1. Medical abortion - clinical aspects
Conférence sur l’avortement par médicament-
16 Septembre FQPN
Medical abortion - clinical aspects
Christian Fiala, MD, PhD
International Association of Abortion and Contraception Associates
Gynmed Clinic
Vienna, Austria
Karolinska University Hospital
Department of Women and Child Health
Stockholm/Sweden
Museum of Contraception and Abortion
Vienna,

2. The quality of care has therefore a huge impact on the whole society.
Abortion is the most frequently performed surgical procedure in Obstetrics and Gynaecology, regardless of whether it is illegal or legal.
The quality of care has therefore a huge impact on the whole society.
Medical abortion - clinical aspects, C. Fiala

3. Marketing of mifepristone
1988: France (49 days LMP)
1991: UK (63)
1992: Sweden (63)
1999 January: Austria (49)
2000: most other European countries (49)
2000: US, Mifeprex® (49)
2007: Portugal; all countries up to 63 days
2010: Italy
Now available in 44 countries
Medical abortion - clinical aspects, C. Fiala 3

4. Medical abortion - clinical aspects, C. Fiala4

5. Mifepristone/Mifegyne® /Mifeprex®
Medical abortion - clinical aspects, C. Fiala

6. Mifepristone Steroid competitively blocking hormone receptors
Affinity to progesterone receptor is 8 times higher than progesterone
Affinity to the cortisol receptor is 3 times higher than cortisol
Fast oral absorption, peak after 1.5 hours
Half life more than 18 hours
3 metabolites, providing 23-33% of the antiprogestagenic effect in a 600mg dose
Medical abortion - clinical aspects, C. Fiala

7. Mifepristone cont. Very safe (no death from the drug reported)
Side effects minimal (nausea)
Regimen mg (1-3 tablets) followed by a prostaglandin hours later
The interval is important for the effectiveness
Rather expensive drug: 22€ (United States 85$) per tablet
Medical abortion - clinical aspects, C. Fiala

8. Mode of action of progesterone in the uterus
Inhibits the regression of the corpus luteum
ß-hCG
Gestational sac
Keeps the endometrium and the gestational sac attached to the uterine wall
Relaxes the uterine muscle
Keeps the cervix closed
Progesterone
Medical abortion - clinical aspects, C. Fiala

9. Mode of action of mifepristone
Leads to the regression of the corpus luteum
Decreases ß-hCG
Blocks the receptors of progesterone
Gestational sac
The endometrium and the gestational sac separates from the uterine wall
The uterine muscle becomes more sensitive to prostaglandin and contracts
The cervix opens
Blocks progesterone receptors and thereby induces the clinical symptoms identical and indistinguishable to a miscarriage (corpus luteum insufficiency)
Medical abortion - clinical aspects, C. Fiala

10. Mifepristone, prostaglandins and uterine contractility
Bygdeman & Swahn 1985
The interval is important for the effectiveness
Medical abortion - clinical aspects, C. Fiala

11.
Medical abortion - clinical aspects, C. Fiala

12. Mifepristone: approved indications in Europe
Voluntary medical abortion <63 days in combination with a prostaglandin (misoprostol/gemeprost)
Priming of the cervix prior to surgical abortion
Medical abortion for medical indications in the Trimester
Induction of labour in intrauterine foetal death
Medical abortion - clinical aspects, C. Fiala

13. The procedure up to 63 days LMP
Website: - information (
First contact /telephone: - Is pregnancy confirmed?
- Has the patient been able to talk to someone close?
- Has the decision for the abortion been taken?
- Answer questions or refer to the website
- Exclude contra indications
- Make appointment
Day 1: - Ultrasound, hCG (gynaecological examination)
- Blood group
- Counselling: abortion only if the decision is clear otherwise give an appointment one week later
- 1 or 3 tab mifepristone
Day 3: - <49 days LMP = 2 tab misoprostol (Cytotec®) orally
50-63 days LMP = 4 tab misoprostol vaginaly
- Option for up to 3 hours in the institution (rarely used)
- Make sure patient has sufficient analgesics
- Start oral contraception the next day
Day 8 -14: - ultrasound and/or hCG
Medical abortion - clinical aspects, C. Fiala

