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Preventing unsafe abortion

Definition of Terms=

Definition of unsafe abortion

Slide 4



Global annual estimates of incidence and mortality for unsafe abortions per year (2000)
WHO 2005

Effects of the introduction of the anti-abortion law in Romania (1966)

Slide 7

Slide 8

Abortion complicati= ons

Abortion complicati= ons

Methods

Antigestagen

Mifepristone

Misoprostol, Gemepr= ost

Strategy - Cochrane systematic review

Approach

Medical abortion – structure of the review

Medical methods for= first trimester abortion

Medical methods Kul= ier 2004

Medical methods    Kulier 2004
dose of mifepristone

Medical methods Kul= ier 2004
misoprostol po vs pv

Medical methods Kul= ier 2004
misoprostol po vs pv

Medical methods WHO= 2003

Medical methods WHO= 2003

Medical methods – outcomes  WHO 2003

Medical methods Kul= ier 2004
mifepristone vs combined regimen

Medical methods Kul= ier 2004 prostaglandin vs combined regimen

Methotrexate

Conclusions - medic= al methods

Medical methods  - unresolved issues

Surgical

Medical vs Surgical= Say 2004

Medical vs surgical=   Say 2004

Medical vs surgical=    Say 2004
Prostaglandin vs VA

Medical vs surgical=    Say 2004
Mifepristone/prostaglandin vs VA

Medical vs surgical=    Say 2004
Mifepristone/PG vs VA

Medical vs surgical= Henshaw 1994
Mifepristone/PG vs VA

Medical vs surgical= Say 2003

Surgical methods

Surgical methods for first trimester abortion   Kulier 2= 003

Surgical methods Ku= lier 2003
VA vs dilatation/curettage

Surgical methods He= mlin 2001

Surgical methods He= mlin 2001

Antibiotic prophyla= xis

Conclusions=

Collaborators

International Confe= rence on Population and Development

Slide 48

References<= /font>

References<= /font>

Slide 51

WHO database on uns= afe abortion

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Preventing unsafe abortion
R Kulier
Geneva Foundation f= or Medical Education and Research
March 2006

Definition of Terms=
"abortion"= ; refers to the termination of pregnancy from whatever cause before the fetus is capa= ble of extrauterine life.
“spontaneous aborti= on" refers to those terminated pregnancies that occur without deliberate meas= ures
"induced abort= ion" refers to termination of pregnancy through a deliberate intervention inte= nded to end the pregnancy (WHO, 1994).

Definition of unsafe abortion
"...a procedur= e for terminating unwanted pregnancy either by persons lacking the necessary sk= ills or in an environment lacking the minimal medical standards of both" = which therefore exposes the women to an increased risk of morbidity and mortali= ty.
(WHO,1993)

Slide 4



Global annual estimates of incidence and mortality for unsafe abortions per year (2000)
WHO 2005

Effects of the introduction of the anti-abortion law in Romania (1966)

Slide 7

Slide 8

Abortion complicati= ons
WHO systematic revi= ew
1990-2000
> 45 datasets
 most developing countries, facility ba= sed
Hospital register, = survey, X-sectional
Haemorrhage , infec= tion, perforation

Abortion complicati= ons
Perforation, perito= nitis, sepsis:
Prevalence: 33.91 (= 28.92-38.91)
Goyaux 1998<= /td>

Methods
Surgical
Non-surgical=
Menstrual regulatio= n (MR)
generally used to d= escribe early evacuation of the uterus, after a delayed menses, often without confirmation of pregnancy

Antigestagen
Developed during 19= 60s
Mifepristone (RU 48= 6)
Suppression of foll= iculogenesis and ovulation
endometrium<= /td>

Mifepristone
Pharmacokinetics
Linear 2-25 mg/day<= /font>
Non-linear above 10= 0 mg/day

Misoprostol, Gemepr= ost
Prostaglandin E1 + = E2
Effectiveness: <= 90%
Side effects=

Strategy - Cochrane systematic review
Randomised controll= ed trials
Critical appraisal<= /font>
Meta - analysis whe= re appropriate
Search and methods = according to Cochrane Fertility Regulation Group Guidelines

Approach
Pregnant women, fir= st trimester (<14 wks)
Interventions
Medical
Surgical
Medical vs Surgical=
Outcomes
effectiveness, comp= lications, side effects, acceptability

Medical abortion – structure of the review
Combined regime: mifepristone/prostaglandin
Dose, route, time of administration, type of PG, split dose
Combined regime: methotrexate/prostaglandin
Dose, route, timing=
Single vs combined = regime
Others
Tamoxifen, laminari= a etc
14 main comparisons=

Medical methods for= first trimester abortion
> 100 studies id= entified; 40 trials included
many different inte= rventions
route-dose-type of agent-interval…...

