Poster Sessions

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    Abortion among minors. A French perspective

    A. Durrieux, Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)

    University Hospital of Marseille, France

    Objective.The rate of abortions among teenagers is steadily increasing in France. We aimed to analyse the medical and social characteristics of minor patients requesting an abortion in order to improve preventive actions.

    Patients and Methods.A retrospective analysis of 184 minor patients requesting an abortion in our department between 2005 and 2007. Minors represented 16% of the population requesting an interruption of pregnancy in our center.

    Results.Mean age was 16.2 years (rang 14-17), 10% had already a child and 5% had repeat abortions during this period. Mean gestational age at abortion was 63 days. One third had a medical abortion and 70% surgical aspiration with general anaesthesia. The adolescents were accompanied during the procedure by their companion in 26% of cases. In 35% of cases, teenagers came with no family members and were accompanied by a social counsellor. Teenagers had been referred to the abortion clinic through a family physician in 47% of cases, through the Family Planning associations in 11% and had come directly to our center in 43% of cases. Concerning contraception, 51% had declared using a condom, 25% used no method and 16% used an oral contraceptive. None of our patients used a dual contraception combining a condom and hormonal contraceptives. Only 5% had used an emergency hormonal contraception. Post abortum contraception prescriptions were : 75% oral contraception, 6% long term reversible contraceptions (IUD or implant) and 4% contraceptive patch or vaginal ring. 15% of the teenagers refused a contraception prescription. At the post abortum visit 46% did not show up for further explanations on their contraceptive method.

    Conclusion.Minors accessed at our abortion center at advanced gestational ages often unaccompanied by their companions. Condoms were frequently used by minors but seem insufficient in preventing unwanted pregnancies. Use of emergency contraception was exceptional. Post abortion contraception was mainly tailored on oral contraceptives and follow-up visit attendance for further contraceptive counselling was low. Other contraceptive options such as IUD or implants were underutilized in post abortum and need to be evaluated.

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    Abortion in Portuguese Health Primary Care

    Cunha José Manuel, C. Ribeiro, R. Aguiar, C. Lomba, A. Mateus, F. Fonseca, A. Simões, L. Campos, C. Silva (Portugal)

    Administração Regional de Saúde do Norte, Porto, Portugal

    Introduction. The fulfilment of the new Portuguese legislation on the interruption of pregnancy by woman’s free option made it necessary the creation of a public care rendering net that involved Hospitals and Health Care Centres. The Centres were attributed the generic function of women reference to the hospitals where if it carried the medical and surgical interruption takes place. The availability of some professionals allowed to organise in three Centres a consultation of medical interruption of the pregnancy by option of the woman until 10 weeks. There is a protocol of joint with the nearby hospitals that answer to the complications and the situations of medical abortion failure.

    Objectives. Description of medical abortion practice by the woman’s option, done by general practitioners in family health services.

    Method. The women appeal to the consultation voluntarily or referred by other institutions. The process consists of previous consultation where dating of pregnancy is confirmed by ultrasonographic scan. The law imposes three days of reflection, followed by a 2nd consultation where the therapeutic with Mifepristone starts; 36 - 48 hours later the process is completed with Misoprostol. Pregnancy termination is confirmed 2- 3 weeks later by ultrasonographic scan.

    Results. Since October 2007 until May 2008, 118 abortions had been carried through. There were 4 medical abortion failures which required surgical termination and 1 case of hemorrhagic complication that needed curettage.

    The study of the evaluation of the women’s satisfaction confirms a high level of satisfaction.

    Conclusions. The results of abortions by the woman’s option done in these family Health Services are similar to the published ones in literature.

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    Abortion request during adolescence and management of confidentiality. A challenging issue

    Danielle Wyss, J.-C. Suris, S.-C. Renteria (Switzerland)

    Mutidisciplinary Unity for Adolescent Health (UMSA) and Family Planning Clinic, Psycho-social Unit, Department for Obstetrics and Gynecology, Centre Hospitalier Universitaire CHUV, 1012 Lausanne, Switzerland

    Introduction. The right for adolescents to access to confidential health services, including requests for abortion,  is broadly recognized by the United Nations Convention on the Rights of the Child. It is widely approved and applied by reproductive health professionals, provided that the capacity to discern of the young person is deemed sufficient. This study focuses on the challenges due to the request for confidentiality towards the holders of parental authority in this context, and on the consequences of the different ways of taking care of it.

    Objectives.To determine whether the situation of minor consultants asking for confidentiality differs from the others and to assess the risks of assuming confidentiality regarding the continuity of follow-up, the contraceptive compliance and the risk of a new unplanned pregnancy.

    Material and methods.Retrospective study of 174 female aged less than 18 years who consulted a specialized unit for adolescents or a family planning center with an abortion request between 2003 and 2006. The sample was divided into two groups depending on whether confidentiality was requested or not. For the groups «without» (N=104) and « with »(N=70) a request for confidentiality, we compared the socio-demographic, relational and medical factors related to the decision and the medical and psycho-social follow-up post abortion.

    Results.Adolescents «with» a request for confidentiality are more likely than those « without» to be of foreign nationality, especially from Africa or South America (59.4% versus 37.1%). They are more likely to be studying (80% versus 62.1%) and they more often  live with both parents (47.1% versus 33.7%); they have more frequently a partner of about the same age (72.1% versus 57.3%) and are less ambivalent before the decision to abort (94.3% versus 83.7%). There was no difference between the two groups regarding the relationship with the parents, the age of the pregnancy, the experience with hormonal contraceptives before the pregnancy, the follow-up post abortion or the occurrence of a new unexpected pregnancy in the following year.

