1. (a) T (b) T (c) T (d) F (e) T

The failure rate of the cervical cap is reduced with increasing parity. In the UK the cumulative life table pregnancy rate for the contraceptive sponge is indeed 24.5/100 WY. The failure rate of vasectomy is quoted as 1:2000 after two negative semen analyses and 1:200 for female sterilisation. The effectiveness of incisional and no-scalpel method for vasectomy was compared in a recent Cochrane systematic review and no difference in clinical effectiveness was observed.

2. (a) T (b) T (c) F (d) T (e) T

All oral contraceptives are reduced by liver enzyme inducing drugs. Three randomised trials have examined the contraceptive efficacy of male condoms, two of which reported no significant difference in pregnancy rates between latex and non-latex condoms. Breakage and slippage rates of condoms are generally used as surrogate markers for contraceptive compromise, but, are poor indicators of condom failure leading to pregnancy.

3. (a) T (b) T (c) T (d) F (e) F

Contraceptive failure rates are estimated from clinical trials and surveys. The terms used to encapsulate the reliability of a method in preventing pregnancy are efficacy and effectiveness. Contraceptive efficacy indicates how well something works under ideal conditions, that is, during perfect use. Contraceptive effectiveness determines how well something works under normal or ‘actual’ or typical use and takes compliance into account. Most failure rates are reduced after 12 months use.

4. (a) F (b) T (c) F (d) T (e) T

Aside from the inherent efficacy of the method, the user characteristics associated with contraceptive failure include age, frequency of sexual intercourse, substance use, and relationship violence. Socio-economic factors and ethnicity play a lesser role. Life-table Analysis determines a failure rate for each month of use allowing the determination of a cumulative failure rate for a given interval of exposure. It allows for appreciation of the change in contraceptive failure throughout a particular time period of contraceptive use.

5. (a) F (b) F (c) T (d) F (e) T

There is a considerable variation in the EU and between continents regarding the legality of abortion. Although there have been changes to the laws in several countries over the last decade, this has not yet been translated into practice in the provision of safe abortion in these countries. The data in countries where restrictions apply on abortion rates is very difficult to interpret but the abortion rates are likely to be equal to or higher than in countries where abortion is illegal.

6. (a) T (b) T (c) F (d) T (e) T

A large proportion of the global decline in the number of legal abortions can be attributed to the large decline seen in countries from Eastern Europe where the rate fell by 51% from 90 per 1,000 women to 44 per 1,000. Individual beliefs and customs mean that not only do abortion rates vary by country but also by populations within countries. Certain countries have a high rate of unreported abortion even when legal. Regardless of the safety or legality of abortion, the average annual rate at which women choose to end unwanted pregnancies is surprisingly similar around the world. The rate for 2003, the most recent year for which data is available, was 29 per 1,000 women aged 15–44 in less developed countries and 26 per 1,000 women in more developed countries. The low abortion rate in Western Europe has been ascribed to a broadly legal and accessible service in addition to the use of effective contraceptive methods.

7. (a) F (b) F (c) T (d) F (e) F

Central America’s estimated rate of unsafe abortion was 25/1000 in 2003, far from the highest of all sub-regions. The Caribbean had a lower rate of 16/1000. Eastern and Central Europe had the highest induced abortion rate. Although it went down from 91 per 1000 in 1995 to 45/1000 in 2003, it was still the highest in the world. Abortions in that region, however, are mostly legal and safe. In the last evaluation of the Alan Guttmacher Institute, in collaboration with the WHO, with data up till 2003, Eastern Africa had the highest unsafe abortion rate, reaching 39/1000 women in the fertile age, up from 32/1000 in 2000. South America had the highest estimated rate of unsafe abortion until the year 2000, but it had a downward trend. In the last evaluation with data up till 2003, Eastern Africa had gained the negative first place in unsafe abortion rate. South Eastern Asia was 10 points below Eastern Africa in unsafe abortion rates in 2003, in part as result of better access to safe legal abortion in India.

