The relationship between duration, bleeding volume, and activity for women in the progress of drug abortion: a cross-sectional study.

doi:10.21203/rs.3.rs-4956718/v1

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The relationship between duration, bleeding volume, and activity for women in the progress of drug abortion: a cross-sectional study.

https://doi.org/10.21203/rs.3.rs-4956718/v1

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Background: To investigate the influential factors associated with abortion time, bleeding volume, pain scores, and anxiety during the progress of drug abortion (DA).

Methods：Participants were randomly assigned to: (Ⅰ) The control group was given routine DA education and nursing, and the activity of subjects was not increased.（Ⅱ） The experimental group as same as the control, but appropriately increased their activity time.

Results: The mean age was 32.14±0.26 years. Advanced age exhibited positive correlation with abortion duration (rs=0.0102, P<0.05), but a negative association with pain scores (rs=-0.178, P<0.001). Dysmenorrhea emerged as a risk factor for prolonged abortion duration (rs=-0.097, P<0.05), but increase pain scores (rs=0.106, P<0.05) and anxiety levels (rs=0.119, P<0.05). Furthermore, history of cesarean section exhibited a positive influence on pain relief (rs=-0.226, P<0.001) and reduction in anxiety (rs=-0.129, P<0.001) during DA.

Conclusions: Women who have a history of vaginal delivery have earlier ovulation time than those who have not given birth, and women who have more activities have earlier ovulation time than those who have less activities under the same conditions;

Drug Abortion

Bleeding

Pain

Influence factors

Anxiety

Approximately 40% of pregnancies worldwide are unintended, with reasons ranging from lack of access to contraception to contraceptive method failures. Alarmingly, nearly half of these unintended pregnancies result in the choice of abortion.[1]. DA is widely recognized as a common and safe procedure for terminating pregnancies, as well as the first choice for many females to end pregnancy unintended[2]. Mifepristone and/or misoprostol are the primary medications used for DA[3]. Studies showed that women in many countries are using or trying to use the abortion pills at home without professional care[4, 5]. It is essential to receive the necessary services and information from qualified healthcare providers to ensure the safe and effective use of these medications. Bleeding, several pain, cramping, headache, and nausea will be experienced after taking the pills, which may result in anemia, syncope, fever, uterine contents retained, and other adverse complications which are harmful to their health or even bad for the subsequent pregnancies[2–9]. Females who choose DA require professional care in the progress of abortion. Numerous studies have demonstrated that the painful experiences associated with DA can lead to psychological trauma. These negative experiences may have long-term effects on women's mental well-being, potentially influencing their relationships with their male partners and their willingness to consider future pregnancies.[6, 10]. Besides, the responsibility sharing from spouse plays an important role for women’s well-being and psychological impact in the progress of abortion[11, 12]. The study of Lauzon et al. in a Canadian community clinic showed that 85% women considered a male partner accompany during the abortion procedure as helpful[13]. Theoretically, the experience of severe pain during DA can occur due to uterine contractions and the potential difficulty in expelling the uterine contents, including the embryo sac[14, 15]. These processes involve the contraction and relaxation of the uterine muscles to expel the pregnancy tissue[16]. While emotional stress and anxious are also significant risk factors related to greater pain when DA[6, 17, 18]. Prior studies reported that the psychological impact, young age, and history of dysmenorrhea are predictive factors of pain for women[19–22]. Whether an increase in walking and light physical activity can enhance uterine contractions and reduce the duration of delivery time is uncertain. However, there is lacking evidence about the relationship between activities and placental expulsion time and the volume of bleeding in the progress of DA.

This cross-sectional study involved the recruitment of 450 female participants who opted for DA within the first 12 weeks of pregnancy. This research was approved by the ethics committee of Hongkong University, Shenzhen Hospital (Approved No. hkuszh2023122). Every participant in this research had been told the aim of the study and signed the informed consent.

Participants recruitment

The inclusion criteria of this study include:

1. Women who choose the DA to end the pregnancy and got the knowledge of DA.

2. A B-ultrasound result showed intrauterine conception.

3. The blood test showed no coagulopathy.

4. The age in 18-50.

The exclusion criteria of this study were as follows:

1. Women missed abortion before taking mifepristone.

2. Females with serious pelvic inflammation or acute vaginitis.

3. Taking anti-anxiety or antidepressant medications in a long-term.

Research Progress

All female participants underwent a comprehensive assessment of their vital signs, including blood pressure, temperature, pulse, and respiratory rate, in the recovery ward to ensure that they were within normal ranges. Furthermore, the researchers conducted additional inquiries and double-checked with women who expressed their intention to undergo DA. These measures aimed to confirm that the participants made the decision without any menace, had no contraindications to misoprostol administration, and accurately determined their gestational age before initiating the intake of medication. Under the guidance and prescription of medical professionals, female participants were instructed to take mifepristone in the form of eight pills (25mg/pill) before two days to the scheduled abortion procedure. On the day of the abortion, the women were administered two sublingual pills of misoprostol, with each pill containing 20mg of the medication under the supervision of medical staff.

