International Journal of Gynecology and Obstetrics 128 (2014) 177–180
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATIONS
Addressing unmet need by expanding access to safe second trimester medical abortion services in Ethiopia, 2010 − 2014 Alison Edelman a,b,⁎, Tibebu Alemayehu b, Yirgu Gebrehiwot c, Saba Kidenemariam d, Yonas Getachew d a
Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA Ipas, Chapel Hill, NC, USA Department of Obstetrics and Gynecology, Addis Ababa University, Addis Ababa, Ethiopia d Ipas Ethiopia, Addis Ababa, Ethiopia b c
a r t i c l e
i n f o
Article history: Received 11 June 2014 Received in revised form 24 July 2014 Accepted 16 September 2014 Keywords: Abortion training Ethiopia Medical abortion Medical induction Second trimester Service delivery
Ethiopia has one of the highest maternal mortality rates (MMR) in the world (676 per 100 000) [1], to which unsafe abortion contributes significantly [2]. To decrease the MMR, the Ethiopian abortion law was liberalized in 2005 and the Ministry of Health (FMOH) issued guidelines including the legal indications for abortion in the second trimester. Women may terminate pregnancies through 28 weeks of pregnancy for reasons of rape/incest, fetal anomaly, maternal physical or mental deficiency including being a minor, or endangerment of the life/health of the mother. After these legal reforms, Ipas—a global nongovernmental organization working to end deaths and disabilities from unsafe abortion—in partnership with the FMOH, successfully introduced first trimester abortion services into the public sector. A 2009 survey on abortion in Ethiopia highlighted that one-third of women needed second trimester services and that providers were not offering services owing to lack of technical training and support [2]. In response, Ipas and the FMOH implemented a systematic approach for second trimester abortion that included meetings with key stakeholders, needs assessments, minor infrastructure and supply updates,
identification of potential sites and trainees, sensitization workshops, technical training, adverse events tracking, and supportive supervision visits [3]. Initial activities started in January 2010. Site assessments at four key centers demonstrated that over 50% of women presenting in the second trimester were suffering from incomplete abortions. Dilation and evacuation (D&E) requires specialized equipment that was not initially available. Thus, the program focused on the introduction of medical abortion using the World Health Organization recommended regimen of mifepristone and misoprostol [4]. Intervention sites were strategically chosen so that each region in Ethiopia would have a second trimester referral center. Between October 2010 and May 2014, eight clinical trainings were conducted with health professionals from 23 hospitals. All sites are currently providing services. Institutional Review Board exemption to review and report logbook data was received. A total of 7484 women accessed services from October 2010 to December 2013. The rate of serious adverse events was within or lower (b 1%) than rates reported in the literature [5–7]. The comprehensive structured program design, the collaboration between the MOH and Ipas, and provider dedication enabled a successful introduction of second trimester abortion services in major regions/ states of Ethiopia. A focus on second trimester medical abortion allows for rapid service introduction without extensive changes to facilities, equipment, or staffing as the needs are similar to obstetric care. Availability of services comes with challenges including ensuring medication availability, providing postabortion contraception (typically provided in a different unit), and limited hospital bed capacity. Ongoing work is focused on determining the impact of these programs on MMR, continuing to expand service provision, and D&E introduction at higher volume sites.
Acknowledgments The training program was funded by Ipas. Conflict of interest
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Mail code UHN 50, Oregon Health and Science University, Portland, OR 97239, USA. Tel.: +1 503 494 5949; fax: +1 503 494 3111. E-mail address: [email protected] (A. Edelman).
A. Edelman (Merck: Nexplanon trainer; Genzyme and Agile Pharmaceuticals: Consultant. The remaining authors have no conflicts of interest.