Medical methods Kul= ier 2004
Combination:=
Mifepristone 200 – = 600 mg
followed by<= /td>
Prostaglandin
Type
Dose
Route
Time interval

Medical methods    Kulier 2004
dose of mifepristone

Medical methods Kul= ier 2004
misoprostol po vs pv

Medical methods Kul= ier 2004
misoprostol po vs pv

Medical methods WHO= 2003
Misoprostol: oral v= s vaginal
Multicentric RCT
N=3D2219

Medical methods WHO= 2003

Medical methods – outcomes  WHO 2003

Medical methods Kul= ier 2004
mifepristone vs combined regimen

Medical methods Kul= ier 2004 prostaglandin vs combined regimen

Methotrexate
Folic acid antagoni= st
Toxic on trophoblas= t
Combination with pr= ostaglandin
Effectiveness ~ 95 = %
Fetal anomalies

Conclusions - medic= al methods
Combined regimes ar= e more effective
Mifepristone 200 mg= seems adequate in the combined regime
vaginal prostagland= in is more effective compared to oral

Medical methods  - unresolved issues
No firm conclusion:=
Effectiveness: dose= , type or time of prostaglandin, splitting of dose
Acceptability po vs= pv
Methotrexate: dose,= time, route of PG
Early vs late ?

Surgical
Lowest complication= rate between 49-56 days of amenorrhoea
Increased morbidity= with age, parity
Major complication = rate is 2.3 times higher with D&C compared to VA
WHO 1997, Grimes 19= 79

Medical vs Surgical= Say 2004
6 randomised contro= lled trials
4 comparisons:
Prostaglandin vs va= cuum aspiration
Mifepristone vs vac= uum aspiration
Mifepristone/prosta= glandin vs vacuum aspiration
Methotrexate/prosta= glandin vs vacuum aspiration

Medical vs surgical=   Say 2004

Medical vs surgical=    Say 2004
Prostaglandin vs VA

Medical vs surgical=    Say 2004
Mifepristone/prostaglandin vs VA

Medical vs surgical=    Say 2004
Mifepristone/PG vs VA

Medical vs surgical= Henshaw 1994
Mifepristone/PG vs VA

Medical vs surgical= Say 2003
Small sample sizes<= /font>
Medical:
Longer duration of = bleeding
Single regimes less= effective than vacuum
Acceptability ?

Surgical methods
Vacuum aspiration
Dilatation/curettag= e
Manual vacuum aspir= ation (MVA)

Surgical methods for first trimester abortion   Kulier 2= 003
3 trials included
2 comparisons:
Vacuum aspiration v= s dilatation &curettage
Metal vs plastic ca= nnula for vacuum aspiration
N =3D 767

Surgical methods Ku= lier 2003
VA vs dilatation/curettage

Surgical methods He= mlin 2001
VA vs MVA
RCT; < 56 days of amenorrhoea
MVA n =3D 91=
VA n =3D 88<= /td>
Effectiveness
Complications

Surgical methods He= mlin 2001

Antibiotic prophyla= xis
Universal AB prophy= laxis
Vs
Screen-and-treat
Contact tracing &am= p; Treatment of sexual partners
Screening for other= STDs
Counselling<= /td>
Costly
Organisational matt= ers

Conclusions=
Safe and effective = methods for first trimester abortion are available
Acceptability data = scarce
Medical methods:
Longer duration of = bleeding
Single regimes less= effective
Serious complicatio= ns are rare

Collaborators
Linan Cheng<= /td>
Anis Feki
Metin Gülmezoglu
Justus Hofmeyr
Lale Say

International Confe= rence on Population and Development

Slide 48

References<= /font>
http://www.who.int/= reproductive-health/pages_resources/listing_unsafe_abortion.html
http://www.who.int/= reproductive-health/publications/MSM_97_16/MSM_97_16_table_of_contents_en.h= tml
http://www.cochrane= .org/cochrane/revabstr/ab003037.htm
http://www.cochrane= .org/cochrane/revabstr/ab002900.htm
http://www.popcounc= il.org/rhfp/pac.html
http://www.who.int/= reproductive-health/hrp/practices/dissemination.html
http://www.who.int/= reproductive-health/hrp/plan_of_work/Unsafe_abortion.en.html
http://www.cochrane= .org

References<= /font>
Edelman DA, Brenner= WE, Berger GS.  The effectiveness and complications of abortion by dilatation and vacuum aspiration versus dilatation and rigid metal curettage.  American Journal of Obstetrics and Gynecology 1974; 119(4): 473-48= 0.
Henshaw RC, Naji SA= , Templeton AA. A comparison of medical abortion (using mifepristone and gemeprost) w= ith surgical vacuum aspiration: efficacy and early medical sequelae.  Human Reproduction 1994;  9 (11): 2167 -2172.
Hemlin L, Moller B.=   Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination.  Acta Obstetrica et Gynecologica Scandinavica 2001; 80(6):563-567.
Kulier R, Fekih A, = Hofmeyr GJ, Campana A. Surgical methods for first trimester termination of pregnancy (Cochrane Review). In: The Cochrane Library, Issue 1, 2005. Oxford: Update Software.
Kulier R, Hofmeyr G= J, Gülmezoglu AM, Cheng L, Campana A. Medical methods for first trimester termination of pregnancy (Cochrane Review). In: The Cochrane Library, Iss= ue 1, 2005. Oxford: Update Software.
Say L, Kulier R, Gü= lmezoglu M, Campana A. Medical versus surgical methods for first trimester terminatio= n of pregnancy (Cochrane Review). In: The Cochrane Library, Issue 1, 2005. Oxf= ord: Update Software.
von Hertzen H, Honk= anen H, Piaggio G, Bartfai G, Erdenetungalag R, Gemzell-Danielsson K, Gopalan S, Horga M, Jerve F, Mittal S, Ngoc NT, Peregoudov A, Prasad RN, Pretnar-Dar= ovec A, Shah RS, Song S, Tang OS, Wu SC; WHO Research Group on Post-Ovulatory = Methods for Fertility Regulation. WHO multinational study of three misoprostol regimens after mifepristone for early medical abortion. I: Efficacy. BJOG. 2003 Sep;110(9):808-18.