8. (a) T (b) T (c) F (d) F (e) T

Several studies have shown a reduction in unsafe abortion after the introduction of family planning programs that provide broad base information on contraception and facilitate access to the use of modern methods of contraception. Country wise, there is a correlation between reduced unmet needs for contraception and drops in the induced abortion rate. To have an induced abortion is a risk factor for repeated abortion, meaning that women assisted for complications of induced abortion have a particularly high risk of aborting if they get pregnant again. Providing counselling and services that allow the women to initiate use of a highly effective method before they leave the health facility reduces the rate of repeated abortion. Post abortion contraceptive programs are some of the most cost-effective intervention to reduce the number of abortions. There are no studies to evaluate the effect of restrictive legislation over the abortion rate, but the observation of the dramatic increase in abortion related maternal mortality in Romania after the imposition of restrictive laws, suggest that it only transforms safe legal terminations of pregnancy into unsafe illegal abortions. In addition countries with the most restrictive laws have induced abortion rates several times higher than Western European countries with liberal abortion laws. There are studies that show an effect of broad based sex education programs over the rate of unwanted pregnancies among adolescents, particularly when they are associated with facilitating access to contraceptives. More broadly, countries with universal sex education and easy access to contraception for adolescents have a much lower adolescent abortion rate than countries with either weak or no sex education or with programs restricted to the promotion of abstinence.

9. (a) F (b) T (c) T (d) F (e) T

Although the combined contraceptive pill has a very high contraceptive efficacy in clinical trials, the pregnancy rate in population based studies reach eight per hundred women years of exposure, or more. The great majority of pregnancies are the result of user failure with inadequate use of the pill. The T-CU 340 and the two models of contraceptive implants currently available have a very high intrinsic effectiveness and they are virtually free of user failure. Considering that contraceptive failures frequently end in induced abortion, the higher the real life effectiveness of the method the more important its role as an instrument to reduce induced and unsafe abortions. All impartial evaluations of both periodic abstinence and the condom show a very high failure rate. The hormonal contraceptives given by injection have a high effectiveness in clinical trials and in population studies, but not as high as the methods that have a longer period of contraceptive effectiveness after one application such as the IUD and Implants. Because they required repeating the injection at either monthly or three months intervals, they are not totally independent of user memory and capacity to have access to a new injection each time it is required. The three monthly injection with Depo-Provera, however, has a relatively wide safety window after the end of the three month period and its real life effectiveness can be very close to that of the Implants or T-Cu 340.

10. (a) F (b) F (c) T (d) T (e) F

In Great Britain, whilst the overall abortion rate has been gradually increasing since the new legal framework took effect in 1968, and especially over the last decade, there have also been changes in the temporal pattern of the procedures. The large majority of procedures are provided in the first trimester and, further, that there has been a general shift towards earlier procedures in recent years. The overall proportion of abortions carried out under 10 weeks has increased from 56 percent in 1995 to 67 percent in 2005. However, these developments have been accompanied by only a slight reduction in the demand for abortions in the second trimester, with the proportions at 13 or more weeks declining from 14 percent in 1985, 11 percent in 1995 to 2000 and ten percent in 2005. Research has shown that some women present at an early point in gestation, but are delayed either at the point of referral or because the procedure is not provided soon enough after referral. There is a large regional variation in services in the UK which impacts on gestation at the time of termination.

11. (a) T (b) F (c) T (d) T (e) T

The following are recognised risk factors: Previous psychiatric history, Poor social support, Late abortion, Abortion for fetal anomaly, Those who are ideologically/religiously opposed to abortion, Ambivalence about abortion, Coerced abortion, Strong maternal instincts, Abortion in the very young and Intimate partner violence.

12. (a) T (b) F (c) F (d) T (e) T

Emerging studies have identified a 30% increased risk for any mental disorder (excluding psychosis) in contrast to earlier work in the area. No studies have reliably demonstrated lower rates of mental illness or relationship improvements in any groups of women. There is some evidence for benefits in the educational and financial outcome among those having abortions as compared to those giving birth though the area is lightly researched. A review of the literature concluded that negative sexual effects were identified by 10–20% of women post abortion although the studies were of variable design and methodological quality.

