Contraception
46:435-442,
1992
WHAT DO WOMEN WANT DURING
MEDICAL
ABORTION?
K Joo Thong, Maria H Dewar and David T Baird Department of Obstetrics and Gynecology Centre for Reproductive Biology University of Edinburgh 37 Chalmers Street Edinburgh EH3 9EW, Scotland
Abstract
A questionnaire study was carried out to investigate the needs of women undergoing a medical abortion induced by mifepristone in combination with either One-hundred-and-eighty women gemeprost pessaries or oral misoprostol. undergoing medical abortion of pregnancy of up to 63 days amenorrhoea were randomised to treatment in the sitting-room (treatment room) or in the ward. Overall, 77% and 69% treated in the sitting-room and ward, respectively, would Fifty-four per cent did not wish have preferred treatment in the sitting-room. their partner or friend to be present and 76% would prefer to stay in hospital Ninety-five per cent of the patients following administration of prostaglandin. would recommend this method of abortion to their friends. Women who received misoprostol required significantly less analgesia than women who were given 1 mg gemeprost as a vaginal pessary. The requirement for opiate analgesia was not influenced by parity, gestation of pregnancy, history of dysmenorrhoea or the dose of mifepristone. Almost 100% of the patients were satisfied with this method of treatment. This study indicates that the majority of women undergoing medical abortion prefer to be treated in a group, a method which is highly cost-effective. Introduction
Large clinical trials have demonstrated that a combination of mifepristone and a suitable prostaglandin is a safe, effective alternative to vacuum termination within the first 8 weeks of pregnancy (1). The two most widely used prostaglandins (gemeprost and sulprostone) are both expensive and require refrigeration. Preliminary studies suggested that the oral prostaglandin, misoprostol, in combination with mifepristone may be a highly effective method of inducing early abortion (2,3). The availability of mifepristone in the United Kingdom, therefore, allows the clinician and the patient to have a choice of the method of abortion if the pregnancy is less than 9 weeks. In practice, most centres still only offer surgical abortion of pregnancy to women who present with an unplanned pregnancy in this gestational age group. Although the efficacy of medical abortion is established, there is a paucity of data on the facilities that should be available to these women who are admitted into hospital for four hours for the administration of prostaglandin. We attempted to answer some of these questions by carrying out a questionnaire survey on women who were admitted for administration of prostaglandin.
Submitted for publication Accepted for publication
June 23, 1992 August 24, 1992
Copyright Q 1992 Butterworth-Heinemann
436
Contraception Methods
Women were referred by their general practitioner to the Gynaecological Out-Patient Department in the Edinburgh Royal Infirmary and by doctors working at the Family Planning Clinics in Edinburgh, for an elective abortion. The majority of these women were requesting a medical abortion; in others, the choice between medical and surgical abortion was made after consultation in the OutPatient Department. Abortion was carried out under the conditions of the United Kingdom 1967 Abortion Act which insists that treatment, that is, the administration of antigestagen and prostaglandin, should take place in a National Health Service Hospital or premises licensed under the Act. All of these women were seen by one of the investigators (KJT). When a decision was made to carry out a medical abortion, a member of the nursing staff explained the procedure and arrangements were made for the patient to come to the medical abortion unit in the Simpson Memorial Maternity Pavilion for administration of mifepristone. The medical abortion unit is a Consultant-led unit comprising of a junior doctor, two nursing sisters and three staff midwives. A rotational shift system meant that the unit could be managed by two trained staff during normal working hours. This unit consists of a sitting-room (treatment room) and an adjoining ward area with three beds. Each woman received a single dose of mifepristone (50, 200, 400, or 600 mg) followed by the administration of prostaglandin 48 hours later. Women were immediately following the administration of mifepristone. allowed home Arrangements were made for the women to be admitted two days later for the administration of a prostaglandin. Women were advised to bring a set of pyjamas and a change of clothing. All women admitted on a given day were allocated to a single treatment, I.e., either in the sitting-room or the ward. The treatment of that day was determined by choosing a brown envelope which contained one or other treatment. Seventy envelopes had been prepared containing equal numbers of the two treatments by shuffling and then numbered consecutively. The number of women treated on any one day ranged from 1 to 5. Following randomization, the women were led into the ward or in the sitting-room by the nursing staff and were then introduced to each other. Smoking was prohibited during their stay in hospital. These women were encouraged to ask questions regarding their treatment and were given contraceptive advice and leaflets by the nursing staff during their stay in hospital. Women who were randomized to the sitting-room (group A) were allowed to wear their own clothing and were given access to books, television and a telephone. There were no restrictions to movement in the sitting-room. They were allowed to lie down in bed if they felt like it or if opiate analgesia was required. Women who were randomised to the ward (group B) were requested to remove their clothes A hospital gown was provided if required. The and to put on their pyjamas. women in the latter group were allowed access to books but were only allowed to Light refreshments were brought in at regular leave the bed to go to the toilet. intervals by the nursing staff to the individual patients who were treated in the ward. Patients who were treated in the sitting-room were provided with light refreshments and they were requested to help themselves.
