Mid-trimester induced abortion: a review

A comparison of two regimens of misoprostol for second trimester medical termination of pregnancy: a randomized trial

The objective of this study was to compare the efficacy and side-effects of two regimens of vaginal misoprostol for second trimester voluntary medical termination of pregnancy (MTP) according to the MTP Act of India. A randomized trial was conducted in 185 women from January 2007 to September 2008. Women in group 1 were given vaginal misoprostol 400 microg every 6 h for a maximum of four doses. Women in group 2 were given vaginal misoprostol 400 microg every 12 h for a maximum of four doses. Our primary outcome measure was induction abortion interval. Secondary outcome measures were success rate, side-effects and completeness of procedure. Results were calculated applying Fisher's exact test, chi-square test, Z test and calculating the P value using an alpha level of 0.05 for Type I error. The mean induction abortion interval in group 1 (12.59 h) was significantly shorter (P < 0.001) than that in the group 2 (16.41 h). The percentage of women who achieved successful abortion within 12 h in group 1 (56.52%) was also significantly higher (P = 0.00005) than that in group 2 (25.80%). The incidence of side-effects was comparable and not clinically serious. It is concluded that the regimen of vaginal misoprostol 400 microg every 6 h was more effective than the regimen of misoprostol every 12 h in medical termination of second trimester pregnancy.

Mifepristone and second trimester pregnancy termination for fetal abnormality in Western Australia: Worth the effort

OBJECTIVE

To determine the impact on the process of second trimester medical termination for fetal abnormality following the introduction of adjunctive mifepristone in an Australian tertiary hospital.

METHODS

All second trimester medical terminations for fetal abnormality between July 2006 and June 2009 were prospectively identified. Two temporal therapeutic cohorts were created: the first (1 July 2006 to 31 December 2007) using vaginal misoprostol alone and the second (1 January 2008 to 30 June 2009) using mifepristone priming prior to the administration of misoprostol. The primary outcome was to evaluate the impact of mifepristone priming upon the duration of pregnancy termination.

RESULTS

During the study period, 388 women with prenatally recognised fetal anomalies between 14 and 24 weeks gestation underwent medical termination: 189 with misoprostol alone and 199 with mifepristone priming followed by misoprostol. There was no difference between the groups for maternal age, parity or prior caesarean delivery. The median abortion duration was 15.5 h (interquartile ranges (IQR) 11.2-22.7) in the misoprostol group and 8.6 h (IQR 5.6-13.8) in the mifepristone primed group (P < 0.001). In both the groups, nulliparity and advancing gestation were associated with a significant prolongation of the abortion interval. Duration of hospitalisation was significantly longer in the misoprostol alone group (31.5 h (27-48.9) vs 27.2 h (22-31.5), misoprostol vs mifepristone priming, respectively, P < 0.001).

CONCLUSIONS

The introduction of mifepristone priming prior to second trimester medical termination with misoprostol has resulted in a significant reduction in the duration of the termination procedure and length of inpatient stay. These observed benefits of mifepristone provide objective support for the decision to permit use of this medication in Australia.

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.

Optimization of third-stage management after second-trimester medical pregnancy termination

OBJECTIVE

Comparison of 3 regimens for third-stage management after second-trimester intravaginal misoprostol termination.

STUDY DESIGN

Prospective randomized trial. Three third-stage management strategies were compared: 10 units of intramuscular oxytocin (group 1), 600 microg oral misoprostol (group 2), or no additional medication (group 3) after fetal expulsion. Primary study outcome was the incidence of placental retention.

RESULTS

Two hundred fifty-one women were randomly assigned to the groups. There was a significant difference in placental retention rates: group 1, 8 of 83 (10%) vs group 2, 24 of 83 (29%) vs group 3, 26 of 85 (31%); P = .002. Blood loss was significantly lower in group 1, 100 mL (interquartile ranges, 50-200) vs group 2, 200 mL (interquartile ranges, 100-370) vs group 3, 200 mL (interquartile ranges, 100-375); P < .001. Requirement for blood transfusion: group 1, 1 of 83 (1%) vs group 2, 1 of 83 (1%) vs group 3, 5 of 85 (6%); P = .103.

CONCLUSION

Intramuscular oxytocin administered after fetal delivery after second-trimester medical termination significantly increases placental expulsion rates and decreases short-term postpartum blood loss.

Safety of late second-trimester pregnancy termination by laminaria dilatation and evacuation in patients with previous multiple cesarean sections

OBJECTIVE

To assess whether there is an increased perioperative risk in termination of late second-trimester pregnancy after multiple cesarean sections by laminaria dilatation and evacuation.

STUDY DESIGN

During the period between January 2002 and June 2008, 636 consecutive patients underwent late second-trimester (17-24 weeks) pregnancy terminations by dilatation and evacuation. Patients were divided into 3 subgroups: those with no previous cesarean section (n = 545), those with 1 previous cesarean section (n = 59), and those with several previous cesarean sections (n = 32).

