Induced-abortion (ELearningPage)

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      <HtmlField Name="References"><![CDATA[<ol>
    <li>World Health Organization, Department of Reproductive Health and Research. Safe abortion: technical and policy guidance for health systems. Second edition. 2012</li>
    <li>Munk-Olsen T et al. Induced first trimester abortion and risk of mental disorder. N Engl J Med 2011; 364:332-339</li>
    <li>Sunde Oppegaard K, Qvigstad, E, Fiala, C, Heikinheimo, O, Benson, L, Gemzell-Danielsson K. A simplified medical abortion protocol using self-assessment for treatment success: a multicentre, non-inferiority, randomised controlled trial. LANCET 2015; 385: 698&ndash;704</li>
    <li>Lalitkumar S, Bygdeman M, Gemzell-Danielsson K. Mid-trimester induced abortion: a review.Hum Reprod Update. 2007 Jan-Feb;13(1):37-52.</li>
    <li>Endler M, Lavelanet A, Cleeve A, Ganatra B, Gomperts R, Gemzell-Danielsson K. Telemedicine for medical abortion: a systematic review. BJOG. 2019 Mar 14. doi: 10.1111/1471-0528.15684
    </li>
</ol>]]></HtmlField>
      <HtmlField Name="Author"><![CDATA[Mette L&oslash;keland-Stai, Abortion Registry, Insitute of Public Health Norway and Betanien Hospital, Bergen, Norway
<br />
<br />
Kristina Gemzell-Danielsson,  Department of Women&rsquo;s and Children&rsquo;s Health, Division of Obstetrics &amp; Gynecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
<br />
<br />
Oskari Heikinheimo, Department of Obstetrics &amp; Gynecology, University of Helsinki and Helsinki University Hospital, Finland<br />]]></HtmlField>
      <HtmlField Name="TakeHomeMessage"><![CDATA[<ul>
    <li>Illegal and unsafe abortion is major cause of maternal mortality and morbidity globally. This is preventable<em> through good and affordable access to legal and safe abortion</em></li>
    <li><em>The rates of induced abortion are lowest were abortion is legal, integrated in the mainstream health care and destigmatized</em>. Training in abortion care is a crucial part of Obstetrics and Gynecology</li>
    <li><em>Medical abortion can be done irrespective of gestational age, has increased access in early first trimester and autonomy for the user, reduced barriers to safe abortion and has become the dominant method in the Nordic countries</em></li>
    <li><em>Legal abortion carried out according to the WHO guidelines is safe and not associated with adverse future health outcomes</em></li>
    <li>Long acting reversible contraceptive methods (LARCs) can be started immediately following an abortion and are the most effective methods to prevent another unwanted pregnancy
    </li>
</ul>]]></HtmlField>
      <HtmlField Name="PageContent"><![CDATA[<p>[VIMEO=302663935|app=true]&nbsp;</p>
<h2>Introduction</h2>
<p>Induced abortion is one of the more frequent, minor and safe procedures within obstetrics and gynecology. At the same time, it is probably the most controversial procedures in medicine. Due to poor access and illegal settings, unsafe abortion is one of the leading causes of maternal mortality and morbidity in many parts of the world. These maternal deaths could be avoided if abortion was made legal and accessible.</p>
<p>In the Nordic countries abortion is legal, safe, easily available, and largely approved by the public. Political debate concerning abortion is surfacing every now and then also in the Nordic countries, but even more so in countries where the procedure is more highly controversial. <br>
<br>
According to the most recent estimates about 56.3 million abortions are performed every year and 45% of them, i.e. 25 million are unsafe, with an estimate of 23 000 maternal deaths as a consequence. The highest abortion rates are found in regions where access to abortion is restricted or prohibited like in African and Latin American countries where the abortion rate reaches 34 and 44 per 1000 women in fertile age. Worldwide approximately one in four pregnancies ends in an abortion. <br>
<br>
In the Nordic countries the abortion figures have remained relatively stable, and with other western European countries among the lowest in the world. During the last ten years teenage abortion rates have shown a marked decrease. The abortion rates ranged from the lowest of 7.7 in Finland to 19 in Sweden per thousand women 15-49 (15-44 in Sweden) year-aged in 2019 (<a href="https://thl.fi/en/web/thlfi-en/statistics/statistics-by-topic/sexual-and-reproductive-health/abortions/induced-abortions-in-the-nordic-countries">Abortion in the Nordic countries</a>). Each Nordic country has an individual law on abortion, those are summarized in Table 1. The laws differ, however their interpretation is liberal.</p>
<h2>
Procedures</h2>
<h3>
First trimester</h3>
<p>Approximately 95% of all abortions in the Nordic countries are performed during the first trimester. The recommended and dominant method for first trimester abortion is medical. Access to surgical abortion is necessary and should be available to all women who for personal or medical reasons prefer surgical abortion and in the case of unsuccessful or incomplete medical abortion (0.5-5%). </p>
<h3>Medical abortion</h3>
<p><strong>&lt;9 weeks gestation</strong>: 200 mg mifepristone orally followed by 800 mcg misoprostol vaginally or sublingually after 24-48 (-72) hours. An additional 400 mcg misoprostol can be administered after 3-4 hours if pregnancy products have not been expelled. Misoprostol can be administered at home in most cases (up to 10 weeks). A shorter interval between mifepristone and misoprostol is associated with less side effects.