During the hospital stay, nurses closely monitored the vital signs of the women and diligently assessed the volume of bleeding, aims to provide medical assistance if necessary. In cases where females experienced excessive bleeding within a short period, such as soaking a night pad in blood within half an hour, healthcare providers would give interventions to control the hemorrhage. Two commonly utilized methods are oxytocin intravenous infusion and misoprostol sublingual administration. The choice of intervention would be based on the specific clinical situation and the healthcare provider's judgment.

Data collection

A questionnaire (Q1) included sections for collecting demographic information such as age, educational level, marital status, BMI, maternity history, menstrual history, abortion history, pregnancy weeks, and social support (spouse, family members, or friends) was sent to the participants to get demographic data. Another questionnaire (Q2) consisted of a table format to record specific data points related to the participants' DA process, which included the time of pills taking, the time of gestational sac expulsion, pain scores, bleeding volume, and walking steps before and after 2 hours of gestational sac expulsion. Furthermore, Q2 included an evaluation of the participants' mental health using the Chinese version of the 7-item Generalized Anxiety Disorder (GAD-7) Scale (score range 0-21) was used to collect participants’ anxiety level.

To accurately measure the bleeding volume, an electric scale was utilized to weigh the blood collected in each participant's pad or bedpan. This method ensured precise measurement and recording of the quantity of blood loss during the DA process. Additionally, participants were provided with an electric wristband equipped with a recording function throughout the abortion procedure, allowing for the continuous and automatic recording of the walk steps taken by the women.

Statistical analysis method

Statistical Package for the Social Science (version SPSS 26.0) was used to date analysis. Demographic characteristics of participants was descripted. Spearman correlation analysis was used to investigate the relationships between various variables.

A total of 450 women who had DA during the 1 May to 31 August in 2023 in Hongkong University, Shenzhen Hospital. All the data were collected and analyzed.

The mean (SD) age of the 450 women was 32.14\(\:\pm\:\)0.26 years. 321 (71.3%) females have the history of dysmenorrhea. 374 (83.1%) participants have caregivers when they come to hospital for DA. 258 (57.3%) of all participants them have the history of cesarean section, 238 of them have cesarean section within 2 times and 20 of them have more than 3 times. 118 (26.2%) of all participants have the experiences of vaginal parity, only 4 of them vaginal parity more than 4 times. For the experiences of abortion, 161 (35.8%) of all participants have the history of surgery abortion and 142 (31.6%) of them have the history of DA. 28 (6.2%) of all participants have uterine complications and 16 (3.6%) of all females have the uterine surgery history.

Demographic characteristics of all participants were listed in Table 1.

Table 1

Demographic information.
	Mean (SD) /Number	percentage
Year	32.14\(\:\pm\:\)0.26
BMI	20.37\(\:\pm\:\)0.14
Marital status Married Unmarried Divorced	260 168 22	57.8% 37.3% 4.9%
Educational level Junior school High school College Master or PhD.	3 61 334 52	0.7% 13.6% 74.2% 11.6%
Dysmenorrhea Yes No	321 129	71.3% 28.7%
Caregiver Yes No	374 76	16.9% 83.1%
Times of cesarean section 0 1–2 \(\:\:\:\:\:\:\:\:\:\:\:\:\:\:\ge\:\)3	192 238 20	42.7% 52.9% 4.4%
Vaginal parity 0 1–2 \(\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\ge\:\)3	332 114 4	73.8% 25.3% 0.9%
Numbers of surgery abortion 0 1–2 \(\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\ge\:\)3	289 148 13	64.2% 32.9% 2.9%
Numbers of medical abortion 0 1–2 \(\:\:\:\:\:\:\:\:\:\:\:\:\:\:\:\ge\:\)3	308 132 10	68.4% 29.3% 2.3%
Uterine complications Yes No	28 422	93.8% 6.2%
Uterine surgery Yes No	16 434	96.4% 3.6%

