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Abokaf H, Korytnikova E, Yaniv-Salem S, Shoham-Vardi I, Sergienko R, Sheizaf B, Weintraub AY. Pregnancy outcomes following second-trimester abortions: A comparison between medical and surgical management. A historic cohort study. Int J Gynaecol Obstet 2024. [PMID: 39425605 DOI: 10.1002/ijgo.15958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 09/30/2024] [Indexed: 10/21/2024]
Abstract
OBJECTIVE To compare perinatal outcomes in subsequent pregnancies following second-trimester abortions, stratified by the method of abortion. METHODS A historic cohort study was conducted in a single tertiary hospital, including women who had second-trimester abortions between 12+0 and 24+0 weeks and subsequent documented pregnancies within 3-60 months. Data were collected from hospitalization and perinatal databases. Composite outcome variables were constructed, and multivariable logistic regression was used to analyze associations, adjusting for confounders. RESULTS Among 771 women meeting the inclusion criteria, 83% had surgical abortions and 17% had medical abortions. Medical abortion was associated with a higher incidence of placenta-associated pregnancy complications compared with surgical abortion. No significant differences were found in other perinatal outcomes. CONCLUSION The study highlights the potential influence of the abortion method on subsequent pregnancy outcomes, particularly regarding placenta-associated complications. This underscores the importance of considering the method of second-trimester abortion in counseling women regarding potential risks to subsequent pregnancies. Adverse outcomes in subsequent pregnancies following second-trimester abortion were associated with the medical method of abortion, warranting further research and careful counseling in clinical practice.
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Affiliation(s)
- Hanaa Abokaf
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Elena Korytnikova
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shimrit Yaniv-Salem
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ilana Shoham-Vardi
- Department of Epidemiology, Biostatistics and Community Health Sciences, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ruslan Sergienko
- Department of Epidemiology, Biostatistics and Community Health Sciences, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Boaz Sheizaf
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Silver RM, Reddy U. Stillbirth: we can do better. Am J Obstet Gynecol 2024; 231:152-165. [PMID: 38789073 DOI: 10.1016/j.ajog.2024.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/23/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.
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Affiliation(s)
- Robert M Silver
- Departments of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, University of Utah, Salt Lake City, UT.
| | - Uma Reddy
- Departments of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, Columbia University, New York, NY
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Meyer R, Toussia-Cohen S, Shats M, Segal O, Mohr-Sasson A, Peretz-Bookstein S, Amitai-Komem D, Sindel O, Levin G, Mashiach R, Blumenthal PD. 24-Hour Compared With 12-Hour Mifepristone-Misoprostol Interval for Second-Trimester Abortion: A Randomized Controlled Trial. Obstet Gynecol 2024; 144:60-67. [PMID: 38781593 DOI: 10.1097/aog.0000000000005535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/18/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To compare 24-hour and 12-hour mifepristone-to-misoprostol intervals for second-trimester medication abortion. METHODS We conducted a prospective randomized controlled trial. Participants were allocated to receive mifepristone either 24 hours or 12 hours before misoprostol administration. The primary outcome was the time from the first misoprostol administration to abortion (induction time). Secondary outcomes included the time from mifepristone to abortion (total abortion time); fetal expulsion percentages at 12, 24, and 48 hours after the first misoprostol dose; side effects proportion; and pain and satisfaction scores. A sample size of 40 per group (N=80) was planned to compare the 24- and 12-hour regimens. RESULTS Eighty patients were enrolled between July 2020 and June 2023, with 40 patients per group. Baseline characteristics were comparable between groups. Median induction time was 9.5 hours (95% CI, 10.3-17.8 hours) and 12.5 hours (95% CI, 13.5-20.2 hours) in the 24- and 12-hour interval arms, respectively ( P =.028). Median total abortion time was 33.0 hours (95% CI, 34.2-41.9 hours) and 24.5 hours (95% CI, 25.7-32.4 hours) in the 24- and 12-hour interval groups, respectively ( P <.001). At 12 hours from misoprostol administration, 25 patients (62.5%) in the 24-hour arm and 18 patients (45.0%) in the 12-hour arm completed abortion ( P =.178). At 24 hours from misoprostol administration, 36 patients (90.0%) in the 24-hour arm and 30 patients (75.0%) in the 12-hour arm had complete abortion ( P =.139). The need for additional medication or surgical treatment for uterine evacuation, pain scores, side effects, and satisfaction levels were not different between groups. CONCLUSION A 24-hour mifepristone-to-misoprostol regimen for medication abortion in the second trimester provides a median 3-hour shorter induction time compared with the 12-hour interval. However, the median total abortion time was 8.5-hours longer in the 24-hour interval regimen. These findings can aid in shared decision making before medication abortion in the second trimester. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04160221.