Slide 51

WHO database on uns= afe abortion

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------=_NextPart_01C64218.02FF9370 Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C64218.02FF9370 Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/v3_slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
<= /td> =
Preventing unsafe
= abortion
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Definition o= f Terms
<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
o &q= uot;abortion" refers to the termination of pregnancy
fro= m whatever cause before the fetus is
cap= able of extrauterine life.
o “sp= ontaneous abortion" refers to those
ter= minated pregnancies that occur without
del= iberate measures
o &qu= ot;induced abortion" refers to termination of
pre= gnancy through a deliberate intervention
int= ended to end the pregnancy (WHO, 1994).
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Definition of u= nsafe abortion
<= /td> = <= /td> <= /td> <= /td> <= /td> <= /td>
o = "...a procedure for terminating
= unwanted pregnancy either by
= persons lacking the necessary skills
= or in an environment lacking the
= minimal medical standards of both"
wh= ich therefore exposes the women to an increased risk
of = morbidity and mortality.
(WHO,1993)
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=
Eff= ects of the introduction of the anti-
abortion law in= Romania (1966)
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Abortion compli= cations
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
o WHO= systematic review
o 1990= -2000
o >= ; 45 datasets
o  most developing countries, facility<= /font>
base= d
o Hos= pital register, survey, X-sectional
o Hae= morrhage , infection, perforation
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Abortion compli= cations
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Methods<= /font>
<= /td> <= /td> <= /td> <= /td> <= /td> = <= /td> <= /td>
o S= urgical
o = Non-surgical
o = Menstrual regulation (MR)
n = generally used to describe early
= evacuation of the uterus, after a delayed
= menses, often without confirmation of
p= regnancy
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Antigestagen
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
o Dev= eloped during 1960s
o Mif= epristone (RU 486)
n Sup= pression of folliculogenesis and
ovul= ation
n end= ometrium
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Mifepristone
<= /td> <= /td> = <= /td>
o Pha= rmacokinetics
n Lin= ear 2-25 mg/day
n Non= -linear above 100 mg/day
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Misoprostol, Ge= meprost
<= /td> = <= /td>
o Pro= staglandin E1 + E2
o Eff= ectiveness: < 90%
o Sid= e effects
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= <= /td>
Strategy - Cochrane systematic
r= eview
<= /td> = <= /td> = <= /td>
o Ran= domised controlled trials
o Cri= tical appraisal
o Met= a - analysis where appropriate
o Sea= rch and methods according to
Coc= hrane Fertility Regulation Group
Gui= delines
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Approach=
<= /td> <= /td> <= /td> <= /td> <= /td> =
o Pr= egnant women, first trimester (<14 wks)
o Int= erventions
n Medi= cal
n Surg= ical
n Med= ical vs Surgical
o Outc= omes
n eff= ectiveness, complications, side effects,
acce= ptability
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=
Med= ical abortion – structure of
the review
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td> = <= /td>
o Co= mbined regime: mifepristone/prostaglandin
n Dos= e, route, time of administration, type of PG,
spli= t dose
o Co= mbined regime: methotrexate/prostaglandin
n Dos= e, route, timing
o Si= ngle vs combined regime
o Othe= rs
n Tam= oxifen, laminaria etc
o 14 = main comparisons
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=
Med= ical methods for first
trimester abort= ion
<= /td> <= /td> <= /td> = <= /td>
o >= ; 100 studies identified; 40 trials
incl= uded
o man= y different interventions
n rou= te-dose-type of agent-interval…...
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Medical methods= Kulier 2004
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
Combination:
Mif= epristone 200 – 600 mg
foll= owed by
Pro= staglandin
Type
Dose=
Rout= e
Time= interval
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=
Med= ical methods    Kulier 2004
dose of mifepri= stone
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Med= ical methods Kulier 2004
misoprostol po = vs pv
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Med= ical methods Kulier 2004
misoprostol po = vs pv
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Medical methods= WHO 2003
<= /td> <= /td> <= /td>
o Mis= oprostol: oral vs vaginal
o Mul= ticentric RCT
o N=3D= 2219
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Medical methods= WHO 2003
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=
Med= ical methods –
outcomes  = WHO 2003
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Med= ical methods Kulier 2004
mifepristone vs= combined regimen
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Med= ical methods Kulier 2004
prostaglandin v= s combined regimen
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Methotrexate
<= /td> <= /td> = <= /td>
o Fol= ic acid antagonist
o Tox= ic on trophoblast
o Com= bination with prostaglandin
n Eff= ectiveness ~ 95 %
o Fet= al anomalies
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=
Con= clusions - medical
methods<= br>
<= /td> = <= /td> =
o Com= bined regimes are more effective
o Mif= epristone 200 mg seems adequate in
the= combined regime
o vag= inal prostaglandin is more effective
com= pared to oral
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<= /td>
Med= ical methods  - unresolved
issues
<= /td> <= /td> = <= /td> <= /td> <= /td> <= /td>
o No = firm conclusion:
n Eff= ectiveness: dose, type or time of
pro= staglandin, splitting of dose
n Acc= eptability po vs pv
n Met= hotrexate: dose, time, route of PG
o Ear= ly vs late ?
------=_NextPart_01C64218.02FF9370 Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/v3_slide0085.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
Surgical<= br>
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<= /td> <= /td> <= /td> <= /td> = <= /td> <= /td> <= /td>
o 6 r= andomised controlled trials
