Unintended pregnancy and early medical abortion

Abstract

Background: Very early medical abortion (VEMA) is performed before the confirmation of intrauterine pregnancy (IUP) by ultrasound. Over the past 25 years, more women have sought abortions earlier in pregnancy. Concerns about VEMA’s effectiveness and the risk of ectopic pregnancy (EPs) have resulted in inconsistent practices, multiple clinic visits, and limited access to care. While many countries adopted telemedicine abortion during COVID-19 to minimize in-person visits, Swedish regulations still required all women seeking medical abortion to attend in person for an examination and to receive mifepristone under clinical supervision. Aim: The overall aim of this thesis was to increase the safety and accessibility of early medical abortion by expanding available knowledge and obtaining data to develop evidence-based guidelines. Methods: This thesis comprises four studies using quantitative and qualitative methodologies. Study I: a retrospective case note review; Study II: a multicenter, multinational randomized controlled trial; Study III: a cohort study from the randomized controlled VEMA trial; Study IV: a qualitative study with semi-structured interviews. Results: Complete abortion was defined as no ongoing pregnancy or need for further surgical intervention. In Paper I, the success rate of VEMA was 97.6% (660/676), and the number of ongoing pregnancies was (0.59%). The success rate was lower (93.1%) in pregnancy of unknown location compared to those with a probable intrauterine pregnancy (98.4%). Six cases of EPs (0,88%) required post-abortion treatment; in Paper II, the success rate was 95.2% (676/710) in the VEMA group and 95.3% (656/688) in the standard (delayed) treatment group, with a risk difference of only 0.1 (CI -2.3, 2.3). Ongoing pregnancy rates were higher (3.0% vs. 0.1%; RR 20.3, CI 2.74, 151), but surgical interventions were lower (1.8% vs. 4.5%; RR 0.41, CI 0.21, 0.77) in the early group. Ten cases of EPs (1.3%) were identified in the early group, and 6 cases (0.8%) in the standard group; Paper III, a decline in hCG level of ≥80% was observed in ≥ 95% of cases with complete abortion (533) 7 (+/- 2) days post-abortion, regardless of baseline hCG levels. Rising or insufficient decline (<80%) indicated ectopic and ongoing pregnancy; in Paper IV the participants found it easy to contact the abortion clinic but faced undesired waiting time, gynecological exams were appreciated by most but distressing for some. Telemedicine abortion and home administration of mifepristone were seen as good options in addition to in-person care. Conclusion: This thesis confirms the efficacy and safety of VEMA, validates hCG monitoring as a reliable follow-up method after VEMA, and emphasizes patient satisfaction with in-person abortion care while highlighting the potential benefits of more flexible abortion services.