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Affiliation(s)
- Raanan Meyer
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, and the Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, the School of Medicine, Tel-Aviv University, Tel-Aviv, and the Department of Obstetrics and Gynecology, Hadassah Medical Center, and the School of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; and the Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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Kerns JL, Brown K, Nippita S, Steinauer J. Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion. Contraception 2024; 129:110292. [PMID: 37739302 DOI: 10.1016/j.contraception.2023.110292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 09/07/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023]
Abstract
Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.
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Affiliation(s)
- Jennifer L Kerns
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA.
| | - Katherine Brown
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
| | - Siripanth Nippita
- New York University, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Jody Steinauer
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
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Anand A, Gupta A, Yadav P, Rijal P. Suspected illegal abortion and unsafe abortion leading to uterine rupture and incomplete abortion: A case report. Ann Med Surg (Lond) 2022; 84:104933. [PMID: 36582916 PMCID: PMC9793220 DOI: 10.1016/j.amsu.2022.104933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/28/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Unsafe abortions are more prevalent in developing countries and countries with restrictive abortion laws, and can lead to significant maternal mortality. Usually, the presentation includes abdominal pain, fever and vaginal bleeding. Case presentation We reported the case of a female in her twenties in her second trimester of pregnancy following unsafe abortion. The patient had abdominal pain, and laboratory investigations revealed anemia and leucocytosis. The patient opted for abortion as the foetus was identified as female by a service provider. Due to unsafe and illegal abortion, the patient developed complications of incomplete abortion and uterine rupture. She was successfully managed by emergency laparotomy followed by repair of uterine rupture and symptomatic management. Clinical discussion Unsafe abortion can lead to complications such as incomplete abortion and uterine rupture. Complications due to abortion are more frequent if not performed by experienced surgeons. In our case, the manual vacuum and aspiration technique was used during the second trimester of pregnancy, which led to uterine perforation. Conclusion Our case highlighted the importance of safe abortion practices and the approach to clinical management of complications of unsafe abortion. Also, global health problems such as unsafe abortion, illegal abortion, sex-selective abortion, and violation of ethical conduct need to be addressed to curb unsafe abortion.
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Affiliation(s)
- Ayush Anand
- BP Koirala Institute of Health Sciences, Dharan, Nepal
- Corresponding author.
| | - Ashwini Gupta
- BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Punita Yadav
- Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Pappu Rijal
- Department of Obstetrics and Gynaecology, BP Koirala Institute of Health Sciences, Dharan, Nepal
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Stifani BM, Mei Hwang S, Rodrigues Catani R, Borges Martins da Silva Paro H, Benfield N. Introducing the Dilation and Evacuation Technique in Brazil: Lessons Learned From an International Partnership to Expand Options for Brazilian Women and Girls. Front Glob Womens Health 2022; 3:811412. [PMID: 35274107 PMCID: PMC8901725 DOI: 10.3389/fgwh.2022.811412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Dilation and evacuation (D&E) is the recommended surgical procedure for uterine evacuation in the second trimester. Despite its established safety record, it is not routinely available in most countries around the world. In this paper, we describe the multi-phase capacity-building project we undertook to introduce D&E in Brazil. First, we invited a highly motivated obstetrician-gynecologist and abortion provider to complete an observership at an established D&E site in the United States. We then organized a month-long clinical training for two experienced gynecologists in Brazil, followed by ongoing remote mentorship. Almost all patients we approached during the training opted for D&E, and all expressed satisfaction with their experience. Despite the restrictive legal setting and prevailing abortion stigma in Brazil, our training was well-received, and we did not experience any overt resistance from hospital staff. We learned that obtaining institutional support is essential; and that presenting scientific evidence during dedicated didactic times was an important strategy to obtain buy-in from other local healthcare providers. An important challenge we encountered was low case volume given the restrictive legal setting. We addressed this by partnering with nearby hospitals and non-profit organizations for patient referrals. We also rescheduled, adapted and optimized this project for implementation in the midst of the COVID-19 pandemic. Despite the challenges we faced, this project led to the successful introduction of D&E up to 16–18 weeks at two sites in Brazil. In the future, we plan additional training to increase capacity for D&E at more advanced gestational ages.
