Complications after Second Trimester Surgical and Medical Abortion

The costs of accessing abortion in South Africa: women's costs associated with second-trimester abortion services in Western Cape Province

OBJECTIVES

To assess women's costs of accessing second-trimester labor induction and dilation and evacuation (D&E) services at four public hospitals in Western Cape Province, South Africa.

STUDY DESIGN

From April to August 2010, in interviews immediately after completion of their abortion, we asked women about specific direct and indirect costs incurred. We collected information on recurring costs (i.e., per visit) and one-time expenditures and calculated total costs.

RESULTS

In total, 194 patients participated (136 D&E; 58 induction). Their median age was 26; 37.6% reported being employed or doing paid work. Most (73.2%) women visited two different facilities, including the study facility, while seeking the procedure. Induction women reported a median of three required visits [interquartile range (IQR) 2.0-3.0] to the study facility, while D&E women reported two required visits [IQR 1.0-2.0]. Twenty-seven percent of women missed work due to the procedure, and few (4.6%) paid for childcare. At each visit, almost all women (180, 92.8%) paid for transportation costs and reported additional one-time costs (177, 91.2%) such as sanitary supplies or doctor's fees. The total median cost incurred per woman was $21.23 [IQR 11.94-44.68]. Roughly half (49.0%) received help with these costs.

CONCLUSIONS

Although technically offered freely or low cost in the public sector, women accessing second-trimester abortion lost income and incurred costs for transport, fees, supplies and childcare. Their total costs could be reduced by minimizing the number of required visits to facilities and freely offering supplies such as sanitary pads and pregnancy tests.

IMPLICATIONS

Limited access to second-trimester, safe abortion services in South Africa may result in some women incurring unnecessary costs. Women make multiple visits in attempting to obtain an abortion, often because of facility or health systems requirements, and incur costs for lost income, child care, transport, fees and supplies.

Experiences, feelings and thoughts of women undergoing second trimester medical termination of pregnancy

Main Objective

The objective of this study was to explore women's expectations and experiences of undergoing second trimester abortion.

Methods

This is a cross-sectional study using a screening questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and 23 of them were later interviewed. The questionnaires were analyzed by descriptive statistics. The interviews were recorded, transcribed verbatim and analyzed with qualitative content analysis.

Most Important Findings

Indications for the abortion were fetal malformation or unintended pregnancy. The women expressed similar feelings and these were irrespective for the reason for having an abortion. Both physical and mental pain was experienced during the abortion process and described by the women. Taking the mifepristone-pill was experienced as especially emotionally difficult for many participants. Professional support from the staff together with support from the partner, a friend or relative helped in transforming the worries related to something unknown to feelings of coping with a new and hard experience. Prior to the abortion most women stated that they did not want to view the fetus but women who chose to view the fetus described this as a way of confronting the reality and an opportunity to say farewell to the pregnancy/fetus. The analysis of the interview transcripts revealed five themes mirroring the women's experiences, thoughts and feelings related to the abortion.

Conclusions

The decision to undergo second trimester abortion sometimes exposes women to strong and conflicting emotions which are irrespective for the reason for having an abortion. Despite this women do not regret their decision to terminate the pregnancy. This analysis shows that their rational thinking outweighs their emotionally difficult feelings. It is important for the attending staff to be responsive to the needs of each individual woman whatever the indication is for the abortion.

Non-invasive prenatal testing: ethics and policy considerations

New technologies analyzing fetal DNA in maternal blood have led to the wide commercial availability of non-invasive prenatal testing (NIPT). We present here for clinicians the ethical and policy issues related to an emerging practice option. Although NIPT presents opportunities for pregnant women, particularly women who are at increased risk of having a baby with an abnormality or who are otherwise likely to access invasive prenatal testing, NIPT brings significant ethics and policy challenges. The ethical issues include multiple aspects of informed decision-making, such as access to counselling about the possible results of the test in advance of making a decision about participation in NIPT. Policy considerations include issues related to offering and promoting a privately available medical strategy in publicly funded institutions. Ethics and policy considerations merge in NIPT with regard to sex selection and support for persons living with disabilities.

