Clinical management of medical abortion beyond 12 gestational weeks

Abstract

Clinical Management of Medical Abortion Beyond 12 Gestational Weeks Johanna Rydelius Department of Obstetrics and Gynecology, Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg Gothenburg, Sweden Background: Abortion beyond 12 gestational weeks (GWs) constitutes a minor part of the total number of abortions globally and access is often restricted due to legal frameworks or lack of necessary resources. In Sweden around 5% of abortions are conducted after 12 GWs. A regimen with mifepristone followed by repeat doses of misoprostol is recommended for medical abortion beyond 12 GWs. With an induction-to-abortion interval around 5–8 h the regimen is suitable for day-care. Placement of an intra-uterine device (IUD) is recommended as soon as possible post-abortion but the optimum timing of insertion after a medical abortion beyond 12 GWs has not been determined. Aims: The overall aim of this thesis was to increase the knowledge about the clinical management of medical abortion beyond 12 GWs. A specific aim was to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on abortion numbers in Sweden and explore reasons for the findings. Material and methods: Paper I was a mixed-methods study with a convergent parallel design. Data regarding the number of abortions during and before the COVID-19 pandemic was collected from the National Board of Health and Welfare. Qualitative data was collected from semi-structured interviews. Paper II was a multicentre, randomised controlled trial (RCT) in which the effects of home compared with hospital administration of the first misoprostol dose for abortion beyond 12 GWs was studied. Paper III was a multicentre RCT in which the effects of IUD-insertion within 48 h compared with after 2–4 weeks was studied. Paper IV was a descriptive cross-sectional study in which data regarding pain, measured by visual analogue scale (VAS), and analgesic treatment was retrieved from the RCT in Paper II. Results: Paper I: The total number of abortions did not change significantly during the study period compared with the years before the pandemic. Interview themes were meeting with abortion care and the impact of the COVID-19 pandemic on the abortion decision. Paper II: 156/220 (70.9%) of the participants who administered the first misoprostol dose at home completed the treatment as a day-care procedure compared with 99/215 (46.0%) for those who administered the first dose at the hospital (difference 24.9 percentage points (pp), 95% CI 15.4 to 34.3; p <0.0001). Paper III: After 6 months 34/67 (50.7%) of the participants in the group with IUD-insertion within 48 h were using an IUD, compared with 48/67 (71.6%) of the participants in the group with insertion after 2–4 weeks (difference 20.9 pp, 95% CI 4.4 to 35.9; p=0.021). Paper IV: The participants reported a mean VAS of 39.1 (SD 34.4) at fetal expulsion and a maximum pain score during the abortion of VAS 65.4 (SD 28.6). A total 266/425 (62.6%), 163/425 (38.4%) and 86/425 (20.2%) of the participants received an oral opioid, a paracervical block (PCB) or an opioid injection respectively. The largest decrease in VAS was achieved with administration of a PCB preceded by an oral or an injectable opioid or by both an oral and an injectable opioid. Conclusions: The abortion numbers in Sweden were not critically affected by the COVID-19 pandemic and, despite pandemic-related factors that influenced the abortion decision-making, abortion-seeking persons did not hesitate to proceed with the abortion. Home-administration of the first misoprostol dose in medical abortion after 12 GWs significantly increased the proportion of day-care procedures, with maintained safety and patient acceptability. Promoting day-care protocols for medical abortion beyond 12 GWs, with support from tertiary care levels, could lead to increased access also in regions with low admission possibilities. IUD-insertion within 48 h after medical abortion beyond 12 GWs resulted in higher expulsion rates and was less advantageous in terms of IUD-use after 6 months when compared with insertion after 2–4 weeks. Persons having a medical abortion beyond 12 GWs reported severe pain and most often required extra analgesia in addition to non-steroidal anti-inflammatory drugs and paracetamol. An oral opioid was the most common analgesia, but a PCB was associated with a larger reduction of VAS when administered after onset of pain. Keywords: Medical abortion, abortion beyond 12 gestational weeks, day-care, intra-uterine device, pain management.