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Affiliation(s)
- Bianca M. Stifani
- Department of Obstetrics & Gynecology, New York Medical College, Valhalla, NY, United States
- Department of Obstetrics & Gynecology, Albert Einstein College of Medicine, Bronx, NY, United States
- *Correspondence: Bianca M. Stifani
| | | | - Renata Rodrigues Catani
- Department of Obstetrics & Gynecology, Universidade Federal de Uberlândia, Uberlândia, Brazil
| | | | - Nerys Benfield
- Department of Obstetrics & Gynecology, Albert Einstein College of Medicine, Bronx, NY, United States
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Tufa TH, Prager S, Wondafrash M, Mohammed S, Byl N, Bell J. Comparison of surgical versus medical termination of pregnancy between 13-20 weeks of gestation in Ethiopia: A quasi-experimental study. PLoS One 2021; 16:e0249529. [PMID: 33793655 PMCID: PMC8016219 DOI: 10.1371/journal.pone.0249529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/20/2021] [Indexed: 11/18/2022] Open
Abstract
Background Dilation and evacuation is a method of second trimester pregnancy termination introduced recently in Ethiopia. However, little is known about the safety and effectiveness of this method in an Ethiopian setting. Therefore, the study is intended to determine the safety and effectiveness of dilation and evacuation for surgical abortion as compared to medical abortion between 13–20 weeks’ gestational age. Methods This is a quasi-experimental study of women receiving second trimester termination of pregnancy between 13–20 weeks. Patients were allocated to either medical or surgical abortion based on their preference. A structured questionnaire was used to collect demographic information and clinical data upon admission. Procedure related information was collected after the procedure was completed and before the patient was discharged. Additionally, women were contacted 2 weeks after the procedure to evaluate for post-procedural complications. The primary outcome of the study was a composite complication rate. Data were collected using Open Data Kit and then analyzed using Stata version 14.2. Univariate analyses were performed using means (standard deviation), or medians (interquartile range) when the distribution was not normal. Multiple logistic regression was also performed to control for confounders. Results Two hundred nineteen women chose medical abortion and 60 chose surgical abortion. The composite complication rate is not significantly different among medical and surgical abortion patients (15% versus 10%; p = 0.52). Nine patients (4.1%) in the medical arm required additional intervention to complete the abortion, while none of the surgical abortion patients required additional intervention. Median (IQR) hospital stay was significantly longer in the medical group at 24 (12–24) hours versus 6(4–6) hours in the surgical group p<0.001. Conclusion From the current study findings, we concluded that there is no difference in safety between surgical and medical methods of abortion. This study demonstrates that surgical abortion can be used as a safe and effective alternative to medical abortion and should be offered equivalently with medical abortion, per the patient’s preference.