437
Contraception
In this study, 94 women received 1 mg of gemeprost and 86 received 600 J.J~ In women who were administered gemeprost, a of a single oral dose of misoprostol. 1 mg pessary was inserted in the posterior vaginal fornix by a member of the Following administration of the pessary, those women who were nursing staff. randomised to the sitting-room were asked to sit up in an arm-chair. Women who were randomised to the ward were requested to stay in bed following administration of the gemeprost pessary. The pulse, blood pressure and temperature were monitored hourly following Women requiring analgesia were given either administration of prostaglandin. paracetamol (1 gram), dihydrocodeine (30 mg) or intramuscular diamorphine (5 Four hours following administration of the prostaglandin, a vaginal mg). examination was carried out to confirm whether products had passed and to These women were then allowed home and they were exclude heavy bleeding. followed-up at 1, 2, and 6 weeks after the procedure. Each woman was given an They were emergency contact number to telephone if they had any problems. advised against the use of tampons and to use a barrier method of contraception until the next period.
complete a) b) c) d) e) f) g)
Prior to discharge from hospital, all a brief questionnaire which included
of these women the following:
were
requested
to
whether they preferred treatment in the sitting-room or ward whether they preferred to have treatment alone or in a group whether they would prefer medical abortion at home or hospital whether they would recommend a friend to undergo a medical abortion if they were asked for an opinion whether they would prefer a friend or a partner to be with them during their stay in hospital to indicate the severity of pain experienced on the visual analogue scale (O100 mm) to rate their treatment overall Statistical
analyses
were carried
out using the chi-square
and Mann-Whitney
tests. Results Ninety-five per cent of women who received gemeprost and 94% who received misoprostol had complete abortion. The details of the clinical efficacy of the different regimens have been reported elsewhere (4,5). In women who received gemeprost and misoprostol, 74% and 71% aborted within four hours, respectively, following administration of prostaglandin. Ninety-three and 87 women were randomised to groups A and B, respectively. There were no significant differences in the age, parity, gestation or experience of previous termination between women allocated to group A or group B (Table I). Overall, 77% and 69% of women randomised to treatment in the sitting-room and ward, respectively, reported that they would prefer treatment in the sittingroom (p=O.2). Of the 93 women treated in the sitting-room, 34% requested to lie down in bed following administration of prostaglandin. The proportion who
438
Contraception Table I: CHARACTERISTICS
OF PATIENTS
Sitting-room n=93
Ward n=87
Age (years)*
25 (17-38)
26 (14-41)
Gestation
52 (36-62)
50 (35-63)
34 (37%)
36 (41%)
22 (24%)
19 (22%)
Parous
(days)*
(%)
Previous
abortion
*Median
(range)
Table II: ANALGESIC
REQUIREMENTS
Misoprostol
Gemeprost
Sitting-room n (%)
Ward n (%)
Sitting-room n (%)
Ward n (%)
22 (60)
30 (61)
24 (43)
18 (47)
Paracetamol
4 (11)
9 (18)
9 (16)
3 (8)
Dihydrocodeine r. paracetamol
9 (24)
10 (21)
11 (20)
12 (32)
Diamorphine +_dihydrocodeine * paracetamol
2 (5)
0
12 (21)
5 (13)
None
439
Contraception requested to lie down misoprostol.
were
similar
in women
treated
with
either
gemeprost
or
Twelve (14%) and 10 (11%) who were randomised to groups A and B, If these 22 patients were respectively, were the only patients treated that day. excluded from analysis, 87% and 80% of the women in group A and group B, respectively, would prefer treatment in the sitting-room. The degree of discomfort recorded on the visual analogue scale (O-100 mm) was similar in the sitting-room and ward group (median 55 and 52, respectively), as was the request for analgesia (Table II). The dose of mifepristone was not related to the degree of pain assessed by the visual analogue scale or analgesic women who were administered gemeprost required However, requirements. significantly more opiate analgesia (chi square = 11.8; p
46:435-442,
1992
WHAT DO WOMEN WANT DURING
MEDICAL
ABORTION?
