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Abortion, Contraception and Women’s Health International Seminar of FIAPAC , RSOG, RC Ob/Gyn &P , 27/28 October 2005. When is a backup aspiration needed? hCG and ultrasound for verification of successful expulsion. Christian Fiala. www.fiapac.org

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Abortion, Contraception and Women’s Health

International Seminar of FIAPAC, RSOG, RC Ob/Gyn &P , 27/28 October 2005

When is a backup aspiration needed?

hCG and ultrasound for verification of successful expulsion

Christian Fiala

www.fiapac.org

International Association of Abortion and Contraception Associates

Gynmed Ambulatorium

Vienna, Austria

Karolinska Institute

Department of Woman and Child Health

Stockholm/Sweden


www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.htmlwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

hCG and US in medical abortion, C. Fiala


Expulsion after Mifepristone and Misoprostol www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

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

unknown

Before miso

(hours after misoprostol)

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

hCG and US in medical abortion, C. Fiala


Treatmentwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

Day 1: hCG 269 mIU/ml

Day 9: hCG 20

hCG and US in medical abortion, C. Fiala


Treatmentwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

Day 1: Gestational

sac 5 mm

hCG 862

Day 7: hCG 7

Day 3: Gestational

Sac

hCG and US in medical abortion, C. Fiala


Treatmentwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

D 8: E 12 mm

hCG 837

D 1: hCG 32.000

D 3: Gestational

sac

hCG and US in medical abortion, C. Fiala


Treatmentwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

D 1: CRL 10 mm

hCG 83.439

D 8: E 8 mm

hCG 312

hCG and US in medical abortion, C. Fiala


Treatmentwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

D 1: CRL 6 mm

hCG 104.900

D 3: Start OC

D 10: E 20 mm,

hCG 16.841

D 17: OC ex

D 21: Withdrawl-bleeding

D 28: hCG 100

hCG and US in medical abortion, C. Fiala


Treatmentwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

D 1: Gestational +

yolk sac

hCG 13.300

D 3: Start OC

D 19: E 8 mm

hCG 718

D 9: missed AB

hCG 10.819

D 16: OC ex

D 18: Withdrawl-bleeding

hCG and US in medical abortion, C. Fiala


Methods
Methodswww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

  • 217 women with

  • an unwanted pregnancy

  • <49 days of amenorrhea

  • received:

    • 600mg of Mifepristone orally

    • 400µg of Misoprostol orally 2 days later

    • hCG was performed at all visits

    • US was performed before Mifepristone and at follow-up

hCG and US in medical abortion, C. Fiala


Results
Resultswww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

  • Curettage:

    • 1 continued pregnancy

    • 1 missed abortion

    • 1 haemorrhage

  • One missed abortion was expelled after withdrawal bleeding

hCG and US in medical abortion, C. Fiala


Serum hCG at follow-up in % of the initial valuewww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

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

3 cases of successful abortion (27,32 and 44%)

2 cases of missed abortion (91 and 159%), 1 case of continued pregnancy (7,900 %)

Fiala et al., 2003

hCG and US in medical abortion, C. Fiala


Endometrium thickness at follow-upwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

Mean 10mm (1-24mm); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 10 patients

Fiala et al., 2003

hCG and US in medical abortion, C. Fiala


hCG for verification of expulsionwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

  • First trimester surgical abortion:

    • Urinary test (cut off 1,000mIU/ml) at two weeks (Paul et al., 2000)

  • Medication abortion <9 weeks:

    • Urinary test, cut off 500mIU/ml at 3 weeks (Karolinska University Hospital, Sweden)

    • Urinary test, cut off 1,000mIU/ml at >1 week (Gynmed Clinic, Vienna)

    • Decline in serum hCG at follow up in % of the initial value:

      • 30% on day 10 (Jourdan and van den Bossche 1991)

      • 40% at 1 week (Legarth et al. 1991)

      • 60-70.5% 24 hours following misoprostol

      • 99.4% on day 14 (Walker et al., 2001, Honkanen et al., 2002)

      • 20% after day 6 (Fiala et al., 2003)

hCG and US in medical abortion, C. Fiala


Retained products of conception rpc
Retained products of conception (RPC)www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

  • Commonly present with sharp or crampy lower abdominal pain and bleeding

  • No difference to haematomata

  • Presence of sparse villi alone after successful surgical abortion is a normal finding and not diagnostic of RPC

  • After abortion, small amounts of retained products may pass spontaneousely, avoiding the need for backup curettage

hCG and US in medical abortion, C. Fiala


Verification of expulsion
Verification of expulsionwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

  • Ultrasound

    • Gives reliable results in most cases when the yolk sac or CRL can be visualised before treatment

    • It is not reliable in very early pregnancy

    • Endometrium is thick in many patients at follow up

  • hCG

    • Has to be used in early pregnancy

    • Is very reliable in most cases > cut off at 20% of initial value after day 6

    • Follow-up can be done at a different laboratory

hCG and US in medical abortion, C. Fiala


Rapid hCG testwww.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

Duo rapid test (urine)

5 mIU/ml and 1.000 mIU/ml

www.VedaLab.com

hCG and US in medical abortion, C. Fiala


Museum of Contraception www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

and Abortion

New Museum wants old contraceptives

Objects (IUDs, Cervical caps etc.),

reports, posters, publications

www.contraceptive-museum.at

The museum will be in Vienna, at conferences and online


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