    Conclusions. It seems to be more difficult for adolescents living in “intact” families or integrated in an educational or professional track to talk to their parents about their unexpected pregnancy. If the request for confidentiality is made in the setting of a specialized unit for adolescents with an explicit therapeutic agreement and closely scheduled follow-ups, it does not appear to have negative consequences on the compliance with follow-up or the risk of a subsequent unplanned pregnancy. In these circumstances, the assumption that recommends the ability to guarantee the care of adolescents in sexual and reproductive health matters in respect of confidentiality is compatible with the responsibility of caregivers vis-à-vis these underage patients, on the short and medium-term.

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    Abortions at home in Gothenburg

    Monika Axelsson, Liselotte Holmqvist (Sweden)

    Sahlgrenska University Hospital, Gothenburg, Sweden

    Background. This poster describes patient satisfaction in women choosing to perform their abortions at home. Since 1975, the number of abortions in Sweden has varied between 30 000 and 38 000 annually; some 2 500 per year are performed at the Abortion Department at Sahlgrenska University Hospital/Östra. New abortion methods have been introduced since the Swedish Abortion Act was passed in 1975. Medical abortion in early pregnancy is undergoing constant development and more women currently choose it over the surgical method. An increasing number of women, currently 20-25%,  want the possibility to conclude their abortions at home. A quality review was performed in order to develop and improve the method.

    Method. A questionnaire was filled out by 60 women at their follow-up appointment with at midwife four weeks after the ”home abortion”.

    Results. The average age was 34.3. Seventy-one percent had given birth, of whom 64.5% had given birth vaginally. Previous abortions were reported by 34.9%; 90.7 appreciated being scheduled for all abortion-related appointments at the first visit; 69.8 found the interval from the positive pregnancy test to the completed abortion appropriate, while the rest thought that the interval was too long.

    Conclusion. Women choosing to conclude their abortions at home report that the method works well for them and they are satisfied with their choice. Questionnaire results also show that information and access to care are important.

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    And after the Referendum?

    Matilde Salta, Mara Carvalho, Vasco Freire (Portugal)

    Médicos pela Escolha – Doctors for Choice in Portugal

    In Portugal, in the past 11th of February of 2007, a certainty became evident: that an important majority of the Portuguese society identified clandestine, illegal abortion like a Public Health problem, legitimizing the right to safe abortion by the woman’s request, as part of a plenum exercise of Sexual and Reproductive Rights, Universal Human Rights.

    The new abortion law respects a person’s autonomy as an ethical principle, ensuring a free and universal access to safe abortion, a procedure performed by or with the help of qualified health care professionals. This new legal setting allows us to have concrete numbers about abortion, so that, by evaluating the numbers, we identify vulnerable groups, try to know its causes and consequences and provide the necessary support and interpret possible variations over the time, with longitudinal studies. 

    The DGS – Direcção Geral da Saúde (General Health Bureau in Portugal) predicted for the year after the implementation of the law 20000 abortions. In a study made by APF – Associação para o Planeamento da Família (the Family Planning Association) the number predicted was around 17000 abortions a year. Still awaiting annual results, in the first 5 months of law application, 6000 abortions were registered, and after eleven months the number was 12000, numbers a bit low when compared with the initial predictions. Why this happened and what can happen next are important discussions in terms of evaluating the effectiveness of the system and constantly, the level of information of the people.

    Regardless of if the next annual numbers corroborate or not the tendency of the first eleven months, it is necessary to stretch the experience in other European countries where abortion is legal for several years: clandestine abortion tends to become almost absent with the legalization, but it’s a process with several years of evolution; the diminishing of the abortion rate and the raising of the women/couples doing effective contraception (to avoid unwanted pregnancies) is fundamentally related with the implementation of an effective Sexual Education and Health Care policies that improve the access to Family Planning and modern Contraception. In Portugal, one year after the implementation of the law, it’s still urgent to:

    • Inform all the women that they have a new right of choice, an informed choice, with access to non-directive and specialized, support and care.
    • Implement consistent Sexual Education policies, with obvious medium/long term benefits in preventing other Public Health Problems, like all the STDs.

    Improve the Family Planning and abortion network. For example: creating conditions so that medical abortion is accessible to women in all the public primary care health services; equip the national health system with more human and technical means that answer not only to the needs of the women that want to interrupt their pregnancies, but also to the ones related to requests for definitive chirurgical contraceptive methods; all the hormonal contraceptives should be freely distributed.

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    Clínica El Sur, a Socially Responsible Company

    C. Rubio, E. Rodríguez, M. Gómez, J. Serrano, P. Hidalgo (Spain)

    Clínica El Sur, Spain

    The society is an integrated and interconnected body in which all parts have their role, their responsibility and are indispensable to build the necessary solutions to the challenges of its time.

    The company, as key agent of the current society, has a strong influence on it since it is part of the richness generation process and distribution causing a too often negative impact on aspects as: environment, human rights, development… In turn, the presence of the society at the companies also rises and then appears a new COMPANY-SOCIETY equation in which companies of XXI century, by breaking the old triangular scheme (workers/customers/shareholders), have become complex structures which must include all its groups of interest (stakeholders): Shareholders, Governments, NGO´s, International Organizations, Mass media, Trade Unions, Employees, Consumers, Citizenship, Local administrations…

    In this context, a new corporate culture appears: the Corporate Social Responsibility (C.S.R.).

    As a result of the European Summit Conference hold in Lisbon in 2000, the “European Green Book on C.S.R.” is published. In this book it is stated “…not only benefits are important, but how you get them”. “Being socially responsible does not mean only meeting fully the legal duties, but also going further by making a higher investment in human capital, environment and relations with the interlocutors”.

