Overview of Abortion in Laos Alongkone Phengsavanh MD

History of abortion in Laos No medical abortion in the past Methods of Induced abortion in the past Dilatation and Curettage Forceful massage Falling from the height Herbal Uterine insertion Uterine insertion of Detergent etc

Complications of abortion in the past Vaginal bleeding Uterine perforation Septicemia Trauma to abdominal organ etc

Where Safe Abortion is Unavailable, Women Seek Unsafe Abortion. Methods of unsafe abortion: Ingestion of herbs, bleach, and toxic chemicals Voluntary blows to the stomach, intentional falls Vaginal insertion of sharp tools, twigs, harmful chemicals Sham procedures, covak’s procedure (Vera Drake), untrained or unskilled providers These are photos of sticks and herbs used as abortifacients in Nigeria. This is from our country director, Ejike Oji, who describes how women or quacks sharpen the stick to a point and insert it into the uterus to induce abortion. Source: Grimes, David, Janie Benson, Susheela Singh, Mariana Romero, Bela Ganatra, Friday Okonofua and Iqbal Shah. 2006. Unsafe abortion: The preventable pandemic. Lancet, 368(9550): 1908-19.

“ Ya chine “ “ Ya Chine “ is abortificients which was illegally imported from China in border of Lao provinces Mifepristone Misoprostol Wrong dosage No indication No insert paper

Misoprostol Registration in Laos Lao MMR 197 mother died /100,000 Live birth Misoprostol was registered as Cytotec on 1999-2002 for gastric ulcer Misoprostol was added in the WHO essential drug list for MCH drugs. Misoprostol was added in the Lao national essential drug list on 2011 Misoprostol was registered in Laos on 2013

Clinical handbook for safe abortion care Pre-abortion Information, counselling and decision-making Medical history Physical examination Laboratory and other investigations Discussing contraceptive options Abortion Infection prevention and control Pain management Methods for medical abortion Methods for surgical abortion (including cervical preparation) Post-abortion Prior to discharge from the health care facility Additional follow-up with a health care provider Post-abortion contraception Assessing and managing abortion complications The handbook is designed as a large pocket reference with 72 pages. It is organized into three sections (pre-abortion, abortion, and post-abortion) addressing a variety of topics essential to providing safe abortion as noted in the table. To be clear, the post-abortion section does not explicitly refer to post-abortion care. Whereas post-abortion care is a harm reduction strategy designed to manage complications from unsafe abortion, the post-abortion section in the handbook generally addresses services to be provided at the completion of a safe abortion. However, this section does contain information about how to identify and manage complications associated with abortion and provision of post-abortion contraception which are very relevant to post-abortion care settings. Filename

Summary of WHO recommendations I have included a figure from the handbook summarizing existing recommendations for medical and surgical abortion organized into a table for quick reference. I apologize for the small text, but the point of the slide is not to review the recommendations in detail, merely demonstrate how this figure might be useful in practice. Briefly, as you know, the most effective medical regimens rely on a combination of mifepristone, an antiprogestogen, and misoprostol, a synthetic prostaglandin analogue. Recommendations for dosing, route and schedule of administration of these regimens differ by gestational age. Prior to 12-14 weeks of gestation, vacuum aspiration is recommended for surgical abortion; electric and manual vacuum aspiration technologies (EVA and MVA) appear to be equally effective. Where it is still practiced, dilatation and curettage (or use of a sharp metal currette to scrape the uterus free of products of conception) should be replaced with vacuum aspiration to improve safety and quality of care for women. Beyond 12-14 weeks gestational age, dilatation and evacuation (D&E) is the safest and most effective surgical technique for later abortion, where trained providers are available. Filename

2012 FIGO Recommendations Put up the WHO guidelines not FIGO, explain FIGO 1: only where legal 2: included on WHO EML list 3: leave to work 1 to 2 weeks, unless bleeding or infection 4: half the dose of previous c-section 5: DO NOR USE IF PREVIOUS C-SECTION 6:Oxytocin is more effective that misoprostol

Lao National Guidelines for safe abortion Pregnancy up to 9 weeks Pregnancy : 9-12 weeks Pregnancy > 12 weeks – Refer to WHO guidelines Pre-abortion care Abortion care Post abortion care Septic abortion

Threaten Abortion Hydroxy progesterone (Proluton depot) 1 amp / week for 3 weeks + Natural progesterone (Utrogestan) 200mg 1 tab , 3 or 4 times perday until bleeding is stopped Continue by Utrogestan 100 mg until 36 weeks of pregnancy

Induced Abortion Medical Abortion Surgical Abortion Mifepristone + Misoprostone Misoprostone only Surgical Abortion Manual Vaccum Aspiration (MVA) Electrical Vaccum Aspiration (EVA)

Surgical Abortion < 12 – 14 weeks Vacuum aspiration is the recommended technique (up to 12-14 weeks) Replace D&C No need to use sharp curettage routinely The preferred technique for surgical abortion up to 14 wks is vacuum aspiration. Complete abortion rates between 95-100% have been reported and are comparable between electric vacuum aspiration which employs an electric vacuum pump to generate suction versus a handheld, hand-activated plastic manual vacuum aspirator. Depending on gestational age, vaccum aspiration can be performed over 3-10 minutes in an outpatient setting using analgesics and/or local anesthesia. It is very safe procedure. Dilatation and curettage or a surgical technique that involves pharmacologic or mechanical cervical dilation followed by the use of sharp metal curettes to scrape the walls of the uterus free of products of conception is not recommended. It is less safe, more painful for women and should be replaced by vacuum aspiration. Additionally, there is no data to support use of curettage after vacuum aspiration to decrease the risk of retained products of conception.

Incomplete Abortion Misoprostol 200 mcg : 3 tabs oral or vaginal route MVA

Septic abortion Evacuation of retained product conceptus Misoprostol MVA Antibiotic use Ceftriazone or ampicilline Gentamycine Metronidazol