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- 1. OMS - Aborto sin riesgos : Guía técnica y de políticas para Sistemas de Salud Sharon Phillips, MD, MPH Departamento de Salud Reproductiva e Investigaciones Organización Mundial de la Salud
- 2. OMS – Trabajando para eliminar el aborto inseguro en forma mundial y local. Mapeo de Mapeo de Evidencias Evidencias Mejorando Mejorando las las tecnologías tecnologías Evaluando las Evaluando las Intervenciones Intervenciones Desarrollo de normas, herramientas Desarrollo de normas, herramientas y guías y guías Eliminación Eliminación del Aborto del Aborto Inseguro Inseguro Apoyo técnico a los países Apoyo técnico a los países 2
- 3. Guías actualizadas: componentes CdA MEC SPRt/ 3 1. Contexto del aborto inseguro 2. Atención clínica 3. Establecimiento y fortalecimiento de los servicios de aborto 4. Temas legales y políticos
- 4. Guías actualizadas: componentes 1. Contexto del aborto inseguro 2. Atención clínica 3. Establecimiento y fortalecimiento de los servicios de aborto CdA MEC SPRt/ 4 4. Temas legales y políticos
- 5. CdA MEC SPRt/ 5 Atención Clínica
- 6. Atención Pre-aborto • Las pruebas de rutina no son un requisito para los servicios de aborto • El uso de ultrasonidos de rutina preaborto no es necesario
- 7. Tratamiento del dolor • • • A todas las mujeres debe ofrecérseles sistemáticamente medicación para el dolor Incluye analgésicos, anestesia local / sedación consciente AINES – Para ambos: abortos medicos y quirúrgicos – No paracetamol No utilizar anestesia general en forma sistemática
- 8. Aborto quirúrgico hasta 12-14 semanas • La técnica recomendada es la aspiración por vacío (hasta 12-14 semanas) – Reemplazo D&C – No hay necesidad de legrado uterino instrumental de rutina
- 9. Aborto Médico versus Aborto Quirúrgico • Se recomiendan ambos métodos tanto quirúrgicos como médicos • Ambos procedimientos tienen diferentes ventajas y desventajas Recomendaciones de la OMS: • Los métodos de aspiración por vacío y médicos son recomendados <12-14 semanas • Tanto la D&E y métodos médicos pueden ser recomendados >12-14 semanas • Los Servicios de Salud deben ofrecer al menos uno y preferentemente ambos métodos
- 10. Aborto Médico • Los métodos médicos recomendados son la mifepristona seguida de misoprostol – Se recomienda misoprostol-solo cuando la mifepristona no está disponible • Recomendaciones según rangos de edad gestacional – <9 semanas, 9-12, 12-14, >14 semanas
- 11. Aborto médico empleando mifepristona: Hasta 9 semanas
- 13. Aborto médico empleando misoprostol solo Hasta 12 semanas
- 14. Métodos abortivos después de 12-14 semanas • Tanto la dilatación como los métodos de evacuación (de D&E) y médicos (mifepristona y misoprostol & misoprostol-solo) pueden recomendarse después de 12 semanas. • Los Servicios de Salud deben ofrecer al menos uno o preferentemente de ser posible ambos métodos
- 15. El uso de antibióticos • El uso de rutina de antibióticos al momento del aborto quirúrgico disminuye el riesgo de infecciones posteriores al procedimiento. • No se debe negar el aborto cuando no se dispone de antibióticos profilácticos • El uso de rutina de antibióticos al momento del aborto medico no es necessario (Tuncalp et al. 2010; Neilson et al. 2010; Diop et al. 2009; Tang et al. 2009)
- 16. Tratamiento de aborto incompleto • Aspiración por vacío – Recomendado sobre el D&C • • • • Menor pérdida de sangre Menos dolor Tiempos de procedimientos Misoprostol – Vía Oral – 600 mcg – Vía Sublingual – 400 mcg – Vía Vaginal – 400-800 mcg • • Presencia de sangrado puede reducir la absorción Tratamiento expectante – Para mujeres estables clínicamente & desean evitar un tratamiento quirúrgico o médico (Tuncalp et al. 2010; Neilson et al. 2010; Diop et al. 2009; Tang et al. 2009)
- 17. Atención posterior – – – No hay necesidad médica de visita regular de seguimiento después un aborto quirúrgico o médico sin complicaciones (con mifepristona y misoprostol) El seguimiento es necesario después de un aborto médico con misoprostol-solo Se puede comenzar de inmediato anticoncepción • Anticoncepción hormonal a tiempo de aborto quirúrgico o primera pastilla de aborto médico • DIU immediatamente despues de un aborto quirúrgico o cuando se tiene una certeza razonable que no se está embarazada despues de un aborto médico
- 18. CdA MEC SPRt/ 18 Consideraciones legales y de políticas