o 4 c= omparisons:
n Pro= staglandin vs vacuum aspiration
n Mif= epristone vs vacuum aspiration
n Mif= epristone/prostaglandin vs vacuum
aspi= ration
n Met= hotrexate/prostaglandin vs vacuum
aspi= ration
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Medical vs surg= ical  = Say 2004
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Med= ical vs surgical   Say 2004
Prostaglandin v= s VA
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Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/v3_slide0077.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
=
Med= ical vs surgical   Say 2004
Mifepristone/pr= ostaglandin vs VA
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Med= ical vs surgical   Say 2004
Mifepristone/PG= vs VA
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=
Med= ical vs surgical Henshaw 1994
Mifepristone/PG= vs VA
<= /td>
Medi= cal
n =3D 172=
<= /td>
Vacu= um
aspi= ration
n =3D 191=
=
95%= CI for difference
between proport= ions
<= /td>
Comp= lete
abortion<= br>
94.2%
97.9%
-0.003 to 0.078<= /font>
<= /td>
Minor
comp= lications
within
11.0%
15.7%
-0.116 to 0.023<= /font>
<= /td> <= /td>
Requ= iring
uterine
cure= ttage
5.8%
2.1%
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<= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
o Sma= ll sample sizes
o Medi= cal:
n Lon= ger duration of bleeding
n Sin= gle regimes less effective than vacuum
o Acc= eptability ?
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Surgical method= s
<= /td> <= /td> =
o Vac= uum aspiration
o Dil= atation/curettage
o Man= ual vacuum aspiration
(MVA= )
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=
Sur= gical methods for first
trimester abort= ion   Kulier 2003
<= /td> <= /td> <= /td> <= /td> <= /td> =
o 3 t= rials included
o 2 c= omparisons:
n Vac= uum aspiration vs dilatation &curettage
n Met= al vs plastic cannula for vacuum
aspi= ration
o N = =3D 767
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=
Sur= gical methods Kulier 2003
VA vs dilatatio= n/curettage
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Surgical method= s Hemlin 2001
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
VA vs MVA
o RC= T; < 56 days of amenorrhoea
n MVA = n =3D 91
n VA n= =3D 88
n Eff= ectiveness
n Com= plications
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Surgical method= s Hemlin 2001
O= utcome
M= VA (n=3D91)
V= A (n=3D88)
= Ongoing pregnancy
0<= /b>
0<= /b>
R= e-curettage
2<= /b>
2<= /b>
i= nfection
2<= /b>
2<= /b>
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Antibiotic prop= hylaxis
<= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td> <= /td>
o Un= iversal AB prophylaxis
o Vs
o Scr= een-and-treat
n Co= ntact tracing & Treatment of sexual
part= ners
n Scr= eening for other STDs
n Coun= selling
n Cost= ly
n Org= anisational matters
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Conclusions
<= /td> <= /td> = <= /td> <= /td> <= /td>
o Sa= fe and effective methods for first
tr= imester abortion are available
o Acc= eptability data scarce
o Med= ical methods:
n Lon= ger duration of bleeding
n Sin= gle regimes less effective
o Ser= ious complications are rare
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= Collaborators
<= /td> <= /td> <= /td> <= /td>
o Lin= an Cheng
o Anis= Feki
o Met= in Gülmezoglu
o Jus= tus Hofmeyr
o Lale= Say
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=
International C= onference on
Pop= ulation and Development
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References
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References
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file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/v3_slide0054.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
<= /td>
WHO= database on unsafe
abortion<= br>
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Preventing unsafe aborti= on
R Kulier
Geneva Foundation for Medical Education and Research
Marc= h 2006
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Definition of Terms
o<= span style=3D'font-size:86%;display:none'>
o"abortion" refers to the termination of pregnancy from whatever cau= se before the fetus is capab= le of extrauterine life.
o“spontaneous abortion" refers to those terminated pregnancies that occur without <= /span>deliberate measures
o"induced abortion" refers to termination= of pregnancy through a deliberate intervention intended to end the pregnancy (WHO, 1994). =
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Definition of un= safe abortion = ;
o"...a procedure for terminating unwanted pregnancy either by persons lacking the necessary ski= lls or in an environment lacking the minimal medical standa= rds of both" which therefore ex= poses the women to an increased risk of morbidity and mortality. 
o
= o(WHO,1993)
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“In no case should abortion be promoted as a metho= d of family plann= ing. All Governments and relevant intergovernmental and non-governmental organizations are urged = to strengthen their commitment to women’s health, to deal with the health aspect = of unsafe abortion as a major public health concern and to reduce the recourse to abortion = through expanded and improved family-= planning services. Prevention of unintended pregnancies must always be given the hi= ghest priority and every attempt should be made to eliminate the need for abortion. <= span style=3D'position:absolute;top:42.75%;left:17.22%;width:85.2%;height:3.5%'= >Women who have unintended pregnancies= should have ready access to reliable information and compassionate counselling. Any measures or <= span style=3D'position:absolute;top:49.75%;left:17.22%;width:71.16%;height:3.5%= '>changes related to abortion
within the health system can only be determined at= the national or local level according to the national legislative process. In circumstances where abortion is not against the law= , such abortion should be safe. In all cases, women should have access to quality ser= vices for manag= ement of complications arising from abortion. Post-abortion counselling, education and family-pla= nning services should be offered promptly, which will also help to avoid repeatabortions.”
ICPD 1994, Cairo
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=

