IVF.

CONCLUSIONS

Infertility necessitating the use of IVF treatment after induced abortion is uncommon. The factors associated with use of IVF after abortion are those generally recognized as risk factors of infertility. Abortion-related outcomes are not associated with an increased need of future IVF-treatment.

Factors Associated with Management Outcome of Incomplete Abortion in Yirgalem General Hospital, Sidama Zone, Southern Ethiopia

Background

Each year, several millions of women who underwent abortion also bear several consequences, including infection, massive blood loss, chronic pelvic pain, infertility, and death. Poor treatment outcomes also cause disability and death. The aim of this study was to determine factors associated with management outcomes of incomplete abortion in Yirgalem General Hospital.

Methods

Health facility-based cross-sectional study design was used. Medical record review of 186 women who received abortion service from July 1^st 2015 to June 30 2017 was done. Then the data were entered into the computer using epi info version 7.2 and exported into SPSS version 20, Descriptive analysis was done to determine social, demographic characteristics, and bivariate and multivariate logistic regression analysis were done to identify factors associated with management outcome of incomplete abortion, 95% CI and odds ratio used to present the result.

Results

A total of 180 (96.7%) of cases managed for incomplete abortion was included in the study. Of this, 53.3% of patients with incomplete abortion belonged to age group of 18-25 years old. More than half incomplete abortion cases were managed surgically 122 (67.8%). Of the total, 36 (19.4%) of the patients developed unfavorable management outcome. Gestational age at which abortion occurs AOR = 3.39, 95% (1.29, 8.89) and delayed seeking of medical help AOR = 2.96, 95% (1.04, 8.4) were found to be significantly associated with unfavorable management outcome.

Conclusion

High numbers of cases managed for abortion resulted unfavorable management outcome. However, no death occurred and major surgery done as the result of abortion management. Delayed seeking of medical care and seeking care past 1st trimester are significantly associated with unfavorable management outcomes. Therefore, awareness creation for adolescent and youth about prompt health-care seeking after the start of the first sign and symptom of spontaneous abortion should be strengthened.

Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Effects of gestational age and the mode of surgical abortion on postabortion hemorrhage and fever: evidence from population-based reproductive health survey in Georgia

Background

Every year around 50 million unintended pregnancies worldwide are terminated by induced abortion. Even in countries, where it is legalized and performed in a safe environment, abortion carries some risk of complications for women. Findings of researchers on the factors that influence the sequelae of abortion are controversial and inconsistent. This study evaluates the effects of gestational age and the method of surgical abortion (i.e., dilatation and curettage and vacuum aspiration) on the most common abortion complications: postabortion hemorrhage and fever.

Methods

We performed a secondary analysis of the data from the population-based Georgian Reproductive Health Survey 2010. Information on 1974 surgical abortions performed >30 days prior to the survey interview were analyzed during the study. Logistic regression statistical analysis was applied to compare the abortion sequelae that followed vacuum aspiration and dilatation and curettage at different gestational ages (<10 weeks and ≥10 weeks). We examined two major early abortion-related complications: postabortion hemorrhage and febrile morbidity (fever ≥38 °C).

Results

Postabortion hemorrhage was reported in 43 cases (1.9%), and febrile morbidity occurred in 44 cases (2%) among all of the surgical abortions. The abortions performed by dilatation and curettage were associated with an estimated fourfold increased risk of developing hemorrhage (OR 4.4, 95% CI 2.2–8.6) and a twofold increased risk of developing fever (OR 2.37, 95% CI 1.17–4.79) compared with the abortions that were performed via vacuum aspiration. The risk of postabortion hemorrhage (OR 1.9, 95% CI 0.8–4.4) or fever (OR 0.9, 95% CI 0.4–2.1) did not significantly differ at gestational age < 10 weeks and ≥10 weeks.

Conclusion

Vacuum aspiration was associated with reduced risks of postabortion hemorrhage and fever compared to dilatation and curettage. Gestational age ≥ 10 weeks was not found to be a predictive factor of immediate postabortion complications: hemorrhage and fever.

Risks of Adverse Perinatal Outcomes after Repeat Terminations of Pregnancy by their Methods: a Nationwide Register-based Cohort Study in Finland 1996-2013

BACKGROUND

Repeat terminations of pregnancy (TOPs) are associated with an increased risk of adverse outcomes in the subsequent birth. The perinatal outcomes after repeat TOPs by their methods have not yet been properly studied. This study aimed to examine perinatal outcomes in subsequent pregnancy among the women with a singleton birth and a history of TOPs.

