Women in Final Stage of Early Medical Abortion
Women in Final Stage of Early Medical Abortion
Introduction Throughout Great Britain, increasing numbers of women having an early medical abortion are choosing to go home soon after administration of misoprostol, to expel the pregnancy at home (early medical discharge, EMD), rather than remain upon the hospital premises (day case). However, data are lacking on how this impacts upon an abortion service in terms of unscheduled re-attendance rates and contraception provision at discharge.
Methods A retrospective audit was carried out of women undergoing medical abortion (up to 64 days' gestation) over 9 months at a National Health Service hospital in Scotland, to determine (1) unscheduled re-attendance rates within 6 weeks of the procedure for an abortion-related complication and (2) method of contraception provided at discharge.
Results Over the audit period 1128 women had an early medical abortion of whom 590 (52%) chose EMD. There was no significant difference in unscheduled re-attendance rates between EMD (n=23, 4%) and day case groups (n=20, 4%). There was no significant difference in the proportion of women in each group who left hospital with an effective method of contraception (n=362, 61% and n=355, 60% for EMD and day case groups, respectively).
Conclusions Women undergoing early medical abortion who choose to expel the pregnancy at home are no more likely to re-attend hospital with a post-abortal complication and are just as likely to receive effective contraception than those who remain on hospital premises.
In most countries throughout the world where early medical abortion with mifepristone and misoprostol is available (including the USA, France and Sweden) women who are in early pregnancy and who request a medical method of abortion are able to choose to administer misoprostol at home and to expel the pregnancy at home. Although there is a growing evidence base that 'home' medical abortion is both safe and acceptable to women, the interpretation of the Abortion Act 1967 is that (in Great Britain) misoprostol is required to be administered on licensed premises. Increasing numbers of women at early gestation who request medical abortion in Great Britain are, however, choosing to go home soon after misoprostol administration, to pass the final stage of the procedure at home. This early medical abortion service that permits women to go home soon after administration of misoprostol has previously been termed 'early medical discharge' (EMD), to distinguish it from 'day case' medical abortion where women are admitted to a medical abortion unit to pass the pregnancy, usually for a period of up to 6 hours. Studies throughout Great Britain have demonstrated high levels of acceptability of EMD among women who choose this service. Data are, however, lacking on how an EMD service impacts upon a National Health Service (NHS) abortion service in Great Britain, and in particular whether or not women who choose EMD have differential unscheduled re-attendance rates at the service for a problem related to the procedure compared to counterparts treated as day cases. There are also concerns that since women choosing EMD do not remain on the abortion service premises, they may be less likely to be provided with an effective method of contraception at discharge.
In Scotland, the vast majority of all abortions are performed in the NHS and almost exclusively within a hospital setting. The Royal Infirmary of Edinburgh (RIE) is a major teaching hospital in Edinburgh and is the main provider of abortion services in Lothian (Edinburgh and the surrounding area). In March 2009, an EMD service was introduced for women requesting an abortion at up to 8 weeks' gestation, who wished to avail themselves of this treatment and who fulfilled previously published criteria. From April 2010 the gestation limit for EMD at the RIE was raised to 9 weeks' gestation. As part of this EMD service, women who choose EMD return to the clinic for the second part of the medical abortion treatment with 800 μg misoprostol administered vaginally, 24–48 hours after receiving 200 mg oral mifepristone. This medical abortion regimen is identical to that used for women undergoing treatment as a day case, with the exception that women treated as a day case (i.e. admitted to a ward for up to 6 hours after misoprostol administration) may be given a further 400 μg dose of misoprostol if they fail to abort within 4 hours of admission. An additional dose of misoprostol is not supplied to women choosing EMD since this medication must be administered on licensed premises. The analgesic regimen used for EMD has previously been described in detail, but is essentially the same for both EMD and day case treatment, with women in both groups receiving empirical analgesia (1 g paracetamol orally and 400 mg ibuprofen orally, unless contraindicated) when misoprostol is administered, and dihydrocodeine offered for subsequent breakthrough pain if required. Women in EMD are given a small supply of dihydrocodeine tablets to take home. Contraception is dispensed to women in both EMD and day case treatment groups at discharge and women are provided with written information on what to expect over the following days, together with 24-hour emergency contact numbers. A follow-up appointment with the abortion service is arranged for all women choosing EMD 2 weeks later to confirm complete abortion, but only for those day case patients who fail to expel the pregnancy during their admission.
The main aim of this study was to determine if unscheduled re-attendance rates for a complication related to early medical abortion (up to 9 weeks' gestation) differed between those women who opted to be treated as EMD and those treated as a day case. A secondary aim was to compare the proportions of women having EMD and day case medical abortion who left the service with an effective ongoing method of contraception.