178
BRIEF COMMUNICATIONS
References [1] Central Statistical Agency [Ethiopia], ICF International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International; 2012 . http://dhsprogram.com/pubs/pdf/ FR255/FR255.pdf. [2] Gebreselassie H, Fetters T, Singh S, Abdella A, Gebrehiwot Y, Tesfaye S, et al. Caring for women with abortion complications in Ethiopia: national estimates and future implications. Int Perspect Sex Reprod Health 2010;36(1):6–15. [3] Ipas. Second-trimester abortion: A service delivery toolkit. Chapel Hill, NC: Ipas; 2014.
[4] World Health Organization. Safe abortion: technical and policy guidance for health systems. Second ed. Geneva: WHO; 2012 . http://www.who.int/reproductivehealth/ publications/unsafe_abortion/9789241548434/en/. [5] Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for second-trimester abortion. Am J Obstet Gynecol 2002;187(2):393–7. [6] Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011;117(4):788–92. [7] Kelly T, Suddes J, Howel D, Hewison J, Robson S. Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial. BJOG 2010;117(12):1512–20.
http://dx.doi.org/10.1016/j.ijgo.2014.07.035 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Breast cancer metastatic to leiomyoma of the broad ligament Awatif Rachdi ⁎, Nadia Benchakroun, Amina Taleb, Zineb Bouchbika, Hassan Jouhadi, Nezha Tawfiq, Souha Sahraoui, Abdellatif Benider Department of Oncology and Radiotherapy, Mohammed VI Cancer Treatment Center, Ibn Rochd University Hospital, Casablanca, Morocco
a r t i c l e
i n f o
Article history: Received 19 March 2014 Received in revised form 9 August 2014 Accepted 18 October 2014 Keywords: Breast cancer Broad ligament of the uterus Female genital tract Leiomyoma Peritoneal carcinomatosis Uterine metastases
Myomas are benign tumors of the female genital tract and leiomyoma of the broad ligament is rare. Breast cancer metastatic to leiomyoma of the broad ligament is extremely rare. A 50-year-old woman underwent a right radical mastectomy in September 2012 at the Mohammed VI Cancer Treatment Center in Casablanca, Morocco. Histopathologic examination revealed infiltrating ductal carcinoma measuring 4 cm in diameter, with metastasis in three of the 17 lymph nodes resected and with (30%) positive progesterone receptors and negative estrogen receptors. Extensive investigations demonstrated multiple brain metastases and a right adnexal mass.The patient underwent an exploratory laparotomy for the mass, which was suspected to be ovarian malignancy. The
tumor was located in the right broad ligament area and showed the classical histological appearance of uterine leiomyoma with high mitotic activity, marked pleomorphism, and lymphatic permeation with bizarre cells. A diagnosis of ductal carcinoma of the breast was confirmed in microscopic foci in the leiomyoma with negative progesterone and estrogen receptors (Fig. 1A, B, C). No involvement of the uterus was detected. Peritoneal carcinomatosis was evident but peritoneal washing was negative for malignant cells. The patient received palliative therapy, whole brain radiation therapy, and chemotherapy. The disease progressed and the patient died four months after she had received two cycles of chemotherapy. Metastatic breast cancer occurs via lymphatic involvement, hematogenous dissemination, and contiguous spread [1]. Metastases to the uterus from extragenital cancers are rare and the presence of breast cancer metastatic to the broad ligament of the uterus is even rarer. The majority of uterine metastases of extragenital origin result from lobular breast carcinoma and this condition is influenced by hormone dependence of tumor cells [2,3]. Metastasis restricted to a leiomyoma has been reported [4]. In the present case the patient had an extremely aggressive tumor with peritoneal carcinomatosis, and soft tissue and brain metastases.
Conflict of interest The authors have no conflicts of interest.
Fig. 1. Immunostaining showing negative estrogen receptors (A); leiomyoma with cell carcinoma shown by arrows (B); immunostaining showing negative HER2 (C).
⁎ Corresponding author at: Department of Oncology and Radiotherapy, Mohammed VI Cancer Treatment Center, Ibn Rochd University Hospital, Quartier des Hopitaux, Casablanca 20100, Morocco. Tel.: +212 22483030; fax: +212 22 262044. E-mail address: [email protected] (A. Rachdi).
