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When is a backup aspiration needed? hCG and ultrasound for verification of successful expulsion

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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When is a backup aspiration needed? hCG and ultrasound for verification of successful expulsion

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  1. 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

  2. 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

  3. Expulsion after Mifepristone and Misoprostol 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

  4. Treatment Day 1: hCG 269 mIU/ml Day 9: hCG 20 hCG and US in medical abortion, C. Fiala

  5. Treatment Day 1: Gestational sac 5 mm hCG 862 Day 7: hCG 7 Day 3: Gestational Sac hCG and US in medical abortion, C. Fiala

  6. Treatment D 8: E 12 mm hCG 837 D 1: hCG 32.000 D 3: Gestational sac hCG and US in medical abortion, C. Fiala

  7. Treatment D 1: CRL 10 mm hCG 83.439 D 8: E 8 mm hCG 312 hCG and US in medical abortion, C. Fiala

  8. Treatment 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

  9. Treatment 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

  10. Methods • 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

  11. Results • 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

  12. 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 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

  13. Endometrium thickness at follow-up 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

  14. hCG for verification of expulsion • 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

  15. Retained products of conception (RPC) • 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

  16. Verification of expulsion • 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

  17. Rapid hCG test Duo rapid test (urine) 5 mIU/ml and 1.000 mIU/ml www.VedaLab.com hCG and US in medical abortion, C. Fiala

  18. Museum of Contraception 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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