<br>
<strong>9-12 weeks gestation</strong>: 200 mg mifepristone orally followed by 800 mcg misoprostol vaginally or sublingually after 24-48 hours followed by 400 mcg misoprostol orally or sublingually every 3-4 hours until expulsion. Misoprostol is mainly administrated in a hospital ward (recommended beyond 10 weeks).
</p>
<h3>Contraindications to medical abortion</h3>
<p>
Absolute contraindications are:
</p>
<ul>
    <li>Allergy to mifepristone or misoprostol/ gemeprost</li>
    <li>Chronic adrenal deprivation or longterm treatment with corticosteroids</li>
    <li>Porfyria</li>
    <li>Ectopic pregnancy</li>
</ul>
<p>Caution should be shown in case of anticoagulants or coagulation disorders. An IUD should be removed prior to the treatment. Previous c-sectio or duplex is not a risk at early medical abortion.</p>
<h3>Surgical abortion</h3>
<p>Vacuum aspiration with 400 mcg misoprostol vaginally (3h) or sublingually (1h) for cervical priming</p>
<h3>Second trimester</h3>
<ol>
    <li>
    <p>The practice of second trimester abortion (medical vs surgical) varies in different parts of the world based on traditions, experience and how abortion care is organized.</p>
    <p>a. <strong>Medical abortion </strong>is the recommended method for second trimester abortions in the Nordic countries. 200 mg mifepristone orally followed by 800 mcg misoprostol vaginally or sublingually after 24-48 hours followed by 400 mcg misoprostol every 3-4 hours until complete expulsion occurs. Misoprostol may be started at home but is usually administrated at a hospital ward, Additional surgical evacuation is needed in case of incomplete placenta (approx. 10% of cases).</p>
    <p>b. <strong>Surgical abortion</strong> by means of dilation and evacuation (D&amp;E) is the most common form of second trimester abortion in some European countries and in USA. In the Nordic countries medical abortion has become the method of choice because the surgical method requires more training to be equally safe as medical abortion, and the numbers of second trimester abortions in the Nordic countries are relatively low. Thus medical abortion can be offered in all gynecological departments and not limited to a few specialized clinics.</p>
    </li>
</ol>
<h2>Expected short term effects</h2>
<h3>Pain and bleeding</h3>
<p>
Pain medication should be given with  NSAID and if needed more  potent analgesics. Heavy bleeding is not a guarantee of complete abortion. Misoprostol induces cramping and bleeding during the expulsion of pregnancy products. For the majority it will be moderate to heavy cramping and bleeding. This is generally well tolerated as long as the women are prepared. Women who have not previous given birth tend to experience more pain. After the expulsion prolonged bleeding and spotting will occur for an average of around 10-14 days. For some women it lasts until the first normal period. The first menstrual period tends to appear after 4-6 weeks and can be slightly heavier than the general period.