- 19. Derechos humanos relacionados al aborto seguro Derechos Humanos Tratado o Convención Derecho a la vida Pacto Internacional de Derechos Civiles y Políticos Derecho a la salud Pacto Internacional de Derechos Sociales, Económicos y Culturales Derecho a no ser discriminado Convención sobre la Eliminación de todas las Formas de Discriminación contra la Mujer Convención sobre los Derechos del Niño Convención Internacional sobre la Eliminación de todas las Formas de Discriminación Racial 08_XXX_MM19 Pacto Internacional de Derechos Civiles y Los derechos a la Políticos libertad, la Convención Americana sobre Derechos seguridad personal Humanos y la privacidad
- 20. Leyes restrictivas • Aun cuando las leyes son restrictivas, algunos abortos suelen ser legal y las mujeres deberían tener acceso
- 22. Barreras Adicionales • • • • • • Falta de acceso a la información Exigencia de la autorización de un tercero Restricción del tipo de proveedores de salud e instalaciones que pueden proveer servicios legalmente No garantizar el acceso a servicios asequibles No garantizar la confidencialidad y la privacidad Permitir la objeción por razones de conciencia sin la intervención de los proveedores de salud y las instalaciones
- 23. GRACIAS
- 24. Recomendaciones de admisibilidad médica post-aborto Condición PostAborton COC CIC Parches / Anillo Vaginal POP DMPA, NET-EN LNG/ETG Implantes Copper DIU LNG DIU Condón Espermicida Diafragma Primer Trimestre 1 1 1 1 1 1 1 1 1 1 1 Segundo Trimestre 1 1 1 1 1 1 2 2 1 1 1* Aborto inmediatamente post-séptico 1 1 1 1 1 1 4 4 1 1 1* * El diafragma y el capuchón cervical son inadecuados hasta después de 6 semanas de un aborto del segundo trimestre Definición de categorías: 1= una condición para la cual no hay restricción para el uso de un método anticonceptivo 2= una condición en la que las ventajas de usar el método generalmente pesan más que los riesgos teóricos o comprobados 3= una condición donde los riesgos teóricos o comprobados generalmente pesan más que las ventajas de usar el método 4= una condición que representa un riesgo inadmisible para la salud si se utiliza el método anticonceptivo (WHO 2009)
- 25. Aborto médico > 9 semanas (mifepristona) Entre 9 y 12 semanas (63 a 84 días) • 200 mg de mifepristona (oral) seguida de, 36 a 48 horas después • 800 μg de misoprostol (vaginal) administrado en un centro de salud. Administrar un máximo de 4 dosis adicionales de 400 μg de misoprostol con intervalos cada 3 horas (vaginal o sublingual) Mayor a 12 semanas •200 mg de mifepristona (oral) seguida de, 36 a 48 horas después •400 μg de misoprostol (oral) u 800 μg (vaginal) seguido de 400 μg de misoprostol (vaginal o sublingual) cada tres horas con un máximo de cinco dosis, administrado en un centro de salud.
- 26. Aborto médico > 12 semanas (misoprostol solo o gemeprost) Misoprostol solo > 12 semanas • 400 μg de misoprostol (vaginal o sublingual) cada 3 horas durante un máximo de cinco dosis, hasta expulsion Gemeprost solo > 12 semanas •1 mg (oral) cada 3 horas con un máximo de 5 veces el primer día y repetida al día siguiente, si necesario. •80 % y 95 % de las mujeres aborta entre las 24 horas y 48 horas
- 27. Procedimientos complementarios: inducción de muerte fetal Realizado para evitar la supervivencia fetal transitoria – La tasa de supervivencia transitoria con los regímenes actuales es del del 7% – 13% con dosis elevadas de oxitocina Es más común con edades gestacionales mayores Recomendación de la OMS: – Cuando se emplean métodos médicos >20 semanas, considerar la posibilidad de la inducción de preprocedimiento de defunción fetal – Varios regímenes posibles
Notes de l'éditeur
- In 2003 the World Health Organization released the first evidence-based global guidance on the provision of safe abortion More than 30,000 copies were distributed and the document was one of the most commonly downloaded documents from the WHO website. However, since publication of the guidelines in 2003, a considerable amount of new data have been produced and published, relating to clinical, service-delivery, legal and human rights aspects of providing safe abortion care, prompting an update of the guidance which is organized into the following sections. Context of unsafe abortion Clinical care Recommended methods; pre and post procedure considerations, management of complications Establishing and strengthening abortion services: Norms and standards; training; assessment; monitoring and evaluation; financing; scaling up Legal and policy issues Human rights frameworks; laws and their implementation; creating an enabling policy environment I hope to focus on only some of the key recommendations from the guidance for this presentation.
