Legal abortion in Sweden Since 1975 ”free abortion” until 18 weeks

Legal abortion in Sweden

• Since 1975 ”free abortion” until 18 weeks

• Thereafter only with permission from the National Board of Health and Welfare on special indications until 22 weeks

• About 30 000 abortions, 90 000 births/ year

The Swedish abortion act

• Has a limited influence on the number of abortions

• Has a profound influence on the conditions under which the abortion is performed

• Has a significant effect on women’s health

• A liberal abortion law is a prerequisite for the development of safe abortion methods

Mifepristone abortion in Sweden

• 1992: up to 63 days

• 1994: II-trimester abortion

• 600 mg mifepristone followed by gemeprost 1mg/ 3h
• 2003: 600 mg mifepristone followed by a suitable prostaglandin analogue

II-trimester abortion 1996 to 1998

• 197 consecutive abortions in 192 women

• Regimen:

• 600 mg mifepristone
• 24 to 48 h later gemeprost 1mg every 6 hours x 4
• If no abortion within 24 h, I mg gemeprost / 3 h

• Curettage routinely performed up to 18 weeks, thereafter when needed

• Gemzell Danielsson K & Östlund 2000

Demography

• Median age: 30 (15 to 44) years

• Median pregnancy length: 17 (14 to 26) weeks

• Primigravidae: 42 (21.3) %

• Multigravidae: 155 (78.7) % (Nulliparous (n=45))

• Indications:

• Social (n=113) 57.4 %
• Chromosomal aberration (n=30) 15.2 %, Foetal malformation (n=34) 17.2%, Missed abortion (n=20) 10.2 %

Results

• Median numbers of gemeprost (Cervagem): 2

• Induction-to-abortion interval:

• Primigravidae: 9.0 (1.4-40.5) h vs.
• Multigravidae: 7.2 (0-152.5) h (ns)
• Nulliparous (n=45) 10.6 (2.8-30.6) h vs.
• Parous (n= 104) 6.0 (0-152.5) h (p<0.001)

Results

• 96.3 % aborted within 24 h (all women with missed abortion)

• Significant correlation between pregnancy length and abortion time

• Narcotic analgesia required by 93 %

• PCB (n=8)

• EDA (n=1)

• One woman required a blood transfusion

II-trimester abortion 200mg mifepristone and gemeprost

• Case series report

• 200mg mifepristone followed 36h later by 1 mg gemeprost/6h x4, /3h

• Median gestational length 16 weeks (12-24 w)

• Median induction-to-abortion interval 7.8h

• Surgical evacuation 11.5%

• Tang OS, Thong KJ, Baird DT, Contraception 2001

II-trimester abortion gemeprost vs.misoprostol orally

• 50 women

• 200 mg mifepristone followed by

• 400 g misoprostol p.o/ 3h or 1 mg gemeprost/ 6h

• Induction – abortion interval 8.7 vs. 10.8 h (ns)

• No difference in incidence of side effects

• Ho et al., 1996

• Similar efficacy: El Refaey et al., 1993, Dickinson et al., 1998, Nuutila et al., 1997

• Higher efficacy: Wong et al., 1996

II-trimester abortion misoprostol 3h vs. 6h intervals

• 148 women

• Misoprostol 400 g vaginally

• Repeated every 3h vs. 6h

• Induction-ab interval 15.2 vs.19.0 h (P< 0.01)

• Abortion within 48 h 90.5 vs. 75.7% (P< 0.02)

• Fever more common in the 3h group (P = 0.01).

• Wong et al., 2001

II - trimester abortion oral vs. vaginal misoprostol

• 142 women: 200 mg mifepristone + misoprostol 400 g oral vs. 200 g vaginal/ 3 h up to x 5

• Complete abortion rate: 81.4% vs.75.4% (ns.)

• Diarrhoea 40 vs. 23.2 % (p= 0.03)

• Total dose 1734 vs. 812 g (p< 0.0001)

• Median induction-to-abortion interval: 10.4 vs. 10 h

• 82% preferred the oral route

• Ngai et al. 2000

II-trimester abortion

• 200 mg mifepristone followed 48h later by

• Misoprostol 400 g vaginally every 3h vs.
• Misoprostol 600 g vaginally + 400 g po/ 3h

• No significant difference between the groups

• El-Refaey & Templeton 1995

II-trimester abortion 1000 women, 13-21 weeks

• Mifepristone 200 mg, after 36-48 h followed by

• vaginal misoprostol 800 g (4 tabl Cytotec) followed by
• 400 g po.(2 tabl Cytotec) every 3h to max 4 doses

• 97% aborted successfully

• median dose of misoprostol: 1200 g

• median induction-to-abortion interval: 6.5 h.

• 9.4% curettage, > 75 % day cases

• Ashok & Templeton 1999, 2004

II-trimester abortion sublingual misoprostol

• Significantly higher acceptance for sublingual administration

• 400 microg misoprostol/ 3h x 5 vaginal. vs. Sublingual

• Tang et al., 2004

• Higher acceptance for sublingual but more pain, more opiates needed

• 600 microg sublingual vs. 800 microg vaginal followed by 400 microg /3h sublingual or vaginal

• Hamoda et al., 2005

Effect of the time interval between mifepristone and the prostaglandin

• No difference in induction to abortion time with mifepristone administered 24, 36 or 48 h prior to the prostaglandin

• Urquhart and Templeton 1990

• Effect on uterine contractility maximal at 36 to 48h

• Bygdeman & Swahn 1985

• Ripening effect of mifepristone on cervix, more pronounced at 36 to 48 h

• Rådestad et al 1988

Conclusion Mifepristone in II-trimester abortion

• Our data confirm the efficacy and safety of mifepristone and gemeprost for II-trimester abortion.

• Oral misoprostol has been shown to be as effective and safe as gemeprost

• Vaginal misoprostol is more effective but less accepted than the oral route

• The combined vaginal-oral regimen is as effective as repeated vaginal misoprostol

II-trimester abortion

• Mifepristone followed 24-48h later by

• Misoprostol 800 g (CytotecR 4 tabl ) vaginally followed by 400 g (CytotecR 2 tabl) orally every 3h

• Curettage only in case of incomplete abortion

Pain prophylaxis

• T Diclofenac 100 mg T Panocod.® together with the first dose of Cytotec

• Contraceptive councelling

• Screening and treatment/ prophylactic antibiotics for STI