METHODS

All the first-time mothers (n = 419 879) with a singleton birth during 1996-2013 in Finland were identified from the Medical Birth Register and linked to the Abortion Register. Adjusted multivariable logistic regression analysis was used to estimate risks of adverse perinatal outcomes.

RESULTS

The increased incidence of adverse perinatal outcomes was found with increasing number of surgical TOPs. After adjusting for confounders, the women with one surgical TOP had slightly increased but significant odds of 1.07 (95% CI 1.02, 1.13) for being small for gestational age compared with the women having no TOP. A significantly high risk for extremely preterm birth (OR 1.51, 95% CI 1.03, 2.23) was found among the women having had repeat surgical TOPs when compared to the women with no TOP. Non-significant risks were found for adverse perinatal outcomes after women's repeat surgical TOPs than repeat medical TOPs.

CONCLUSION

Information regarding the consequences of repeat induced TOPs will be significant in sexual health education as well as counselling women after first termination.

Perinatal outcomes after induced termination of pregnancy by methods: A nationwide register-based study of first births in Finland 1996-2013

Background

Women with previous terminations of pregnancy (TOPs) before their first birth have been associated with poorer perinatal outcomes. However, previous studies on the perinatal outcomes by the method in previous TOPs are inconsistent.

Objective

To examine the perinatal outcomes of the first-time mothers with singleton births, by the method of previous TOP (medical and surgical vs no TOP, and surgical vs medical).

Method

This is a nationwide register-based study including 419,879 first-time Finnish mothers with singleton birth during the time period 1996–2013. Mothers having their first birth were identified from the Medical Birth Register and linked to the Abortion Register by their identification numbers. Multinomial logistic regression analysis was performed to examine the risk for preterm birth, low birth weight, small for gestational age and perinatal death by the method in previous TOPs.

Results

Among the first-time mothers, 87.0% had no history of TOPs, 3.2% had a history of medical TOP(s), 9.2% had a history of surgical TOP(s) and 0.6% had a history of both (medical and surgical) TOP(s). No significant differences in perinatal outcomes were found among the women with surgical TOPs, compared to the women with no TOPs. In unadjusted analysis, increased odds for preterm birth and low birth weight were found when comparing women having previous surgical TOPs with medical TOPs. Even after the adjustment of potential confounders, odds for preterm birth < 37 weeks (OR = 1.19, 95% CI = 1.04–1.36) and low birth weight < 2500 g (OR = 1.16, 95% CI = 1.00–1.35) remained significant. After restricting data to the single TOP, the results were similar; OR for both preterm birth and low birth weight was 1.18 (95% CIs = 1.02–1.36 and 1.01–1.38).

Conclusion

Perinatal outcomes did not differ among the mothers with surgical TOPs compared to the mothers with no TOPs, while the outcomes were poorer after surgical TOP(s) than after medical TOP(s).

Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework

OBJECTIVES

To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events.

STUDY DESIGN

As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework.

RESULTS

The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion- or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%).

CONCLUSIONS

Distinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care.

IMPLICATIONS

The PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first-trimester aspiration abortion procedures. Standardization will assist healthcare providers, researchers and policymakers to anticipate morbidity and prevent abortion adverse events, improve care metrics and enhance abortion quality.

How reliable are health registers? Registration of induced abortions and sterilizations in Finland

Finland's population-based health registers are widely used in health-monitoring and research. We assessed the quality of the Finnish Register on Induced Abortions and Sterilisations and compared it to the Hospital Discharge Register. Ten hospitals out of 67 public hospitals performing induced abortions and sterilizations and three randomly selected months in 2011 were included. This data was compared to the data in the Register on Induced Abortions and Sterilisations. The sample presented 43.1% of all induced abortions and sterilizations during the study months. The coverage on data on induced abortions was excellent: 97.0% of induced abortions were found in the register. Coverage on data on sterilizations was good: 89.4% of sterilizations performed were found in the register. More detailed comparisons of the variable data showed good to very good validity. The coverage of the Hospital Discharge Register was found also to be good. The validity of Finland's Register on Induced Abortions and Sterilisations makes it a good base for research and health-monitoring. The Hospital Discharge Register was a good source in measuring volumes of hospital use as well as the main diagnoses or procedures, but the registration of single diagnoses or procedures may be less ideal for research.