Complex organ injuries after mid-trimester termination of pregnancy: pushing boundaries in laparoscopic management

Surgical termination of pregnancy is one of the most often performed gynecologic procedures in the United Kingdom and worldwide. Although complications are rare, they can be devastating because they include hemorrhage and pelvic organ damage often necessitating hysterectomy. Traditionally, these complications have been managed via laparotomy; however, with increasing technological advances and surgical expertise, it is now possible to manage extreme complications of these procedures via operative laparoscopy. Herein is reported successful laparoscopic management of 3 cases of complex uterine perforation in young women after mid-trimester surgical termination of pregnancy.

Uterine perforation as a complication of surgical abortion causing small bowel obstruction: a review

OBJECTIVE

Small bowel obstruction after unrecognized or conservatively treated uterine perforation is extremely rare. It is a surgical emergency and the delay in diagnosis and treatment has deleterious consequences for the mother. The purpose of this study is to critically review the available literature and ascertain the level of evidence for the mechanisms, diagnosis and management of small bowel obstruction after uterine perforation due to surgical abortion.

METHODS

Systematic literature search was conducted in Pubmed (1946 to 2012) and Pubmedcentral (1900 to 2012) including all available English and French language fulltext articles. Three evaluators reviewed and selected all available case reports and case series. Search terms included small bowel obstruction, bowel obstruction, bowel incarceration, bowel entrapment, vaginal evisceration, uterine perforation, uterine rupture, and abortion. The exclusion criteria were (1) complex injuries where small bowel incarceration was present but with bleeding and/or bowel perforation as the leading symptomatology; (2) articles only numbering the patients without details on the topic. Analyses of incidence, risk factors, mechanisms of the disease, time of clinical presentation, diagnostic modalities, treatment, and maternal outcome were included.

RESULTS

Of the 73 articles screened 30 cases of small bowel obstruction were included in the review forming incidence, risk factors, and mechanisms of the disease, diagnosis, therapy, and maternal outcome.

CONCLUSIONS

A systematic review defined four mechanisms of small bowel obstruction after transvaginal instrumental uterine perforation with significant variations in clinical presentation and time of presentation. Duration of symptoms depend on the mechanism of small bowel obstruction. Vaginal evisceration is surgical emergency and treatment is mandatory without diagnostic workup. Survival rate during last century is 93 %. Multicentric trials and publication of all such cases are needed to determine algorithms for diagnosis and management of small bowel obstruction caused by instrumental uterine perforation.

Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later

During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.

A minimally invasive approach to an iatrogenic pelvic mass

A case report describing an unusual complication following a 17-week elective termination of pregnancy in a pediatric patient that was managed laparoscopically.

Trends in teenage termination of pregnancy and its risk factors: a population-based study in Finland, 1987-2009

STUDY QUESTION

What are the current trends in teenage termination of pregnancy (TOP) and its risk factors?

SUMMARY ANSWER

The incidence of teenage TOP fluctuated substantially during the study period and the incidence of repeat TOP among adolescents increased markedly in the 2000s.

WHAT IS KNOWN ALREADY

Teenage pregnancy is associated with difficulties in psychological, sexual and overall health. The proportion of teenage pregnancies resulting in termination varies by country and time, but only few countries have reliable statistics on TOPs.

STUDY DESIGN, SIZE, DURATION

This nationwide retrospective register study included all the TOPs (n= 52 968) and deliveries (n= 58 882) in Finland between 1987 and 2009 among girls <20 years of age at the beginning of pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The cohorts were divided into three subgroups; 13-15- (n= 6087), 16-17- (n= 18 826) and 18-19- (n= 28 055) year-olds.

MAIN RESULTS AND THE ROLE OF CHANCE

After an initial steady decline, the incidence of teenage TOP increased by 44% between 1993 (8.0/1000) and 2003 (11.5/1000), and thereafter declined by 16% until 2009 (9.7/1000). The incidence was higher in older adolescents, but the trends were alike in all age groups. Early TOPs (performed at <56 days of gestation) more than tripled from 11 to 36% during the study period. However, the proportion of second-trimester TOPs remained steady at ≈ 7%. Young age [13-15 years: odds ratio (OR) 1.75 (95% confidence interval (CI) 1.57-1.94), 16-17 years: OR 1.13 (1.05-1.23), 18-19 years: OR 1 (reference category)] and non-use of contraception [(OR 11.16 (10.15-12.27)] were related to a higher risk of second-trimester TOP. The incidence of repeat TOP increased by 95% from 1.9/1000 to 3.7/1000 in 18-19-year-olds and by 120% from 0.5/1000 to 1.1/1000 in 16-17-year-olds between 1993 and 2009. Increasing age [13-15 years: OR 0.16 (95% CI 0.14-0.19), 16-17 years: OR 0.49 (0.45-0.52), 18-19 years 1 (Ref)], living in an urban area [rural: OR 0.62 (0.56-0.67), urban: OR 1 (Ref)] and having undergone a second-trimester TOP [OR 1.46 (1.31-1.63)] were risk factors for repeat TOP. The planned use of intrauterine contraception for post-abortal contraception increased from 2.6 to 6.2% and among girls with repeat TOP from 10 to 19%.