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Affiliation(s)
- Tesfaye Hurissa Tufa
- Department of Obstetrics and Gynecology, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- * E-mail:
| | - Sarah Prager
- Department of Obstetrics and Gynecology, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mekitie Wondafrash
- Department of Obstetrics and Gynecology, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Shikur Mohammed
- Department of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Nicole Byl
- University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Jason Bell
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, United States of America
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Smorti M, Ponti L, Bonassi L, Cattaneo E, Ionio C. Centrality of Pregnancy and Prenatal Attachment in Pregnant Nulliparous After Recent Elective or Therapeutic Abortion. Front Psychol 2020; 11:607879. [PMID: 33424718 PMCID: PMC7793931 DOI: 10.3389/fpsyg.2020.607879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022] Open
Abstract
Background There are two types of voluntary interruption of pregnancy: elective and therapeutic abortion. These forms are different for many reasons, and it is reasonable to assume that they can have negative consequences that can last until a subsequent gestation. However, no study has analyzed the psychological experience of gestation after a previous abortion, distinguishing the two forms of voluntary interruption of pregnancy. Objective This study aims to explore the level of prenatal attachment and centrality of pregnancy in nulliparous low-risk pregnant women with a recently (<3 years) previous elective or therapeutic abortion. Methods A total of 34 nulliparous pregnant women with a history of abortion (23 elective and 11 therapeutic abortion), aged from 27 to 48 years (mean = 37.17), were recruited in the maternity ward of a public hospital of the metropolitan area of Tuscany and Lombardy (Italy) during the third trimester of gestation. The participants filled out a battery of questionnaires aimed at assessing prenatal attachment and centrality of pregnancy. Results Analyses of variance showed that women with a history of elective abortion reported a higher centrality of pregnancy than women with a past therapeutic abortion. On the contrary, women with a past therapeutic abortion reported higher prenatal attachment. Conclusion Elective and therapeutic abortions are different experiences that impact the way women experience a subsequent pregnancy. Future research should further investigate the psychological experience of gestation after abortion.
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Affiliation(s)
- Martina Smorti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Lucia Ponti
- Department of Education, Languages, Intercultures, Literatures and Psychology, University of Florence, Firenze, Italy
| | - Lucia Bonassi
- Department of Mental Health, Azienda Socio Sanitaria Territoriale (ASST) Bergamo-Est, Seriate, Italy
| | - Elena Cattaneo
- Department of Mental Health, Azienda Socio Sanitaria Territoriale (ASST) Bergamo-Est, Seriate, Italy
| | - Chiara Ionio
- Department of Psychology, Catholic University of the Sacred Heart, University of Milan, Milan, Italy
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Whitehouse K, Morroni C, Kapp N. Medical abortion at 13 weeks of gestation and above. Hippokratia 2020. [DOI: 10.1002/14651858.cd013804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Chelsea Morroni
- Institute for Women's Health; University College London; London UK
| | - Nathalie Kapp
- Department of Reproductive Health and Research; World Health Organization; Geneva 27 USA
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Shahrani M, Asgharzadeh N, Kheiri S, Karimi R, Sadeghimanesh A, Asgharian S, Lorigooini Z. Astragalus fascicolifolius manna abortifacient risk and effects on sex hormones in BALB/c mice. Biomedicine (Taipei) 2020; 10:11-17. [PMID: 33854929 PMCID: PMC7735977 DOI: 10.37796/2211-8039.1113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/05/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Astragalus fascicolifolius manna is used to treat different diseases. Because pregnant women tend to use Astragalus. fascicolifolius and Iranian traditional medicine emphasizes the abortifacient potential of this plant, this study aimed to investigate Astragalus fascicolifolius manna abortifacient property and effects on estrogen, progesterone, LH and FSH levels in BALB/c mice. METHOD This experimental study was conducted with 70 female BALB/c mice assigned to seven groups: Nonpregnant, untreated; nonpregnant, Astragalus. fascicolifolius extract (400 mg/kg)-treated; pregnant, Astragalus. fascicolifolius extract (400, 800 and 1200 mg/kg)-treated; and two pregnant control groups. On 18 and 19 days of pregnancy, cesarean section performed on mice, resorbed embryos counted; then Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), estrogen and progesterone levels were measured by the ELISA. RESULTS Astragalus. fascicolifolius extract caused a significant increase abortion in mice. The levels of progesterone, FSH and LH were significantly different among the groups such that mean progesterone level was lower and mean LH and FSH levels were higher in the Astragalus. fascicolifolius extract-treated groups than the pregnant, untreated group. CONCLUSION This extract has abortifacient properties and this plant can be used cautiously in pregnancy. Decreasing progesterone, increasing FSH and LH feedback in response to decreased progesterone by this extract is one of the potential mechanisms involved in abortion.