Abstract and Introduction
Abstract
Introduction Throughout Great Britain, increasing numbers of women having an early medical abortion are choosing to go home soon after administration of misoprostol, to expel the pregnancy at home (early medical discharge, EMD), rather than remain upon the hospital premises (day case). However, data are lacking on how this impacts upon an abortion service in terms of unscheduled re-attendance rates and contraception provision at discharge.
Methods A retrospective audit was carried out of women undergoing medical abortion (up to 64 days' gestation) over 9 months at a National Health Service hospital in Scotland, to determine (1) unscheduled re-attendance rates within 6 weeks of the procedure for an abortion-related complication and (2) method of contraception provided at discharge.
Results Over the audit period 1128 women had an early medical abortion of whom 590 (52%) chose EMD. There was no significant difference in unscheduled re-attendance rates between EMD (n=23, 4%) and day case groups (n=20, 4%). There was no significant difference in the proportion of women in each group who left hospital with an effective method of contraception (n=362, 61% and n=355, 60% for EMD and day case groups, respectively).
Conclusions Women undergoing early medical abortion who choose to expel the pregnancy at home are no more likely to re-attend hospital with a post-abortal complication and are just as likely to receive effective contraception than those who remain on hospital premises.
Introduction
In most countries throughout the world where early medical abortion with mifepristone and misoprostol is available (including the USA, France and Sweden) women who are in early pregnancy and who request a medical method of abortion are able to choose to administer misoprostol at home and to expel the pregnancy at home. Although there is a growing evidence base that 'home' medical abortion is both safe and acceptable to women, the interpretation of the Abortion Act 1967 is that (in Great Britain) misoprostol is required to be administered on licensed premises. Increasing numbers of women at early gestation who request medical abortion in Great Britain are, however, choosing to go home soon after misoprostol administration, to pass the final stage of the procedure at home. This early medical abortion service that permits women to go home soon after administration of misoprostol has previously been termed 'early medical discharge' (EMD), to distinguish it from 'day case' medical abortion where women are admitted to a medical abortion unit to pass the pregnancy, usually for a period of up to 6 hours. Studies throughout Great Britain have demonstrated high levels of acceptability of EMD among women who choose this service. Data are, however, lacking on how an EMD service impacts upon a National Health Service (NHS) abortion service in Great Britain, and in particular whether or not women who choose EMD have differential unscheduled re-attendance rates at the service for a problem related to the procedure compared to counterparts treated as day cases. There are also concerns that since women choosing EMD do not remain on the abortion service premises, they may be less likely to be provided with an effective method of contraception at discharge.
In Scotland, the vast majority of all abortions are performed in the NHS and almost exclusively within a hospital setting. The Royal Infirmary of Edinburgh (RIE) is a major teaching hospital in Edinburgh and is the main provider of abortion services in Lothian (Edinburgh and the surrounding area). In March 2009, an EMD service was introduced for women requesting an abortion at up to 8 weeks' gestation, who wished to avail themselves of this treatment and who fulfilled previously published criteria. From April 2010 the gestation limit for EMD at the RIE was raised to 9 weeks' gestation. As part of this EMD service, women who choose EMD return to the clinic for the second part of the medical abortion treatment with 800 μg misoprostol administered vaginally, 24–48 hours after receiving 200 mg oral mifepristone. This medical abortion regimen is identical to that used for women undergoing treatment as a day case, with the exception that women treated as a day case (i.e. admitted to a ward for up to 6 hours after misoprostol administration) may be given a further 400 μg dose of misoprostol if they fail to abort within 4 hours of admission. An additional dose of misoprostol is not supplied to women choosing EMD since this medication must be administered on licensed premises. The analgesic regimen used for EMD has previously been described in detail, but is essentially the same for both EMD and day case treatment, with women in both groups receiving empirical analgesia (1 g paracetamol orally and 400 mg ibuprofen orally, unless contraindicated) when misoprostol is administered, and dihydrocodeine offered for subsequent breakthrough pain if required. Women in EMD are given a small supply of dihydrocodeine tablets to take home. Contraception is dispensed to women in both EMD and day case treatment groups at discharge and women are provided with written information on what to expect over the following days, together with 24-hour emergency contact numbers. A follow-up appointment with the abortion service is arranged for all women choosing EMD 2 weeks later to confirm complete abortion, but only for those day case patients who fail to expel the pregnancy during their admission.
The main aim of this study was to determine if unscheduled re-attendance rates for a complication related to early medical abortion (up to 9 weeks' gestation) differed between those women who opted to be treated as EMD and those treated as a day case. A secondary aim was to compare the proportions of women having EMD and day case medical abortion who left the service with an effective ongoing method of contraception.
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