K Joo Thong, Maria H Dewar and David T Baird Department of Obstetrics and Gynecology Centre for Reproductive Biology University of Edinburgh 37 Chalmers Street Edinburgh EH3 9EW, Scotland
Abstract
A questionnaire study was carried out to investigate the needs of women undergoing a medical abortion induced by mifepristone in combination with either One-hundred-and-eighty women gemeprost pessaries or oral misoprostol. undergoing medical abortion of pregnancy of up to 63 days amenorrhoea were randomised to treatment in the sitting-room (treatment room) or in the ward. Overall, 77% and 69% treated in the sitting-room and ward, respectively, would Fifty-four per cent did not wish have preferred treatment in the sitting-room. their partner or friend to be present and 76% would prefer to stay in hospital Ninety-five per cent of the patients following administration of prostaglandin. would recommend this method of abortion to their friends. Women who received misoprostol required significantly less analgesia than women who were given 1 mg gemeprost as a vaginal pessary. The requirement for opiate analgesia was not influenced by parity, gestation of pregnancy, history of dysmenorrhoea or the dose of mifepristone. Almost 100% of the patients were satisfied with this method of treatment. This study indicates that the majority of women undergoing medical abortion prefer to be treated in a group, a method which is highly cost-effective. Introduction
Large clinical trials have demonstrated that a combination of mifepristone and a suitable prostaglandin is a safe, effective alternative to vacuum termination within the first 8 weeks of pregnancy (1). The two most widely used prostaglandins (gemeprost and sulprostone) are both expensive and require refrigeration. Preliminary studies suggested that the oral prostaglandin, misoprostol, in combination with mifepristone may be a highly effective method of inducing early abortion (2,3). The availability of mifepristone in the United Kingdom, therefore, allows the clinician and the patient to have a choice of the method of abortion if the pregnancy is less than 9 weeks. In practice, most centres still only offer surgical abortion of pregnancy to women who present with an unplanned pregnancy in this gestational age group. Although the efficacy of medical abortion is established, there is a paucity of data on the facilities that should be available to these women who are admitted into hospital for four hours for the administration of prostaglandin. We attempted to answer some of these questions by carrying out a questionnaire survey on women who were admitted for administration of prostaglandin.
Submitted for publication Accepted for publication
June 23, 1992 August 24, 1992
Copyright Q 1992 Butterworth-Heinemann
436
Contraception Methods
Women were referred by their general practitioner to the Gynaecological Out-Patient Department in the Edinburgh Royal Infirmary and by doctors working at the Family Planning Clinics in Edinburgh, for an elective abortion. The majority of these women were requesting a medical abortion; in others, the choice between medical and surgical abortion was made after consultation in the OutPatient Department. Abortion was carried out under the conditions of the United Kingdom 1967 Abortion Act which insists that treatment, that is, the administration of antigestagen and prostaglandin, should take place in a National Health Service Hospital or premises licensed under the Act. All of these women were seen by one of the investigators (KJT). When a decision was made to carry out a medical abortion, a member of the nursing staff explained the procedure and arrangements were made for the patient to come to the medical abortion unit in the Simpson Memorial Maternity Pavilion for administration of mifepristone. The medical abortion unit is a Consultant-led unit comprising of a junior doctor, two nursing sisters and three staff midwives. A rotational shift system meant that the unit could be managed by two trained staff during normal working hours. This unit consists of a sitting-room (treatment room) and an adjoining ward area with three beds. Each woman received a single dose of mifepristone (50, 200, 400, or 600 mg) followed by the administration of prostaglandin 48 hours later. Women were immediately following the administration of mifepristone. allowed home Arrangements were made for the women to be admitted two days later for the administration of a prostaglandin. Women were advised to bring a set of pyjamas and a change of clothing. All women admitted on a given day were allocated to a single treatment, I.e., either in the sitting-room or the ward. The treatment of that day was determined by choosing a brown envelope which contained one or other treatment. Seventy envelopes had been prepared containing equal numbers of the two treatments by shuffling and then numbered consecutively. The number of women treated on any one day ranged from 1 to 5. Following randomization, the women were led into the ward or in the sitting-room by the nursing staff and were then introduced to each other. Smoking was prohibited during their stay in hospital. These women were encouraged to ask questions regarding their treatment and were given contraceptive advice and leaflets by the nursing staff during their stay in hospital. Women who were randomized to the sitting-room (group A) were allowed to wear their own clothing and were given access to books, television and a telephone. There were no restrictions to movement in the sitting-room. They were allowed to lie down in bed if they felt like it or if opiate analgesia was required. Women who were randomised to the ward (group B) were requested to remove their clothes A hospital gown was provided if required. The and to put on their pyjamas. women in the latter group were allowed access to books but were only allowed to Light refreshments were brought in at regular leave the bed to go to the toilet. intervals by the nursing staff to the individual patients who were treated in the ward. Patients who were treated in the sitting-room were provided with light refreshments and they were requested to help themselves.