Glob= al annual estimates of incidence and mortality for unsafe abortions per year (2000)
WHO 2005
17
20
13
12
13
Proportion of mat= ernal <= span style=3D'font-size:38%;color:#00060C'>deaths
(% of maternal deaths due to unsafe abortion)=
3700
300
34 000
29 800
67 900
Estimated number = of = deaths due to unsafe <= span style=3D'position:absolute;top:69.0%;left:9.17%;width:14.6%;height:2.0%'><= span style=3D'font-size:38%;color:#00060C'>abortion
32
7
14
14
14
Incidence ratio (= unsafe = abortions <= /div>
per 100
live births)
3700
500
10 500
4200
19 000
Number of unsafe = <= span style=3D'font-size:38%;color:#00060C'>abortions
(thousands)
Latin America
Europe
Asia
Africa
Worl= d = total
 
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Effects of the introduction of the anti-abortion law in Romania (1966)=
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Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
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Kulier
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Abortion complica= tions =
oWHO systematic review
o1990-2000
o> 45 datasets
o=  most developing coun= tries, facility based
oHospital register, survey, X-sectional
<= span class=3DBB style=3D'position:absolute;left:-4.98%;top:.16em'>oHaemorrhage , infection, perforation
o =
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Abortion complica= tions =
oPerforation, peritonitis, sepsis:
oPrevalence: 33.91 (28.92-38.91)
o
oGoyaux 1998
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Methods
oSurgical
oNon-surgical
oMenstrual regulation (MR)
ngenerally used to describe early evacuation of the uterus, after a delayed menses, often without confirmation of pregnancy
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Antigestagen
oDeveloped during 1960s
oMifepristone (RU 486)
nSuppression of folliculogenesis and = ovulation
nendometrium
o
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Mifepristone
oPharmacokinetics
<= span class=3DB1B style=3D'position:absolute;left:-4.77%;top:.39em'>nLinear 2-25 mg/day
<= span class=3DB1B style=3D'position:absolute;left:-4.77%;top:.39em'>nNon-linear above 100 mg/day
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Misoprostol, Geme= prost
oProstaglandin E1 + E2
oEffectiveness: < 90%
oSide effects
n
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Strategy - Cochrane systematic = review
oRand= omised controlled trials
oCrit= ical appraisal
<= span style=3D'font-size:114%'>oMeta= - analysis where appropriate
oSear= ch and methods according to Cochrane Fertility Regulation Group Guidelines
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Approach
oPregnant women, first trimester (<14 wks)
oInterventions
nMedical
nSurgical
nMedical vs Surgical
oOutcomes
neffectiveness, complications, side effects, acceptability
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Medical abortion – structure of the rev= iew
oCombined regime: mifepristone/prostaglandin
nDose, route, time of administration, = type of PG, split dose
oCombined regime: methotrexate/prostaglandin
nDose, route, timing
= oSingle vs combined regime =
= oOthers
nTamoxifen, laminaria etc <= /span>
o
= o14 main comparisons
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Medical methods for first trimester abortio= n
o> 100 studies identified; 40 trials included
omany different interventions
nroute-dose-type of agent-interval…...
o
o
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Medical methods Kulier 2004
oCombination:
o
oMifepristone 200 –= 600 mg
ofollowed by <= /span>
oProstaglandin =
nType
nDose
nRoute =
nTime interval =
n =
n
o
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Medical methods =    Kulier 2004
dose = of mifepristone
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Medical methods Kulier 2004
misop= rostol po vs pv
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Medical methods Kulier 2004
misop= rostol po vs pv
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AooooAKKKKACiiigAooooAKKKKACiiigAooooAKKKKACiiigAooooAKKKKACiiigAooooAKKKKAC iiigAooooA//2Q== ------=_NextPart_01C64218.02FF9370 Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/slide0073.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
Medical methods WHO 2003<= span lang=3DEN-GB style=3D'font-size:46%;mso-special-format:lastCR;display:none= '>
oMisoprostol: oral vs vaginal
oMulticentric RCT
oN=3D2219
o =
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Medical methods WHO 2003<= span lang=3DEN-GB style=3D'font-size:46%;mso-special-format:lastCR;display:none= '>
Oral placebo twice daily
Oral misoprostol (0.4 mg) tw= ice daily
Oral misoprostol (0.4 mg) twice daily
Days 4-10
Vaginal misoprostol (0.8 mg) and oral placeb= o
Vaginal misoprostol (0.8 mg) and oral placeb= o
Oral misoprostol (0.8 mg) and vaginal placebo
Day 3
Oral mifepristone
(200 mg)
