1. When is a backup aspiration needed? hCG and ultrasound for verification of successful expulsion Christian Fiala Gynmed Ambulatorium Vienna, Austria Karolinska Institute Department of Woman and Child Health Stockholm/Sweden www.fiapac.org International Association of Abortion and Contraception Associates Abortion, Contraception and Women’s Health International Seminar of FIAPAC, RSOG, RC Ob/Gyn &P, 27/28 October 2005

2. hCG and US in medical abortion, C. Fiala www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html

3. hCG and US in medical abortion, C. Fiala 1 23 4 5 6 7 8 9 10 11 5 10 15 12 13 14 15 16 17 18 19 20 21 20 22 23 24 Expulsion after Mifepristone and Misoprostol in % (hours after misoprostol) Time to expulsion of the sac in 1720 women with successfull termination of pregnancy. The women took mifeprostone on day 1 and misoprostol 48 hours later. Uncertain means expulsion at some point during 24 hours following misoprostol. Unknown means expulsion at some point later than 24 after misoprostol. Source: The New England Journal of Medicine, 1998; 338 (18): 1244 Before miso More than 24 h later unknown uncertain

4. hCG and US in medical abortion, C. Fiala Day 1: hCG 269 mIU/mlDay 9: hCG 20 Treatment

5. hCG and US in medical abortion, C. Fiala Day 7: hCG 7 Day 3: Gestational Sac Day 1: Gestational sac 5 mm hCG 862 Treatment

6. hCG and US in medical abortion, C. Fiala D 1: hCG 32.000 D 8: E 12 mm hCG 837 D 3: Gestational sac Treatment

7. hCG and US in medical abortion, C. Fiala D 1: CRL 10 mm hCG 83.439 D 8: E 8 mm hCG 312 Treatment

8. hCG and US in medical abortion, C. Fiala D 28: hCG 100D 10: E 20 mm, hCG 16.841 D 17: OC ex D 21: Withdrawl-bleeding D 1: CRL 6 mm hCG 104.900 D 3: Start OC Treatment

9. hCG and US in medical abortion, C. Fiala D 1: Gestational + yolk sac hCG 13.300 D 3: Start OC D 19: E 8 mm hCG 718 D 9: missed AB hCG 10.819 D 16: OC ex D 18: Withdrawl-bleeding Treatment

10. hCG and US in medical abortion, C. Fiala Methods –217 women with –an unwanted pregnancy –<49 days of amenorrhea –received: 600mg of Mifepristone orally 400µg of Misoprostol orally 2 days later hCG was performed at all visits US was performed before Mifepristone and at follow-up

11. hCG and US in medical abortion, C. Fiala Results Curettage: –1 continued pregnancy –1 missed abortion –1 haemorrhage One missed abortion was expelled after withdrawal bleeding

12. hCG and US in medical abortion, C. Fiala Mean 3,8% (0,1-44); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 25 patients 3 cases of successful abortion (27,32 and 44%) 2 cases of missed abortion (91 and 159%), 1 case of continued pregnancy (7,900 %) Serum hCG at follow-up in % of the initial value Fiala et al., 2003

13. hCG and US in medical abortion, C. Fiala Mean 10mm (1-24mm); the size of the circles correlates with the number of patients. The smallest circles represent 1 patient; the biggest represent 10 patients Endometrium thickness at follow-up Fiala et al., 2003

14. hCG and US in medical abortion, C. Fiala First trimester surgical abortion: –Urinary test (cut off 1,000mIU/ml) at two weeks (Paul et al., 2000) Medication abortion <9 weeks: –Urinary test, cut off 500mIU/ml at 3 weeks (Karolinska University Hospital, Sweden) –Urinary test, cut off 1,000mIU/ml at >1 week (Gynmed Clinic, Vienna) –Decline in serum hCG at follow up in % of the initial value: 30% on day 10 (Jourdan and van den Bossche 1991) 40% at 1 week (Legarth et al. 1991) 60-70.5% 24 hours following misoprostol 99.4% on day 14 (Walker et al., 2001, Honkanen et al., 2002) 20% after day 6 (Fiala et al., 2003) hCG for verification of expulsion

15. hCG and US in medical abortion, C. Fiala Retained products of conception (RPC) Commonly present with sharp or crampy lower abdominal pain and bleeding No difference to haematomata Presence of sparse villi alone after successful surgical abortion is a normal finding and not diagnostic of RPC After abortion, small amounts of retained products may pass spontaneousely, avoiding the need for backup curettage

16. hCG and US in medical abortion, C. Fiala Verification of expulsion Ultrasound –Gives reliable results in most cases when the yolk sac or CRL can be visualised before treatment –It is not reliable in very early pregnancy –Endometrium is thick in many patients at follow up hCG –Has to be used in early pregnancy –Is very reliable in most cases > cut off at 20% of initial value after day 6 –Follow-up can be done at a different laboratory

17. hCG and US in medical abortion, C. Fiala Rapid hCG test Duo rapid test (urine) 5 mIU/ml and 1.000 mIU/ml www.VedaLab.com

18. New Museum wants old contraceptives Objects (IUDs, Cervical caps etc.), reports, posters, publications www.contraceptive-museum.at The museum will be in Vienna, at conferences and online Museum of Contraception and Abortion