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATIONS
Addressing unmet need by expanding access to safe second trimester medical abortion services in Ethiopia, 2010 − 2014 Alison Edelman a,b,⁎, Tibebu Alemayehu b, Yirgu Gebrehiwot c, Saba Kidenemariam d, Yonas Getachew d a
Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA Ipas, Chapel Hill, NC, USA Department of Obstetrics and Gynecology, Addis Ababa University, Addis Ababa, Ethiopia d Ipas Ethiopia, Addis Ababa, Ethiopia b c
a r t i c l e
i n f o
Article history: Received 11 June 2014 Received in revised form 24 July 2014 Accepted 16 September 2014 Keywords: Abortion training Ethiopia Medical abortion Medical induction Second trimester Service delivery
Ethiopia has one of the highest maternal mortality rates (MMR) in the world (676 per 100 000) [1], to which unsafe abortion contributes significantly [2]. To decrease the MMR, the Ethiopian abortion law was liberalized in 2005 and the Ministry of Health (FMOH) issued guidelines including the legal indications for abortion in the second trimester. Women may terminate pregnancies through 28 weeks of pregnancy for reasons of rape/incest, fetal anomaly, maternal physical or mental deficiency including being a minor, or endangerment of the life/health of the mother. After these legal reforms, Ipas—a global nongovernmental organization working to end deaths and disabilities from unsafe abortion—in partnership with the FMOH, successfully introduced first trimester abortion services into the public sector. A 2009 survey on abortion in Ethiopia highlighted that one-third of women needed second trimester services and that providers were not offering services owing to lack of technical training and support [2]. In response, Ipas and the FMOH implemented a systematic approach for second trimester abortion that included meetings with key stakeholders, needs assessments, minor infrastructure and supply updates,
identification of potential sites and trainees, sensitization workshops, technical training, adverse events tracking, and supportive supervision visits [3]. Initial activities started in January 2010. Site assessments at four key centers demonstrated that over 50% of women presenting in the second trimester were suffering from incomplete abortions. Dilation and evacuation (D&E) requires specialized equipment that was not initially available. Thus, the program focused on the introduction of medical abortion using the World Health Organization recommended regimen of mifepristone and misoprostol [4]. Intervention sites were strategically chosen so that each region in Ethiopia would have a second trimester referral center. Between October 2010 and May 2014, eight clinical trainings were conducted with health professionals from 23 hospitals. All sites are currently providing services. Institutional Review Board exemption to review and report logbook data was received. A total of 7484 women accessed services from October 2010 to December 2013. The rate of serious adverse events was within or lower (b 1%) than rates reported in the literature [5–7]. The comprehensive structured program design, the collaboration between the MOH and Ipas, and provider dedication enabled a successful introduction of second trimester abortion services in major regions/ states of Ethiopia. A focus on second trimester medical abortion allows for rapid service introduction without extensive changes to facilities, equipment, or staffing as the needs are similar to obstetric care. Availability of services comes with challenges including ensuring medication availability, providing postabortion contraception (typically provided in a different unit), and limited hospital bed capacity. Ongoing work is focused on determining the impact of these programs on MMR, continuing to expand service provision, and D&E introduction at higher volume sites.
Acknowledgments The training program was funded by Ipas. Conflict of interest
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Mail code UHN 50, Oregon Health and Science University, Portland, OR 97239, USA. Tel.: +1 503 494 5949; fax: +1 503 494 3111. E-mail address: [email protected] (A. Edelman).
A. Edelman (Merck: Nexplanon trainer; Genzyme and Agile Pharmaceuticals: Consultant. The remaining authors have no conflicts of interest.
178
BRIEF COMMUNICATIONS
References [1] Central Statistical Agency [Ethiopia], ICF International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International; 2012 . http://dhsprogram.com/pubs/pdf/ FR255/FR255.pdf. [2] Gebreselassie H, Fetters T, Singh S, Abdella A, Gebrehiwot Y, Tesfaye S, et al. Caring for women with abortion complications in Ethiopia: national estimates and future implications. Int Perspect Sex Reprod Health 2010;36(1):6–15. [3] Ipas. Second-trimester abortion: A service delivery toolkit. Chapel Hill, NC: Ipas; 2014.