RESULTS

There were no significant differences in major perioperative complications, such as anesthetic complications, need for blood transfusion, and cervical lacerations comparing the 3 subgroups. Importantly, there were neither cases of uterine perforation nor retained products of conception in the 3 subgroups.

CONCLUSION

Late second-trimester pregnancy termination after multiple cesarean sections by laminaria dilatation and evacuation is probably not associated with an increased perioperative risk. Larger studies are needed to empower this study.

Cervical preparation with laminaria tents improves induction-to-delivery interval in second- and third-trimester medical termination of pregnancy

BACKGROUND

The purpose of our study was to determine whether cervical preparation with laminaria tents would improve the procedure of second- and third-trimester medical termination of pregnancy (TOP) in terms of duration of abortion and hospitalization.

STUDY

A retrospective comparative study of two historical periods of women undergoing second- and third-trimester medical TOP at a single tertiary care center from September 2004 to December 2006 was conducted. During Period A, patients received oral mifepristone and vaginal misoprostol, while during Period B, laminaria tents were added. Main outcome measures included initiation-to-delivery (ITD) time, induction-to-delivery interval and hospitalization time.

RESULTS

Of 186 eligible women, 174 were enrolled in the study: 91 patients during Period A and 83 patients during Period B. The ITD time was reduced during Period B compared to Period A (43.2+/-6.2 h and 48.5+/-13.2 h, respectively; p=.001). Similarly, the induction-to-delivery interval was significantly shorter during Period B (7.5 h) compared to Period A (12.7 h; p=.001). A significant reduction in total hospital stay was observed during Period B (3 days) versus Period A (4 days; p<.001).

CONCLUSION

Cervical preparation with laminaria tents significantly shortens the duration of medical TOP that uses mifepristone-misoprostol without adverse events or serious complications.

Recent advances in second-trimester abortion: an evidence-based review

The proportion of US abortions performed in the second trimester has varied little since 1992. Although 30 years of cumulative data corroborate the safety of dilation and evacuation (D&E), the most commonly used method of second-trimester abortion in the United States, both D&E and alternative induction regimens continue to evolve such that the traditional safety gap between medical and surgical regimens has narrowed. Providers now have options that allow them to either expedite D&E by diminishing the cervical-ripening period or reduce induction abortion intervals during medical induction.

Second trimester abortions in India

This article gives an overview of what is known about second trimester abortions in India, including the reasons why women seek abortions in the second trimester, the influence of abortion law and policy, surgical and medical methods used, both safe and unsafe, availability of services, requirements for second trimester service delivery, and barriers women experience in accessing second trimester services. Based on personal experiences and personal communications from other doctors since 1993, when I began working as an abortion provider, the practical realities of second trimester abortion and case histories of women seeking second trimester abortion are also described. Recommendations include expanding the cadre of service providers to non-allopathic clinicians and trained nurses, introducing second trimester medical abortion into the public health system, replacing ethacridine lactate with mifepristone-misoprostol, values clarification among providers to challenge stigma and poor treatment of women seeking second trimester abortion, and raising awareness that abortion is legal in the second trimester and is mostly not requested for reasons of sex selection.

Second trimester medical abortion with mifepristone-misoprostol and misoprostol alone: a review of methods and management

Second trimester abortions constitute 10-15% of all induced abortions worldwide but are responsible for two-thirds of major abortion-related complications. During the last decade, medical methods for second trimester induced abortion have been considerably improved and become safe and more accessible. Today, in most cases, safe and efficient medical abortion services can be offered or improved by minor changes in existing health care facilities. Second trimester medical abortion can be provided by a nurse-midwife with the back-up of a gynaecologist. Because of the potential for heavy vaginal bleeding and serious complications, it is advisable that second trimester terminations take place in a health care facility where blood transfusion and emergency surgery (including laparotomy) are available. This article provides basic information on regimens recommended for second trimester medical abortion. The combination of mifepristone and misoprostol is now an established and highly effective method for second trimester abortion. Where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective, although a higher total dose is needed and efficacy is lower than for the combined regimen. Therefore, whenever possible, the combined regimen should be used. Efforts should be made to reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus. Future studies should focus on improving pain management, the treatment of women with failed medical abortion after 24 hours, and the safety of medical abortion regimens in women with a previous caesarean section or uterine scar.

Cervical obstruction complicating second-trimester abortion: treatment with misoprostol

BACKGROUND

Cervical cone biopsy or loop electrosurgical excision procedures (LEEP) may lead to cervical scarring, agglutination, or stenosis. Leiomyomas may also obstruct the lower uterine segment such that instruments cannot be passed from the vagina to the gestation.

CASE

Two women requested second trimester abortion. Both women had undergone cervical LEEP. In addition, one woman had a 10-cm leiomyoma, which seemed to be obstructing the lower segment. In both, the external cervical os was essentially obliterated. After administration of misoprostol, the cervix softened markedly in 18-24 hours. In both women, the cervix dilated readily and allowed dilation and evacuation of the uterus.

CONCLUSION

Misoprostol resulted in the ability to evacuate the uterus vaginally, in a situation that might have otherwise resulted in hysterotomy.