Characteristics of women who present for abortion towards the end of the mid-trimester in Scotland: national audit 2013-2014.

OBJECTIVES: Women in Scotland who request an abortion (for non-medical reasons) within the legal gestational limit (up to 24 weeks) but beyond the gestational limit of all abortion facilities in Scotland (only up to 20 weeks) must travel to England if they wish to terminate the pregnancy. We wished to determine the number and characteristics of women presenting at ≥16 weeks' gestation for abortion, and compare the characteristics of those proceeding to abortion with those continuing the pregnancy. METHODS: Over a period of 12 months we conducted a prospective audit of women presenting at ≥16 weeks' gestation to abortion services throughout Scotland. The characteristics of women proceeding to abortion and those continuing the pregnancy were compared. RESULTS: A total of 267 women presented for abortion at ≥16 weeks' gestation. Their median age was 22 years (range 14 to 47 years); 231 were from deprived areas (86.5%), 128 (47.9%) already had a child and 73 (27.3%) had previously undergone abortion. A total of 175 women (65.5%) proceeded to abortion, locally (n = 125; 46.8%) or in England (50; 18.7%). Those at ≥20 weeks' gestation were statistically more likely to continue the pregnancy than those at earlier gestations (p < 0.001). CONCLUSIONS: Relatively few women present for abortion in Scotland at ≥16 weeks' gestation. Those who are over 20 weeks' gestation and would need to travel to England for abortion are more likely to continue the pregnancy, suggesting that travel is a barrier to accessing legal abortion for this group of women. Provision of abortion services up to 24 weeks' gestation should be considered within Scotland.

The online Managed Knowledge Network that shares knowledge for eHealth in NHS Scotland.

The Managed Knowledge Network (MKN) for Nurses, Midwives and the Allied Health Professions (NMAHPs) in NHS Scotland was launched in November 2007. The online portal supports the NMAHP network to manage its knowledge and information sources that facilitate engagement with the national eHealth programme and realisation of benefits that eHealth offers to improve healthcare and service delivery. It is an integrated change management and knowledge management initiative. Web2 technologies support the social networking side of knowledge management and learning, allowing people to contact each other and collaborate. MKN resources are managed within the e-Library also giving access to over 5,000 online journals and over 500 bibliographic databases.

Who has a repeat abortion? Identifying women at risk of repeated terminations of pregnancy: analysis of routinely collected health care data.

BACKGROUND: Repeat termination of pregnancy highlights the issues of unplanned pregnancies and effective post-termination contraceptive practices. OBJECTIVE: To examine the risk factors at the time of a first termination that are associated with subsequent repeat termination. DESIGN: Registry-based study. SETTING: Grampian region of Scotland, UK. METHODS: A retrospective study using data from the Termination of Pregnancy Database, NHS Grampian for the period 1997-2013. Associations between repeat termination and women's sociodemographic characteristics and contraceptive use were assessed using multivariable logistic regression models. RESULTS: This study showed that 23.4% of women who had an initial termination (n=13 621) underwent a repeat termination. Women who had repeat terminations were more likely to be aged under 20 years at their initial termination with an adjusted odds ratio (AOR) of 5.59 [95% confidence interval (CI) 4.17-7.49], to belong to the most deprived social quintile [AOR 1.23 (95% CI 1.05-1.43)], and to be more likely to have had two or more previous livebirths [AOR 1.51 (95% CI 1.12-2.02)] or miscarriages [AOR 1.40 (95% CI 1.02-1.92)]. The likelihood of having a repeat termination was increased in women who had a contraceptive implant as post-termination contraception [AOR 1.78 (95% CI 1.50-2.11)] compared to women who left with none or unknown methods following the first termination. In those who had repeat terminations, women who had an implant or Depo-Provera(®) were at increased odds of repeat termination in the 2-5 years interval compared to the 0-2 years after their initial termination. CONCLUSIONS: Teenage pregnancy, social deprivation, two or more previous livebirths or miscarriages at the time of the initial termination were identified as risk factors for repeat terminations. Post-termination contraception with implants and Depo-Provera® were associated with repeat termination 2-5 years after the first termination.