[4] World Health Organization. Safe abortion: technical and policy guidance for health systems. Second ed. Geneva: WHO; 2012 . http://www.who.int/reproductivehealth/ publications/unsafe_abortion/9789241548434/en/. [5] Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for second-trimester abortion. Am J Obstet Gynecol 2002;187(2):393–7. [6] Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011;117(4):788–92. [7] Kelly T, Suddes J, Howel D, Hewison J, Robson S. Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial. BJOG 2010;117(12):1512–20.
http://dx.doi.org/10.1016/j.ijgo.2014.07.035 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Breast cancer metastatic to leiomyoma of the broad ligament Awatif Rachdi ⁎, Nadia Benchakroun, Amina Taleb, Zineb Bouchbika, Hassan Jouhadi, Nezha Tawfiq, Souha Sahraoui, Abdellatif Benider Department of Oncology and Radiotherapy, Mohammed VI Cancer Treatment Center, Ibn Rochd University Hospital, Casablanca, Morocco
a r t i c l e
i n f o
Article history: Received 19 March 2014 Received in revised form 9 August 2014 Accepted 18 October 2014 Keywords: Breast cancer Broad ligament of the uterus Female genital tract Leiomyoma Peritoneal carcinomatosis Uterine metastases
Myomas are benign tumors of the female genital tract and leiomyoma of the broad ligament is rare. Breast cancer metastatic to leiomyoma of the broad ligament is extremely rare. A 50-year-old woman underwent a right radical mastectomy in September 2012 at the Mohammed VI Cancer Treatment Center in Casablanca, Morocco. Histopathologic examination revealed infiltrating ductal carcinoma measuring 4 cm in diameter, with metastasis in three of the 17 lymph nodes resected and with (30%) positive progesterone receptors and negative estrogen receptors. Extensive investigations demonstrated multiple brain metastases and a right adnexal mass.The patient underwent an exploratory laparotomy for the mass, which was suspected to be ovarian malignancy. The
tumor was located in the right broad ligament area and showed the classical histological appearance of uterine leiomyoma with high mitotic activity, marked pleomorphism, and lymphatic permeation with bizarre cells. A diagnosis of ductal carcinoma of the breast was confirmed in microscopic foci in the leiomyoma with negative progesterone and estrogen receptors (Fig. 1A, B, C). No involvement of the uterus was detected. Peritoneal carcinomatosis was evident but peritoneal washing was negative for malignant cells. The patient received palliative therapy, whole brain radiation therapy, and chemotherapy. The disease progressed and the patient died four months after she had received two cycles of chemotherapy. Metastatic breast cancer occurs via lymphatic involvement, hematogenous dissemination, and contiguous spread [1]. Metastases to the uterus from extragenital cancers are rare and the presence of breast cancer metastatic to the broad ligament of the uterus is even rarer. The majority of uterine metastases of extragenital origin result from lobular breast carcinoma and this condition is influenced by hormone dependence of tumor cells [2,3]. Metastasis restricted to a leiomyoma has been reported [4]. In the present case the patient had an extremely aggressive tumor with peritoneal carcinomatosis, and soft tissue and brain metastases.
Conflict of interest The authors have no conflicts of interest.
Fig. 1. Immunostaining showing negative estrogen receptors (A); leiomyoma with cell carcinoma shown by arrows (B); immunostaining showing negative HER2 (C).
⁎ Corresponding author at: Department of Oncology and Radiotherapy, Mohammed VI Cancer Treatment Center, Ibn Rochd University Hospital, Quartier des Hopitaux, Casablanca 20100, Morocco. Tel.: +212 22483030; fax: +212 22 262044. E-mail address: [email protected] (A. Rachdi).