    Clinica El Sur (El Sur Clinic) and its staff feel fully identified with this new way of thinking and behaviour and then, since one year ago, we work in the implementation of a C.S.R. management system which we present you in our poster. This system mainly pursues:

    • Active listening and dialogue with the stakeholders.

    Promotion with the example of a management system more egalitarian, fair, caring and equitable which includes the social and environmental concerns.

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    Coresponsibility and equity fairness in abortion services oriented to vulnerable groups of women

    Elvira Méndez (Spain)

    Asociación Salud y Familia, Via Laietana, 40, 3º 2ª B, 08003 Barcelona, Spain

    The Asociación Salud y Familia, a non-profit NGO, has been the leader of a programme aimed at providing abortion services to vulnerable groups of women for the past fifteen years. This programme, called “Safe Motherhood Assistance”, has served more than 41,000 women, 4,693 women during 2007 alone (20% of all abortions in Catalonia). The programme is based on a tripartite scheme, involving collaborations between private abortion clinics, public healthcare services and the association. Among its greatest achievements are: accessibility to a co-payment system for abortions; free post-abortion contraception services (IUD insertion); and the capability to adapt to new social and individual vulnerable situations.

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    Detection of violence against women via screening at the occasion of request for pregnancy termination

    C.D. Liengme, F. Coquillat, M. Demierre, P. Hohlfeld, S.-C. Renteria (Switzerland)

    Family Planning Center, Psycho-social Unit, Department for Obstetrics and Gynecology of University Hospital of Lausanne (CHUV), Switzerland

    Introduction. In Switzerland one out of five women is subject to interpersonal violence at least once in her life and 24 women die from such violence every year. Several surveys show that the problem of violence is generally underestimated as only about one case out of twenty is detected. Again surveys show that women would like to be questioned about violence when consulting a doctor.

    In the summer of 2007 a new chapter concerning present and past violence was introduced into medical files. Doctors or midwives complete these files, while they are taking the medical history of women requesting a termination of pregnancy. The Family Planning Centre carried out a research to see what changes resulted from the introduction of this chapter and also to see which effects, if any, taking care of women after detection had on the spiral of violence.

    Material and Methodology. This quantitative retrospective survey covered 2 four-month periods, the first extending from January to April 2007 and the second from January to April 2008. The data that were analyzed were collected from the medical files kept by doctors and midwives on women requesting a termination of pregnancy or re-considering the idea, and from the files of the Family Planning Centre advisors, who interview all the women concerned according to the protocol for termination of pregnancy at the Gynecology and Obstetric Department of the Lausanne University Hospital (CHUV)

    Results. During these two periods a total of 451 women were taken care of. 82 of them admitted being or having been victims of violence, 21 out of 201 (10%) during the first period, and 61 out of 250 (25%) during the second period.  These numbers show an increase of 150% in detected cases. A detailed analysis of the data collected concerning these 82 women will be presented: the type of violence, requests for help, legal and medical assistance provided.

    Conclusion. Our study confirms the importance, for health professionals who take care of these women, of paying systematic attention to the fact that they may be or have been victims of violence. Women who are victims of violence are thus able to talk about it, to be listened to, informed and helped according to their specific needs. In the case of requests for a termination of pregnancy after a rape, the fact that the victim claims having been raped, allows the biological proof of sexual contact to be registered and kept on file.

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    Emergency contraceptive use among 5677 abortion seeking women in Shanghai

    Chun-Xia Meng (China), Kristina Gemzell  (Sweden), Olof Stephansson (Sweden), Li-Nan Cheng (China)

    Woman and Child Health Department, Division of Gynecology and Obstetrics, Karolinska University Hospital / Karolinska Institute, Stockholm, Sweden, and International Peace Maternity and Child Health Hospital / School of Medicine, Shanghai Jiao Tong University, Shanghai, China

    Introduction.Unintended pregnancy is a global reproductive health problem. Emergency contraceptive pill (ECP) provides women with a safe and convenient means of preventing pregnancy following unprotected sexual intercourse. Levonorgestrel only or low dose of mifepristone has recently emerged as the most effective ECP with a low rate of side effect and both are over-the-counter available in China. Discrepancy between the wide-spread use of ECP and large proportion of abortions indicates that how women use ECP may be a strong determinant of its final effect. Lack of understanding of fertility and concerns about its side effects may contribute to the underutilization of emergency contraceptive pill. This study aims to study the use of ECP among women seeking abortions and different demographic factors involved, as well as to explore the possible concerns for not using ECP.

    Materials & Methods.A six-month cross-sectional survey was done by using face-to-face questionnaire interview among abortion seeking women in Shanghai, China. Respondents were asked about their experience in using ECP and from which source did they access ECP. The differences between ECP users and non-users regarding various demographic characteristics and their cited reasons for seeking abortion were analysed by using chi-square test. Respondents who had previously used ECP, but did not use it to try to prevent this current pregnancy were asked to state their reasons for non-use.

    Results. A total of 5677 abortion seeking women aged between 15 to 48 years were recruited, among whom 48.8% are ECP users and 55.3% had experienced at least one abortion. Young, married, well-educated, nulliparous women were more likely to use ECP. Unawareness of the risk of pregnancy was the main reason for not using any contraceptive methods among abortion applicants who had never used ECP. Among 2773 women who had experience in emergency contraceptive use, 72.7% did not use it to try to prevent this current pregnancy, for which the major reason was not realizing the need to use ECP. Pharmacy was the preferable source to access ECP for the sake of convenience and privacy protection.