- Because I only have 15 minutes, I will be focusing primarily on the clinical recommendations, though I will discuss legal and policy themes briefly.
- So, now I’d like to walk you through some of the key recommendations. And, we’ll start with clinical care.
- In most cases, health care providers only require the information obtained from a woman’s history and physical exam to confirm pregnancy and estimate its duration. Laboratory testing is not necessary unless the typical signs of pregnancy are not clearly present and the provider is unsure whether a woman is actually pregnant. Obtaining such tests should not delay uterine evacuation. Routine laboratory testing is not a prerequisite for abortion services. Measuring hemoglobin or hematocrit levels to detect anemia may be helpful when treating rare cases of hemorrhage occurring at the time of the abortion procedure. Tests for Rhesus blood group typing should be provided when feasible to administer Rh-immunoglobin when indicated. Additionally, ultrasound scanning is not routinely required for the provision of abortion. Where it is available, it can help to identify and intrauterine pregnancy and exclude ectopic pregnancy from 6 wks of gestation. It may also be helpful to determine gestational age and diagnose pathologies or fetal demise. Some health care providers also find it a helpful aid to guide D &E.
- Medication for pain management should always be offered for both medical and surgical methods of abortion and provided without delay to women who request it. Non-narcotic analgesics included on the WHO Model List of Essential Medicines, such as ibuprofen, reduce pain, including uterine cramping associated with abortion. Paracetamol was found, in randomized controlled trials, to be ineffective to relieve post procedural pain following surgical abortion and similarly ineffective at addressing pain associate with medical abortion. General anesthesia should not be routinely used as a strategy to address pain during abortion. It increases the clinical risks of the procedure with higher rates of hemorrhage. It also increases the costs for both the health care facility and the woman, particularly as some hospital policies require women who receive it to stay overnight. Where mechanical cervical dilation is required for surgical abortion, a paracervical block using local infiltration with lidocaine is commonly used. Nevertheless, some women prefer general anesthesia and its use may be preferable from the provider’s perspective during difficult procedures. Any facility that offers general anesthesia must have speciallized staff and equipment to administer it and handle any complications.
- Vacuum aspiration is the recommended technique for surgical abortion up to 12-14 weeks. Dilation and sharp curettage (D&C), where still practiced, should be replaced by vacuum aspiration. Observational studies indicate that vacuum aspiration is associated with fewer complications than dilation and sharp curettage (D&C); however, randomized controlled trials were underpowered to detect a difference in complication rates. D&C is more painful for women. Also, randomized controlled trials comparing D&C and vacuum aspiration found that, for up to 10 weeks LMP, vacuum aspiration is quicker and associated with less blood loss than D&C. No evidence supports the use of curette checks (i.e. use of sharp curettage to “complete” the abortion) following vacuum aspiration. Abortion with vacuum aspiration takes from 3 to 10 minutes to complete. The completion of abortion is verified by examination of the aspirated tissue. In very early pregnancy, the cannula may be inserted without prior dilatation of the cervix.
- Both surgical and medical methods of abortion are recommended. One approach is not superior to the other and each method has its relative advantages and disadvantages.
- Now, I would like to talk a bit about medical abortion. As you know, Mifepristone is an antiprogestogen which binds to progesterone receptors, inhibiting the action of progesterone and interfering with the continuation of pregnancy and Misoprostol is a synthetic prostaglandin primarily responsible for uterine contractions necessary for the expulsion of the pregnancy. Medical abortion regimens combining mifepristone and misoprostol are superior in effectiveness to misoprostol regimens alone; and the combination of mifepristone and misoprostol for medical abortion is included on the WHO Model List of Essential Medicines. However, there are still many places where mifepristone is not available. In such situations, there are recommendations for misoprostol alone regimens. The recommendations vary by gestational age.
