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Legal abortion in Sweden Since 1975 ”free abortion” until 18 weeks
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tarix | 29.12.2016 | ölçüsü | 216 Kb. | | #3844 |
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Legal abortion in Sweden Since 1975 ”free abortion” until 18 weeks Thereafter only with permission from the National Board of Health and Welfare on special indications until 22 weeks About 30 000 abortions, 90 000 births/ year
The Swedish abortion act Has a limited influence on the number of abortions Has a profound influence on the conditions under which the abortion is performed Has a significant effect on women’s health A liberal abortion law is a prerequisite for the development of safe abortion methods
Mifepristone abortion in Sweden 1992: up to 63 days 1994: II-trimester abortion - 600 mg mifepristone followed by gemeprost 1mg/ 3h
- 2003: 600 mg mifepristone followed by a suitable prostaglandin analogue
II-trimester abortion 1996 to 1998 197 consecutive abortions in 192 women Regimen: - 600 mg mifepristone
- 24 to 48 h later gemeprost 1mg every 6 hours x 4
- If no abortion within 24 h, I mg gemeprost / 3 h
Curettage routinely performed up to 18 weeks, thereafter when needed Gemzell Danielsson K & Östlund 2000
Demography Median age: 30 (15 to 44) years Median pregnancy length: 17 (14 to 26) weeks Primigravidae: 42 (21.3) % Multigravidae: 155 (78.7) % (Nulliparous (n=45)) Indications: - Social (n=113) 57.4 %
- Chromosomal aberration (n=30) 15.2 %, Foetal malformation (n=34) 17.2%, Missed abortion (n=20) 10.2 %
Results Median numbers of gemeprost (Cervagem): 2 Induction-to-abortion interval: - Primigravidae: 9.0 (1.4-40.5) h vs.
- Multigravidae: 7.2 (0-152.5) h (ns)
- Nulliparous (n=45) 10.6 (2.8-30.6) h vs.
- Parous (n= 104) 6.0 (0-152.5) h (p<0.001)
Results 96.3 % aborted within 24 h (all women with missed abortion) Significant correlation between pregnancy length and abortion time Narcotic analgesia required by 93 % PCB (n=8) EDA (n=1) One woman required a blood transfusion
II-trimester abortion 200mg mifepristone and gemeprost Case series report 200mg mifepristone followed 36h later by 1 mg gemeprost/6h x4, /3h Median gestational length 16 weeks (12-24 w) Median induction-to-abortion interval 7.8h Surgical evacuation 11.5% Tang OS, Thong KJ, Baird DT, Contraception 2001
II-trimester abortion gemeprost vs.misoprostol orally 50 women 200 mg mifepristone followed by 400 g misoprostol p.o/ 3h or 1 mg gemeprost/ 6h Induction – abortion interval 8.7 vs. 10.8 h (ns) No difference in incidence of side effects Ho et al., 1996 Similar efficacy: El Refaey et al., 1993, Dickinson et al., 1998, Nuutila et al., 1997 Higher efficacy: Wong et al., 1996
II-trimester abortion misoprostol 3h vs. 6h intervals 148 women Misoprostol 400 g vaginally Repeated every 3h vs. 6h Induction-ab interval 15.2 vs.19.0 h (P< 0.01) Abortion within 48 h 90.5 vs. 75.7% (P< 0.02) Fever more common in the 3h group (P = 0.01). Wong et al., 2001
II - trimester abortion oral vs. vaginal misoprostol 142 women: 200 mg mifepristone + misoprostol 400 g oral vs. 200 g vaginal/ 3 h up to x 5 Complete abortion rate: 81.4% vs.75.4% (ns.) Diarrhoea 40 vs. 23.2 % (p= 0.03) Total dose 1734 vs. 812 g (p< 0.0001) Median induction-to-abortion interval: 10.4 vs. 10 h 82% preferred the oral route Ngai et al. 2000
II-trimester abortion 200 mg mifepristone followed 48h later by - Misoprostol 400 g vaginally every 3h vs.
- Misoprostol 600 g vaginally + 400 g po/ 3h
No significant difference between the groups El-Refaey & Templeton 1995
II-trimester abortion 1000 women, 13-21 weeks Mifepristone 200 mg, after 36-48 h followed by - vaginal misoprostol 800 g (4 tabl Cytotec) followed by
- 400 g po.(2 tabl Cytotec) every 3h to max 4 doses
97% aborted successfully median dose of misoprostol: 1200 g median induction-to-abortion interval: 6.5 h. 9.4% curettage, > 75 % day cases Ashok & Templeton 1999, 2004
II-trimester abortion sublingual misoprostol Significantly higher acceptance for sublingual administration 400 microg misoprostol/ 3h x 5 vaginal. vs. Sublingual Tang et al., 2004 Higher acceptance for sublingual but more pain, more opiates needed 600 microg sublingual vs. 800 microg vaginal followed by 400 microg /3h sublingual or vaginal Hamoda et al., 2005
Effect of the time interval between mifepristone and the prostaglandin No difference in induction to abortion time with mifepristone administered 24, 36 or 48 h prior to the prostaglandin Urquhart and Templeton 1990 Effect on uterine contractility maximal at 36 to 48h Bygdeman & Swahn 1985 Ripening effect of mifepristone on cervix, more pronounced at 36 to 48 h Rådestad et al 1988
Conclusion Mifepristone in II-trimester abortion Our data confirm the efficacy and safety of mifepristone and gemeprost for II-trimester abortion. Oral misoprostol has been shown to be as effective and safe as gemeprost Vaginal misoprostol is more effective but less accepted than the oral route The combined vaginal-oral regimen is as effective as repeated vaginal misoprostol
II-trimester abortion Mifepristone followed 24-48h later by Misoprostol 800 g (CytotecR 4 tabl ) vaginally followed by 400 g (CytotecR 2 tabl) orally every 3h Curettage only in case of incomplete abortion
Pain prophylaxis T Diclofenac 100 mg T Panocod.® together with the first dose of Cytotec Contraceptive councelling Screening and treatment/ prophylactic antibiotics for STI
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