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Affiliation(s)
- Mehrdad Shahrani
- Medical Plants Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Najmeh Asgharzadeh
- Medical Plants Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Soleiman Kheiri
- Clinical Biochemistry Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Roya Karimi
- Medical Plants Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Arezo Sadeghimanesh
- Medical Plants Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Shirin Asgharian
- Medical Plants Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Zahra Lorigooini
- Medical Plants Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
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Meyer R, Cahan T, Yagel I, Afek A, Derazne E, Bar-Shavit Y, Yuval Y, Admon D, Shina A. A double-blind randomized trial comparing lidocaine spray and placebo spray anesthesia prior to cervical laminaria insertion. Contraception 2020; 102:332-338. [PMID: 32652092 DOI: 10.1016/j.contraception.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare pain during laminaria insertion after lidocaine spray versus placebo spray anesthesia in women about to undergo a surgical abortion procedure. STUDY DESIGN A double blind, randomized, placebo-controlled trial of women at 12-24 weeks gestation one day prior to surgical uterine evacuation procedure. Participants received lidocaine 10% or placebo (saline 0.9%) spray to the endocervix and ectocervix two minutes before laminaria insertion. The primary outcome was participants' pain score immediately after initial laminaria insertion, measured using a 10 cm visual analog scale (VAS). Secondary outcomes included scores at speculum removal and 15 min after speculum insertion. RESULTS From 7/2016 through 8/2018, we enrolled 68 and 66 women to the lidocaine and placebo groups, respectively. Baseline characteristics were similar in both groups. The primary outcome did not differ between lidocaine and placebo groups (median VAS 2.0 vs. 2.0 respectively, p = 0.69). Reported VAS after speculum removal and 15 min from speculum insertion were similar in the lidocaine and placebo groups (median 2.0, p = 0.99; median 1.0 vs. 1.5 respectively, p = 0.32). In multivariate analyses, lidocaine use was associated with decreased VAS score at 15 min from speculum insertion [95%CI -0.96 (-1.74 to -0.18), p = 0.016]. Reported VAS ≥7 at 1st laminaria insertion did not differ between lidocaine and placebo groups (5.88% vs. 10.61% respectively, p = 0.362). CONCLUSION In women scheduled for laminaria insertion prior to surgical uterine evacuation at 12-24 weeks gestation, topical application of lidocaine spray to the cervix before insertion did not result in lower reported pain as compared with placebo. IMPLICATIONS Our results imply that physicians should not use topical application of lidocaine spray to the cervix before laminaria insertion to reduce women's pain. Continued efforts must be made to find means to relieve pain by using simple, effective analgesia or adjusting the technique, and not using a tenaculum whenever possible.
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Affiliation(s)
- Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel.
| | - Tal Cahan
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Itai Yagel
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Arnon Afek
- The Chaim Sheba Medical Center, Ramat-Gan, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Estela Derazne
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yochai Bar-Shavit
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yefet Yuval
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dahlia Admon
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avi Shina
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
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Risk of surgical evacuation and risk of major surgery following second-trimester medical abortion in Denmark: A nationwide cohort study. Contraception 2020; 102:201-206. [DOI: 10.1016/j.contraception.2020.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 11/23/2022]
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Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1080-1085. [PMID: 32345554 DOI: 10.1016/j.jogc.2020.02.115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. METHODS We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. RESULTS Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). CONCLUSION Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.
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Kerns JL, Turk JK, Corbetta-Rastelli CM, Rosenstein MG, Caughey AB, Steinauer JE. Second-trimester abortion attitudes and practices among maternal-fetal medicine and family planning subspecialists. BMC Womens Health 2020; 20:20. [PMID: 32013926 PMCID: PMC6998287 DOI: 10.1186/s12905-020-0889-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/24/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients deciding to undergo dilation and evacuation (D&E) or induction abortion for fetal anomalies or complications may be greatly influenced by the counseling they receive. We sought to compare maternal-fetal medicine (MFM) and family planning (FP) physicians' attitudes and practice patterns around second-trimester abortion for abnormal pregnancies. METHODS We surveyed members of the Society for Maternal-Fetal Medicine and Family Planning subspecialists in 2010-2011 regarding provider recommendations between D&E or induction termination for various case scenarios. We assessed provider beliefs about patient preferences and method safety regarding D&E or induction for various indications. We compared responses by specialty using descriptive statistics and conducted unadjusted and adjusted analyses of factors associated with recommending a D&E. RESULTS Seven hundred ninety-four (35%) physicians completed the survey (689 MFMs, 105 FPs). We found that FPs had 3.9 to 5.5 times higher odds of recommending D&E for all case scenarios (e.g. 80% of FPs and 41% of MFMs recommended D&E for trisomy 21). MFMs with exposure to family planning had greater odds of recommending D&E for all case scenarios (p < 0.01 for all). MFMs were less likely than FPs to believe that patients prefer D&E and less likely to feel that D&E was a safer method for different indications. CONCLUSION Recommendations for D&E or induction vary significantly depending on the type of physician providing the counseling. The decision to undergo D&E or induction is one of clinical equipoise, and physicians should provide unbiased counseling. Further work is needed to understand optimal approaches to shared decision making for this clinical decision.