13. (a) T (b) F (c) F (d) T (e) F

A specific post abortion syndrome has never been reliably demonstrated. Psychotic illness has been poorly studied and those that exist all report a very low prevalence of psychotic illness. In a Norwegian sample of women under the age of 25, odds ratios of between 2 and 4.7 were identified for the misuse of alcohol, cannabis, nicotine and other illegal substances in those having abortions compared to those giving birth or not being pregnant, results that were broadly similar to those of another study which found significantly higher risks for tobacco dependence and illicit substance misuse associated with either abortion or miscarriage. A number of record linkage studies from Finland and the United States have found higher rates of suicide in women who had had abortions than in other groups. One study described rates of 34.7/100,000 in women who had abortions compared to 5.9/100,000 in those giving birth and a mean national rate for women of 11.3/100,000. These studies cannot demonstrate that abortion causes suicide although of course this is one possibility. Another is that there may be common factors associated with abortion seeking and suicide such as impulsivity or pre-existing mental illness.

14. (a) T (b) T (c) F (d) F (e) F

Rhesus prophylaxis should be given to all women undergoing abortion. The evidence to support this is sparse, however, there is a theoretical advantage of its necessity. Performing surgical abortion under local anaesthesia could minimise the complications associated with general anaesthesia. A review comparing the outcomes of surgical abortion under local anaesthetic showed no difference in the rate of major complications when compared to general anaesthesia, but the rates of haemorrhage, cervical injury and uterine perforation were all higher with general anaesthesia while febrile and convulsive morbidity was higher with local anaesthesia. Manual vacuum aspiration is as effective as electric vacuum aspiration. Combined regimens are more effective than the misoprostol only regimens. Abortion could be successfully induced with PG alone, but the doses required are likely to have a high frequency of side effects. Most current clinical protocols use PG in lower doses in combination with mifepristone. Pre-treatment with mifepristone has also been shown to shorten the induction-to-abortion interval, improve the efficacy of the regimen and reduce the amount of pain experienced. However, in many parts of the world mifepristone might not be available due to cost or licensing implications, and in such situations a misoprostol only regimen could offer an alternative option. Misoprostol has a higher teratogenic potential compared to mifepristone. Mifepristone crosses the placental barrier, and this raises concerns about the possible teratogenic effects on the fetus in cases where the pregnancy continues. The long-term safety data are limited, but animal data are largely reassuring. Exposure to misoprostol in early pregnancy has been associated with multiple congenital defects including skull defects, cranial nerve palsies, facial malformations, constriction rings, equinovarus, erythrogryposis and congenital transverse limb defects limb. The absolute risk of these abnormalities following exposure to misoprostol, however, could not be evaluated from these reports, and would be difficult to estimate due to the illegal nature of using misoprostol in the context of abortion in these countries and the likely under-reporting of use.

15. (a) F (b) T (c) F (d) F (e) F

While the medical regimen is not licensed for use with abortions at 9–13 weeks of gestation, there is plenty of evidence on its efficacy. The RCOG guidelines on induced abortion state that the medical regimen using mifepristone in combination with misoprostol would be a safe and effective alternative to surgery for women undergoing abortion at 9–13 weeks gestation. Studies have shown similar efficacy for the two regimens. The earlier medical termination of pregnancy protocols used misoprostol in doses of 400 μgm administered orally. A randomised trial compared vaginal to oral administration of misoprostol 800 μgm following mifepristone 600 mg with medical abortion up to 63 days gestation and showed greater efficacy and lower side effects with vaginal administration (complete abortion rate of 95% compared to 87% for the oral group). The majority of women undergoing medical abortion only use oral analgesia and do not require intramuscular opiates. A review on analgesia requirement for women undergoing medical abortion at all gestations up to 22 weeks showed that 72.3% of the women included in the review required analgesia. Of these, 97.3% used oral analgesia, while 2.4% required intramuscular opiates. Analgesia requirements increased with advanced gestational age, longer induction-to-abortion intervals, increased doses of misoprostol and with younger age, while women with previous live birth were less likely to use analgesia. The time to peak concentration is shorter with oral and sublingual administration of misoprostol compared to vaginal administration. The systemic bioavailability, however, is significantly greater with vaginal and sublingual administration compared to oral administration. Uterine contractility studies show significantly higher uterine contractions with vaginal and sublingual administration, but not after oral administration. This explains the higher efficacy noted with vaginal administration compared to the oral route of administration.

