Management of early medical abortion
Reynolds-Wright, John Joseph
BACKGROUND: Unintended pregnancy is common. Many of these pregnancies end in abortion. Abortion is increasingly performed at earlier gestations and using medical methods, that is through administration of the medications mifepristone and misoprostol, known as ‘early medical abortion’. Abortion in the UK is strictly regulated in law, but changes in legislation have recently been made that have enabled delivery of medical abortion to evolve in terms of setting of the abortion and peri-abortion care. AIMS AND OBJECTIVES: The aim of this research was to evaluate three aspects of medical abortion care: information delivery prior to abortion treatment; use of telemedicine, including remote consultation, for the provision of medical abortion; and methods of pain management for medical abortion. METHODS: I used a variety of methods to achieve the research objectives. I conducted a randomised controlled trial to compare standard consultations with a short audio-visual animation for information giving about early medical abortion regarding information recall and acceptability. I conducted a prospective observational cohort study of women receiving early medical abortion using a novel telemedicine service, which collected data on effectiveness of treatment, complications and side effect profiles and acceptability of this method. Finally, I conducted a systematic review of the current evidence for management of pain during early medical abortion. RESULTS: 50 women were recruited to the randomised controlled trial of the audio-visual animation. Recall of information was the same for women receiving a standard consultation and audio-visual animation. Acceptability was high in both groups. 663 women participated in the prospective observational cohort study of a novel telemedicine early medical abortion pathway. A complete abortion took place in 650/663 cases (98%). Complication rates were low and comparable to previous service models. Acceptability was high, with 628/663 (95%) of women rating the experience as ‘somewhat’ or ‘very’ acceptable. After initial screening of 4065 titles, 185 papers were considered for full text review. From these only five were eligible for inclusion, the evidence was of moderate to very low certainty and two papers were at high risk of bias. There was some evidence that high-dose ibuprofen (800-1600mg), used prophylactically or in response to pain, leads to a reduction in pain scores. However, the study designs were heterogenous, suffered from a lack of consistent reporting and did not use a validated pain measurement tool. CONCLUSIONS: An audio-visual animation functions as well as an in-person discussion with a clinician for providing information about early medical abortion. This animation can be used to supplement a telemedicine consultation to provide highly effective, safe, and acceptable abortion care. There are still side-effects to early medical abortion, including pain, that are imperfectly managed. There is limited evidence for the best method of pain relief in early medical abortion and further research is needed to develop a validated tool for measuring pain and well-designed randomised controlled trials of pain-relief interventions in non-hospital settings, where the majority of abortions occur.