    Conclusions. The large proportion of repeated abortions necessitates the sexual education to avoid unintended pregnancy. We need to find ways to raise people’s awareness of the high risk of pregnancy associated with non-use, incorrect or inconsistent use of contraception. Women of reproductive age should be well-informed of knowledge about and access to emergency contraceptive pill, which provides a “second-chance” to prevent an unwanted pregnancy. All reproductive health-care providers including pharmacists should be trained for family planning counselling with a special emphasis on emergency contraception.

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    High failure rates of medical termination of pregnancy after the introduction to a large teaching hospital

    D. Vitner, R. Machtinger, M. Baum, M. Goldenberg, E. Schiff, D.S. Seidman (Israel)

    Department of Ob. & Gyn., Sheba Medical Center, Tel-Hashomer, affiliated to Sackler School of Med., Tel-Aviv University, Tel-Aviv, Israel

    Background. The outcome of all 349 women who chose to undergo medical termination of pregnancy in a tertiary medical center during 2000-2003 was studied.

    Methods. The success rates in two time periods (2000-2001 and 2002-2003) were compared in order to assess the effectiveness of medical abortion with mifepristone and misoprostol after its introduction to a large academic tertiary medical center.

    Results. The success rates were overall disappointing and significantly declined over time (87.0% vs. 79.3%, p=0.029).

    Conclusions. The continuing relatively high failure rate is probably due to the difficulty in defining clear sonographic criteria for treatment failure, and the complexity of a follow-up program implemented at a large teaching hospital by a broad staff with widely varying experience and knowledge of the new procedure.

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    Home abortion. Experiences of women and their partners

    Marianne Wulff, Anneli Kero, Katarina Bergström, Ann Lalos (Sweden)

    Department of Clinical sciences, obstetrics and gynecology, Umeå University, 901 87 Umeå, Sweden

    Background.At Umeå university hospital in Sweden 34% (2007) of all medical abortions were homeabortions. A team of counsellor, nurse as well as a gynaecologist will take care of the abortion seeking woman/couple and offer the opportunity to choose between medical abortion (when early in pregnancy) or surgical abortion. If medical abortion is preferred by the woman, she can do it at home if she wants to and if she fulfils certain criteria (not being too young or immature, not suffering from heavy dysmenorrhoea, not being alone at the time for abortion and not living too far from the hospital). The aim of the study was to gain deeper knowledge about experiences, opinions and reactions among women who choose homeabortions and among their partners present when the abortion took place.

    Subjects and methods.Telephone interview by the counsellor in the abortion team using a semi-structured questionnaire with 41 questions, most of these being open-ended. Interviewed were: 100 women and 25 partners. Most women were interviewed one week after the abortion. Quantitative data were analysed using SPSS -programme and the open-ended qualitative data were analyzed using content analysis.

    Results.The mean age was 32 years and the majority was married or cohabiting. Pregnant for the first time were 18 women and almost half (45) had had an abortion earlier. The women wanted to do the abortion at home because of a wish of: “control and integrity”, “not having  to respond to other people”, “becoming more peaceful when in your own environment”, “not making the process so dramatic”. The overall experience of the homeabortion was that it was “as expected or easier than expected”. The day of mifepristone however, was for many women filled of strong emotions, often paradoxical feelings, and a waiting to the day of prostaglandin and the expulsion of the fetus. That day were dominated by physical symptoms such as nausea, pain and bleeding. Women expressed with emphasis that they would recommend homeabortion to other women. Regarding the partners present during the day of the abortion, they were present because: “it felt natural” or “because she asked for it . Theirreflexions included feelings of “contribution”, “involvement” and “I had a greater role than I would have had at the hospital”.

    Conclusions.When having the opportunity to choose homeabortions, the vast majority of women 26-45 years who chose this type of care felt healthier, freer and more empowered having done the abortion at home. They experienced the abortion “as expected or easier than expected” and would strongly recommend it to other women. Their partners were satisfied too, mostly due to the opportunity to be involved to a greater extent than if being at the hospital.

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    Local Anaesthesia compared to General Anaesthesia

    Giovanna Scassellati (Italy)

    Azienda Ospedaliera S.Camillo, Rome, Italy

    We beavered to abait the general anaesthesia in the IVG operation.

    We have dispensed to women 250 questionary on the 2008, with psycologic and pain ratings and we have allocated the questionary at first of abortion and after abortion, so we have perceived that women prefer local anaesthesia and they are supported in the rate.

    On patients undergones in local anaesthesia operation, 30 minutes before the operation to be effected pre-medication.

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    Management of first trimester termination of pregnancy as an out-patient in Paisley – is it feasible, is it acceptable and is it worthwhile?

    Rosemary Cochrane (Great Britain)

    Crawford JH – Department of Obstetrics and Gynaecology, Royal Alexandra Hospital, Paisley, UK

    Introduction. The earlier in pregnancy an abortion is performed, the lower the rate of complication. The RCOG recommends that ideally all women requesting pregnancy termination should undergo the procedure within 7 days of the decision to proceed being agreed. As a minimum standard, all women should undergo the procedure within 2 weeks of agreement, with no woman waiting longer than 3 weeks between initial referral to time of procedure. Medical termination of 1st trimester pregnancy (MTOP) has been shown to be effective, safe and acceptable if carried out on an entirely out-patient basis. It has therefore been suggested that a service to allow “home” MTOP might be beneficial, however patients would have to fulfil several strict criteria.

    Method. To ascertain eligibility every patient attending the pregnancy termination assessment clinic was asked to complete a confidential questionnaire.

