[Pain assessment during medical abortion up to 14 weeks: A 1-year prospective comparative study]. / Évaluation de la douleur lors des interruptions volontaires de grossesse médicamenteuses jusqu'à 14 semaines d'aménorrhées : une étude prospective comparative sur 1 an.

OBJECTIVES: Pain assessment of patients requesting a medical abortion according to the term, up to 14 weeks, by a numerical rating scale (NRS). METHODS: This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020. RESULTS: There was no significant difference in pain assessed by the NRS for medical abortion performed between 7-9 weeks and those performed between 9-14 weeks (6.5±2.5 vs. 6.6±2.2, P=0.85). Regardless of the term (before 7 weeks, between 7-9 weeks and between 9-14 weeks), patients felt relieved by taking painkillers in the case of medical abortion in 88.9%, 80.3% and 87.3% of cases respectively (P=0.18). The use of analgesics allowed a decrease of 3 points of the NRS in the 3 groups (P=0.67). Patients were more painful in case of medical protocol vs. surgical (maximum pain at 6.0±2.6 vs. 1.4±2.0, P<0.01), but declared to be relieved by analgesics in 85.1 and 94.3% of cases (P=0.24). CONCLUSIONS: As pain is similar whatever the term in the case of medical abortion, and its management by analgesics seems to be effective, this criterion should not guide the professional in the choice of method, particularly between 9 and 14 weeks. This choice must be made by the patient.

Luteal phase progesterone supplementation following induced natural cycle frozen embryo transfer: A retrospective cohort study.

INTRODUCTION: The objective of this study was to assess the impact on the clinical pregnancy rate of luteal phase progesterone treatment in patients being prepared for natural cycle frozen embryo transfer (FET) with induced ovulation. MATERIAL AND METHODS: This retrospective cohort study collect all the FET protocols over a 6-month period at Strasbourg University Hospital fertility unit between December 2016 and May 2017. In total 293 consecutive patients with regular menstrual cycles were prepared for natural cycle FET during this period. All patients had an embryo cryopreservation secondary to in vitro fertilisation (IVF) or by intracytoplasmic sperm injection (ICSI). There were 2 protocols during this period and patients either received or did not received progesterone. Ovulation was routinely triggered in all patients by injection of choriogonadotrophin alfa. Patients in the treated group received vaginal natural micronized progesterone treatment of 400mg daily, starting on the day of ovulation. The principal assessment criterion was the occurrence of pregnancy. RESULTS: In total, 231 patients were analysed: 108 in the group not receiving progesterone and 123 in the group receiving progesterone. Patient characteristics were comparable between groups. A higher clinical pregnancy rate (39% vs. 24.1%, p=0.02; 95CI [1.10; 3.74]) was recorded in the treated group. CONCLUSIONS: Our results suggest that luteal phase support with vaginal progesterone statistically increases the clinical pregnancy rate following hCG-triggered natural cycle FET and that it should be used more widely.

Elective abortion: Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF).