Medical abortion at 9-13 weeks' gestation: a review of 1076 consecutive cases.

OBJECTIVE: The aim of the study was to assess the use, efficacy and factors influencing the outcome of medical abortion at 9-13 weeks' gestation. METHODS: Retrospective chart review of consecutive women undergoing medical abortion at 9-13 weeks' gestation was done. RESULTS: A total of 1927 abortions were carried out at 9-13 weeks' gestation, of which 1076 (55.8%) were undertaken medically. Efficacy decreased with increasing gestation (p=.02). Surgical evacuation was carried out in 45 (4.2%) women including 10 (2.7%) at 64-70 days, 11 (3.3%) at 71-77 days, 10 (5.1%) at 78-84 days and 14 (8.0%) at 85-91 days of gestation (p=.02). Indications for surgery included continuing pregnancy [16 (1.5%) women], retained sac [5 (0.5%)], incomplete abortion [20 (1.9%)] and emergency curettage for bleeding [4 (0.4%)]. The number of misoprostol doses used and the induction-to-abortion interval both significantly increased with gestation (p<.001), while analgesia requirements did not vary with increasing gestation (p=.18). CONCLUSIONS: Medical abortion at 9-13 weeks' gestation is an effective alternative to surgery. Medical methods should be offered routinely at these gestations, thus increasing women's choice.

Patient preference in a randomized study comparing medical and surgical abortion at 10-13 weeks gestation.

The aim of this study was to assess women's preferences and acceptability of medical (MA) and surgical abortion (SA) at 10-13 weeks gestation. This was a partially randomized patient preference trial. Women were offered to enter the randomized arm of the trial. Those who expressed a strong preference for a method were entered into the preference arm. A total of 368 women were randomized (188 medical and 180 surgical) while 77 entered the preference arm (15 medical and 62 surgical). Prior to abortion, 253 women (72%) indicated a preference for MA while 98 (28%) showed a preference for surgery (p < .0001). Despite having a preference for a particular method, women were content with alternatives. Women were more likely to choose the same abortion method again if they had shown a preference for that method prior to abortion (p = .002 and .01 for MA and SA, respectively). The availability of MA is an important option for many women who wish to avoid surgery or anesthesia and should now be offered routinely in the late first trimester.

Medical termination of pregnancy in the early first trimester.

Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.

Surgical abortion using manual vacuum aspiration under local anaesthesia: a pilot study of feasibility and women's acceptability.

OBJECTIVE: Studies from the USA have reported the efficacy and high acceptability of surgical abortion using manual vacuum aspiration (MVA) under local anaesthesia. The aim of this study was to assess the feasibility, acceptability and efficacy of surgical abortion using MVA under local anaesthesia for termination of pregnancy up to 63 days' gestation, within a UK National Health Service setting. METHODS: Surgical abortion was carried out using MVA under local anaesthesia. Women's satisfaction with the procedure, and pain and anxiety levels, were assessed. The main outcome measures were: (1) feasibility assessed through successful completion of the procedure without the need for general anaesthetic or conversion to suction vacuum aspiration, (2) efficacy assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure. RESULTS: The mean (SD) gestation was 50 (9.4) days. A total of 55/56 (98%) women had a successful procedure and did not require any further surgical or medical treatment. Fifty-five (98%) women were satisfied with the procedure, 48 (86%) said they would recommend it to a friend and 45 (80%) said they would have the same method again in the future. Anxiety levels, as reflected by the visual analogue scales, showed a significant fall in anxiety scores following the procedure (p<0.01). CONCLUSIONS: Surgical abortion using MVA under local anaesthesia is effective and acceptable to women. These findings now need to be assessed in the context of a randomised trial.

Home self-administration of misoprostol for medical abortion up to 56 days' gestation.