    Results. 65 women completed the questionnaire (71% of those who attended). Of the 33 (51%) women opting for MTOP only 7 were eligible. 32 (49%) opted for a surgical TOP; of these, 12 would have considered a home MTOP if available but only 4 women were eligible. Reasons for ineligibility are discussed.

    Conclusion. Overall 11 (16.9%) patients requesting TOP would have fitted the criteria if the service was available. On the basis of this small sample we were unable to demonstrate a significant need for a home MTOP service.

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    Medical abortion efficacy at 8 and 9 weeks

    Ana Rita Pinto, Inês Vaz, Alfredo Gouveia, Rute Magarinho, Paulo Sarmento (Portugal)

    Centro Hospitalar do Porto – Unidade Maternidade Júlio Dinis, Portugal

    Objective. Abortion by request is allowed in Portugal if carried out within the first 10 weeks since April 17 2007. It implicates a minimum of a 3-day introspection period and the availability of psychological counselling, as well as support from social services technicians and women are given the choice between medical and surgical procedures. This law is a response to illegal abortions and to the need of eradicating its practice, as they are often carried out without the required conditions and with high risks to the sexual and reproductive health of the women involved. Most studies carried out on this subject are related to medical abortions within the first 49 days. This study, however, aims at evaluating the efficacy of medical treatment in abortions after the first 7 weeks.

    Design and Methods. Retrospective study reviewing 380 cases related to abortion by request between July 1 2007 and February 29 2008. The variables analysed were gestational age, treatment methods (medical vs. surgical), dosage administered, treatment efficacy, need of additional intervention as a follow up to protocol and the need for curettage as an aid to uterus emptying completion.

    Results. From the 380 women who underwent abortion, the gestational age in 151 (39,7%) was over 49 days; 7 (4,6%) underwent surgical procedure and 144 (95,4%) medical procedure. Initially, 46 women were administered 200 mg of Mifepristone orally and 800 µg misoprostol orally 36 hours later. From October 1 2007 protocol was changed and in 98 (68,1%) women were administered 600 mg Mifepristone orally and 800 µg misoprostol orally 36 hours later. In the initial procedure, 69,6% (n=32) had a complete abortion although 4,3% (n=2) failed to appear for follow-up. 4 (8,7%) were evolutional pregnancies, 1 (2,2%) had a missed abortion and in 7 cases (15,2%) emptying was considered incomplete, 3 (6,5%) of which needed curettage to aid uterus emptying. In the following procedure, 61,2% (n=60) had a complete abortion although 7,1% (n=7) failed to appear for follow-up. 14 (14,3%) were evolutional pregnancies, 3 (3,1%) were missed abortions and in 14 (14,3) cases emptying was considered incomplete, 1 (1,0) of which needed curettage. Overall, medical treatment was administered to 144 women. Abortion was complete in 92 (63,9%) cases, 18 (12,5%) were evolutional gestations and 25 (17,4%) were incomplete abortions. Defining the presence of live embryo after medical cycle as medical abortion failure, it is calculated as 12,5%.

    Conclusions. Medical abortion had an 87,5% efficacy rate for the absence of live embryo at the time of ultrasound control. In our service the efficacy rate in the same period of time of medical treatment for any gestational age was 91,9%. Although scientific evidence of efficacy of medical treatment relates mainly to pregnancies within the first 49 days, the authors conclude that its use in cases of higher gestational ages is highly efficient, thus contributing to a lower number of surgical abortions.

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    Medical abortion in France. The benefits of a complex procedure

    Pascale Roblin, A. Agostini, F. Bretelle, R. Shojai (France)

    University Hospital of Marseille, France

    Objective. Medical abortion in an ambulatory setting is possible in France since 2004. However, many physicians have been reluctant to use this new option at the office because of the complexity of the protocol. Our aim was to evaluate the feasibility of this procedure in a private practice and to show it’s benefit in terms of contraception counselling.

    Patients and methods. A prospective study was realized among 300 consecutive women, with gestational age less than 49 days, choosing a medical abortion at a general practionner’s office. Under the French law, patients had to undergo five supervised visits (V). The first visit (V1) was to inform patients on the procedure and proposition to encounter a social worker for alternatives to abortion. V2 was for medical examination, cervical cytology, screening for IST and counselling on contraception. After a reflection period of seven days, the third visit was for administration of 600mg of mifepristone under the physician’s supervision. The fourth visit was for administration of 400µg of oral misoprostol at the office. Medications were bought by the physician at the pharmacy. Women were not obliged to remain under supervision and could depart within minutes of receiving medications but were not given the possibility to take the medications themselves at home. They had access to a 24-hour hotline and walk-in emergency service. The fifth visit was for post-abortion control at 10 days with HCG and/or sonography.

    Results.Among the 300 patients, 10 (3%) were lost at follow-up. The rate of complete abortion with no major complications among the 115 patients with a known outcome was 97%. Four patients (3,5%) required surgical aspiration : 2 for haemorrhage, 1 for incomplete abortion and 1 for continuation of pregnancy. Seventy-six women (63%) fully adhered to the protocol and came to the 5 scheduled visits. The mean number of visits at the office was 4,1. An unscheduled visit was required in 7 cases (6%) for repeat administration of misoprostol and 19 patients (16%) phoned for advice. The reflection period of seven days was not possible to respect in 55% of cases because of the time limit of 49 days but all patients had at least 48 hours to confirm their decision. None of our patients requested to encounter a social worker. Concerning contraception, 75% had no use of birth control methods and only 2 women used emergency hormonal contraception. At the control visit, 46% opted for oral contraception and 38% for a long term reversible method (IUD or implant). Overall rate of satisfaction for the method was 78%.