The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa

Background

Despite a liberal abortion law, access to safe abortion services in South Africa is challenging for many women. Medication abortion was introduced in 2013, but its reach remains limited. We aimed to estimate the costs and cost effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings.

Methods

We obtained data on service provision and outcomes from an operations research study where medication abortion was introduced alongside existing MVA services in public hospitals in KwaZulu-Natal province. Clinical data were collected through interviews with first-trimester abortion clients and summaries completed by nurses performing the procedures. In parallel, we performed micro-costing at three of the study hospitals. Using a model built in Excel, we estimated the average cost per medical and surgical procedure and determined the cost per complete abortion performed. Results are presented in 2015 US dollars.

Results

A total of 1,129 women were eligible for a first trimester abortion at the three study sites. The majority (886, 78.5%) were eligible to choose their abortion procedure; 94.1% (n = 834) chose medication abortion. The total average cost per medication abortion was $63.91 (52.32–75.51). The total average cost per MVA was higher at $69.60 (52.62–86.57); though the cost ranges for the two procedures overlapped. Given average costs, the cost per complete medication abortion was lower than the cost per complete MVA despite three (0.4%) medication abortion women being hospitalized and two (0.3%) having ongoing pregnancies at study exit. Personnel costs were the largest component of the total average cost of both abortion methods.

Conclusion

This analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.

[Complications of termination of pregnancy]

The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.

Is It Safe to Provide Abortion Pills over the Counter? A Study on Outcome Following Self-Medication with Abortion Pills

BACKGROUND

Medical abortion is a safe method of termination of pregnancy when performed as per guidelines with a success rate of 92-97 %. But self-administration of abortion pills is rampant throughout the country due to over the counter availability of these drugs and complications are not uncommon due to this practice. The society perceives unsupervised medical abortion as a very safe method of termination and women use this as a method of spacing.

AIM OF THE STUDY

The aim of this study was to study the implications of self-administration of abortion pills by pregnant women.

MATERIALS AND METHODS

Retrospective observational study done in Sri Manakula Vinayagar Medical College & Hospital between the period of July 2013 to June2014. Case sheets were analysed to obtain data regarding self-administration of abortion pills and complications secondary to its administration. The following data were collected. Age, marital status, parity, duration of pregnancy as perceived by the women, confirmation of pregnancy, duration between pill intake and visit to hospital, whether any intervention done elsewhere, any known medical or surgical complications, Hb level on admission, whether patient was in shock, USG findings, evidence of sepsis, blood transfusion, treatment given and duration of hospital stay. Descriptive analysis of the collected data was done.

RESULTS

Among the 128 cases of abortion in the study period, 40 (31.25%) patients had self-administered abortion pills. Among these 40 patients 27.5% had consumed abortion pills after the approved time period of 63 days of which 17.5% had consumed pills after 12 weeks of gestation. The most common presentation was excessive bleeding (77.5%) Severe anaemia was found in 12.5% of the patients and 5% of patients presented with shock. The outcome was as follows : 62.5% of the patients were found to have incomplete abortion, 22.5% had failed abortion and 7.5% of patients had incomplete abortion with sepsis. Surgical evacuation was performed in 67.5% of the patients whereas 12.5% of the patients required surgical evacuation with blood transfusion. Medical methods were used in 15% of the patients whereas 2.5% required transfusion along with medical methods.

CONCLUSION

Unsupervised medical abortion can lead to increased maternal morbidity and mortality. To curtail this harmful practice, strict legislations are required to monitor and also to restrict the sales of abortion pills over the counter and access to abortion pills for the public should be only through centers approved for MTP. Large scale prospective studies are required to assess the actual magnitude of this problem.

Safety of induced abortions at less than 12 weeks of pregnancy in Japan

OBJECTIVE

To assess the safety of various methods of induced abortion when used before 12 weeks of pregnancy in Japan.

METHODS

A retrospective study was undertaken of induced abortions conducted between January 1 and December 31, 2012. Questionnaires were sent to 4154 institutions that employed doctors who were licensed to conduct induced abortions. Information was obtained about the numbers of induced abortions performed before 12 weeks, methods, complications, and routine management.

RESULTS

Completed questionnaires from 2434 institutions showed that 100 851 induced abortions had been performed. Vacuum aspiration (VA) was used in 20 458 (20.3%) abortions, VA with sharp curettage in 47 148 (46.8%), dilatation and curettage (D&C) in 32 958 (32.7%), and medical abortion in 287 (0.3%). Overall, 358 complications were reported (355.0 per 100000 procedures). The rate of complications was significantly higher after D&C than after VA and after VA with sharp curettage (P<0.001 for both). However, incomplete abortion requiring repeat procedures was the only complication that was significantly associated with D&C (P<0.001).