OBJECTIVE: Studies from the USA have suggested the feasibility and acceptability of home medical abortion, however the issue has not been addressed in the UK. This study aimed to assess the feasibility, efficacy and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. METHODS: Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 600 microg and advised to take them sublingually 36-48 hours later. The main outcome measures were (1) feasibility, assessed through successful completion of abortion at home without the need for hospital admission, (2) efficacy, assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure as assessed by questionnaire. RESULTS: A total of 49 women participated in this study. Of these, 48 women aborted at home while one opted to be admitted to hospital after receiving misoprostol at home. One woman underwent surgical evacuation 5 weeks following abortion for excessive bleeding and retained products of conception. A total of 43/44 (98%) women were satisfied with having the abortion at home. Side effects experienced by women included nausea [32/40 (80%], vomiting [17/41 (42%)], diarrhoea [17/41 (42%)], shivering [26/40 (65%)], tiredness [32/40 (80%)], headache [12/39 (31%)], hot flushes [14/40 (35%)], dizziness [24/39 (62%)] and unpleasant mouth taste [19/38 (50%)]. CONCLUSIONS: This study suggests the feasibility and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. These findings need to be assessed in the context of a randomised trial.

Surgical abortion.

This review of surgically-induced abortion focuses on conventional first trimester suction evacuation. Manual vacuum aspiration at early gestations and dilatation and evacuation at more advanced gestation are also considered. The place of surgical abortion in contemporary abortion practice is reviewed alongside developments in medical abortion. There is still debate about the best method for later abortions. Patient choice and pre-procedure assessment are considered fundamental to practice. The importance of antibiotic prophylaxis or infection screening is highlighted. The value of ultrasound emerges. The need for cervical priming is considered along with choice of suitable pharmacological agents. Current practice and the procedure of surgical abortion is outlined. Complications and strategies to minimize risk are detailed. The overview concludes with consideration of the impact on future reproductive health.

Opportunistic screening for genital Chlamydia trachomatis infection and partner follow-up in family planning clinics in three Scottish cities.

Three large urban family planning clinics (FPCs) in Scotland participated in a study to examine the implications of opportunistically offering urine testing for genital Chlamydia trachomatis infection and FPC follow-up of positive women and of their male partners. Ninety-eight percent (3029) of women accepted the test. The prevalence of infection was 5.2% and this decreased significantly with age. There was no significant difference in prevalence between centres. Ninety-one percent of positive women intended to inform at least one partner about their infection status. Pretest counselling took about 10 minutes per woman while management (excluding full screening for sexually transmitted infections) of positive women took an additional 10 minutes. Screening in the FPC is acceptable to many women and to some of their male partners. Training and resources for administration and staffing are required if opportunistic screening is to be implemented.

Access to and experience of later abortion: accounts from women in Scotland.

CONTEXT: Except in the presence of significant medical indications, the legal limit for abortion in Great Britain is 24 weeks' gestation. Nevertheless, abortion for nonmedical reasons is not usually provided in Scotland after 18-20 weeks, meaning women have to travel to England for the procedure. METHODS: In-depth interviews were conducted with 23 women presenting for "later" abortions (i.e., at 16 or more weeks' gestation) in Scotland. Participants were women who sought an abortion at a participating National Health Service clinic between January and July 2013. Interviews addressed reasons for and consequences of later presentation, as well as women's experiences of abortion. Thematic analysis attended to emerging issues and employed the conceptual tool of candidacy. RESULTS: Delayed recognition of pregnancy, changed life circumstances and conflicting candidacies for motherhood and having an abortion were common reasons for women's presentation for later abortion. Women perceived that the resources required to travel to England for a later abortion were potential barriers to access, and felt that such travel was distressing and stigmatizing. Participants who continued their pregnancy did so after learning they were at a later gestational age than expected or after receiving assurances of support from partners, friends or family. CONCLUSIONS: Reasons for seeking later abortion are complex and varied among women in Scotland, and suggest that reducing barriers to access and improving local provision of such abortions are a necessity. The candidacy framework allows for a fuller understanding of the difficulties involved in obtaining abortions.

A randomised controlled trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion up to 13 weeks of gestation.