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Affiliation(s)
- J. L. Kerns
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, 1001 Potrero Avenue, Ward 6D, San Francisco, CA 94110 USA
| | - J. K. Turk
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, 1001 Potrero Avenue, Ward 6D, San Francisco, CA 94110 USA
| | - C. M. Corbetta-Rastelli
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, 550 16th Street, San Francisco, CA 94158 USA
| | - M. G. Rosenstein
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, 1001 Potrero Avenue, Ward 6D, San Francisco, CA 94110 USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, 550 16th Street, San Francisco, CA 94158 USA
| | - A. B. Caughey
- Department of Obstetrics and Gynecology of Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 USA
| | - J. E. Steinauer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, 1001 Potrero Avenue, Ward 6D, San Francisco, CA 94110 USA
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McQuade M, Barbour K, Betstadt S, Harrington A. Intubation and intensive care after laminaria anaphylaxis in second-trimester abortion. Am J Emerg Med 2020; 38:163.e1-163.e2. [PMID: 31477354 DOI: 10.1016/j.ajem.2019.158409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 11/17/2022] Open
Abstract
Laminaria are cervical dilators inserted for several days preceding second-trimester abortions and other uterine procedures. Our patient was intubated after a life-threatening anaphylactic reaction to laminaria prior to her surgical abortion. Abortions with laminaria dilators are frequently performed outpatient across the United States. Due to stigma, increasing restrictions, and forced closure of family planning clinics, these procedures are often obtained covertly and remotely. Patients may present obtunded, in shock, without records or proxy, and with no external evidence of the allergen's location or continued presence. Emergency and critical care physicians may consider this etiology in obtunded women with anaphylaxis who are responding poorly to standard care.
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Affiliation(s)
- Miriam McQuade
- University of Rochester, Department of Obstetrics and Gynecology, Rochester, NY, USA
| | - Kyle Barbour
- University of Rochester, Department of Emergency Medicine, Rochester, NY, USA.
| | - Sarah Betstadt
- University of Rochester, Department of Obstetrics and Gynecology, Rochester, NY, USA
| | - Amy Harrington
- University of Rochester, Department of Obstetrics and Gynecology, Rochester, NY, USA
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Derbyshire SW, Bockmann JC. Reconsidering fetal pain. JOURNAL OF MEDICAL ETHICS 2020; 46:3-6. [PMID: 31937669 DOI: 10.1136/medethics-2019-105701] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/05/2019] [Accepted: 10/17/2019] [Indexed: 05/04/2023]
Abstract
Fetal pain has long been a contentious issue, in large part because fetal pain is often cited as a reason to restrict access to termination of pregnancy or abortion. We have divergent views regarding the morality of abortion, but have come together to address the evidence for fetal pain. Most reports on the possibility of fetal pain have focused on developmental neuroscience. Reports often suggest that the cortex and intact thalamocortical tracts are necessary for pain experience. Given that the cortex only becomes functional and the tracts only develop after 24 weeks, many reports rule out fetal pain until the final trimester. Here, more recent evidence calling into question the necessity of the cortex for pain and demonstrating functional thalamic connectivity into the subplate is used to argue that the neuroscience cannot definitively rule out fetal pain before 24 weeks. We consider the possibility that the mere experience of pain, without the capacity for self reflection, is morally significant. We believe that fetal pain does not have to be equivalent to a mature adult human experience to matter morally, and so fetal pain might be considered as part of a humane approach to abortion.
