In The Name of In The Name of GodGod

Dr.F Behnamfar MDDr.F Behnamfar MD

Medical Means for First Medical Means for First Trimester AbortionTrimester Abortion

MifepristoneMifepristoneMifepristoneMifepristone(RU 486),progestrone (RU 486),progestrone analogue,antagonist with strong affinity analogue,antagonist with strong affinity for progestrone receptorfor progestrone receptorCombination with a low dose of Combination with a low dose of prostaglandinsprostaglandins very effective 96-99% very effective 96-99%MethotrexateMethotrexate also may be used with also may be used with prostaglandinsprostaglandins Mifepristone reverses progestrone effect Mifepristone reverses progestrone effect and prostaglandins directly stimulate and prostaglandins directly stimulate myometrial contractionmyometrial contraction

ACOG and FDA approved 600mg ACOG and FDA approved 600mg orally Mifepristone followed 2 days orally Mifepristone followed 2 days later by 400ug oral misoprostol for later by 400ug oral misoprostol for up to 49days pregnancyup to 49days pregnancy

other investigators:200mg other investigators:200mg Mifepristone,followed by 800ug Mifepristone,followed by 800ug vaginal misoprostol is highly vaginal misoprostol is highly effective up to 63 days gestationeffective up to 63 days gestation

Misoprostol TeratogenicityMisoprostol Teratogenicity malformations include cranial nerve defects (especially malformations include cranial nerve defects (especially pairs 6 and 7, characteristic of the Möbius syndrome) and pairs 6 and 7, characteristic of the Möbius syndrome) and various limb abnormalities. Malformations, including one various limb abnormalities. Malformations, including one case of Möbius syndrome, have been reported in France case of Möbius syndrome, have been reported in France after medically supervised use of misoprostol. after medically supervised use of misoprostol. In practice, when a patient wishes to continue a pregnancy In practice, when a patient wishes to continue a pregnancy after a failed attempt at drug-induced abortion, she needs after a failed attempt at drug-induced abortion, she needs to be informed of the risk to her unborn child. to be informed of the risk to her unborn child. Cranial nerve defects are rarely detectable by sonography, Cranial nerve defects are rarely detectable by sonography, however thorough.however thorough. In addition, misoprostol has a negative risk-benefit balance In addition, misoprostol has a negative risk-benefit balance in the prevention or treatment of gastro-duodenal ulcers in in the prevention or treatment of gastro-duodenal ulcers in young women. young women.

Cotraindications EP,IUD in place (must be Cotraindications EP,IUD in place (must be removed first),chronic adrenal failure...removed first),chronic adrenal failure...9-13 weeks,larger proportion will have 9-13 weeks,larger proportion will have heavy bleeding and need curettageheavy bleeding and need curettageMisoprostol aloneMisoprostol alone:800ug and repeat in :800ug and repeat in 24 hours if expultion not occured,up to 24 hours if expultion not occured,up to 91% complete abortion up to 56 days 91% complete abortion up to 56 days gestationgestationIf expultion not happened,1-2 weeks later If expultion not happened,1-2 weeks later suction curettagesuction curettage

soaking more than 2 pads per hour more soaking more than 2 pads per hour more than 2 hours,contact with caregiverthan 2 hours,contact with caregiver

Complications:Heavy or prolonged Complications:Heavy or prolonged bleeding ,up to 8% some bleeding up to 30 bleeding ,up to 8% some bleeding up to 30 daysdays

need for surgical curettage 2% <7weeks need for surgical curettage 2% <7weeks and 5%>8weeksand 5%>8weeks

1 in 100,000 fatality(sepsis,MI,EP,...)1 in 100,000 fatality(sepsis,MI,EP,...)

Unnecessary surgical intervention in Unnecessary surgical intervention in women undergoing medical abortion can women undergoing medical abortion can be avoided if sonography results are be avoided if sonography results are interpreted appropriately.interpreted appropriately.Specifically if no gestational sac is Specifically if no gestational sac is present in the abscence of heavy present in the abscence of heavy bleeding intervention in most women bleeding intervention in most women is Unnecessaryis Unnecessary,,This is true even when as is common the This is true even when as is common the uterus contains ultrasonographically uterus contains ultrasonographically evident debrisevident debris

Verifying the effectiveness of medical Verifying the effectiveness of medical abortion;abortion;

ultrasound versus hCG testingultrasound versus hCG testing

Christian Fialaa,b, Peter Christian Fialaa,b, Peter Safara, Marc Bygdemanb, Safara, Marc Bygdemanb,

Kristina Gemzell-DanielssonKristina Gemzell-Danielsson

Material and methodsMaterial and methods

Two-hundred and seventeen women with an Two-hundred and seventeen women with an unwanted pregnancy up to 49 days of unwanted pregnancy up to 49 days of amenorrhoea, requesting medicalamenorrhoea, requesting medical

abortion, were treated . The treatment was abortion, were treated . The treatment was performed on an outpatient basis at in Austria.performed on an outpatient basis at in Austria.