OBJECTIVE: To assess women's acceptability, the efficacy and side effects of sublingual versus vaginal administration of misoprostol in combination with mifepristone for medical abortion up to 13 weeks of gestation. DESIGN: Randomised controlled trial. SETTING: Aberdeen Royal Infirmary. POPULATION: Women undergoing medical abortion under the terms of the 1967 Abortion Act. METHODS: Mifepristone (200 mg) was given orally followed 36-48 hours later by misoprostol administration (sublingual: 600 microg; vaginal: 800 microg). A second dose of misoprostol 400 microg was given 3 hours later (sublingually or vaginally). Women between 9 and 13 weeks of gestation received a further (third) dose of misoprostol 400 microg (sublingually or vaginally), 3 hours later if abortion had not occurred. MAIN OUTCOME MEASURES: Women's acceptability, efficacy of the regimen and side effects experienced. RESULTS: A total of 340 women were recruited (171 sublingual and 169 vaginal). A total of 70% of women in the sublingual group expressed satisfaction with the route of misoprostol administration; 18% answered 'Don't know' while 12% were dissatisfied, compared with 68%, 28% and 4%, respectively, in the vaginal group (P= 0.02). There was no significant difference in the need for surgical evacuation for women in the sublingual (3/158, 1.9%) and vaginal groups (4/156, 2.6%) (P= 0.70). Women receiving misoprostol sublingually were more likely to experience diarrhoea (P < 0.01), shivering (P < 0.01) and unpleasant mouth taste (P < 0.01). CONCLUSIONS: Sublingual administration of misoprostol is an effective alternative to vaginal administration for medical abortion up to 13 weeks of gestation. The prevalence of prostaglandin-related side effects, however, was higher with this route of administration.

A randomized trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion at 13-20 weeks gestation.

BACKGROUND: Several studies have now reported the successful use of the sublingual administration of misoprostol for medical abortion in the first trimester. The objective of this study was to assess the acceptability to women, the efficacy of the regimen, as well as the acceptability to staff of sublingual versus vaginal administration of misoprostol following mifepristone for medical abortion at 13-20 weeks gestation. METHODS: Women were randomized by opening consecutive sealed envelopes generated using random number tables. Mifepristone (200 mg) was followed 36-48 h later by sublingual administration of misoprostol 600 microg or vaginal misoprostol 800 microg. This was followed by 3 hourly doses of misoprostol 400 microg administered sublingually or vaginally. RESULTS: A total of 76 women were randomized. Of women in the sublingual group, 24 (66.7%) expressed satisfaction with the route of misoprostol administration compared with 25 (62.5%) in the vaginal group. A higher proportion in the sublingual group used intramuscular opiates. There was no significant difference in the surgical evacuation rate between the sublingual (three out of 36 women, 8.3%) and vaginal groups (one out of 40, 2.5%), (P=0.26) and acceptability to staff was the same for both methods. CONCLUSIONS: Sublingual administration of misoprostol following mifepristone is an acceptable and effective alternative to vaginal administration for medical abortion at 13-20 weeks gestation. However, women should be advised about the greater likelihood of requiring stronger analgesia.

Psychological sequelae of medical and surgical abortion at 10-13 weeks gestation.

BACKGROUND: Although not much research comparing the emotional distress following medical and surgical abortion is available, few studies have compared psychological sequelae following both methods of abortion early in the first trimester of pregnancy. The aim of this review was to assess the psychological sequelae and emotional distress following medical and surgical abortion at 10-13 weeks gestation. METHODS: Partially randomized patient preference trial in a Scottish Teaching Hospital was conducted. The hospital anxiety and depression scales were used to assess emotional distress. Anxiety levels were also assessed using visual analog scales while semantic differential rating scales were used to measure self-esteem. A total of 368 women were randomized, while 77 entered the preference cohort. RESULTS: There were no significant differences in hospital anxiety and depression scales scores for anxiety or depression between the groups. Visual analog scales showed higher anxiety levels in women randomized to surgery prior to abortion (P < 0.0001), while women randomized to surgical treatment were less anxious after abortion (P < 0.0001). Semantic differential rating scores showed a fall in self-esteem in the randomized medical group compared to those undergoing surgery (P = 0.02). CONCLUSIONS: Medical abortion at 10-13 weeks is effective and does not increase psychological morbidity compared to surgical vacuum aspiration and hence should be made available to all women undergoing abortion at these gestations.