<br>
<br>
Complications to medical abortion are rare and include heavy bleeding, infections, and hypotonia. Side effects to misoprostol include gastrointestinal side effects (nausea, vomiting and diarrhea) skin rash, shivering and fever. Mifepristone has no known teratogenic effect while this effect is unclear for misoprostol. Limb defects have been associated with impared placento blood flow. Failed abortion (ongoing pregnancy occur in 0.5%, and incomplete abortion in 2-3%.
<br>
<br>
Complications to surgical abortion is directly correlated to gestational length and the experience of the surgeon. Failed abortion (ongoing pregnancy occur in 1%, and incomplete abortion in 0.3% but is higher before 7 weeks. %.&nbsp;Uterine perforation, pelvic inflammatory disease and serious complications are rare both for surgical and medical abortion.All the above complications can be reduced by using following current guidelines including cervical dilatation, ultrasound or viewing the products and screening for infection.</p>
<h2>Pre- and post- abortion procedures</h2>
<p>
Additional testing and procedures are performed according to national guidelines. These may include:
</p>
<ol style="list-style-type: lower-alpha;">
    <li>Pre abortion tests (such as screening Chlamydia, possibility of cervical smear and blood group testing)</li>
    <li>Administration of anti-D immunoglobulin to RhD-negative women.</li>
    <li>Administration of prophylactic antibiotics before (surgical) abortion.</li>
</ol>
<h3>Post abortion contraception</h3>
<p>Many women who opt for an abortion has either not been using any contraception or has experienced contraception failure. Thus, the offer of contraceptive counselling and provision is an important part of abortion care.&nbsp;</p>
<p>Return of follicular development and ovulation occurs rapidly, and many women resume sexual activity soon after an induced abortion. Prompt initiation of contraception after an induced abortion is important. Oral contraceptive pills, vaginal rings or contraceptive patches can be started on the day of induced abortion (day of misoprostol administration in medical abortion), or the day after.
<br>
<br>
A series of studies have found that the use of long active reversible contraception ([LARC], i.e. contraceptive implants and intrauterine devices) has the strongest effect in reducing the need of subsequent abortion. It is important to give women good information on effective contraception with low risk of incorrect use.
</p>
<p>Implants can be inserted at the day of mifepristone intake approximately one hour following administration of mifepristone This will not interfere with the efficacy of medical abortion. In contrast DepoProvera should not be initiated until the day of misoprostol to avoid interfering with the efficacy of the medical abortion.&nbsp;</p>
<p>IUD can be safely inserted at the end of the surgical procedure or when the pregnancy has been expelled in medical abortion. If inserted immediately after expulsion in medical abortion an increased rate of expulsions are noted However, insertions on day 5 do not result in any increased expulsion rate compared to insertion 4 weeks after the medical abortion in the Ist trimester.
</p>
<h3>Follow-up visit</h3>
<p>
Recommendations concerning the need of follow-up visit vary. It is important to rule out continuing pregnancy. This is best done by verifying low levels of hCG either from serum or urine sample after abortion.
<br>
<br>
For further information and references:
</p>
<p><a href="http://www.dsog.dk/gynkologi/">Danish guidelines</a>
<br>
<a href="https://www.kaypahoito.fi/hoi27050">Finnish guidelines</a>
<br>
<a href="http://legeforeningen.no/Fagmed/Norsk-gynekologisk-forening/Veiledere/Veileder-i-gynekologi-2015/Provosert-abort11/">Norwegian guidelines</a>
<br>
<a href="https://www.sfog.se/natupplaga/ARGrappor9792c7d5-5648-475e-bee6-81478b0d9323.pdf">Swedish guidelines (ARG report nu 78, www,sfog.se)</a><br>
Iceland guidelines
<br>
<a href="http://apps.who.int/iris/bitstream/handle/10665/97415/9789241548717_eng.pdf;jsessionid=15942D8EED2268BF6F86328156DD7687?sequence=1">WHO guidelines</a></p>
<h2>Long term effects</h2>
<h3>Mental effects</h3>
<p>
The risk of adverse psychological experiences as a consequence of induced abortion has been a continuous concern among many parties. The current evidence suggest that the effects of abortion on mental wellbeing are neutral.