A vaginal ultrasound was performed to confirm A vaginal ultrasound was performed to confirm pregnancy in all women.pregnancy in all women.A crown-rump length (CRL) of 10 mm was used as A crown-rump length (CRL) of 10 mm was used as upper limit for treatment, consistent with 49 days upper limit for treatment, consistent with 49 days amenorrheaamenorrheaserum hCG levels were determined inserum hCG levels were determined in

all women.all women.

Material and methodsMaterial and methods

A second dose of 400 mg A second dose of 400 mg misoprostol orally after 3 h was misoprostol orally after 3 h was

given, according to routine, if given, according to routine, if bleeding had not started at that time bleeding had not started at that time or if bleeding was less than on the or if bleeding was less than on the first day of menstruationfirst day of menstruation

Material and methodsMaterial and methodsWomen who wanted combined oral contraceptives (OC)Women who wanted combined oral contraceptives (OC)were advised to start on day 3 (day 1 being the day ofwere advised to start on day 3 (day 1 being the day ofmifepristone treatment).mifepristone treatment). If there was suspected retention orIf there was suspected retention or

heavy bleeding at follow-up, women on OC were asked toheavy bleeding at follow-up, women on OC were asked to stop taking the pill after the fourteenth tablet.stop taking the pill after the fourteenth tablet.

The hCG levels at follow-up are given as the percentage ofThe hCG levels at follow-up are given as the percentage of the value before the treatment the value before the treatment

Measurements of endometrial thickness are given in mmMeasurements of endometrial thickness are given in mm

ResultsResults

217 217 women treated, women treated, 213213 aborted aborted without surgical interventionwithout surgical intervention

overall success rate of overall success rate of 98.2%.98.2%.

Vacuum aspiration was performed in Vacuum aspiration was performed in four womenfour women due to due to continuing continuing pregnancypregnancy (two women) or (two women) or heavy heavy bleedingbleeding (two women). (two women).

ResultsResults

Treatment was successful without Treatment was successful without the need for surgical intervention in the need for surgical intervention in 98.2% of cases.98.2% of cases.

A total of four vacuum aspirations A total of four vacuum aspirations had to be performed; two for had to be performed; two for continuing pregnancy and two for continuing pregnancy and two for haemorrhage.haemorrhage.

ResultsResultsVerification of successful abortion by ultrasound wasVerification of successful abortion by ultrasound was

possible only for the cases where the initial ultrasoundpossible only for the cases where the initial ultrasound examination had shown the presence of an intrauterineexamination had shown the presence of an intrauterine pregnancy (yolk sac or CRL). pregnancy (yolk sac or CRL). This was the case in 167 women (77%). Endometrium at This was the case in 167 women (77%). Endometrium at

follow-up measured 10 mmfollow-up measured 10 mm(mean, S.D. 4) in cases of successful abortion, ranging (mean, S.D. 4) in cases of successful abortion, ranging from1 to 24mm (Fig. 8).from1 to 24mm (Fig. 8). The content of the uterine cavity was inhomogeneous in The content of the uterine cavity was inhomogeneous in some cases, making interpretation difficultsome cases, making interpretation difficult

(see Figs. 3 and 5). (see Figs. 3 and 5). Complete abortion could not be verified at first follow-up Complete abortion could not be verified at first follow-up (performed on days 7–12) by ultrasound alone in 17 of (performed on days 7–12) by ultrasound alone in 17 of these cases (10.2%) due to the inhomogeneous picture. A these cases (10.2%) due to the inhomogeneous picture. A further follow-up was scheduled in these casesfurther follow-up was scheduled in these cases

DiscussionDiscussionThere is no general agreement on how to There is no general agreement on how to verify the outcome of medical abortion. verify the outcome of medical abortion.

Some centres use ultrasound before Some centres use ultrasound before

administration of mifepristone and at administration of mifepristone and at follow-up,follow-up,

others rely on serum hCG levels or use a others rely on serum hCG levels or use a less sensitive urine pregnancy test (500 less sensitive urine pregnancy test (500 mU/ml) at follow-up.mU/ml) at follow-up.

Whether ultrasound examination or serum Whether ultrasound examination or serum hCG measurement is more suitable hCG measurement is more suitable depends on several factorsdepends on several factors

UltrasoundUltrasound

Ultrasound is not reliable in very early Ultrasound is not reliable in very early pregnancy before the yolk sac is visible. pregnancy before the yolk sac is visible.

It could be useful to exclude a persisting It could be useful to exclude a persisting extra uterine pregnancy not in all casesextra uterine pregnancy not in all cases

gives an immediate result in most cases gives an immediate result in most cases and is inexpensive where available. and is inexpensive where available.

