Ipas issues 2017 updates to clinical abortion recommendations

New additions focus on medical abortion regimens, bimanual exam, processing Ipas aspirators, and more

Friday, March 3, 2017

cover of Clinical Updates in Reproductive Health

Ipas’s annual release of Clinical Updates in Reproductive Health continues to offer the most up-to-date, evidence-based clinical recommendations on comprehensive abortion care in English and Spanish (and French coming soon), with new topics and resources added for 2017. As an organization offering technical assistance to health systems, Ipas promotes evidence-based clinical practice and the right to high-quality health care for all people—and uses the Clinical Updates to further these priorities.

The Clinical Updates include a broad spectrum of topics related to comprehensive abortion care, such as postabortion contraception, pain management, medical abortion regimens, and the safety of abortion for adolescent and young women. For abortion providers and trainers, the publication provides concise, easy-to-read answers to common clinical questions, such as:

  • What regimen of mifepristone and misoprostol should I use for abortion at or after 13 weeks gestation?
  • What are the right medications to treat pain during vacuum aspiration?
  • When can I place an intrauterine device after a medical abortion?

Clinical and public health professionals working in health systems and the private sector can use Clinical Updates to inform patient care and protocols. The short summaries of evidence are also useful for advocates and policymakers working to create laws and policies that fulfill women’s and girls’ right to health, as well as their right to access and benefit from the latest scientific information.

New clinical recommendations in 2017

“We’ve revised and updated our clinical recommendations this year based on advances in scientific research and in response to requests by Ipas-trained health workers and clinical trainers,” says Dr. Dalia Brahmi, medical editor of the Clinical Updates.

Medical abortion

1. Summary of recommended medical abortion regimens (see page 6 in Clinical Updates)

As multiple cadres of health workers increasingly offer medical abortion services, Ipas’s staff and trainers noted the need for a succinct collection of all recommended regimens before and after 13 weeks gestation for easy reference. The new Update provides a summary of evidence-based regimens for mifepristone and misoprostol for induced abortions, and also includes the misoprostol-only regimen for induced abortion in settings where mifepristone is not available.

Important: The Update also summarizes the evidence for use of misoprostol for treatment of incomplete abortion and miscarriage management (commonly included in postabortion care programs).

2. Confirming success of misoprostol-only medical abortion (see page 92 in Clinical Updates)

The efficacy of misoprostol alone for induced abortion is around 85 percent, so assessing a woman for ongoing pregnancy is an important factor in quality of care.

“Ipas’s recommendation is consistent with the World Health Organization’s guidance that women who use misoprostol alone for medical abortion before 13 weeks gestation need follow-up with a clinician to ensure the abortion was successful,” Brahmi says.

3. Misoprostol product quality (see page 10 in Clinical Updates)

Misoprostol is an essential part of treatment for induced and spontaneous abortion as well as other obstetric emergencies like postpartum hemorrhage. Ipas’s updated recommendation emphasizes that health facilities should purchase misoprostol in double-aluminum blister packs when possible to minimize the drug’s degradation over time, especially in warm and tropical climates.

“A 2016 study found that after one year, only 28 percent of misoprostol pills stored in double-aluminum blister packs had degraded, compared to 100 percent of pills in plastic-aluminum blister packs,” Brahmi explains.

Vacuum aspiration

1. Instrument processing (see page 50 in Clinical Updates)

All Ipas multiple-use aspirators and adapters need to be soaked, cleaned and high-level disinfected (HLD) or sterilized between patients, and this new Update provides easy-to-follow steps and a chart summarizing sterilization and HLD options.

2. Bimanual exam before vacuum aspiration (see page 33 in Clinical Updates)

A bimanual exam indicates a woman’s uterine size and position—essential information that helps clinicians avoid complications during uterine procedures, including abortion.

“Ipas’s recommendation is that a bimanual exam must be performed by the clinician doing the procedure, and this is particularly important for new learners,” Brahmi says. “Given the prevalence of sexual violence and the fact that many clients seeking abortion care may be experiencing the health system for the first time, clinician training on compassionate care during a bimanual exam is essential.”

3. Routine examination of products of conception (see page 41 in Clinical Updates)

By routinely examining the products of conception after vacuum aspiration, a clinician ensures the procedure is successfully completed and can further rule out a molar or ectopic pregnancy in settings where clinical exam is more available than ultrasound.

“This new Update conveys Ipas’s recommendation that clinicians must inspect the products of conception immediately after vacuum aspiration as part of a systematic and routine intervention to improve the quality of care,” Brahmi explains.

4. Step-by-step job aid for paracervical block (see page 151 in Clinical Updates)

Ipas recommends that all women receive a paracervical block for pain management prior to vacuum aspiration (see page 39 in Clinical Updates). The Clinical Updates now include a new job aid with step-by-step guidance that can be used by health workers and trainers as a reference tool.

“Our new job aid is informed by the latest published literature on techniques for paracervical block,” Brahmi says. “For example, studies have shown that a four-point injection and deep injection technique lead to improved pain control for women.”


Read and share the new Clinical Updates: www.ipas.org/clinicalupdates

Also available in Spanish: www.ipas.org/actualizacionesclinicas

For comments, questions or feedback on the Clinical Updates, please email clinicalaffairs@ipas.org