A randomized controlled comparison of sublingual and vaginal administration of misoprostol for cervical priming before first-trimester surgical abortion.

OBJECTIVE: The purpose of this study was to compare the effectiveness of the sublingual and vaginal administration of misoprostol for cervical priming before surgical termination of pregnancy. STUDY DESIGN: In a randomized controlled trial, 74 primigravid women who were undergoing surgical abortion were assigned randomly to receive misoprostol (400 microg) sublingually or vaginally. RESULTS: There was no statistically significant difference in the cumulative force that was required to dilate the cervix to 9 mm, for baseline cervical dilatation, for priming to abortion interval, for operating time, or for intraoperative blood loss between the two groups. Women in the sublingual group had more nausea (P=.008), vomiting (P=.01), diarrhea (P=.01), and unpleasant mouth taste (P=.0001) compared with the women in the vaginal group. In the sublingual group, 65% of women were satisfied with the route of misoprostol administration compared with 78% in the vaginal group (P=.11). Most of the staff members (84%) said that they would recommend the sublingual administration of misoprostol (P=.0001). CONCLUSION: The sublingual administration of misoprostol is an effective alternative to vaginal administration for cervical priming before surgical abortion; despite a higher incidence of side effects, there was high patient and staff acceptability.

Medical abortion at 64 to 91 days of gestation: a review of 483 consecutive cases.

OBJECTIVE: The purpose of this study was to assess the uptake and outcome of medical abortion in the late first trimester of pregnancy. STUDY DESIGN: We conducted a review of the cases of 483 consecutive women in a university hospital who underwent medical abortion at 64 to 91 days of gestation and who used mifepristone that was followed 36 to 48 hours later by repeated doses of misoprostol. RESULTS: A total of 891 abortions were carried out at 64 to 91 days of gestation from October 2000 to April 2002; of these, 483 cases (54.2%) were undertaken medically. Complete abortion occurred in 458 cases (94.8%). Efficacy decreased with advancing gestational age. Surgical evacuation was carried out in 1 woman (0.9%) at 9 to 10 weeks of gestation, in 8 women (5.3%) at 10 to 11 weeks of gestation, in 7 women (6.2%) at 11 to 12 weeks of gestation, and in 9 women (7.9%) at 12 to 13 weeks of gestation. Indications for surgery included ongoing pregnancy in 8 cases (1.7%), missed abortion in 3 cases (0.6%), incomplete abortion in 13 cases (2.7%), and emergency curettage for bleeding in 1 case (0.2%). The mean number of misoprostol doses used was 2.3; of those women who had a complete abortion, 152 women (32.6%) aborted within 4 hours of receiving the misoprostol. The mean induction to abortion interval was 5.5 hours; most cases (452; 93.6%) were treated as day cases. CONCLUSION: Medical abortion between 64 and 91 days of gestation is effective and has a high uptake. Consideration should be given to extending the availability and choice of medical abortion to women in this gestational group.

Factors affecting the outcome of early medical abortion: a review of 4132 consecutive cases.