16. (a) F (b) F (c) T (d) F (e) T

Young age and higher gestational age are risk factors associated with an increased risk of uterine perforation and cervical laceration. Cervical priming reduces the incidence of complications associated with surgical termination of pregnancy such as uterine perforation, cervical injury, haemorrhage and incomplete abortion. It also makes the procedure quicker and easier to perform. Studies have shown that misoprostol is an effective alternative to gemeprost in the context of cervical priming prior to surgical termination of pregnancy. In fact, this remains the only licensed PG for use in this context. Several randomised trials have compared the oral to the vaginal routes of misoprostol administration. In the largest of these studies, higher efficacy was reported with vaginal administration of misoprostol 400 μgm four hours prior to surgery compared to oral administration of misoprostol 400 μgm eight hours before surgery. A priming interval of three hours has been reported to be the optimal time interval for vaginal administration of misoprostol prior to first trimester surgical abortion. Studies show greater efficacy with this compared to shorter intervals of two hours and similar efficacy to longer intervals of four hours. Misoprostol 400 μgm administered vaginally has been reported to be the optimal dose for cervical priming prior to surgical abortion. This was significantly more effective than a dose of 200 μgm and as effective as higher doses of 600–800 μgm, although the latter two doses were associated with significantly more side effects.

17. (a) F (b) T (c) T (d) F (e) F

1 in 5 women have abortions worldwide. Northern America had an abortion rate of 21/1000 in 2003 compared to Europe with a rate of 28/1000. Rates of abortion are indeed increasing in the UK. Approximately 35% of abortions are carried out medically in the United Kingdom. It has been estimated that about 5 million women worldwide are hospitalized for the treatment of abortion related complications and a great majority are related to unsafe abortion practice.

18. (a) F (b) T (c) F (d) F (e) T

Nearly half of all induced abortions are estimated to be unsafe. Unsafe abortions account for approximately 13% of maternal deaths. Infective abortions account for approximately 1% in developed nations. This figure varies widely worldwide accounting for 1–45% of all induced abortions. Infective complications associated with medical methods irrespective of gestation at induced abortion have been reported to be low. LARCS are associated with lower rates of unwanted pregnancy and therefore are effective at reducing abortion related complications.

19. (a) T (b) F (c) F (d) F (e) F

Universal prophylaxis is cost-effective compared to a screen and treat policy and is at least as effective as screen and treat policy in treating short term sequelae. Bearing in mind the low prevalence of Gonorrhoea in United Kingdom (0.2%) screening for gonorrhoea is controversial. It is not thought to be cost-effective. The prevalence of chlamydia is rising in the world especially among those under 25 years of age. For confirmed chlamydia infection, treatment with Azithromycin is cost-effective as it relates to higher compliance with a single dose of treatment with Azithromycin as compared to seven days treatment with doxycycline.

20. (a) F (b) F (c) T (d) F (e) F

There are no differences in effectiveness between the two Misoprostol routes in the RCT studies reported to date and dosages are the same. Interval abortion rates are not significantly different with these two regimens. Both regimens are cost-effective and advocated by the RCOG. Because of the reduced costs of Misoprostol, it is preferred over Gemeprost. Medical termination is the treatment of choice, as training in late surgical termination of pregnancy is less available. The optimal interval is 24–36 h.

21. (a) F (b) T (c) F (d) F (e) F

D&E is recommended by the RCOG from the early second trimester only when undertaken by trained practitioners. In a meta-analysis of RCTs comparing D&E to medical termination, surgical procedures had fewer complications, but the medical approach was considered to be as safe and effective. Cervical osmotic dilators are safe and effective. Medical regimens are also effective for cervical preparation. Uterine rupture is an extremely rare event (<1%). Even though, increasing numbers of previous scarred uteri could increase the incidence.

22. (a) F (b) F (c) F (d) F (e) T

In dichorionic twins selective fetal reduction before 24 weeks has a 7.5% fetal loss rate.

The most common abnormalities are midline in nature, such as congenital heart defects. There is no good evidence to support one technique over the other. RCOG guidelines state that feticide should be performed by fetal medicine practitioners only. There are only a few reports on selective termination from cases with discordant fetal anomalies.

