H. von Hertzen

Timing of emergency contraception with levonorgestrel or the Yuzpe regimen

A World Health Organization (WHO) study of combined oral contraceptives (Yuzpe regimen) and levonorgestrel alone for emergency contraception found that the effectiveness of both treatments declined with increasing time since unprotected intercourse. An earlier review of primarily observational studies found no such timing effect however. The authors reanalysis of the WHO data revealed a consistent linear relationship between efficacy and time from intercourse to treatment. The pregnancy rate rose from 0.5% when treatment was given within 12 hours of treatment to 4.1% when 61-72 hours had elapsed. The odds ratio of pregnancy associated with either treatment at a given time compared with treatment 12 hours earlier was 1.46 (95% confidence interval 1.20-1.77). This estimate was not affected by adjustment for confounding factors such as age weight cycle length or cycle day in which unprotected intercourse took place. The consistency between the WHO trial and an earlier randomized controlled trial the statistically significant temporal effect observed with both treatment regimens and biologic plausibility all suggest that the effect of timing on emergency contraception efficacy is real.

Cervical priming with misoprostol prior to transcervical procedures

Cervical priming with misoprostol has shown to facilitate transcervical procedures and to reduce side‐effects. Cervical priming is recommended by several evidence‐based guidelines prior to surgical abortion, dilatation and curettage, hysteroscopy and intrauterine device insertion. It is effective in pregnant as well as in non‐pregnant women while the results in post‐menopausal women are conflicting. Misoprostol is the best suited prostaglandin for a number of reasons: it has a short half‐life, few side effects, it is stable at room temperature, it is relatively cheap and the dosage can easily be adjusted according to the clinical need. Various doses, routes, and time intervals between misoprostol application and the intervention have been evaluated. A single dose of 400 μg given sublingually or vaginally 3h before the intervention has given the best efficacy with the least side effects. Higher doses or longer intervals do not improve the effect on the cervix. Pain is a frequent side effect, but usually responds well to NSAIDs. Other side effects are rare.

Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial

Please cite this paper as: Wu S, Godfrey E, Wojdyla D, Dong J, Cong J, Wang C, von Hertzen H. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial. BJOG 2010;117:1205–1210.

Misoprostol dose and route after mifepristone for early medical abortion: a randomised controlled noninferiority trial

Please cite this paper as: von Hertzen H, Huong N, Piaggio G, Bayalag M, Cabezas E, Fang A, Gemzell‐Danielsson K, Hinh N, Mittal S, Ng E, Chaturachinda K, Pinter B, Puscasiu L, Savardekar L, Shenoy S, Khomassuridge A, Tuyet H, Velasco A, Peregoudov A, for the WHO Research Group on Postovulatory Methods of Fertility Regulation. Misoprostol dose and route after mifepristone for early medical abortion: a randomised controlled noninferiority trial. BJOG 2010;117:1186–1196.

Two mifepristone doses and two intervals of misoprostol administration for termination of early pregnancy: a randomised factorial controlled equivalence trial*

Objective  To compare the efficacy of 100 mg and 200 mg of mifepristone and 24‐ and 48‐hour intervals to administration of 800μg vaginal misoprostol for termination of early pregnancy.

Expanding access to emergency contraception

Emergency contraception (EC) is safe and has the potential to prevent unwanted pregnancies. However, use remains low in most settings, due to a range of barriers to access. This paper reviews key issues related to EC and describes recommendations reached during the Womens Health Alliance pre‐Congress workshop, held in advance of the FIGO 2006 World Congress. The working group concluded that national societies of obstetrics and gynecology can play an important role in increasing access to this unique contraceptive method.

Cervical ripening with mifepristone (RU 486) in late first trimester abortion

In order to further evaluate the usefulness of the antiprogestogen, mifepristone, as a cervical ripening agent, a double-blind multicentre study was undertaken of 230 primigravid women with 10-12 weeks amenorrhoea who were randomly assigned to receive either 0 (placebo) or 200 mg of mifepristone 36 hours before surgical pregnancy termination. Fifteen women who did not fulfil all of the selection criteria were excluded from analysis. In the mifepristone group (N = 105) 12 women experienced some pre-operative vaginal bleeding as compared with only one subject in the placebo group (N = 110), but only one of these 12 women described the bleeding as more than her usual menstrual flow. In mifepristone-treated women the cervix was about 1 mm more dilated at operation and further mechanical dilatation was needed less frequently than in placebo-treated controls. High resistance during further mechanical stretching was encountered significantly more often and at a smaller cervical diameter in the placebo group than in the women given mifepristone. Also, dilatation was reported by the operating surgeons to be easier in women given the antiprogestogen. Other significant differences included a shorter operation time, lower peroperative blood loss and less frequent use of analgesic drugs post-operatively in the mifepristone group. Post-operative complications, the duration of post-operative bleeding and the interval to the first menstruation were similar in both groups. The results confirm that the antiprogestogen, mifepristone, is an effective cervical ripening agent which deserves further study in comparison with the currently used methods, i.e. prostaglandins and osmotic dilators.

Demographic aspects of induced abortion

Abstract Every day some 150 000 unwanted pregnancies, close to 53 million in a year, are terminated by induced abortion. One third of these abortions are performed under unsafe conditions, resulting in about 500 deaths every day — or approximately 180 000 in 1 year. The majority of these deaths occur in countries in the developing part of the world, where access to abortion is restricted either by law or because existing services are inadequate. The trend towards liberalisation of abortion started in Europe in the 1930s and continues today. Currently, some 63% of the worlds people live in countries where abortion is available on request or where social factors can be taken into consideration when evaluating a womans request for pregnancy termination. Liberalisation of abortion does not inevitably lead to an increase in the number of abortions, as illustrated by the example of the Netherlands which has the lowest reported abortion rate in the world despite its liberal law. Other factors such as universal sex education in schools and easily accessible family planning services, including services for adolescents and the provision of emergency contraception, influence a countrys abortion rate to a much greater extent than the degree of liberalness of its law. This is also reflected by the demographic characteristics of the women who most often utilise abortion. In English-speaking countries, especially the USA, and in Scandinavia, young unmarried women make up the largest proportion of those who obtain abortion and the major challenge in these countries, therefore, is to improve sexual education and contraceptive use and hence reduce unintended pregnancy amongst this group. In most other developed countries, including those in Central and Eastern Europe, that have reliable abortion statistics, and probably also in most of the developing world, married women with children constitute the largest group of abortion users and thus the greatest need here is to provide contraceptive services and supplies and encourage their use. But neither the family planning methods currently available nor the people who use them are perfect, and it would be unrealistic to believe, therefore, that unplanned pregnancy and induced abortion are totally preventable.

Acceptability of misoprostol-only medical termination of pregnancy compared with vacuum aspiration: an international, multicentre trial

Please cite this paper as: Rodriguez M, Seuc A, Kapp N, von Hertzen H, Huong N, Wojdyla D, Mittal S, Arustamyan K, Shah R, the World Health Organization Research Group on Post‐Ovulatory Methods of Fertility Regulation. Acceptability of misoprostol‐only medical termination of pregnancy compared with vacuum aspiration: an international, multicentre trial. BJOG 2012;119:817–823.

Copper T380A intrauterine device for emergency contraception

Please cite this paper as: Wu S, Godfrey E, Wojdyla D, Dong J, Cong J, Wang C, von Hertzen H. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial. BJOG 2010;117:1205–1210.