Medical abortion - clinical aspects Gynmed Clinic Vienna, Austria Karolinska University Hospital...

Medical abortion - clinical aspects

Gynmed Clinic

Vienna, Austria

www.gynmed.atKarolinska University Hospital

Department of Women and Child Health

Stockholm/Sweden

Christian Fiala, MD, PhD

International Association of Abortion and Contraception Associates

www.fiapac.org

Conférence sur l’avortement par médicament-

16 Septembre 2014 - FQPN

www.mifegyne.infowww.misoprostol.org

Museum of Contraception and Abortion

Vienna, www.muvs.org

Medical abortion - clinical aspects, C. Fiala

2

Abortion is the most frequently

performed surgical procedure

in Obstetrics and Gynaecology,

regardless of whether it is illegal or legal.

The quality of care has therefore

a huge impact on the whole society.


3

• 1988: France (49 days LMP)

• 1991: UK (63)

• 1992: Sweden (63)

• 1999 January: Austria (49)

• 2000: most other European countries (49)

• 2000: US, Mifeprex® (49)

• 2007: Portugal; all countries up to 63 days

• 2010: Italy

• Now available in 44 countries

Marketing of mifepristone


4


5

Mifepristone/Mifegyne® /Mifeprex®

www.mifegyne.info


6

Mifepristone

• Steroid competitively blocking hormone receptors

• Affinity to progesterone receptor is 8 times higher than

progesterone

• Affinity to the cortisol receptor is 3 times higher than cortisol

• Fast oral absorption, peak after 1.5 hours

• Half life more than 18 hours

• 3 metabolites, providing 23-33% of the antiprogestagenic

effect in a 600mg dose


7

Mifepristone cont.

• Very safe (no death from the drug reported)

• Side effects minimal (nausea)

• Regimen 200-600 mg (1-3 tablets) followed by a

prostaglandin 36-48 hours later

• The interval is important for the effectiveness

• Rather expensive drug: 22€ (United States 85$) per tablet


8

Inhibits the regression of the corpus luteum

Gestational sac Progesterone Keeps the endometrium

and the gestational sac attached to the uterine wall

Relaxes the uterine muscle

Keeps the cervix closed

Mode of action of progesterone in the uterus

ß-hCG


9

Leads to the regression of the corpus luteum

Gestational sac

Blocks the receptors of progesterone

The endometrium and the gestational sac separates from the uterine wall

The uterine muscle becomes more sensitive to prostaglandin and contracts

The cervix opens

Mode of action of mifepristone

Decreases ß-hCG

Blocks progesterone receptors and thereby induces the clinical symptoms identical and indistinguishable to a miscarriage (corpus luteum insufficiency)


10

Bygdeman & Swahn 1985

Mifepristone, prostaglandins and uterine contractility

The interval is important for the effectiveness


11

www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html


12

• Voluntary medical abortion <63 days in

combination with a prostaglandin

(misoprostol/gemeprost)

• Priming of the cervix prior to surgical abortion

• Medical abortion for medical indications in the 2. +

3. Trimester

• Induction of labour in intrauterine foetal death

Mifepristone: approved indications in Europe


13

Website: - information (www.gynmed.org)

First contact /telephone: - Is pregnancy confirmed?- Has the patient been able to talk to someone close?- Has the decision for the abortion been taken?- Answer questions or refer to the website- Exclude contra indications- Make appointment

Day 1: - Ultrasound, hCG (gynaecological examination) - Blood group- Counselling: abortion only if the decision is clear otherwise give an appointment one week later- 1 or 3 tab mifepristone

Day 3: - <49 days LMP = 2 tab misoprostol (Cytotec®) orally 50-63 days LMP = 4 tab misoprostol vaginaly- Option for up to 3 hours in the institution (rarely used)- Make sure patient has sufficient analgesics- Start oral contraception the next day

Day 8 -14: - ultrasound and/or hCG

The procedure up to 63 days LMP


14

When does the abortion take place?

Phase of psychological confrontation -Phase of coming to a decision

Mifepristone

Prostaglandin

• Detachment of the gestational sac

• Bleeding may start• Expulsion may take place

• Bleeding becomes heavy• Expulsion takes place

• Beginning of a new cycle/fertility

The abortion/Point of no return

Expulsion ≠ Abortion


15

Medical abortion: impact of the interval

Mifepristone Misoprostol

36-48 hours

Reducing the interval needs a higher dose of prostaglandin > more side effects


16

1 2 3 4 5 6 7 8 9 10 11

5

10

15

12 13 14 15 16 17 18 19 20 21

20

22 23 24

in %

(hours after misoprostol)

Time to expulsion of the sac in 1720 women with successfull termination of pregnancy. The women took mifeprostone on day 1 and misoprostol 48 hours later. Uncertain means expulsion at some point during 24 hours following misoprostol. Unknown means expulsion at some point later than 24 after misoprostol.

Source: The New England Journal of Medicine, 1998; 338 (18): 1244

Befor

e m

iso

Mor

e th

an 2

4 h

late

run

know

n

unce

rtain

When does the expulsion take place?


17

D 1: CRL 10 mmhCG 83.439

D 8: E 8 mmhCG 312

The procedure


18

Day 1: hCG 32.000yolk sac visible

Day 8: E 12 mmhCG 837

Day 3: Gestational sac

The procedure


19

Day 7: hCG 7Day 3: Gestational sac

Day 1: Gestational sac5 mmhCG 862

The procedure


20

Day 1: ß-hCG 269 mIU/ml Day 9: ß-hCG 20

The procedure


21

D 28: hCG 100D 10: E 20 mm, hCG 16.841

D 17: OC exD 21: Withdrawl-bleeding

D 1: CRL 6 mmhCG 104.900

D 3: Start OC

The procedure


22

D 1: Gestational + yolk sachCG 13.300

D 3: Start OC

D 19: E 8 mmhCG 718

D 9: missed ABhCG 10.819

D 16: OC exD 18: Withdrawl-bleeding

The procedure


23hCG before and after an abortion

Top curve: women after vacuum aspiration for elective abortionMiddle curve: women with spontaneous abortions uterine aspirationLower curve: women with ectopic removed surgically

,

,

,

,

,

,

,

Montagnana et al., Clinica Chimica Acta, 2011


24

Mean 3,8% (0,1-44); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 25 patients, Fiala et al., 2003

0

5

10

15

20

0 2 4 6 8 10 12 14 16 18 20

%

days

Serum hCG at follow-up in % of the initial value

3 cs of successful abortion were at 27,32 and 44%,2 cs of missed abortion at 91 and 159%, 1 cs of continued pregnancy 7.900 %


25

Thickness of the uterine cavity at follow upAverage: 10mm (1-24mm) after successful medical abortion

Endometrium in ultrasound

0

5

10

15

20

25

30

0 2 4 6 8 10 12 14 16 18 20

Days

mm

Fiala et al. Eur J Obstet Gynecol, 2003

A new

training CD

and manual

Can be ordered at: [email protected]

New Museum wants old contraceptives

Wanted:

Objects (IUDs,

Cervical caps

etc.), Reports,

posters,

publications

Museum of Contraception and Abortion

www.muvs.org

Vienna

Reproductive Health a Gender Problem

What about

sharing rights

including the

right to

exercise them?

Carrying the burden of

reproduction...

Medical abortion - clinical aspects Gynmed Clinic Vienna, Austria Karolinska University Hospital...

Documents

Transcript of Medical abortion - clinical aspects Gynmed Clinic Vienna, Austria Karolinska University Hospital...