The results showed that elder age plays a positive influence in abortion time (rs = 0.0102, P < 0.05), but a negative role in influencing pain score in the progress of DA (rs=-0.178, P < 0.001). Dysmenorrhea is a risk factor to delay abortion time (ra=-0.097,P < 0.05) but a positive factor in increasing pain score (rs = 0.106,P < 0.05) and anxiety score (rs = 0.119,P < 0.05). Females with history of cesarean section have positive influence in relieving pain score (rs=-0.226, P < 0.001) and anxiety (rs=-0.129,P < 0.001) in the progress of DA. Women who have the history of vaginal delivery can decrease the pain score of DA (rs=-0.117, P < 0.05) but no statistic significant effect in other results. Females with DA have no statistic influence in abortion time, bleeding, pain score and anxiety but those who have experienced surgery abortion takes a negative role in pain (rs=-0.139, P < 0.001) and anxiety (rs=-0.093, P < 0.05) when DA. The experience of uterine surgery is a significant role in increasing anxiety score in medical score (rs = 0.101, P < 0.05). Time of pregnancy (pregnancy days) is a positive role that increase the pain score (rs = 0.103, P < 0.05). We got the results that total walk steps can increase the abortion time (rs = 0.379,P < 0.001), bleeding(rs = 0.095,P < 0.05), and pain score(rs = 0.206,P < 0.001) in the progress of DA. While walk steps minutely takes positive effect in shorten the abortion time (rs=-0.133,P < 0.05) and increase pain score (rs = 0.235,P < 0.001).

The overall process and planning path of the experimental design were described in Table 2.

Table 2

Influence factor between different variables.
	Abortion time	Bleeding	Bleeding/min	Pain score	Anxiety
Age	0.0102^*	0.061	-0.010	-0.178^**	-0.064
Dysmenorrhea	-0.097^*	-0.072	-0.031	0.106^*	0.119^*
Cesarean section	0.009	0.054	0.049	-0.226^**	-0.129^**
Vaginal delivery	0.054	0.020	0.001	-0.117^*	-0.028
Surgery abortion	-0.048	0.059	0.073	-0.139^**	-0.093^*
Medical abortion	0.016	-0.011	0.026	0.058	-0.041
Uterine surgery	-0.018	0.017	0.025	0.032	0.101^*
Duration gestation	0.027	0.086	0.078	0.103^*	0.014
Total walk steps	0.379^**	0.095^*	-0.116	0.206^**	-0.026
Walk steps/min	-0.113^*	-0.058	0.017	0.235^**	0.027
^{* :P<0.05; **:P<0.001; min:minute}.

Main findings

This study analyzed the factors which are effect to females’ bleeding, pain, and time duration in the progress of DA. The experience of pain, and in some cases, severe pain, is a common occurrence among patients undergoing DA. This discomfort has been identified as a significant factor leading some females to opt for surgical abortion instead[19, 20]. Research detected that painkiller could decrease the pain in DA. Instances of incomplete or failed abortion, as well as complications such as heavy bleeding and infection, maybe arise when women do not know how to use the abortion pills correctly[23]. Abortion education and provision from medical staff are very important, as it can have a significant impact on reducing negative emotions such as anxiety and depression[24]. By ensuring that women receive accurate information, counseling, and appropriate care throughout the abortion process, medical staff can help alleviate emotional distress and promote overall well-being. Our hypothesis suggested that older age might be associated with longer abortion duration; however, the results contradicted this assumption. Surprisingly, although the effect size was small, there was a positive relationship observed between age and abortion duration. Additionally, our findings indicated that older females tended to experience lighter pain during DA. This result is consistent with another study, which reported that teenagers experienced longer durations of pain during DA compared to adult women[19]. In this study, we discovered that women who had a history of dysmenorrhea were more likely to experience increased pain and anxiety scores during the DA procedure. These findings are consistent with previous research that has also shown a correlation between a history of dysmenorrhea and more severe pain, higher levels of anxiety, and a greater need for analgesics[19, 21]. Results of this research also insisted that history of dysmenorrhea was associated with a shorter abortion time during DA; embryo are excreted earlier in women with a history of dysmenorrhea compared to women without such a history. This finding highlights a potential relationship between dysmenorrhea and the efficiency of the DA process.

Women who have the history of cesarean section seems a protect role in relieving pain and anxiety score when DA in this study. This conclusion is similar to other studies that women with higher age, richer experiences of previous pregnancies and deliveries (including cesarean section and vaginal delivery) can contribute to decreased pain level during DA[21, 25]. This research indicated that the history of childbirth, including parity and previous delivery route, did not have any significant relationship with both abortion time and bleeding during DA. These findings are inconsistent with our initial hypothesis and are in line with a retrospective study conducted in Turkey, which also concluded that parity and previous delivery route do not impact the duration of DA[26]. While other previous studies indicate that there is indeed a relationship between the history of childbirth and the duration of DA. These studies have reported that median duration of the abortion was decreased by 25% in multiparous women nulliparous women, and the time interval between the first inclusion and fetal expulsion was significantly shorter in multiparous than in primiparous women[27–29].