23. (a) T (b) F (c) F (d) F (e) F

D&E was done in 98.6% of abortions between 13-15 weeks, 95.4% between 16–20 weeks, and 85.1% at 21 weeks or later in USA. There is no good evidence as to whether D&X or D&E is the better option, while a retrospective analysis revealed the safety of both methods. Adequate cervical dilatation before D&E can help to reduce the risk of complications. Bleeding is the most common complication of surgical abortion in the second trimester. Its incidence increases with gestational age. The use of uterotonics, such as oxytocin, is commonly employed in order to reduce the amount of blood loss of the procedures. However, its efficacy was not proved by any prospective trial.

24. (a) T (b) F (c) T (d) F (e) T

Misoprostol is cheap and stable at room temperature while gemeprost must be stored below −10 °C. These properties make misoprostol particularly attractive in developing countries. In a study comparing 400 μg of vaginal misoprostol every 3 h with 1 mg of gemeprost every 3 h, the induction-to-abortion interval was significantly shorter in the vaginal misoprostol group. Another randomised trial comparing the same regimens of misoprostol and gemeprost also showed that women in the misoprostol group aborted earlier while there was more pyrexia in the gemeprost group. There was evidence that the regimen of vaginal misoprostol 400 μg every 3 h is in fact more effective than the standard gemeprost regimen of 1 mg every 3 h. Two randomised trials showed the regimen of vaginal misoprostol 400 μg every 6 h is less effective than vaginal misoprostol every 3 h. There was only one randomized trial on the comparison head-to-head of the D&E and mifepristone followed by misoprostol. However, the study was stopped prematurely at one year because of slow enrolment with only 18 women participated. The mifepristone–misoprostol abortion caused more pain and adverse events such as fever in 3 patients (33.3%). 3 patients required surgical removal of placenta in the mifepristone–misoprostol group for retained placentae while one patient required suction curettage 6 days after abortion for retained products of conception. Intra-vaginal route of administration was shown to have a shorter induction-to-abortion interval compared with oral route in a small prospective study, while the overall success rates were similar in 2 groups. Using vaginal administration of misoprostol alone was shown to have a significantly shorter mean induction-to-delivery interval (19.6 ± 17.5 h vs 34.5 ± 28.2 h, P < .01) and shorter length of hospital stay (32.3 ± 17.3 h vs 50.9 ± 27.9 h, P < .01) when compared with oral administration. Another randomized controlled trial on the vaginal administration and sublingual administration by WHO also showed a higher effectiveness in the vaginal route (85.9%) than sublingual administration (79.8%) in terminating second trimester pregnancies, but this result was mainly driven by nulliparous women at 24 h. Fever was more prevalent with vaginal administration.

25. (a) T (b) T (c) F (d) T (e) T

Second trimester abortions account for 11.2% of all abortions in the United States (USA) in 2005 and 9.7% in the United Kingdom (UK) in 2008. Overall, two thirds of all major complications of abortions are attributable to those performed in the second trimester. Uterine perforation is one of the most serious complications in second trimester surgical abortion, with the incidence of 0.32%. It was shown that the use of routine intra-operative ultrasound guidance during D&E reduced the rate of perforation. As the complication rate was much higher in abortions performed in the second trimester, it is important to facilitate the access to first trimester abortion to reduce the incidence of second trimester abortions, and to provide facilities for safe second trimester abortion in order to reduce the complication rates.

26. (a) T (b) F (c) F (d) T (e) T

Bleeding is the most common complication of surgical abortion in the second trimester. Its incidence increases with gestational age. The use of uterotonics, such as oxytocin, is commonly employed in order to reduce the amount of blood loss of the procedure. However, its efficacy was not proved by any prospective trial. A retrospective analysis over 8 years’ data showed the effectiveness of uterine artery embolization as the sole method to control the haemorrhage due to disruption of fibroid, placenta accreta and cervical lacerations. Adequate cervical dilatation before D&E can help to reduce the risk of complications. It was shown by various studies that the more that laminaria is used it resulted in a decreased need for intra-operative cervical dilatation and the less likely it is to have complications like cervical injury or vaginal bleeding during D&E.

