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



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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






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