Gunilla Kleiverda

Using telemedicine for termination of pregnancy with mifepristone and misoprostol in settings where there is no access to safe services

Women on Web is a service that uses telemedicine to help women access mifepristone and misoprostol in countries with no safe care for termination of pregnancy (TOP). This study reviews the telemedicine service. After an online consultation, women with an unwanted pregnancy of up to 9 weeks are referred to a doctor. If there are no contraindications, a medical TOP is conducted by mail. After maximising the follow up from 54.8 to 77.6%, 12.6% decided not to do the TOP and 6.8% of the women who did the medical TOP at home needed a vacuum aspiration. Telemedicine can provide an alternative to unsafe TOP. Outcomes of care are in the same range as TOP provided in outpatient settings.

Place of delivery in The Netherlands: maternal motives and background variables related to preferences for home or hospital confinement

The decision-making process regarding the preferred site for confinement was investigated in a total of 170 nulliparous women with initially uncomplicated pregnancies. Of these women, 100 had a preference for delivery at home and 45 for hospital confinement. The remaining 25 women were in doubt about the preferred location. Interviews were held at the 18th week of pregnancy. Motives for choosing either a home or a hospital confinement were analysed. Preferences for either home or hospital confinement were predicted by a stepwise discriminant analysis. Educational level, psychological well-being, anxiety concerning complications at birth, and attitudes towards female social roles accounted for 78.6% of the variance. Fear that something might go wrong during labour together with an older age predicted for 62% the group of women doubtful about the place of confinement.

Regional differences in surgical intervention following medical termination of pregnancy provided by telemedicine

Objective. Analysis of factors influencing surgical intervention rate after home medical termination of pregnancy (TOP) by women in countries without access to safe services using the telemedical service ‘Women on Web’. Design. Cohort study. Setting. Women with an unwanted pregnancy less than nine weeks pregnant who used the telemedicine service of Women on Web between February 2007 and September 2008 and provided follow‐up information. Sample. Women who used medical TOP with a known follow up. Methods. Information from the online consultation, follow‐up form and emails was used to analyze the outcome of the TOP. Main Outcome Measures. Ongoing pregnancy, reason for surgical intervention, perceived complications and satisfaction. Results. Of the 2 323 women who did the medical TOP and had no ongoing pregnancy, 289 (12.4%) received a surgical intervention. High rates were found in Eastern Europe (14.8%), Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%; p=0.000). More interventions occurred with longer gestational age (p=0.000). Women without a surgical intervention more frequently reported satisfaction with the treatment (p=0.000). Conclusions. The large regional differences in the rates of reported surgical interventions after medical TOP provided by telemedicine cannot be explained by demographic factors or differences in gestational length. It is likely that these differences reflect different clinical practice and local guidelines on (incomplete) abortion rather than complications that genuinely needed surgical intervention. Surgical interventions significantly influenced womens’ views on the acceptability of the TOP.

Vaginal birth after a caesarean section: the development of a Western European population‐based prediction model for deliveries at term

To develop and internally validate a model that predicts the outcome of an intended vaginal birth after caesarean (VBAC) for a Western European population that can be used to personalise counselling for deliveries at term.

Predicting successful intended vaginal delivery after previous caesarean section: external validation of two predictive models in a Dutch nationwide registration-based cohort with a high intended vaginal delivery rate

To externally validate two models from the USA (entry‐to‐care [ETC] and close‐to‐delivery [CTD]) that predict successful intended vaginal birth after caesarean (VBAC) for the Dutch population.

Nifedipine as a uterine relaxant for external cephalic version: a randomized controlled trial.