437
Contraception
In this study, 94 women received 1 mg of gemeprost and 86 received 600 J.J~ In women who were administered gemeprost, a of a single oral dose of misoprostol. 1 mg pessary was inserted in the posterior vaginal fornix by a member of the Following administration of the pessary, those women who were nursing staff. randomised to the sitting-room were asked to sit up in an arm-chair. Women who were randomised to the ward were requested to stay in bed following administration of the gemeprost pessary. The pulse, blood pressure and temperature were monitored hourly following Women requiring analgesia were given either administration of prostaglandin. paracetamol (1 gram), dihydrocodeine (30 mg) or intramuscular diamorphine (5 Four hours following administration of the prostaglandin, a vaginal mg). examination was carried out to confirm whether products had passed and to These women were then allowed home and they were exclude heavy bleeding. followed-up at 1, 2, and 6 weeks after the procedure. Each woman was given an They were emergency contact number to telephone if they had any problems. advised against the use of tampons and to use a barrier method of contraception until the next period.
complete a) b) c) d) e) f) g)
Prior to discharge from hospital, all a brief questionnaire which included
of these women the following:
were
requested
to
whether they preferred treatment in the sitting-room or ward whether they preferred to have treatment alone or in a group whether they would prefer medical abortion at home or hospital whether they would recommend a friend to undergo a medical abortion if they were asked for an opinion whether they would prefer a friend or a partner to be with them during their stay in hospital to indicate the severity of pain experienced on the visual analogue scale (O100 mm) to rate their treatment overall Statistical
analyses
were carried
out using the chi-square
and Mann-Whitney
tests. Results Ninety-five per cent of women who received gemeprost and 94% who received misoprostol had complete abortion. The details of the clinical efficacy of the different regimens have been reported elsewhere (4,5). In women who received gemeprost and misoprostol, 74% and 71% aborted within four hours, respectively, following administration of prostaglandin. Ninety-three and 87 women were randomised to groups A and B, respectively. There were no significant differences in the age, parity, gestation or experience of previous termination between women allocated to group A or group B (Table I). Overall, 77% and 69% of women randomised to treatment in the sitting-room and ward, respectively, reported that they would prefer treatment in the sittingroom (p=O.2). Of the 93 women treated in the sitting-room, 34% requested to lie down in bed following administration of prostaglandin. The proportion who
438
Contraception Table I: CHARACTERISTICS
OF PATIENTS
Sitting-room n=93
Ward n=87
Age (years)*
25 (17-38)
26 (14-41)
Gestation
52 (36-62)
50 (35-63)
34 (37%)
36 (41%)
22 (24%)
19 (22%)
Parous
(days)*
(%)
Previous
abortion
*Median
(range)
Table II: ANALGESIC
REQUIREMENTS
Misoprostol
Gemeprost
Sitting-room n (%)
Ward n (%)
Sitting-room n (%)
Ward n (%)
22 (60)
30 (61)
24 (43)
18 (47)
Paracetamol
4 (11)
9 (18)
9 (16)
3 (8)
Dihydrocodeine r. paracetamol
9 (24)
10 (21)
11 (20)
12 (32)
Diamorphine +_dihydrocodeine * paracetamol
2 (5)
0
12 (21)
5 (13)
None
439
Contraception requested to lie down misoprostol.
were
similar
in women
treated
with
either
gemeprost
or
Twelve (14%) and 10 (11%) who were randomised to groups A and B, If these 22 patients were respectively, were the only patients treated that day. excluded from analysis, 87% and 80% of the women in group A and group B, respectively, would prefer treatment in the sitting-room. The degree of discomfort recorded on the visual analogue scale (O-100 mm) was similar in the sitting-room and ward group (median 55 and 52, respectively), as was the request for analgesia (Table II). The dose of mifepristone was not related to the degree of pain assessed by the visual analogue scale or analgesic women who were administered gemeprost required However, requirements. significantly more opiate analgesia (chi square = 11.8; p