    Conclusions.Our findings confirm that medical abortion in a general solo practice is a safe and acceptable procedure. A complex procedure based on five visits at the office may be a shortcoming and considered as a setback in the era of increased patient autonomy. In our view it improves patient-doctor relationship which is essential for counselling in post-abortion contraception.

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    Medicated IUD after induced abortion

    Giovanna Scassellati (Italy)

    Azienda Ospedaliera S.Camillo, Rome, Italy

    We report our experience of the use of progesterone medicated IUDs (Mirena® Bayer Schering) as contraception after induced abortion.

    Between February 2007 and February 2008 255 women who came to our centre for the implementation of Law 194/1978 (the one that legalised induced abortion in our country) were enrolled.

    Among these patients who underwent IUD insertion we selected a number of those who, because of specific clinical situations (history of menometrorrhagia, uterine fibromatosis, endometriosis, etc.), needed the application of the progesterone medicated IUD. These women, in number of 22, underwent a gynaecological examination and a transvaginal pelvic ultrasound examination immediately after application of the device, two weeks after the operation and then every six months.

    All these 22 patients demonstrated a perfect situation and satisfaction both on the basis of clinical and ultrasound objectivity and also regarding the symptomatology, with a progressive reduction of menstrual flow and dysmenorrhoea.  None of the IUDs had to be removed or repositioned, to our great satisfaction and that of the patients. Thanks to this positive experience, which is still underway, we are strongly in favour of an increasing use of post-surgical IUDs.

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    Misoprostol-only compared with solution of NaCl 20%for induction of second trimester abortion

    A. Manaj, A. Musta (Albania)

    Obsetric Gynecological Hospital Mbreteresha Xheraldine, Tirana, Albania

    Objective. The effect of Misoprostol in induced abortions of second trimester as treatment of choice.

    Design & Method. In our country, the main method to terminate the second trimester pregnancies was the solution of NaCl 20%. These five last years this method is being replaced with misoprostol-only regimen. This was a comperative study. During a 12-month period, were selected and voluntary involved, two groups of healthy pregnant women (13-24 weeks) wishing to terminate their pregnancy due to medical reasons. A total of 80 patients, treated with misoprostol (experiment group) were compared with 77 patients treated with NaCl 20% (control group). Chi Square test for comparison of these proportions was used.

    In the first group of 80 women the abortion was induced by misoprostol (Cytotec) 400 mcg vaginally 3-hourly (x5). The abortion time varied from 18 hours and 20 (pluripara) to 25 hours and 5 minutes (primigravida) hours. In the second group of 77 women abortion induced by intramniotic transabdominal instillation of 20 % NaCl, amounting to 250 ml. The shortest abortion-instillation time was 28 hours and 10 minutes (pluripara), while the longest was 36 hours and 8 minutes (primipara). 2 cases pertaining the first group and 8 cases pertaining to the second one, experienced haemorrhage due to partial retention of the placenta which were subsequently removed by curettage. In the second group we experienced two cases of distacco placenta.

    Results. From data analyses resulted that patients treated with misoprostol have a much lower rate of haemorrhage P=0.01, cramps P=0.02 and curettage after misoprostol/ NaCl administration P=0.3.

    There is no statistically significant difference in the rates of infections P=0.6, pelvic pain P=0.7, diarrhoea P=0.67, and the difference in the amniotic fluid embolism P=0.7 and distacco placenta P=0.7.

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    Monitoring the reproductive health

    Marcela Bulcu (Italy)

    Azienda Ospedaliera S.Camillo, Rome, Italy

    In the last forty years, Italy has known signficant demographical changes. Italy’s rate birth is the lowest in Europe and indeed the lowest in the worls today. The fertility rate began to decrease dramatically from the end of the 1960s. The natality rates declined steadily until it reached a value of about 1.2 children per woman during the most recent years. Morover, the infant mortality has been reduced thanks to the success of the reproductive health system.

    A positive sign of the demographic developpement is a continuing and satble decline in nembers of legal abortions. A reduction attributed to the correct use of contraceptive methods and the institution of family planning centers in the 1970s.

    However, the abortion rate increased among the migrant population, passing from 10,1% in 1996 to 29,6% in 2005 and 31% in 2006. For this reason, a lot of programs and compaigns has been created to promote  the reproductive health among the migrants, taking in consideration their life conditions.

    • Recourse of indused abortion abaits (-3% respecting 2006 and -45,9% respecting 1982).
    • The decrease is more aloud between Italian women (-3,7% respecting 2005 and 61,4% respecting 1982).
    • While between foreigners women it’s confirm the increase of indused abortion (+4,5% respecting 2005).

    Breast objection increased, in some country redoubles respecting anterior years.

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    Paracervical block versus intracervical injection for pain management during first-trimester surgical abortion under local anaesthesia

    Nathalie Ambassa, K. Bourzoufi, Francis Collier (France)

    Orthogenics and medicine of the couple department, Hôpital Jeanne de Flandre, CHRU Lille, France

    Objective.Two different local anaesthesia techniques are commonly used for pain relief during first-trimester surgical abortion: paracervical block (PCB) or intracervical injection (ICI). The superiority of one technique versus the other has not been clearly established. In practice, the choice between these two techniques is made empirically, according to specific habits of each centre or each practitioner. This prospective observational study compared the effectiveness and acceptability of these two techniques to reduce pain during first-trimester surgical abortion following cervical priming with misoprostol.