LIMITATIONS

The retrospective nature of the study remains a limitation and the quality of the data is reliant on the accuracy of reporting. We were not able to link repeat TOPs of the same woman in our data set. However, the share of repeat abortions was moderate. WIDER IMPLICATIONS OF THE FINDINGS The rate of teenage TOP seems to rapidly reflect changes in national sexual and reproductive health services and policy. The rising rate of repeat TOP is alarming and may represent a sign of marginalization among these girls. All efforts to maintain a low rate of teenage pregnancy are welcomed.

Perioperative antibiotics to prevent infection after first-trimester abortion

BACKGROUND

There are two main strategies for the prevention of post-abortal upper genital tract infection: antibiotics given around the time of surgery for all women; and 'screen-and-treat', in which all women presenting for abortion are screened for genital infections and those with positive results are treated.

OBJECTIVES

To determine:1. the effectiveness of antibiotic prophylaxis in preventing post-abortal upper genital tract infection; 2. the most effective antibiotic regimen; 3. the most effective strategy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, POPLINE and LILACS. The search was last updated in May 2011.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in any language including women undergoing induced first trimester surgical or medical abortion, comparing: 1) any antibiotic regimen to placebo, nothing, or another antibiotic; 2) screen-and-treat versus antibiotics. The primary outcome was the proportion of women diagnosed with post-abortal upper genital tract infection.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected references and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI). We used meta-analysis where appropriate and examined between trial heterogeneity using the I(2) statistic. In the presence of between trial heterogeneity we also estimated the 95% prediction interval (PI).

MAIN RESULTS

A total of 703 unique items was identified. We included 19 RCTs. There was evidence of small study biases (Egger test, P = 0.002). In 15 placebo-controlled RCTs there was an effect of antibiotic prophylaxis (pooled RR 0.59, 95% CI 0.46 to 0.75, 95% PI 0.30 to 1.14, I(2) = 39%). There were insufficient data (three trials) to determine whether one regimen was superior to another. In one trial, the incidence of post-abortal upper genital tract infection was higher in women allocated to the screen-and-treat strategy (RR 1.53, 95% CI 0.99 to 2.36).

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis at the time of first trimester surgical abortion is effective in preventing post-abortal upper genital tract infection. Evidence of between trial heterogeneity suggests that the effect might not apply to all settings, population groups or interventions.This review did not determine the most effective antibiotic prophylaxis regimen. Antibiotic choice should take into account the local epidemiology of genital tract infections, including sexually transmitted infections.Further RCTs comparing different antibiotics or combinations of antibiotics with each other would be useful. Such trials could be done in low and middle income countries and where the prevalence of genital tract infections in women presenting for abortion is high.

Fetopathologic examination for early termination of pregnancy: dogma or necessity?

OBJECTIVE

Our objective was assessment of fetopathological examination after termination of pregnancy (TOP) for fetal anomalies with normal karyotype <17 weeks of gestation.

STUDY DESIGN

This was a multicenter retrospective study. Records of TOP for fetal anomalies with normal karyotype were analyzed. Primary outcomes were modifications of genetic counseling and management of next subsequent pregnancies. Medical TOPs were compared with surgical TOPs.

RESULTS

In all, 59 pregnancies were included (30 aspirations, 29 inductions). Fetopathological examination modified genetic counseling for 22 patients: 62% for the medical induction group vs 13% in the vacuum aspiration group (P < .001). Management of subsequent pregnancies was modified in 17% in the medical induction group vs 3% in the aspiration group (P = .06).

