Medicinsk abort gravv 9-13

Swedish abortion
guidelines
Helena Kopp Kallner
Swedish association for Ob/Gyn (SFOG)
Special committee on family planning (FARG)
Swedish setting
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Abortion law from 1975
Abortion on woman´s request up to and
including 18w+0days
Mandatory meeting with professional social
worker (counsellor) and application to Swedish
National Board of Health and Welfare from
18weeks+1day up to and including 22w+0 days
Helena Kopp Kallner juni -12
Abortion provision
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Only in certified centers
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May be private or public, but all publicly financed
Counselling offered to all but not mandatoryfocus is on helping woman make her choice
Examination including ultrasound by
gynecologist (research on task sharing ongoing)
Contraceptive counselling by midwife in some
centers
Follow up by midwife or gynecologist
Helena Kopp Kallner juni -12
Principles for guidelines
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”Lowest common denominator”
Evidence based
Different alternatives stated if possible
Helena Kopp Kallner juni -12
Evidence and implementation
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Guidelines
WHO
 RCOG
 misoprostol.org
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Literature search
No defined period of validity
No enforcement of guidelines- information only
Helena Kopp Kallner juni -12
Recommendationbefore abortion
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Counselling in case of ambivalence etc by
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Contraceptive advice by
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gynecologist, midwife or social worker (except after
22w+0d)
gynecologist or midwife (healthy women without
contraindications, specified rules)
Examination by
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gynecologist including ultrasound- research on task
shifting of ultrasound by midwife
Helena Kopp Kallner juni -12
Recommendationbefore abortion
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Screening for
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bacterial vaginosis (pH, discharge and sniff test) and
Chlamydia
Treatment for bacterial vaginosis before
abortion
Treatment of Chlamydia before surgical
abortion
Helena Kopp Kallner juni -12
Medical abortion
≤ 9weeks +0 days
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Early medical abortion
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Choice of home or clinic administration of misoprostol
200 mg mifepristone day 1 in clinic
800mcg misoprostol adminstered vaginally 24-48 hours after
mifepristone in clinic or at home
If no or scant bleeding after 3h an additional 400mcg
misoprostol is taken orally1
”It should be ensured that the abortion is complete”
1
Ashok et al Factors affecting the outcome of early medical abortiona review of 4132 cases, BJOG 2002
Helena Kopp Kallner juni -12
Surgical abortion
≤12 weeks and 0 days (14w+0d)
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Pre-treatment with 400mcg vaginal misoprostol 3 hours prior to
surgery is strongly recommended (mandatory for nulliparous
women, ”rigid cervix”, below 18yrs)
No routine antibiotics
Vacuumaspiration is only stated method
Inspection of abortion material or ultrasound is recommended
If heavy bleeding 5IU of oxytocin may be given
Follow up should be offered to all patients
Helena Kopp Kallner juni -12
Recommendation
9weeks+1day – 12weeks+0days
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Surgical abortion
Medical abortion
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200 mg mifepristone in clinic
800mcg misoprostol vaginally in clinic 36-48 hours after
mifepristone
Repeated doses of misoprostol 400mcg in clinic with 1st dose
3-4 hours after initial misoprostol (maximum 1,6mg
misoprostol in total)
Inspection of aborted material (ultrasound only if
uncertainty)
Vacuum aspiration next day if patient has not aborted.
Helena Kopp Kallner juni -12
Recommendation
>12 weeks+0days
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D&E for special cases up to 15weeks with experienced
surgeon (very seldomly performed)
Medical abortion
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200 mg mifepristone in clinic
800 mcg vaginal misoprostol 36-48 hours later
Repeated doses of 400 mcg misoprostol
Helena Kopp Kallner juni -12
Recommendation
>12 weeks+0days
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If not aborted after 12 hours another dose of 200mg
mifepristone is given at night
Same procedure repeated next day
After 48hours individualized treatment
No routine curettage after abortion
Helena Kopp Kallner juni -12
Pain management
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Medical abortion
NSAID prophylaxis
 Paracetamol prophylaxis
 Opioids when needed
 In clinic
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Injection of opioids
 PCB
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In addition TENS, acupuncture among others
Surgical abortion- general anaestesia or PCB
Helena Kopp Kallner juni -12
Post abortion contraception
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Hormonal contraception to be started day after
abortion (surgical and medical)
IUC inserted at surgical abortion
IUC inserted 1-4 weeks after medical abortion
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Back up contraception until then
Helena Kopp Kallner juni -12