Strengths and limitations

Based on the available research, there is a lack of studies that have specifically examined the impact of abortion history on DA outcomes. To the best of our knowledge, this study represents the first attempt to evaluate the effect of abortion history on later DA. By exploring the relationship between abortion history and DA outcomes, this research contributes to the existing knowledge in the field and sheds light on a previously unexplored area. The findings of this study may provide valuable insights into the potential influence of abortion history on the outcomes of DA procedures. Our study revealed that a history of surgical abortion was associated with a reduction in pain and anxiety scores during DA. However, no significant relationship was found between a history of surgical abortion and DA time or bleeding. Furthermore, previous experiences of DA did not have an impact on abortion time, bleeding, pain, or anxiety during subsequent DAs. These findings suggest that a history of surgical abortion may play a role in mitigating pain and anxiety during DA, but it does not affect the duration of the procedure or the amount of bleeding. Additionally, prior experiences of DA do not appear to influence the outcomes of subsequent DAs in terms of time, bleeding, pain, or anxiety.

Interpretation

Limited research has addressed the correlation between physical activity and the duration of DA. We previously assumed that appropriate activities, such as walking during the abortion procedure rather than remaining lying in bed, may facilitate the expulsion of the placenta and lead to a shorter abortion duration. However, contrary to our initial expectations, the findings of this study indicate that walking during the DA process is associated with a longer abortion duration and increased bleeding. According to analysis, the study design maybe one reason that have contributed to the unexpected results. It is possible that focusing on participants' step count in the initial 2 or 3 hours after taking the misoprostol tablets, rather than until embryo expulsion, would have provided a more accurate assessment of the immediate impact of activity on the abortion process. Although total walk steps may be associated with a longer abortion duration and increased bleeding, the walk steps per minute emerged as a protective factor in reducing the duration of abortion time in this study.

In this study, we got the conclusions as follows:

1. Individuals with a history of dysmenorrhea and those who engage in walking at a higher pace per minute may experience a shorter duration of abortion.

2. Elderly individuals, a history of delivery and surgical abortion, may contribute to a decreased perception of pain during DA.

3.On the other hand, a history of dysmenorrhea, longer gestation duration, and increased walk steps were identified as risk factors for experiencing pain during DA.

4. History of dysmenorrhea and uterine surgery were associated with higher levels of anxiety, while a history of cesarean section and surgical abortion were associated with lower levels of anxiety.

These findings highlight the complex interplay of various factors in relation to the duration of abortion, pain, and anxiety experienced during DA. Further research and consideration are necessary to better understand and optimize the management of these factors to improve the overall experience and outcomes of DA procedures.

drug abortion

Author Agreement stating

that the article is the author(s) original work; the article has not received prior publication and is not under consideration for publication elsewhere; that all authors have seen and approved the manuscript being submitted; the author(s) abide by the copyright terms and conditions of Elsevier and the Australian College of Midwives;

Acknowledgements:

We thank all doctors in genecology department in The University of Hongkong-Shenzhen University for their assistants in patients’ abortion process. And thanks to Fangmei Ou for her help to clean blood timely and keep the healthcare ward clean when we collected data. Thanks for the assistants from Ying Chang, Ruijuan Cai, and Huayun Li in the progress of data collection.

Conflict of interest:

The authors declare that they have no competing interests.

Ethical statement:

Ethics approval was obtained from the Institutional Review Board of the University of Hong Kong–Shenzhen Hospital with approval number: (2023)152.

Funding:

The Basic Research Scheme of Shenzhen Science and Technology Innovation Commission (JCYJ20220531092208018，JCYJ20230807094815031);

Authorship Contribution:

W.B.W drafting the article. L.Y.W and W.J.W substantial contributions to conception. W.X.Y and X.F.Z collected data. Q.Q.J and Y.G and W.C analyzed the data. Y.H.D and Y.H.Z final approval of the version to be published.

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No competing interests reported.

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You are reading this latest preprint version

The relationship between duration, bleeding volume, and activity for women in the progress of drug abortion: a cross-sectional study.

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Version 1

Abstract

Introduction

Material and Methods

Results

Discussion

Main findings

Strengths and limitations

Interpretation

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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Status:

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