= Oral mifepristone (200 mg)
Oral mifepristone (200mg)
Day 1
V-only
V/O
O/O
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Medical methods – outcomes  WHO 2003
0.8-1.9
1.2
48/738
V-only
(ref)
39/741
V/O
1.0-2.2
1.5
57/740
O/O
All
1.0-4.7
2.2
21/268
V-only
(ref)
9/254
V/O
1.3-5.8
2.8
26/264
O/O
> 57
0.5-1.9
1.0
16/242
V-only
(ref)
17/246
V/O
0.5-1.9
1.0
16/240
O/O
50-56
0.4-2.0
0.9
11/223
V-only
(ref)
13/240
V/O
0.6-2.4
1.2
15/236
O/O
< 49
95% CI
Relative risk&= #13;
n/N
Group
Length of amenorrhoea (days)
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Medical methods Kulier 2004
mifep= ristone vs combined regimen
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Medical methods Kulier 2004 prostaglandin vs combined regimen
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Methotrexate
oFolic acid antagonist
oToxic on trophoblast
oCombination with prostaglandin
nEffectiveness ~ 95 %
oFetal anomalies
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Conclusions - medical methods
<= span class=3DBB style=3D'position:absolute;left:-4.79%;top:.16em'>oCombi= ned regimes are more effective
oMifep= ristone 200 mg seems adequate in the combined regime ovagin= al prostaglandin is more effective compared to oral
o
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Medical methods  - unresolved issues
oNo firm conclusion:
nEffectiveness: dose, type or time of= prostaglandin, splitting of dose
nAcceptability po vs pv
nMethotrexate: dose, time, route of P= G
oEarly vs late ?
o
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Surgical =
oLowest complication rate between 49-56 days of amenorrhoea
<= span class=3DBB style=3D'position:absolute;left:-5.07%;top:.16em'>oIncreased morbidity with age, parity
oMajor complication rate is 2.3 times higher with D&C compared to VA
o
oWHO 1997, Grimes 1979
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Medical vs Surgic= al Say 2004
o6 randomised controlled trials
o4 comparisons:
n= Prostaglandin vs vacuum aspiration
n= Mifepristone vs vacuum aspiration
n= Mifepristone/prostaglandin vs vacuum aspiration =
n= Methotrexate/prostaglandin vs vacuum aspiration =
o =
o
o
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Medical vs surgical  Say 2004
o
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Medical vs surgical   Say 2004
Prost= aglandin vs VA
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Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
Medical vs surgical   Say 2004
Mifep= ristone/prostaglandin vs VA
------=_NextPart_01C64218.02FF9370 Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/slide0078.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
Medical vs surgical   Say 2004
Mifep= ristone/PG vs VA
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Eur10ikYElpI4ZoFZyW3Nk735Y91RRQAUUUUAFFFFABRRRQAUUUUAFFFFABRRRQAUUUUAFFFFABR RRQAUUUUAFFFFABRRRQAUUUUAf/Z ------=_NextPart_01C64218.02FF9370 Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/slide0026.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preventing unsafe abortions - Regina Kulier
Medic= al vs surgical Henshaw 1994
Mifepr= istone/PG vs VA
= o
= o
= o
= o
= o
= o
= o
2.1%
5.8%
Requiring uterine curettage
-0.116 to 0.023
15.7%
11.0%
Minor complications within
-0.003 to 0.078
97.9%
94.2%
Complete abortion
95% CI for difference between proportions
Vacuum aspiration
n =3D 191
Medical
n =3D 172
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Medical vs surgic= al Say 2003
oSmall sample sizes
oMedical:
nLonger duration of bleeding
nSingle regimes less effective than vacuum
n
oAcceptability ?
o
o
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Surgical methods
oVacuum aspiration
oDilatation/curettage
oManual vacuum aspiration (MVA)
o
o
n =
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Surgical methods for first trimester abortio= n   Kulier 2003
o3 trials included
o2 comparisons:
nVacuum aspiration vs dilatation &curettage
nMetal vs plastic cannula for vacuum = aspiration
oN =3D 767
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Surgic= al methods Kulier 2003
VA vs dilatation/curettage
2.03 (0.38 – 10.97)
467
2
Abdominal pain
0.67 (0.11 – 3.95)
467
2
Incomplete evacuation
0.84 (0.26 – 2.71)
467
2
Febrile morbidity
1.02 (0.21-4.95)
257
2
Excessive blood loss
RR (95%CI)
No of participants
No of trials
Outcome
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Surgical methods = Hemlin 2001
oVA vs MVA
o
oRCT; < 56 days of amenorrhoea
nMVA n =3D 91
nVA n =3D 88
nEffectiveness
nComplications
o
n
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Surgical methods = Hemlin 2001
2
2
infection
2
2
Re-curettage
0
0
Ongoing pregnancy
VA (n=3D88)
MVA (n=3D91)
Outcome
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Antibiotic prophy= laxis =
o= Universal AB prophylaxis
o= Vs
o= Screen-and-treat
n= Contact tracing & Treatment of sexual partne= rs