OBJECTIVE: To estimate the effectiveness of nifedipine as a uterine relaxant during external cephalic version to correct breech presentation. METHODS: In this randomized, double-blind, placebo-controlled trial, women with a singleton fetus in breech presentation and a gestational age of 36 weeks or more were eligible for enrollment. Participating women received two doses of either nifedipine 10 mg or placebo, 30 and 15 minutes before the external cephalic version attempt. The primary outcome was a cephalic-presenting fetus immediately after the procedure. Secondary outcome measures were cephalic presentation at delivery, mode of delivery, and adverse events. A sample size of 292 was calculated to provide 80% power to detect a 17% improvement of the external cephalic version success rate, assuming a placebo group rate of 40% and alpha of .05. RESULTS: Outcome data for 310 of 320 randomly assigned participants revealed no significant difference in external cephalic version success rates between treatment (42%) and control group (37%) (relative risk 1.1, 95%; 95% confidence interval 0.85–1.5). The cesarean delivery rate was 51% in the treatment group and 46% in the control group (relative risk 1.1, 95% confidence interval 0.88–1.4). CONCLUSION: Nifedipine did not significantly improve the success of external cephalic version. Future use of nifedipine to improve the outcome of external cephalic version should be limited to large clinical trials. CLINICAL TRIAL REGISTRATION: Current Controlled Trials, http://isrctn.org, ISRCTN 28715121 LEVEL OF EVIDENCE: I

Place of delivery in The Netherlands: actual location of confinement

Preferred and actual locations of confinement were compared in a group of 170 nulliparous women. Voluntary changes in preferred location for birth were rare and concerned only changes from hospital to home confinement. Obligatory changes due to referral to consultant obstetricians occurred frequently: 58.8% of the total sample. Fewer referrals were found for women with an initial preference for a home confinement (53%) than for those who preferred a hospital confinement (64%). Most referrals occurred in the group of older women initially in doubt about their preferred location for giving birth: 72%. The differences were not significant, however. To reveal differences between referrals and non-referrals, discriminant analysis was performed at the 18th week of gestation. The explained variance for the total group of referrals was 64.7%. Partially, the variables pertaining to the explained variance were the same as those related to a preferred hospital confinement. The explained variance for the group of referrals in which psychosocial influences were presupposed was not better, with the exception of referrals due to insufficient progress during labour: 76.4% of the variance could be explained at the 34th gestational week. When birth weight and amenorrhoea were included, these percentages increased to 79.0 and 84.8%, respectively.

Prediction of progression to a high risk situation in women with gestational hypertension or mild pre-eclampsia at term

Objective:  To evaluate whether progression to a high‐risk situation is predictable in women with gestational hypertension (GH) or mild pre‐eclampsia (PE) at term.

Economic analysis of use of pessary to prevent preterm birth in women with multiple pregnancy (ProTWIN trial)

To assess the cost‐effectiveness of a cervical pessary to prevent preterm delivery in women with a multiple pregnancy.

Provision of medical abortion using telemedicine in Brazil.

OBJECTIVE To evaluate the need for and outcome of self-administered medical abortion with mifepristone and misoprostol in Brazil, provided through Women on Web, a global telemedicine abortion service. STUDY DESIGN A retrospective case review of women from Brazil who contacted Women on Web in 2011. Information from the online consultation, follow-up questionnaire and emails were used to analyze data including demographics, gestational age, outcome of the medical abortion and symptoms that lead to surgical interventions. RESULTS The Women on Web website had 109779 unique visitors from Brazil, 2104 women contacted the helpdesk by email. Of the 1401 women who completed the online consultation, 602 women continued their request for a medical abortion. Of the 370 women who used the medicines, 307 women gave follow-up information about the outcome of the medical abortion. Of these, 207 (67.4%) women were 9 weeks or less pregnant, 71 (23.1%) were 10, 11 or 12 weeks pregnant, and 29 (9.5%) women were 13 weeks or more pregnant. There was a significant difference in surgical intervention rates after the medical abortion (19.3% at <9 weeks, 15.5% at 11-12 weeks and 44.8% at >13 weeks, p=.06). However, 42.2% of the women who had a surgical intervention had no symptoms of a complication. CONCLUSION There is large need for medical abortion in Brazil. Home use of mifepristone and misoprostol provided through telemedicine is safe and effective. However, after 13 weeks gestation, there is an increased risk of surgical intervention that may be due to the regimen used and local clinical practices in Brazil. IMPLICATIONS The current study shows that there is an unmet need for medical abortion in Brazil, a country with legal restrictions on access to safe abortion services. Telemedicine can help fulfill the need and self administration of medical abortion is safe and effective even at late first trimester abortion. Prospective trials are needed to establish safety, effectiveness and acceptability of home use of medical abortion beyond 12 weeks of pregnancy.