Choice between medical and surgical abortion,
Philippe Lefèbvre MD, Président de l’ Association Nationale des Centres d’Interruption de grossesse et de Contraception, Chef du Service d’Orthogènie – Hôpital La Fraternité, Roubaix, France
Interrupting her pregnancy is a decision which belongs to the woman and only to her. However, once this decision is made, since a medical environment is required to guarantee her safety, the choice of a technique will take place whereas medical power is potentially at risk of being overbearing. The purpose of this paper is to evaluate if the objective and subjective elements of choice are the sole factors to intervene in the choice of the TOP method.
The duty of informing the patient about the various available options , their respective efficiency, and their potential risks, allows in theory , the woman to make an informed choice.
However, the medical practices are subject to numerous contingencies such as : access time, availability of mifepristone, presence of an anesthesist practitioner, economical viability of the medical act, implementation of the hospital-city network, lack of training, and sometimes , the difficulty for a doctor to challenge himself his own practices or habbits.
The litterature about good practices and clinical guidelines states that the type of technique , medical TOP or chirurgical TOP, is defined by the gestationnel age. But working by this sole criteria is obviously not enough, while the choice of a technique should be reached through a good medical consultancy , establishing a dialog between the patient and the professional (counsellers, nurses, doctors,) developping appropriate proposals.
The buy-in of the patient to the chosen method plays an essential role in the physical as well as psychical acceptance of the TOP.
Experience in the field shows that the TOP method will be all the more accepted by the patient that her buy-in shall have been seeked and reached.
Despite the ongoing upgrades of the techniques for the last 30 years , it is a shame that making a true choice available to the patient remains so highly dependant on some practitioners good will.
Comparison between local and general anaesthesia
Philippe Lefèbvre, Marie Duriez (France)
Service d’Orthogénie (Hospital Family Planning Service), Roubaix, France
Aim. To identify potential risk factors of inefficiency for elective medical termination of pregnancy based on records of failures of this technique in a hospital environment.
Patients and methods. A retrospective study was conducted on elective medical pregnancy terminations performed up to 49 days post amenorrhoea in the Family Planning Service of Roubaix hospital between January 1st 2001 and December 31st 2005.
The service's termination protocol consists in an oral dose of 600mg mifepristone, followed by an oral dose of 400mg misoprostol 48 hours later. A 2nd oral dose of misoprostol (400mg) is given 3 hours later if there has been no expulsion. Every patient is required to return 15 days later to check their bHCG levels.
Failure is defined as ongoing pregnancies, total or partial retentions, and cases requiring emergency surgery. Success is defined as complete abortion requiring no additional surgical or medical treatment.
Five items were analysed: patient age, patient parity, duration of pregnancy, bHCG levels on the day mifepristone (D1) was given, and the dose of misoprostol received.
Results. 1,975 medical terminations were performed during this period. 125 (6.33%) of these patients did not return to be checked and have been excluded from the study. The analysis was thus performed on 1,850 patients.
The method was a success in 97.08% of cases (1,796/1,850). 54 failures (2.92%) were recorded, including 7 ongoing pregnancies (0.38%). Patients for whom the method resulted in a success compared to patients who had failures have a significantly lower age. The duration of pregnancy was not different for the two groups. Nulliparous (873/1,850) patients had significantly fewer failures (12/873: 1.37%) than multiparous patients (42/977: 4.30%). Age is significantly higher for failures amongst the nulliparous patients. Conversely, for patients who have had at least one child, age is not a determining factor.
28 patients did not receive any misoprostol because they expulsed prior to the 48th hour (1.51%). Amongst the 673 patients who received only a single dose of misoprostol, 11 (1.63%) required additional actions including one emergency admission for haemorrhage. Amongst those who received two doses of misoprostol, 43 failed (3.74%), including 2 re-admitted the same day for haemorrhages and 1 for pelvic pains.
Discussion and conclusion. The overall efficiency results for the method are excellent despite an exhaustive and detailed analysis of the failures. The various studied factors have demonstrated that there is an increase in failure rates for the method with parity and, to a lesser extent, with the patient's age. High plasma beta HCG levels are also seem to be more often associated with failures of the method. The addition of a second dose of misoprostol is likely to increase the chances of an expulsion during the hospital stay but, this non-comparative retrospective study can not conclude on the beneficial effect of a second dose of misoprostol on overall efficiency.
Finally, it should be noted that none of the criteria evaluated in this study can be used as a diagnosis factor to predict the outcome of an elective termination as none of them has the sensitivity / specificity that is required to identify 'at risk' patients from amongst other patients.