14. When does the abortion take place?
Phase of psychological confrontation -
Phase of coming to a decision
Mifepristone
The abortion/Point of no return
Detachment of the gestational sac
Bleeding may start
Expulsion may take place
Bleeding becomes heavy
Expulsion takes place
Beginning of a new cycle/fertility
Prostaglandin
Expulsion ≠ Abortion
Medical abortion - clinical aspects, C. Fiala

15. Medical abortion: impact of the interval
Mifepristone
Misoprostol
36-48 hours
Reducing the interval needs a higher dose of prostaglandin > more side effects
Medical abortion - clinical aspects, C. Fiala

16. When does the expulsion take place?
in % 20 15 10 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Before miso
(hours after misoprostol)
unknown
uncertain
More than 24 h later
Time to expulsion of the sac in 1720 women with successfull termination of pregnancy. The women took mifeprostone on day 1 and misoprostol 48 hours later. Uncertain means expulsion at some point during 24 hours following misoprostol. Unknown means expulsion at some point later than 24 after misoprostol. Source: The New England Journal of Medicine, 1998; 338 (18): 1244
Medical abortion - clinical aspects, C. Fiala

17. The procedure D 1: CRL 10 mm hCG 83.439 D 8: E 8 mm hCG 312
Medical abortion - clinical aspects, C. Fiala

18. The procedure Day 1: hCG 32.000 yolk sac visible
Day 3: Gestational sac
Day 8: E 12 mm
hCG 837
Medical abortion - clinical aspects, C. Fiala

19. The procedure Day 1: Gestational sac 5 mm hCG 862 Day 3:
Day 7: hCG 7
Medical abortion - clinical aspects, C. Fiala

20. The procedure Day 1: ß-hCG 269 mIU/ml Day 9: ß-hCG 20
Medical abortion - clinical aspects, C. Fiala

21. The procedure D 1: CRL 6 mm hCG 104.900 D 3: Start OC D 10: E 20 mm,
D 17: OC ex
D 21: Withdrawl-bleeding
D 28: hCG 100
Medical abortion - clinical aspects, C. Fiala

22. The procedure D 1: Gestational + yolk sac hCG 13.300 D 3: Start OC
D 9: missed AB
hCG
D 16: OC ex
D 18: Withdrawl-bleeding
D 19: E 8 mm
hCG 718
Medical abortion - clinical aspects, C. Fiala

23. hCG before and after an abortion, , , , , , ,
Top curve: women after vacuum aspiration for elective abortion
Middle curve: women with spontaneous abortions uterine aspiration
Lower curve: women with ectopic removed surgically
Medical abortion - clinical aspects, C. Fiala
Montagnana et al., Clinica Chimica Acta, 2011

24. Serum hCG at follow-up in % of the initial value
Mean 3,8% (0,1-44); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 25 patients, Fiala et al., 2003
3 cs of successful abortion were at 27,32 and 44%, 2 cs of missed abortion at 91 and 159%, 1 cs of continued pregnancy %
Medical abortion - clinical aspects, C. Fiala

25. Endometrium in ultrasound
Thickness of the uterine cavity at follow up
Average: 10mm (1-24mm) after successful medical abortion
Medical abortion - clinical aspects, C. Fiala
Fiala et al. Eur J Obstet Gynecol, 2003

26. A new training CD and manual
Can be ordered at:

28. Museum of Contraception
New Museum wants
old contraceptives
Museum of Contraception
and Abortion
Vienna
Wanted:
Objects (IUDs, Cervical caps etc.), Reports, posters, publications

29. Reproductive Health a Gender Problem

30. Carrying the burden of reproduction...
What about sharing rights including the right to exercise them?

31. 2014