27. (a) F (b) T (c) T (d) T (e) F

Laminaria is a genus of brown algae. After dehydration and sterilisation, the stem of the seaweed forms a thin rod. When it is inserted into the cervical canal, it absorbs moisture and then expands, leading to the dilatation of the cervix. The major drawbacks include the need for overnight placement for adequate dilatation and the lack of uniformity with unpredictable dilatation in the natural product. Lamicel, a synthetic osmotic dilator, is a sterile tent of dehydrated polyvinyl alcohol impregnated with 450 mg MgS04, which absorbs water and swells 4-fold in diameter after 4 h, with faster action than laminaria. However, Skjeldestad et al reported only about half of the lamicel remained in place after overnight insertion, whereas the other half was partially displaced or completely expelled in first trimester abortion. Dilapan-S is a hygroscopic cervical dilator that is manufactured from an aquacryl, a proprietary hydrogel. There are 3 different sizes available and it is recommended by the manufacturer to have overnight insertion for second trimester abortion with more than one dilator according to gestation. It continues to expand over 24 h, although it can achieve 10 mm dilation after 2–4 h of insertion. There was no published data on the direct comparison between Dilapan and Lamicel.

28. (a) T (b) T (c) T (d) F (e) T

With the increase in the incidence of caesarean delivery for whatever reasons, there is an increased demand for performing abortion in women with prior caesarean. The safety issue and the relationship with uterine rupture are of great concern. Both medical and surgical methods for second trimester abortion were shown to be effective and safe. Both misoprostol and gemeprost were found to be safe in this aspect. A small observational study in Egypt over 50 women with one prior caesarean delivery undergoing abortion between gestations 16 and 26 weeks showed the safety of the use of 4 doses of 200 μg of misoprostol applied vaginally every 4 h daily, with a 12 h nightly rest from misoprostol applications. The success rate of the regimen was 90% with no uterine rupture noted. For one retrospective study using gemeprost 1 mg every 3 h for a maximum of 5 pessaries over 24 h, the overall success rate of abortion within 72 h was 98.4% in women with one to three prior caesarean deliveries. There was one woman out of 67 having heavy vaginal bleeding requiring emergency surgical removal of placenta and blood transfusion. One women at 20 weeks pregnant with 2 lower-segment transverse cesarean sections required hysterotomy due to uncontrolled vaginal bleeding and hysterectomy during the procedures due to unresponsive uterine atony. A small case series of 15 women with one to two prior low-transverse caesarean deliveries having second trimester abortion between gestations of 16–28 weeks revealed no uterine rupture without specifically describing the regimen. There was one uterine rupture among the two women with previous classical caesarean deliveries. The authors also did a systematic review which showed the incidence of uterine rupture was 0.4% in women with one prior low transverse caesarean delivery. Another systematic review estimated that the risk of uterine rupture among women with a prior caesarean delivery undergoing second trimester abortion using misoprostol is 0.28% (95% CI 0.08%–1%) after pooling results of 16 studies, including 3556 patients with 3 uterine ruptures noted.

29. (a) T (b) F (c) F (d) F (e) F

The terms safe abortion and unsafe abortion are used to distinguish the difference in risk to women who undergo induced abortions. The World Health Organization (WHO) defines unsafe abortion as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both”. In contrast, a medical or surgical abortion performed by a well-trained professional with the necessary resources and in a suitable medical environment is considered a safe abortion because the procedure involves little risk (not no risk) to the woman. Most unsafe abortions are performed in countries with legal restrictions to the procedure. However, some occur in countries where abortion is legal, but access to safe legal abortions is limited. The opposite is also true, as many safe abortions are performed in countries where abortion is legally restricted. Therefore, it is important that usage of the terms safe abortion and unsafe abortion be clearly differentiated from usage of the terms legal abortion and illegal abortion.

30. (a) T (b) T (c) T (d) T (e) T

Studying why women have unintended conceptions is complicated by the fact that there is evidence that women’s perception of whether the pregnancy was planned or wanted can change over time. As such, response to a pregnancy intention measure may vary depending on whether it was asked in the early stages of pregnancy or after the birth when women may view the pregnancy more favourably. Thus retrospective measures may be inaccurate. In contrast, prospective studies in the United States and Asia have found that women’s desire for fertility is somewhat stable over time, although personal situations may change abruptly and impact on childbearing intentions. Many studies quote the reasons for not using contraception often involve an expressed ambivalence about falling pregnant. In a study of 1,568 pregnant adolescents, the most frequently endorsed reason for non-use of contraception was simply that they were not ready to prevent pregnancy. Studies in non pregnant women also demonstrate that ambivalence towards pregnancy is common and is associated not only with non use but also with use of less effective methods.