n= Screening for other STDs
n= Counselling
n= Costly
n= Organisational matters
n<= span lang=3DEN-GB style=3D'mso-special-format:lastCR;display:none'> =
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Conclusions
oSafe and effective methods for first trimester abortion are available
oAcceptability data scarce
oMedical methods:
nLonger duration of bleeding
nSingle regimes less effective
oSerious complications are rare
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Collab= orators
oLinan Cheng
oAnis Feki
oMetin Gülmezoglu
oJustus Hofmeyr
oLale Say
o
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International Conference o= n Population and Development
In circumstances where abortion is not against the law… to ensure that aborti= on
is safe a= nd
accessibl= e."
(Key actions ICPD+5, paragraph 63)
"In = all cases,
women sho= uld have
access to quality services for the management of complications arising from = abortion."
(Key actions ICPD+5, paragraph 63)
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•<= span style=3D'color:white;mso-color-index:3'>F1. Promote policy dialogue on uns= afe abortion, and provide guidance to countries on how to develop, implement and evaluate programmes to prevent and address <= span style=3D'color:white;mso-color-index:3'>unsafe abortion.
•<= span style=3D'color:white;mso-color-index:3'>F2. Promote the effective manageme= nt of abortion complications and postabortion care, including its integration within other reproductive health services.
= •<= span style=3D'color:white;mso-color-index:3'>F3. Develop and promote interventi= ons to improve access to quality care in circumstances where abortion is not against the law, wi= th special emphasis on underserved populations.
UNDP/UNFPA/WHO/World= Bank Special Programme of Research, Development and Research Training in Human = Reproduction (HRP)
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References=
oEdelman DA, Brenner WE, Berger GS.  The effectiveness and complications of abortion by dilat= ation and vacuum aspiration versus dilatation and rigid metal curettage.  American Journal of Obstetrics and Gynecology 1974; 119(4): 473-480= .
oHenshaw RC, Naji SA, Templeton AA. A comparison of medical abortion (using mifepristone and gemeprost) with surgical vacuum aspiration: efficacy and early medical sequelae.  Human Reproduction 1994;  9 (11): 2167 -2172.
oHemlin L, Moller B.  Manual vacuum aspiration, a safe and effective alternative in early= pregnancy termination.  Acta Obstetrica et Gynecologica Scandinavica 2001; 80(6):563-567.&#= 13;
oKulier R, Fekih A, Hofmeyr GJ, Campana A. Surgical methods for first trimester termination of pregnancy (Cochrane Review). In: The Cochrane Libr= ary, Issue 1, 2005. Oxford: Update Software.
oKulier R, Hofmeyr GJ, Gülmezoglu AM, Cheng L, Camp= ana A. Medical methods for first trimester termination of pregnancy (Cochrane Review). In: The Cochrane Library, Issu= e 1, 2005. Oxford: Update Software.
oSay L, Kulier R, Gülmezoglu M, Campana A. Medical = versus surgical methods for first trimester termination of pregnancy (Cochrane Review). In: The Cochrane Library, Issue 1, 2005. Oxford: Update Software. =
ovon Hertzen H, Honkanen H, Piaggio G,= Bartfai G, Erdenetungalag R, Gemzell-Danielsson K, Gopalan S, Horga M, Jerve F, Mittal S= , Ngoc NT, Peregoudov A, Prasad RN, Pretnar-Darovec A, Shah RS, Song S, Tang OS, Wu SC; W= HO Research Group on Post-Ovulatory Methods for Fertility Regulation. WHO multination= al study of three misoprostol regimens after mifepristone for early medical abortion. I: Effica= cy. BJOG. 2003 Sep;110(9):808-18.
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WHO dat= abase on unsafe abortion
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g_origH=3Dsld.style.posHeight g_origW=3Dsld.style.posWidth g_scaleHyperlinks=3D(document.all.tags("AREA").length>0) if( g_scaleHyperlinks ) InitHLinkArray() if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) ) document.body.scroll=3D"no" _RSW() if( IsWin("PPTSld") && parent.IsFullScrMode() ) FullScrInit(); =09 MakeSldVis(); ChkAutoAdv() if( runAnimations ) { if( document.all("NSPlay") ) document.all("NSPlay").autoStart =3D false; if( sld.filters && sld.filters.revealtrans ) setTimeout( "document.body.start()", sld.filters.revealtrans.duration * = 1000 ); else document.body.start(); } } function MakeSldVis()=20 { var fTrans=3Dg_showAnimation && SldHasTrans() if( fTrans )=09 { if( g_bgSound ) { idx=3Dg_bgSound.indexOf(","); pptSound.src=3Dg_bgSound.substr( 0, idx ); pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1))); } SlideObj.filters.revealtrans.Apply()=09 } SlideObj.style.visibility=3D"visible" if( fTrans ) SlideObj.filters.revealtrans.Play() } function MakeNotesVis()=20 { if( !IsNts() ) return false=20 SlideObj.style.display=3D"none" nObj =3D document.all.item("NotesObj") parent.SetHasNts(0) if( nObj ) {=20 nObj.style.display=3D"" parent.SetHasNts(1) } return 1 } function ChkAutoAdv() { if(SldHasTrans()) SlideObj.onfilterchange=3DAutoAdv else AutoAdv() } function AutoAdv() { if(!IsWin("PPTSld") || !gUseSldTimings )return var sld=3DGetCurSld() if( (sld.mAdvDelay>0) && !parent.IsFramesMode() ) setTimeout("parent.GoToNextSld()",sld.mAdvDelay) } function GetObj(id) { if(g_supportsPPTHTML) return document.all(id); else return document.getElementById(id); } function SldHasTrans() { return SlideObj.style.filter !