CONCLUSION

Fetopathological examination for early TOP with normal karyotype is relevant, especially when an intact fetus is examined. Thanks to it, genetic counseling is often modified, as is management of the next pregnancy. Medical procedures should be preferred to surgical procedures.

Surgical and medical second trimester abortion in South Africa: a cross-sectional study

BACKGROUND

A high percentage of abortions performed in South Africa are in the second trimester. However, little research focuses on women's experiences seeking second trimester abortion or the efficacy and safety of these services.The objectives are to document clinical and acceptability outcomes of second trimester medical and surgical abortion as performed at public hospitals in the Western Cape Province.

METHODS

We performed a cross-sectional study of women undergoing abortion at 12.1-20.9 weeks at five hospitals in Western Cape Province, South Africa in 2008. Two hundred and twenty women underwent D&E with misoprostol cervical priming, and 84 underwent induction with misoprostol alone. Information was obtained about the procedure and immediate complications, and women were interviewed after recovery.

RESULTS

Median gestational age at abortion was earlier for D&E clients compared to induction (16.0 weeks vs. 18.1 weeks, p < 0.001). D&E clients reported shorter intervals between first clinic visit and abortion (median 17 vs. 30 days, p < 0.001). D&E was more effective than induction (99.5% vs. 50.0% of cases completed on-site without unplanned surgical procedure, p < 0.001). Although immediate complications were similar (43.8% D&E vs. 52.4% induction), all three major complications occurred with induction. Early fetal expulsion occurred in 43.3% of D&E cases. While D&E clients reported higher pain levels and emotional discomfort, most women were satisfied with their experience.

CONCLUSIONS

As currently performed in South Africa, second trimester abortions by D&E were more effective than induction procedures, required shorter hospital stay, had fewer major immediate complications and were associated with shorter delays accessing care. Both services can be improved by implementing evidence-based protocols.

Risk and uncertainty: shifting decision making for aneuploidy screening to the first trimester of pregnancy

PURPOSE

The clinical introduction of first trimester aneuploidy screening uniquely challenges the informed consent process for both patients and providers. This study investigated key aspects of the decision-making process for this new form of prenatal genetic screening.

METHODS

Qualitative data were collected by nine focus groups that comprised women of different reproductive histories (N = 46 participants). Discussions explored themes regarding patient decision making for first trimester aneuploidy screening. Sessions were audio recorded, transcribed, coded, and analyzed to identify themes.

RESULTS

Multiple levels of uncertainty characterize the decision-making process for first trimester aneuploidy screening. Baseline levels of uncertainty existed for participants in the context of an early pregnancy and the debate about the benefit of fetal genetic testing in general. Additional sources of uncertainty during the decision-making process were generated from weighing the advantages and disadvantages of initiating screening in the first trimester as opposed to waiting until the second. Questions of the quality and quantity of information and the perceived benefit of earlier access to fetal information were leading themes. Barriers to access prenatal care in early pregnancy presented participants with additional concerns about the ability to make informed decisions about prenatal genetic testing.

CONCLUSIONS

The option of the first trimester aneuploidy screening test in early pregnancy generates decision-making uncertainty that can interfere with the informed consent process. Mechanisms must be developed to facilitate informed decision making for this new form of prenatal genetic screening.

Confronting the challenge of unsafe second-trimester abortion

Unsafe abortion accounts for approximately 13% of maternal deaths worldwide-roughly 47,000 deaths per year. Most deaths from unsafe abortion occur in low-resource countries. Second-trimester abortion carries a higher risk of morbidity and mortality compared with first-trimester abortion and, although the former comprises the minority of abortion procedures worldwide, it is responsible for the majority of serious complications and death where unsafe abortion is prevalent. Therefore, improving access to safe second-trimester abortion must be a priority in low-income regions of the world if the majority of deaths from unsafe abortion are to be prevented. In the present paper, we consider a variety of barriers to second-trimester care, including healthcare provider training and abortion stigma, which may lead to neglect of unmet need for second-trimester services.

The potential of medical abortion to reduce maternal mortality in Africa: what benefits for Tanzania and Ethiopia?

Background

Unsafe abortion is estimated to account for 13% of maternal mortality globally. Medical abortion is a safe alternative.

Methods

By estimating mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, we modelled changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. We selected Ethiopia and Tanzania because of their high maternal mortality ratios (MMRatios) and contrasting situations regarding health care provision and abortion legislation. We focused on misoprostol-only regimens due to the drug's low cost and accessibility. We included the impact of medical abortion on women who would otherwise choose unsafe abortion and on women with unwanted/mistimed pregnancies who would otherwise carry to term.