The use of ultrasound to determine the outcome ofThe use of ultrasound to determine the outcome ofmedical abortion and possible need for surgical interventionmedical abortion and possible need for surgical interventionclearly requires knowledge of the ultrasound finding clearly requires knowledge of the ultrasound finding following medical abortion. following medical abortion. In the present study follow-up was performed according to In the present study follow-up was performed according to the wish of the patient between days 6 and 18.the wish of the patient between days 6 and 18.Ultrasound at follow-up was sometimes difficult to interpret. Ultrasound at follow-up was sometimes difficult to interpret. The endometrium was often thick and sometimes The endometrium was often thick and sometimes inhomogeneous resembling an incomplete abortion (Figs. 3inhomogeneous resembling an incomplete abortion (Figs. 3

and 5).and 5).

It might be difficult to abstain from surgical interventionIt might be difficult to abstain from surgical intervention in such cases. However, no negative consequencesin such cases. However, no negative consequences were observed whilst waiting for the next menstrual were observed whilst waiting for the next menstrual

bleeding to occur. bleeding to occur. Thus, the need for curettage in cases with missed Thus, the need for curettage in cases with missed abortion or a thick endometrium at follow-up couldabortion or a thick endometrium at follow-up could

be reduced by refraining from immediate surgical be reduced by refraining from immediate surgical intervention.intervention.An increasing hCG level at follow-up on the other hand,An increasing hCG level at follow-up on the other hand,

indicates a need for surgical intervention.indicates a need for surgical intervention.

Successful expulsions were consistent with aSuccessful expulsions were consistent with a marked decline in hCG value marked decline in hCG value 20% of the initial 20% of the initial

value as cut-off at follow-up value as cut-off at follow-up gave a high gave a high sensitivity. sensitivity. It allowed correct diagnosis in It allowed correct diagnosis in 98.5%98.5% of the of the patients withpatients with

successful expulsion.successful expulsion.Only one patientOnly one patient with missed abortion at follow- with missed abortion at follow-up discovered by ultrasound had a marked up discovered by ultrasound had a marked decrease of hCG.decrease of hCG.She She expelledexpelled the gestational sac with time the gestational sac with time without complications.without complications.

There is probably a high frequencyThere is probably a high frequency of spontaneous expulsion until or during of spontaneous expulsion until or during

the next menstruation in such cases.the next menstruation in such cases.

Measuring hCG can easily be done in most Measuring hCG can easily be done in most places and might be more convenient for places and might be more convenient for the woman than an ultrasound the woman than an ultrasound examination. examination.

Furthermore there is no need to have it Furthermore there is no need to have it performed in the same institution that performed in the same institution that provided the medical abortion.provided the medical abortion.

Even following medical abortion an Even following medical abortion an ovulation could occur before the first ovulation could occur before the first menstruation. It is therefore of importance menstruation. It is therefore of importance to provide the woman with an effective to provide the woman with an effective contraceptive method immediately after contraceptive method immediately after treatment.treatment. It has previously been demonstrated that It has previously been demonstrated that OC can be given immediately after OC can be given immediately after treatmenttreatment

without influencing outcome or bleedingwithout influencing outcome or bleeding

conclusionconclusionhCG levels are a safe and effective way to verify complete hCG levels are a safe and effective way to verify complete abortionabortion

Plasma hCG level at follow-up compared to the initial value gave Plasma hCG level at follow-up compared to the initial value gave a reliable result in 98.5% of successful abortions, when using a reliable result in 98.5% of successful abortions, when using 20% of the initial value as cut-off20% of the initial value as cut-off

In contrast the reliability of ultrasound examination in In contrast the reliability of ultrasound examination in diagnosing successful expulsion was 89.8% diagnosing successful expulsion was 89.8%

Ultrasound at follow-up showed a thick endometriumUltrasound at follow-up showed a thick endometrium in many cases, sometimes with an inhomogeneous structurein many cases, sometimes with an inhomogeneous structure even when the abortion was complete.even when the abortion was complete.

The ultrasound findings might be difficult to interpret and may The ultrasound findings might be difficult to interpret and may lead tolead to

unnecessary surgical interventions.unnecessary surgical interventions.

ConclusionConclusionConservative management i.e. waiting Conservative management i.e. waiting

for the menstruation or an for the menstruation or an withdrawal Surgical intervention was withdrawal Surgical intervention was performedperformed only in cases of continuous only in cases of continuous evolving pregnancy or heavy evolving pregnancy or heavy bleeding. Thus if ultrasound is used bleeding. Thus if ultrasound is used alone to verify outcome of treatment, alone to verify outcome of treatment, caution should be made to avoid caution should be made to avoid unnecessary interventions.unnecessary interventions.