=3D ""; } function GetSldId() { return sId=3Dlocation.href.substring(location.href.la= stIndexOf('/')+1) } function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx= tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl= e.display=3D'none'; return true } return false } function IsWin( name ) { return window.name =3D=3D name } function IsNts() { return IsWin("PPTNts") } function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) } function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"= && navigator.appVersion.indexOf("Windows")>0 ) } function SupportsPPTHTML() { var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0 if( msie >=3D 0 ) ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) ) else ver=3DparseInt(appVer) return( ver >=3D 4 && msie >=3D 0 ) } function _RSW() { if( !g_supportsPPTHTML || IsNts() || ( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) ) return var padding=3D0; if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6 cltWidth=3Ddocument.body.clientWidth-padding cltHeight=3Ddocument.body.clientHeight-padding factor=3D(1.0*cltWidth)/g_origW if( cltHeight < g_origH*factor ) factor=3D(1.0*cltHeight)/g_origH newSize =3D g_origSz * factor if( newSize < 1 ) newSize=3D1 s=3DSlideObj.style s.fontSize=3DnewSize+"px" s.posWidth=3Dg_origW*factor s.posHeight=3Dg_origH*factor s.posLeft=3D(cltWidth-s.posWidth+padding)/2 s.posTop=3D(cltHeight-s.posHeight+padding)/2 if( g_scaleHyperlinks ) ScaleHyperlinks( factor ) } function _InitAnimations() { animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined'; isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode(); g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } }function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames= Mode() ) || (event && event.keyCode=3D=3D32) ) { =09 if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex= t ) return; parent.GoToNextSld(); } } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram= es", gIsEndShow=3D0, NUM_VIS_SLDS=3D52, SCRIPT_HREF=3D"script.js", FULLSCR_= HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0001.htm",1,-1,1),new hrefList(= "slide0005.htm",1,-1,1),new hrefList("slide0003.htm",1,-1,1),new hrefList("= slide0079.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("s= lide0063.htm",1,-1,1),new hrefList("slide0081.htm",1,-1,1),new hrefList("sl= ide0082.htm",1,-1,1),new hrefList("slide0083.htm",1,-1,1),new hrefList("sli= de0086.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("slid= e0033.htm",1,-1,1),new hrefList("slide0021.htm",1,-1,1),new hrefList("slide= 0015.htm",1,-1,1),new hrefList("slide0069.htm",1,-1,1),new hrefList("slide0= 070.htm",1,-1,1),new hrefList("slide0068.htm",1,-1,1),new hrefList("slide00= 71.htm",1,-1,1),new hrefList("slide0056.htm",1,-1,1),new hrefList("slide004= 6.htm",1,-1,1),new hrefList("slide0057.htm",1,-1,1),new hrefList("slide0058= .htm",1,-1,1),new hrefList("slide0073.htm",1,-1,1),new hrefList("slide0075.= htm",1,-1,1),new hrefList("slide0076.htm",1,-1,1),new hrefList("slide0059.h= tm",1,-1,1),new hrefList("slide0060.htm",1,-1,1),new hrefList("slide0034.ht= m",1,-1,1),new hrefList("slide0065.htm",1,-1,1),new hrefList("slide0067.htm= ",1,-1,1),new hrefList("slide0085.htm",1,-1,1),new hrefList("slide0010.htm"= ,1,-1,1),new hrefList("slide0023.htm",1,-1,1),new hrefList("slide0024.htm",= 1,-1,1),new hrefList("slide0077.htm",1,-1,1),new hrefList("slide0078.htm",1= ,-1,1),new hrefList("slide0026.htm",1,-1,1),new hrefList("slide0038.htm",1,= -1,1),new hrefList("slide0012.htm",1,-1,1),new hrefList("slide0049.htm",1,-= 1,1),new hrefList("slide0050.htm",1,-1,1),new hrefList("slide0040.htm",1,-1= ,1),new hrefList("slide0052.htm",1,-1,1),new hrefList("slide0084.htm",1,-1,= 1),new hrefList("slide0066.htm",1,-1,1),new hrefList("slide0061.htm",1,-1,1= ),new hrefList("slide0043.htm",1,-1,1),new hrefList("slide0044.htm",1,-1,1)= ,new hrefList("slide0002.htm",1,-1,1),new hrefList("slide0030.htm",1,-1,1),= new hrefList("slide0080.htm",1,-1,1),new hrefList("slide0054.htm",1,-1,1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="windows-1252" Preventing unsafe abortions - Regina Kulier ------=_NextPart_01C64218.02FF9370 Content-Location: file:///C:/5D87B112/Preventing_unsafe_abortion_Kulier_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252"
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