    Patients and methods. Two-hundred and forty-nine women undergoing suction evacuation up to 12 weeks gestation were randomized into two groups: (ICI) 5 mL of 2% lidocaine injected at the 4 and 8 o’clock positions of the cervix; (PCB) 10 mL of 1% lidocaine injected at the 4 and 8 o’clock positions of the vaginal vault. Using a 0-10 scale, women rated pain associated with local anaesthetic administration, cervical dilatation and during and after suction evacuation. Pain scores, post-operative analgesic demand and satisfaction levels were compared among the two groups.

    Results.Pain levels during local anaesthetic administration were significantly lower (p<0.0001) in the paracervical group (2.1±2.1) than in the intracervical group (3.9±2.4). There were no statistically significant differences in the pain scores during cervical dilatation and suction evacuation. Post-operative demand for analgesics was significantly (p=0.0286) higher in the intracervical group. There was no difference between the groups concerning the global satisfaction of the patients (p=0.2489).

    Conclusion. The paracervical block is less painful and at least as effective against the pains related to the cervical dilatation as the intracervical injection. Therefore, the paracervical block seems to be the technique of choice in first-trimester surgical abortion under local anaesthesia. This study should lead to a modification of our practice in Lille with a broader use of the paracervical block for our patients.

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    Reproductive health women rights in Tunisia

    R. Ben Aissa, N. Abedrabo, F. Temimi, M. Ben Attia, E. Hsairi, N. Gueddana (Tunisia)

    Office national de la famille et de la Population Tunisie, Tunisia

    Women’s rights are a part of human rights and reinforce gender equality and then economic development and at term reduction of poverty.

    Reproductive rights in Tunisia, according Cairo conference in 1994, as been facilitated by an enabling legal framework and a political will and are one of the foundations of the socio-economic development plan.

    The presentation is related to: Women’s rights, right to education for girls, rights to contraception and reproductive health services, right to abortion, right to a safe maternity, women’s rights against violence, and rights for youth to a safe sexuality.

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    Sociologic Aspects of Legalized Abortion in Portugal. 1 Year Experience

    Renato Martins, Marisa Moreira, Teresa Bombas, Teresa Sousa Fernandes, Paulo Moura (Portugal)

    Genetics, Reproduction and Fetal Maternal Medicine Department, Coimbra University Hospitals, Portugal

    Introduction. According to United Nations, about 13% of maternal deaths in world were attributed to complications after non safe abortions. In Portugal, in last decades, ten maternal deaths occurred per year due to complications of illegal abortion. Since, July 16th of 2007 abortion is legal before ten weeks.

    Objectives. Characterization of the female population that came to our Service for abortion.

    Material and Methods. We analysed the clinical files of medical abortion appointment during the period of 1 year from 16th July 2007.

    Results. We included 298 females. Average age 28,2±7,6 years.(11,8% adolescents and 20,1% more than 35 years). We reported a 10% of non Portuguese women in our sample. Almost 52% were married. In this sample the authors report an average of 27% of women that had no contraceptive method in use before the abortion. In 90% of the cases this was the first abortion, and the majority of women pointed out economics reasons to justify it. Nearly 90% had a medical interruption, with few cases of complications associated to the method.

    Conclusions. The great group of women that come for abortion are not adolescents as it was firstly expected. The majority are Portuguese and live with their partner. A great number of women are not users of Family Planning Services.

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    Status of reproductive health of women after surgical abortion

    O. Revenko, I. Vovk, A. Kornatskaja (Ukraine)

    Institute of pediatrics, obstetrics and gynecology, Kiev, Ukraine

    In branch of planning of family the statistical analysis of 300 histories of illnesses of patients with pelvic inflammatory diseases with the purpose of definition of risk factors is spent. Wereresearch of the woman with secondary infertility - 1 group (150 women) and with not broken reproductive function - 2 group (150 women).

    Women with not broken reproductive function authentically connected the beginning of disease with the beginning of a sexual life 78 (52,0 %) is more often, while women with secondary infertility the main reason of disease considered surgical abortion - 78 (52,0 %) against 8 (5,3 %) - in 2 group).

    Operative intervention in the anamnesis was at 98 (65,3 %) women of 1-st and at 53 (35,3 %) women of 2-nd group, authentically more often at women with secondary infertility, (р <0,05).

    At the same time, there are more than complications after abortions it was marked at women with secondary infertility: in 76 (50,7 %) against 24 (16,0 %) women with not broken reproductive function.

    At gynecologic survey presence of chronic inflammatory diseases of internal genitals has been diagnosed for all women of 1-st group.

    Thus, the comparative analysis of data of clinical inspection has shown, that for the majority of women with secondary infertility (78,0 %) which were in marriage interruption of the first non-planned pregnancy by means of surgical abortion (46,7 % against 18,7 % at women with not broken {disturbed} reproductive function), and also smaller quantity of sorts of 30,6 % (against 81,4 % accordingly) and greater percent of operative interventions - 65,3 % (against 35,3 % accordingly) is characteristic.

    The received results testify, that interruption of non-planned pregnancy is beyond especially medical question and is an actual social problem.

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    The effectiveness of ultrasound and s-βhCG measurement in predicting failure after medical abortion

    Raquel Maciel, Maria Céu Rodrigues, Teresa Oliveira, Fátima Sousa, Lurdes Lima, Paulo Sarmento (Portugal)

    Centro Hospitalar do Porto - Maternidade Júlio Dinis, Porto, Portugal

    Objective. Diagnostic tests’ effectiveness in predicting failure after medical abortion has been subject of discussion in some studies. We compared ultrasound findings and β-hCG levels and tried to determine its cut-off value that would allow us to excuse a routine ultrasound examination as follow-up.