- For medical abortion up to 9 weeks gestation, the recommended method is oral mifepristone 200 mg, followed in 24-48 hours by misoprostol. For gestations up to 7 weeks, oral misoprostol 400mcg may be recommended. However, the recommended route of misoprostol administration for gestations up to 9 weeks is 800 mcg vaginal, buccal, or sublingual. For medical abortion up to 9 weeks (63 days) efficacy rates of up to 98% are reported. 2-5% of women treated with the combination of mifepristone and misoprostol will require surgical intervention to resolve an incomplete abortion, terminate a continuing pregnancy, or control bleeding (Trussell et al. 1999; Fjerstad M et al. 2009; WHO 2000). (The strength of this recommendation is strong. The quality of evidence behind it is moderate.) Recommendation 2: Strength of Recommendation – Strong; Quality of Evidence - Moderate
- This map (kept up to date by Gynuity and available on their website) demonstrates sites where mifepristone is currently registered. It is not widely available in Africa except in Tunisia, Ghana and some States in Southern Africa. (?South Africa, Mozambique and Zambia)
- Where mifepristone is not available, for pregnancies up to 12 weeks, the recommended regimen for medical abortion is vaginal or sublingual misoprostol, 800 mcg, repeated at intervals of 3-12 hours. Sublingual misoprostol is associated with higher rates of side-effects than vaginal administration. When using misoprostol alone in nulliparous women, vaginal administration is more effective than sublingual administration. __________ (The strength of the recommendation for gestations up to 12 weeks is strong. The quality of the evidence behind it is high.) Recommendation 4: Strength of Recommendation – Strong; Quality of Evidence – High
- Read the bullets Evidence for this question is limited by women’s willingness to be randomized in clinical trials between surgical and medical methods of abortion. A woman’s choice of abortion method may be limited or not applicable if she has medical contraindications to one of the methods.
- Following an induced or spontaneous abortion, women should receive appropriate post-abortion care. For those women who had abortions performed unsafely, post-abortion care is used as a strategy to attenuate the morbidity and mortality associated with complications, including uterine aspiration for incomplete abortion. It is also important to offer contraception during this time to prevent future unintended pregnancy and is an opportunity to link women with other needed services in the community. All women should receive contraceptive information and be offered counseling for and methods of post-abortion contraception, including emergency contraception, before leaving the health care facility. All methods of contraception, including IUDs and hormonal contraceptives, can be immediately initiated immediately following surgical or medical abortion, as long as attention is paid to each woman’s health profile and the limitations associated with certain methods.
- This summary chart illustrates how several human rights discussed in various treaties and conventions specifically apply to safe abortion care. For instance, the rights to liberty, security of person and privacy discussed in the International Covenant on Civil and Political Rights, as well as the other treaties listed, requires removal of third-party authorization requirements for women to utilize abortion services. This rights-based approach has informed changes in law in the Constitutional Court of Colombia (2006), the Parliament of Nepal (2002), and in South Africa (1996).
- Read slide
- This is a summary of information pertaining to the legal grounds for abortion in the countries represented by the member associations.
- The legal grounds and the scope of their interpretation are only one dimension of the legal and policy environment that affects women’s access to abortion. Health system and service-delivery barriers can also be codified in laws, regulations, policies and practices. Here is a list of some of these barriers. Read slide.
- This is information extracted from the Medical Eligibility Criteria for Contraceptive Use. As you can see, most methods can be provided immediately following abortion with no restriction. IUD insertion should be delayed following a septic abortion.
- 2008 study did do a regression controlling for confounding and found no effect Nucatola 2010: Fifty-two women presenting for elective termination of pregnancy between 18 and 24 weeks' gestation were randomized to one of four digoxin treatment groups: 1.0 mg intraamniotic (1.0 IA), 1.0 mg intrafetal (1.0 IF), 1.5 mg intraamniotic (1.5 IA) or 1.5 mg intrafetal (1.5 IF). Ultrasound was used to assess for the presence of fetal cardiac activity prior to the abortion procedure. Data on the presence and severity of pain, nausea and other potential side effects were collected before digoxin injection, immediately following digoxin injection and on the day after digoxininjection. RESULTS: Digoxin effectively induced fetal death in 87% of women. The failure rate did not vary by route of administration (IA or IF) and was not lowered by increasing the dose from 1.0 to 1.5 mg. IF injections induced fetal death more rapidly than IA injections. Digoxin administration did not result in increased pain or nausea. CONCLUSIONS: IA or IF injection of digoxin is safe and effective for inducing fetal death prior to second-trimester surgical abortion. Doses greater than 1.0 mg may not be necessary