<br>
<br>
Most studies find that the number of women who experience psychological ill being after an abortion are few and a population study from Denmark found no increased risk. Among persons undergoing an abortion a higher incidence rate of psychologic morbidity already prior to the abortion compared to the general population has been reported. A Norwegian study found that those who had psychological negative experiences were mainly women who had been pressured into having an abortion, had been very ambivalent in their decision on having an abortion or had previous mental health issues. Supporting vulnerable persons and those who are ambivalent is crucial. All persons seeking an abortion should be offered social counselling.
<br>
<br>
The negative consequences for the individual woman, her partner, future child family and society by an unwanted pregnancy and delivery is well documented.  A vast majority of teenage pregnancies are unplanned and unwanted. Teenage pregnancy is a leading course of maternal mortality globally and is a risk factor for another unwanted delivery or repeat abortion.
</p>
<h3>
Fertility</h3>
<p>
A medical or surgical abortion without complications have no impact on future fertility.
</p>
<h3>
Premature delivery</h3>
<p>
While surgical abortion has been connected with a slightly increased risk for premature delivery this has not been seen following medical abortion. Priming with misoprostol prior to vacuum aspiration and correct surgical technique will also reduce this risk.
</p>
<h3>
Breast cancer</h3>
<p>Induced abortion does not increase the risk of developing breast cancer or any other type of cancer.
</p>
<h2>
Legal aspects</h2>
<p>
In all Nordic countries, pregnancy can be terminated at any time if continuation of the pregnancy is a threat to the woman&rsquo;s life or health.</p>
<table class="vandret-layout">
    <thead>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="col">Country</th>
            <th class="vandret-layoutTableOddCol" scope="col">Early abortion</th>
            <th class="vandret-layoutTableEvenCol" scope="col">Late abortion</th>
            <th class="vandret-layoutTableOddCol" scope="col">Upper limit</th>
            <th class="vandret-layoutTableEvenCol" scope="col">Access for non citizens</th>
            <th class="vandret-layoutTableOddCol" scope="col">Link to law <br>
            and year of enactment</th>
        </tr>
    </thead>
    <caption>Table 1</caption>
    <tbody>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Denmark</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">On request up to 12 weeks </td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Viability</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Yes, for those over 18 years</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">1973 <br>
            <a href="hhttps://www.retsinformation.dk/Forms/R0710.aspx?id=183932#id7c019489-4f25-427b-832d-c1af16f0c234">In Danish</a> <br>
            <a href="https://cyber.harvard.edu/population/abortion/Denmark.abo.htm">In English</a></td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Finland</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Up to 12+0 weeks with the consent of one/two doctors</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Up to 20+0 weeks with approval from national authority</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">24+0 weeks in cases of fetal deformity with approval from national authority</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Yes</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">1970 <br>
            In Finish <br>
            In Swedish <br>
            <a href="https://cyber.harvard.edu/population/abortion/Finland.abo.htm">In English</a><br>
            </td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Iceland</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">On request up to 22 +0 weeks</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">On request up to 22+0 weeks</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Yes</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">2019 <br>
            <a href="http://www.althingi.is/lagas/nuna/1975025.html">In Icelandic</a></td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Norway</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">On request up to 12 weeks</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Viability, the regulations to the law state 21+6 weeks and days</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Yes. It is defined as emergency treatment</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">1975, on request from 1978 <br>
            <a href="https://lovdata.no/dokument/NL/lov/1975-06-13-50">In Norwegian</a> <br>
            <a href="http://app.uio.no/ub/ujur/oversatte-lover/cgi-bin/sok.cgi?dato=&amp;nummer=&amp;tittel=svangerskapsavbrudd&amp;type=LOV&amp;S%F8k=Search">In English</a></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Sweden</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">On request up to 18+0 weeks</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">From 18+1 weeks and day if approved by the Board of Health. And Welfare </td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Viability, for healthy fetus currently defined as 21+6 weeks and days</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Yes</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">1974 <br>
            <a href="http://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/abortlag-1974595_sfs-1974-595">In Swedish</a> </td>
        </tr>
    </tbody>
</table>
<p><a href="https://www.retsinformation.dk/Forms/R0710.aspx?id=183932#id7c019489-4f25-427b-832d-c1af16f0c234">Denmark, abortion law</a> (<a href="https://cyber.harvard.edu/population/abortion/Denmark.abo.htm">English version</a>) The law from 1973 grants abortion on request up to 12 weeks&rsquo; gestation. After twelve weeks abortion can be granted by a commission for a number of psychosocial reasons and foetal malformation up until the foetus is viable. Abortion is only available to citizens of Denmark.