Results

Thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Changes in MMRatios would be less pronounced because the intervention would also affect national birth rates.

Conclusions

This is the first analysis of impact of medical abortion provision which takes into account additional potential users other than those currently using unsafe abortion. Thousands of women's lives could be saved, but this may not be reflected in as substantial changes in MMRatios because of medical abortion's demographic impact. Therefore policy makers must be aware of the inability of some traditional measures of maternal mortality to detect the real benefits offered by such an intervention.

Young age and termination of pregnancy during the second trimester are risk factors for repeat second-trimester abortion

OBJECTIVE

The objective of the study was to characterize women undergoing a termination of pregnancy (TOP) during the second trimester and to evaluate the risk factors and timing of repeat TOP.

STUDY DESIGN

This nationwide retrospective cohort study investigated 41,750 women who underwent TOP during the first (n = 39,850) or second (n = 1900) trimester in Finland in 2000-2005. The follow-up time was until repeat TOP or until Dec. 31, 2006.

RESULTS

TOP during the second trimester increases the risk of repeat TOP (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.3-1.6), repeat second-trimester TOP (HR, 3.8; 95% CI, 2.9-5.1), and repeat TOP after 16 weeks of gestation (HR, 5.0; 95% CI, 3.3-7.7). The other risk factor for these is young age (HR, 7.0, 95% CI, 5.3-9.3; and HR, 12.5; 95% CI, 3.1-50.4 for age <20 years).

CONCLUSION

Second-trimester TOP and young age are risk factors for repeat second-trimester TOP. Special focus on these women might be effective in decreasing repeat abortions.

Audit of short term outcomes of surgical and medical second trimester termination of pregnancy

Background

As comparisons of modern medical and surgical second trimester termination of pregnancy (TOP) are limited, and the optimum method of termination is still debated, an audit of second trimester TOP was undertaken, with the objective of comparing the outcomes of modern medical and surgical methods.

Methods

All cases of medical and surgical TOP between the gestations of 13 and 20 weeks from 1st January 2007 to 30th June 2008, among women residing in the local health board district, a tertiary teaching hospital in an urban setting, were identified by a search of ICD-10 procedure codes (surgical terminations) and from a ward database (medical terminations). Retrospective review of case notes was undertaken. A total of 184 cases, 51 medical and 133 surgical TOP, were identified. Frequency data were compared using Chi-squared or Fischer's Exact tests as appropriate and continuous data are presented as mean and standard deviation if normally distributed or median and interquartile range if non-parametric.

Results

Eighty-one percent of surgical terminations occurred between 13 to 16 weeks gestation, while 74% of medical terminations were performed between 17 to 20 weeks gestation. The earlier surgical TOP occurred in younger women and were more often indicated for maternal mental health. Sixteen percent of medical TOP required surgical delivery of the placenta. Evacuation of retained products was required more often after medical TOP (10%) than after surgical TOP (1%). Other serious complications were rare.

Conclusion

Both medical and surgical TOP are safe and effective for second trimester termination. Medical TOP tend to be performed at later gestations and are associated with a greater likelihood of manual removal of the placenta and delayed return to theatre for retained products. This case series does not address long term complications.

A critical appraisal of laws on second trimester abortion

There will always be women who need abortions after 12 weeks of pregnancy, and their reasons are often compelling. Although second trimester abortions carry relatively more risks than first trimester abortions, abortion is still very safe throughout the second trimester if done in safe conditions. This paper is about law and policy on second trimester abortions, which are allowed on more restrictive grounds than first trimester abortions in most countries, if at all. It focuses on countries where most or at least some second trimester abortions are allowed, including in Europe, where many women are still forced to travel for second trimester abortions, and countries in the developing world, where most second trimester abortions remain unsafe. The need for second trimester abortion should be met in a safe, timely and sympathetic manner. Abortion should be legal at the woman's request up to 24 weeks and on therapeutic grounds after that, and no other barriers or hurdles should be imposed on women seeking second trimester abortion. In-depth, country-based research is needed, to bring out the facts on second trimester abortion, as evidence of why it should be treated as a legitimate form of women's health care and supported in public health policy.