The number of elective abortions has been stable for several decades. Many factors explain women's choice of abortion in cases of unplanned pregnancies. Early initiation of contraceptive use and a choice of contraceptive choices appropriate to the woman's life are associated with lower rates of unplanned pregnancies. Reversible long-acting contraceptives should be favored as first-line methods for adolescents because of their effectiveness (grade C). Ultrasound scan before an elective abortion must be encouraged but should not be obligatory (professional consensus). As soon as the embryo appears on the ultrasound scan, the date of pregnancy is estimated by measuring the crown-rump length (CRL) or, from 11 weeks on, by measuring the biparietal diameter (BPD) (grade A). Because reliability of these parameters is ±5 days, the abortion may be done if measurements are respectively less than 90 mm for CRL and less than 30 mm for BPD (professional consensus). A medically induced abortion, performed with a dose of 200 mg mifepristone combined with misoprostol, is effective at any gestational age (Level of Evidence (LE) 1). Before 7 weeks, mifepristone should be followed 24-48 h later by misoprostol, administered orally, buccally, sublingually, or even vaginally followed if needed by a further dose of 400 µg after 3 h, to be renewed if needed after 3 h (LE 1, grade A). After 7 weeks, administration of misoprostol by the vaginal, sublingual, or buccal routes is more effective and better tolerated than by the oral route (LE 1). Cervical preparation is recommended for systematic use in surgical abortions (professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 µg (grade A). Vacuum aspiration is preferable to curettage (grade B). A uterus perforated during surgical aspiration should not routinely be considered to be scarred (professional consensus). An elective abortion is not associated with a higher risk of subsequent infertility or ectopic pregnancy (LE 2). The medical consultation before an elective abortion generally does not affect the decision to end or continue the pregnancy, and most women are sufficiently certain about their choice at this time. Women appear to find the method used most acceptable and to be most satisfied when they were able to choose the method (grade B). Elective abortions are not associated with an increased rate of psychiatric disorders (LE 2). However, women with psychiatric histories are at a higher risk of psychological disorders after the occurrence of an unplanned pregnancy than women with such a history (LE 2). For surgical abortions, combined hormonal contraceptives - oral or transdermal - should be started on the day of the abortion, while the vaginal ring should be inserted 5 days afterwards (grade B). For medical abortions, the vaginal ring should be inserted in the week after mifepristone administration, while the combined contraceptives should begin the same day as the misoprostol or the day after (grade C). Contraceptive implants should be inserted on the same day as a surgical abortion, and may be inserted the day the mifepristone is administered for medical abortions (grade B and C respectively). In case of medical abortion, the implant can be inserted the same day the mifepristone is administered (grade C). Both the copper IUDs and levonorgestrel intrauterine system should be inserted on the day of the surgical abortion (grade A). After medical abortions, an IUD can be inserted in 10 days after mifepristone administration, after ultrasound scan verification of the absence of an intrauterine pregnancy (grade C).

Medical management of unwanted pregnancy in France: modalities and outcomes. The aMaYa study.

OBJECTIVES: Medical termination of pregnancy (MToP) has become more frequently used, and specific recommendations have been issued by the French Authorities regarding protocols. The aim of this prospective, multicenter, longitudinal observational study was to record actual practices and to describe efficacy and safety of drugs used for MToP in real-life conditions in France. STUDY DESIGN: The study was performed between 2011 and 2012 in a representative sample of 47 centers dealing with abortions. Pregnant women with less than 14 weeks of amenorrhea, requesting MToP, for whom a drug regimen including mifepristone was decided, were recruited and information was recorded from the center and through the patient's auto questionnaire. The main efficacy parameter was complete abortion without surgical procedure. RESULTS: A total of 1585 women (mean age: 27.6 ± 6.8 years) were included by 47 centers. At inclusion time, when women were given mifepristone, the mean term of pregnancy was 46.5 ± 7.8 days of amenorrhea (DA), the term was >49 DA for 28.3% of patients, and >63 DA for 1.6%. The most frequently used protocol was the one recommended by the French authorities (mifepristone 600 mg-misoprostol 400 µg oral), used in 35.4% of patients, but other protocols were used (mifepristone 600 mg or 200mg in association with misoprostol 2 × 400 µg per os, for respectively 23.4% and 13.5%). Gemeprost prostaglandin was used by 1.4% of patients only. Of the patients, 10.3% did not return to the center and were considered as lost to follow up. For the 1421 patients for whom information was available, the successful abortion rate was 94.4%. In the remaining 5.6% there were no ongoing pregnancies, but their condition required a secondary surgical procedure. Over 90% of the 1421 patients with follow-up were satisfied with the procedure. Safety was good, with only 16 cases of major bleeding(1%), and one of endometritis (0.1%) reported as serious adverse events. CONCLUSION: Our study showed, in real-life settings, a high rate of success for MToP. Whatever the protocol used, this approach is effective, well tolerated, and satisfactory for the majority of patients.