<br>
<br>
Finland, abortion law (<a href="https://cyber.harvard.edu/population/abortion/Finland.abo.htm">English version</a>) The law from 1970 grants abortion (indications include socioeconomic reasons, age (&lt;17 or &ge;40 years of age) or having delivered &ge;4 children) up to 12+0 weeks&rsquo; gestation with the consent of one or two doctors. After twelve weeks abortion can be granted up to 20+0 weeks by the National Supervisory Authority for Welfare and Health (Valvira) if the indications are filled, or up to 24+0 weeks in cases of confirmed fetal malformation or severe illness.
</p>
<p><a href="http://www.althingi.is/lagas/nuna/1975025.html">Iceland, abortion law</a>&nbsp;(<a href="https://www.womenonwaves.org/en/page/4787/abortion-law-iceland">English version</a>) The law from 2019 allows abortion on request up to 22 weeks gestation regardless of circumstances. This was extended from an up to 16 weeks limit in the previous law from 1975. Where one could only obtain an abortion after 16 weeks by the consent of a committee.
<br>
<br>
<a href="https://lovdata.no/dokument/NL/lov/1975-06-13-50">Norway, abortion law</a> The law is from 1975. From 1978 abortion is granted on request up to 12 weeks&rsquo; gestation. After twelve weeks abortion can be granted by a commission for a number of psychosocial reasons and fetal malformation up until the fetus is viable. Abortion is available to all regardless of citizenship.
<br>
<br>
<a href="http://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/abortlag-1974595_sfs-1974-595">Sweden, abortion law</a> The law from 1974 (came in practice in 1975) allows abortion on request up to 18 weeks&rsquo; gestation. After 18 weeks abortion can be granted by a central commission (R&auml;ttsliga r&aring;det) at the Board of Health and Welfare up to viability which at present is set at 21+6 weeks&rsquo; and days gestation for social reasons and fetal disorders. Abortion is always granted if the fetus is not expected to be viable. Abortion is available to all regardless of citizenship.
<br>
<br>
The Nordic countries have some of the world&rsquo;s most liberal abortion laws. In many parts of the world abortion is either prohibited or available only for restricted reasons. For more information on the worlds abortion laws you can visit WHO&rsquo;s global abortion policy database and <a href="http://worldabortionlaws.com/">The worlds abortion laws</a>.
</p>
<h2>Global perspective</h2>
<p>
It is difficult to estimate the number of abortions in most regions of the world where health registries are non-existent, abortion is stigmatised and performed illegally. Due to that abortions are very often underreported. It has been estimated that the annual number of abortions in 2010-2014 was 56.3 million with an abortion rate of 35 per 1000 women between the age 15-44 years. The abortion rate had dropped significantly from 1990-94 to 2010-14 in the developed world from 44 to 27 per 1000 women age 15-44 and only 39 to 37 in the developing world. Another study by the WHO found that 55% of the abortions were safe while 45% were unsafe. A safe abortion in that study was defined as performed by a trained provider in accordance with methods recommended by the WHO. They also acknowledged that safety is influenced by other factors than provider and method. Factors such as legal situation, stigma and economy also influences access to abortion and telemedicine counselling and provision of medical abortion, and self-administration such as provided by women on web can be a safe procedure. The use of self-medication and telemedicine services of medical abortion is increasing globally.
</p>
<p>The proportion of unplanned pregnancies ending in an abortion has declined in developed countries while there is an increase in developing countries. It is estimated that 18% of maternal mortality is caused by unsafe abortion and key interventions recognized to reduce MM are access to family planning, safe abortion services and post abortion care.
</p>
<p>&nbsp;</p>
<p><strong>Keywords: </strong>Induced Abortion, mifepristone, misoprostol, medical abortion, vacuum aspiration</p>
<h2>Multiple choice quiz</h2>
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