CONCLUSION

D&C can be safely used for induced abortion before 12 weeks of pregnancy, but changing from D&C to VA could reduce incomplete abortions and improve the safety of induced abortions before 12 weeks of pregnancy in Japan.

Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India--study protocol and intervention adaptation of a randomised control trial

BACKGROUND

The World Health Organisation suggests that simplification of the medical abortion regime will contribute to an increased acceptability of medical abortion, among women as well as providers. It is expected that a home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic.

METHODS/DESIGN

This study protocol describes a study that is a randomised, controlled, non-superiority trial. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. The randomisation list will be generated using a computerized random number generator and opaque sealed envelopes with group allocation will be prepared. Randomization of the study participants will occur after the first clinical encounter with the doctor. Eligible women randomised to the home-based assessment group will use a low-sensitivity pregnancy test and a pictorial instruction sheet at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. The primary objective of the study this study protocol describes is to evaluate the efficacy of home-based assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet 10-14 days after an early medical abortion. Providers or research assistants will not be blinded during outcome assessment. To ensure feasibility of the self-assessment intervention an adaption phase took place at the selected study sites before study initiation. This resulted in an optimized, tailor-made intervention and in the development of the pictorial instruction sheet with a guide on how to use the low-sensitivity pregnancy test and the danger signs after a medical abortion.

DISCUSSION

In this paper, we will describe the study protocol for a randomised control trial investigating the efficacy of simplified follow-up in terms of home-based assessment, 10-14 days after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01827995. Registered 04 May 2013.

Do women with a repeat termination of pregnancy prefer a medical or a surgical regimen?

We compared the risk of a repeat termination and the method of termination in women with a prior medical or surgical termination, or both, in a cohort study of women with a pregnancy termination at gestational age ≤63 days in 1999-2001. Within 5 years, 24% (330/1379) had a repeat abortion, and repeat terminations were more frequent in the surgical [27% (159/588)] than the medical group [22% (171/791)] (p < 0.05). The method used at the repeat termination was medical in 49% (83/171) of women with an earlier medical termination, compared with 13% (21/159) (p < 0.01) in women with an earlier surgical termination. In 125 women who had experienced both procedures, 37% (46/125) of the next terminations were performed medically and 63% (79/125) surgically (p < 0.01). Women in our study with a repeat termination tended to choose the same method as used before, and more often a surgical termination.

Cell-free fetal DNA testing for fetal aneuploidy and beyond: clinical integration challenges in the US context

The recent release of new, non-invasive prenatal tests for fetal aneuploidy using cell-free fetal DNA (cffDNA) has been hailed as a revolution in prenatal testing and has triggered significant commercial interest in the field. Ongoing research portends the arrival of a wide range of cffDNA tests. However, it is not yet clear how these tests will be integrated into well-established prenatal testing strategies in the USA, as the timing of such testing and the degree to which new non-invasive tests will supplement or replace existing screening and diagnostic tools remain uncertain. We argue that there is an urgent need for policy-makers, regulators and professional societies to provide guidance on the most efficient and ethical manner for such tests to be introduced into clinical practice in the USA.

Attendance at post-abortal follow-up visits is low - can the risks of non-attendance be identified?

Post-abortal follow-up visits are recommended following induced abortion. To assess the rates of attendance and the factors affecting it, we performed a retrospective study of 500 women who had an induced abortion up to 20 weeks of gestation. Altogether, 285 (57%) women attended for the follow-up visit as scheduled. In univariable analysis a history of drug abuse (OR=0.22, 95%CI 0.06-0.81, p=0.02) was associated with non-attendance. Women who underwent medical abortion either at the hospital (OR=3.93, 95%CI 2.61-5.92, p<0.01) or partly at home (OR=3.30, 95%CI 1.86-5.84, p<0.01) and those with a history of human papilloma virus manifestation (OR=2.38, 95%CI 1.04-5.26, p=0.04) were more likely to attend the follow-up visit. The effects of medical abortion and a history of human papilloma virus manifestation persisted in multivariable analysis. We conclude that attendance at post-abortal follow-up visits is low, with only a few clinically significant risk factors predicting non-attendance.