    Methods.In 49 women who had opted to interrupt the pregnancy, with a mean gestacional age of 50 days, ultrasound examination and serum β-hCG were performed prior and around the 20th day after medical treatment. On the follow-up we considered as ultrasound findings the endometrial thickness – virtual or with heterogeneous content – the presence of an empty gestacional sac or an embryo arrest, and compared them with their corresponding s-hCG levels – its decrease %, its initial level % and its absolute final value.

    Results.Treatment was successful in 92%. There was evidence of a close relation between ultrasound images and their β-hCG levels. The sensitivity of the ultrasound examination was 100% and its specificity was 49%. Despite the ratio of β-hCG initial level’s sensitivity, with a 1,3% cut-off, was the same as the one with a 0,8% cut-off (75%), the specificity of the first revealed to be more favorable (93,3% vs 86,6%).

    Conclusion.The percentage of β-hCG initial level determination, combined with clinical examination, can be an effective method in predicting the success of the medical treatment, as an initial procedure. Therefore, ultrasonography should only be considered in prompt cases.

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    The experience of the settling of a new abortion center in the French speaking part of Belgium

    Cécile Artus (Belgium)

    Center Eve & Adam, Bastogne, Belgium

    The province of Luxemburg shows specificities due to the rural environment : scattered population, great geographical distances, lack of publictransports. This province has also a political story where the catholic party is well present. So, it is only in 2007 that the idea to open the unique abortion center  in this province was born.

    It is obvious that the access to abortion (as well as to contraception and to pregnancy test) is difficult in this rural environment for all the reasons mentionned above.

    The question of the anonymity is raised and reduces this access to abortion. It is the reason why this right must be guaranteed to the women that push the door of the center.

    Since the begining of the abortion center, the staff has established a surprising statement: 25-35 years old women under contraception with a non desired pregnancy of 13-19 weeks old. The hypothesis is that these women have contraceptive accidents and do not have any awareness of the risk taken.

    As a conclusion, the abortion is still a taboo subjet. The professionnal workers of the contraception and abortion have still to focus on prevention and information about reproductive health.

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    The psycho-social aspect of the second trimester abortion with teenagers

    Milica Berisavac, Rajka Argirovic, Radmila Sparic, Nebojsa Markovic, Ivan Pavlovic, Ivana Cmiljic (Serbia)

    Institute for Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia

    Introduction. There are numerous barriers for establishing communication with and education of teenagers in respect of protection from unwanted pregnancies and sexual behavior. Unwanted pregnancy at this age is often detected in the second trimester, due to sense of fear and embarrassment to confide with the mother, friend, or partner, as well as to the sense of possible condemnation and lack of understanding of the environment. The legal procedure stipulating the abortion in the second trimester is explicit. Both the psychological and physical immaturity, uncompleted education, often unstable and temporary relationship, can cause a significant alteration of teenagers’ mental health. A sexual relationship with drug users additionally complicates the psychological state of the patients.

    Method. The retrospective study encompasses all the patients  who were hospitalized during the years 2006 and 2007 due to second trimester abortion. We analyzed the age of the patients, the knowledge of methods of protection from unwanted pregnancy, gestational age in which the unwanted pregnancy was diagnosed, the psychological state of the patients and indications for the abortion.  

    Results. During the study period there were 173 second trimester abortions at the Institute for Gynecology and Obstetrics Clinical Center of Serbia, 18 of which with under-age patients (9.33%). Teenagers did not have any or of little knowledge on contraceptive methods. In the group to the age of sixteen a greater gestational age was diagnosed  (18-20 weeks). In the age group from 16 to 18 the gestational age was 16-18 weeks. Three teenagers were mentally retarded, and one pregnancy happened at the institution. Reactio depresiva was indication for abortion in 15 cases. The abortive procedure was performed  by application of hypertonic Na Cl, with abortive interval of 20-24 hours.

    Discussion. In younger life age, advanced gestations were detected. The fear of condemnation by the family and the environment affected the late reference at younger teenagers. Even with older teenagers, there were no decisions to continue the pregnancy because they did not have the support of the family, partner nor had they the financial means or completed education. The absence of knowledge on protection methods from unwanted pregnancy imposes the necessity of comprehensive education of this population group, and inappropriate relationships in the family deprived of sincerity and understanding, bring the under-aged patient to the medical institution late in the pregnancy.

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    Women’s experience of home-abortion

    R. Hjertberg, M. Jahnson, M. Jarkander-Rolff, K. Lindelöw, I. Rosengren (Sweden)

    Octaviakliniken, Stockholm, Sweden

    Background. Medical abortion with the use of the antiprogestin mifeprostone combined with a prostaglandin has been approved in Sweden since 1992. Misoprostol has been shown to be the most optimal prostaglandin analogue and since 2006 it is possible to perform the abortion at home which is both safe and efficient. (Gemzell Danielsson et al). There has been an increasing demand from women to perform medical abortion at home.

    Objective.To evaluate women’s experience of home-abortion and also to evaluate if our routines with counselling, possibility of advice on the telephone met the women’s need of safety.

    Methods.100 questionnaires regarding given information, feeling of safety, acceptability, and complications, were given to women who chose to use misoprostol at home. Response rate was 56%.

    Results. Mean age 34 yrs (18-46). The information regarding the procedure given from doctor and nurse was sufficient (98%). 85 % felt very safe and 15% rather safe in the home-setting. 100% had enough time for questions before the abortion and 98 % were satisfied with the telephone-contact during the day. 83% had good and 8% had sufficient analgesics during the day. The procedure went as expected although 44% found it not as painful as anticipated.

    Conclusions. Home-abortion with the use of misoprostol presents a good alternative for many women. It is safe and has a high acceptability. However it demands enough time for detailed counselling and good routines at the clinic as well as written information to the women.