Danielle Hassoun

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    Feasibility of a self-performed urinary test for the follow-up of medical abortion: the Betina study

    Danielle Hassoun1, Ines Perin2 1Private Practice Office, Paris, France, 2Gynaecology Department, Delafontaine Hospital, Saint Denis, France - sbarbeau@gecem.com

    Background: Medical Termination of Pregnancy (MToP) implies a follow-up visit (14 to 21 days after mifepristone intake) to verify the effectiveness of the abortion procedure and the absence of any complication. Studies have shown that a level of hCG in the serum less than 1000 IU, two weeks after the intake of the mifepristone means the success of the method in 90% of the case. Objectives and method: We set up an observational study among French specialized centres either private practice offices, academic hospital centres or family planning facilities. The objectives were to assess the benefit of a self-performed urinary semi-quantitative test in the follow-up of MToP, assessing the feasibility, acceptability and user-friendliness of the test as well as the women’s capacity to interpret it correctly. Concordance between qualitative results from the test and quantitative values from the blood hCG measurement was also assessed. Results: 322 women were included by 17 centres (47% private practice, 35% hospital practice, 18% family planning centers) from May to October 2013. The mean age was 28.1 ± 6.4 years. 82% (N=264) of patients attended the follow-up visit and 13% (N=42) of patients were lost to follow-up. 69% (N=183) patients had performed the two tests on the same day ± 1 day. Concordance between urinary test and hCG blood measurement was 94.5% [90.2%; 97.4%]. A large majority of women (90%, N=198)) read the urinary test correctly whatever the levels of hCG. Performing the test at home was found reassuring for 40% (N=71) of them, and satisfactory for 26% (N=46) of them but 3% (N=5) considered it to be alarming and 12% (N=46) unsettling. Conclusion: The semi-quantitative urinary test shows good concordance with plasma level. Proposing a urinary test for the women to control the success of the procedure appears to be relevant, efficient and safe.

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    Is ultrasound necessary
    Danielle Hassoun, MD, Paris, France 
    The question remains whether Ultrasound (US) is a mandatory requirement for performing
    medical abortion. In fact, it is very useful in diagnosing early pregnancy, in allowing early
    diagnosis of ectopic pregnancy and finally in confirming success or failure of the method.
    However, not having access to US technology should not be considered as a barrier to
    introducing medical abortion.
    To diagnose very early pregnancy requires very good equipment and highly trained
    providers. Without a vaginal probe, the diagnosis of a pregnancy less than 6 weeks
    remains nearly impossible.
    At the follow up visit, the use of US can confirm the success or failure of the method and
    especially the reassurance there is no on going pregnancy but it can also be responsible
    for unnecessary interventions because of faulty interpretations of the images.
    In high resource settings, where the equipment is readily available and the providers are
    highly trained, the possible risk is that US may be used as a replacement for clinical exam,
    resulting in a potential loss of clinical skills.
    In low resource settings, where the equipment is possibly inadequate and providers not
    sufficiently trained to use it, relying on their very good clinical skill
    can make them good medical abortion providers.
    Lessons learned after almost 20 years of experience in this field show that US is not a
    requirement when clinical exam and BHCG (when accessible) are concordant with the
    condition that the providers maintain a good level of clinical skill.