OBJECTIVE: To assess the outcome of a regimen of a reduced dose of mifepristone followed by one or two doses of vaginal misoprostol as a non-surgical method for termination of pregnancy. DESIGN: Prospective observational study. SETTING: Aberdeen Royal Infirmary, Aberdeen, Scotland. POPULATION: Women seeking abortion under the 1967 Abortion Act. METHODS: Factors influencing the outcome in a consecutive series of 4132 women undergoing early medical abortion in one Scottish teaching hospital since 1994. MAIN OUTCOME MEASURES: Complete abortion rates following one or two doses of misoprostol. The effect of age, gestation, previous pregnancy and previous termination on complete abortion rates following the medical regimen. RESULTS: Of the 4132 women, 95 (2.3%) aborted within 48 hours of mifepristone and a further 3942 (95.4%) achieved complete abortion following administration of one or two doses of misoprostol. Thus, the overall complete abortion rate was 97.7% (4037/4131). A total of 94 (2.3%) women required surgical intervention of whom 13 (0.3%) had a continuing pregnancy. Following change of the regimen to include the possibility of two doses of misoprostol the continuing pregnancy rates were significantly reduced (OR = 5.88) and gestation ceased to have an effect on overall efficacy. Women who had a previous abortion were more likely to have a failed medical abortion (OR = 2.09), while women with no previous termination, but a previous live birth were more likely to have a failed abortion (OR = 2.03). CONCLUSION: Mifepristone in combination with one to two doses of vaginal misoprostol is an effective regimen for early medical abortion. The option of administering two doses of misoprostol significantly reduced the ongoing pregnancy rates and abolished the effect of gestation on overall efficacy. Previous termination was the strongest predictor of failed medical abortion.

Randomised controlled study comparing oral and vaginal misoprostol for cervical priming prior to surgical termination of pregnancy.

OBJECTIVE: To compare the effectiveness of oral misoprostol with vaginal misoprostol as a cervical priming agent prior to first trimester vacuum aspiration. DESIGN: Randomised study. SETTING: Scottish teaching hospital. POPULATION: Primigravid women at gestations up to 91 days requesting surgical abortion under the 1967 Abortion Act. METHODS: Sixty-four women were randomised to receive misoprostol 400 microg orally at home or vaginally in hospital 2-4 hours pre-operatively for cervical priming. MAIN OUTCOME MEASURES: The main outcome measures were cumulative force required to dilate the cervix to 9 mm, baseline cervical dilatation, intra-operative blood loss and patient and staff acceptability. RESULTS: There was no significant difference in baseline cervical dilatation, peak force required to dilate the cervix at 8 and 9 mm and cumulative force required between the two groups. Operating time and intra-operative blood loss were not significantly different between the two groups. The priming to abortion interval was significantly longer with oral misoprostol when compared with the vaginal group (P < 0.0001). Women receiving oral misoprostol were significantly more likely to experience nausea (OR: 3.9, 95% CI: 1.3 to 11.2), while women receiving vaginal misoprostol were more likely to complain of tiredness (OR: 0.2, 95% CI: 0.1 to 0.7) with no significant differences in other side effects between the two groups. There was no significant difference in patient acceptability in relation to the priming agent between the two groups (P = 0.96). However, majority of the nursing staff (83%) admitting women preferred the oral route of administration. CONCLUSION: Cervical priming with oral misoprostol at home is effective with high patient and staff acceptability.

A randomized comparison of medical abortion and surgical vacuum aspiration at 10-13 weeks gestation.

BACKGROUND: Since 1991, mifepristone in combination with a prostaglandin analogue has been licensed for termination of pregnancy in the UK at up to 9 weeks amenorrhoea, and since 1995, beyond 13 weeks. Surgical methods are used almost exclusively at 10-13 weeks amenorrhoea. METHODS: A patient-centred, partially randomized, controlled trial was carried out. Those who expressed a strong preference for either medical (n = 15) or surgical (n = 62) abortion were allocated to that method. The remainder agreed to be randomized. The medical method (n = 188) was mifepristone 200 mg followed by misoprostol up to 3 doses, and surgery (n = 180) was by vacuum aspiration under general anaesthesia. Outcome measures included efficacy rates, medical complications within 8 weeks of the procedure, patient preferences and acceptability. RESULTS: Among women who underwent medical abortion, 5.4% required a second procedure compared with 2.1% who had surgery, although this difference was not statistically significant. Side effects experienced were higher in women who underwent medical abortion compared with those who underwent surgery. There were no significant differences in the rates of major complications up to 8 weeks. Prior to termination, 80% of women had a preference for a method, with 72% preferring medical and 28% preferring surgical abortion. Following abortion, 70% of those who underwent medical termination and 79% who underwent surgery would opt for the same method in the future. CONCLUSION: Medical abortion is safe and effective at 10-13 weeks gestation and should be considered an option for those women who wish to avoid surgery and anaesthesia.