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Affiliation(s)
- Stuart Wg Derbyshire
- Psychology and NUS Clinical Imaging Research Centre, National University of Singapore, Singapore
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17
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Babra DS, Lyus R, Black B, Roberts C, Dorman EK, Masters T. Development of a national referral centre for surgical abortion at Homerton University Hospital. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:bmjsrh-2019-200368. [PMID: 31434662 DOI: 10.1136/bmjsrh-2019-200368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/16/2019] [Accepted: 07/21/2019] [Indexed: 06/10/2023]
Affiliation(s)
| | - Richard Lyus
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - Benjamin Black
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - Cathy Roberts
- Homerton University Hospital NHS Foundation Trust, London, UK
| | | | - Tracey Masters
- Homerton University Hospital NHS Foundation Trust, London, UK
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The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa. PLoS One 2018; 13:e0197485. [PMID: 29953434 PMCID: PMC6023192 DOI: 10.1371/journal.pone.0197485] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/03/2018] [Indexed: 11/19/2022] Open
Abstract
Background In South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings. Methods We derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013–2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars. Results D&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances. Conclusion D&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa’s reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs.
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Garofalo G, Garofalo A, Sochirca O, Alemanno MG, Pilloni E, Biolcati M, Muccinelli E, Viora E, Todros T. Maternal outcomes in first and second trimester termination of pregnancy: which are the risk factors? J Perinat Med 2018; 46:373-378. [PMID: 29055174 DOI: 10.1515/jpm-2017-0106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 09/11/2017] [Indexed: 11/15/2022]
Abstract
AIMS To evaluate maternal complications of first trimester and second trimester termination of pregnancy (TOP) performed after first or second trimester positive prenatal diagnosis (PD). RESULTS We performed a retrospective study from January 2007 to December 2011, on 844 patients, who underwent a TOP after positive amniocentesis or chorionic villus sampling (CVS) for foetal aneuploidies, performed for maternal age ≥35 years of age, positive prenatal screening (PS) or for genetic reasons. Exclusions criteria were gestational age >22+0 weeks, twin pregnancy and co-existing maternal pathologies. We compared maternal complications of first trimester and second trimester TOP and we established which risk factors were correlated to higher maternal complications (haemorrhages, transfusion, repeated uterine curettage and infections). Maternal complications were significantly higher in second trimester TOP. Previous uterine surgery is a significant risk factor for maternal complications in second trimester TOP, but not in first trimester TOP. Six uterine ruptures and three hysterectomies occurred, all in multiparous women with second trimester TOP. All uterine ruptures occurred in women with previous caesarean sections. CONCLUSIONS First trimester TOP in women with risks factors for maternal complications guarantees better maternal outcomes and less health costs. Thus, in these women we should prefer a first trimester PS and PD.
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Affiliation(s)
- Giulia Garofalo
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Anna Garofalo
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Olga Sochirca
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Maria Grazia Alemanno
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Eleonora Pilloni
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Marilisa Biolcati
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Elisabetta Muccinelli
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Elsa Viora
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
| | - Tullia Todros
- Department of Obstetrics and Gynecology, University of Turin, Sant'Anna Hospital, Turin, Italy
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20
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Purcell C, Brown A, Melville C, McDaid LM. Women's embodied experiences of second trimester medical abortion. FEMINISM & PSYCHOLOGY 2017; 27:163-185. [PMID: 28546655 PMCID: PMC5431358 DOI: 10.1177/0959353517692606] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abortions in general, and second trimester abortions in particular, are experiences which in many contexts have limited sociocultural visibility. Research on second trimester abortion worldwide has focused on a range of associated factors including risks and acceptability of abortion methods, and characteristics and decision-making of women seeking the procedure. Scholarship to date has not adequately addressed the embodied physicality of second trimester abortion, from the perspective of women's lived experiences, nor how these experiences might inform future framings of abortion. To progress understandings of women's embodied experiences of second trimester abortion, we draw on the accounts of 18 women who had recently sought second trimester abortion in Scotland. We address four aspects of their experiences: later recognition of pregnancy; experiences of a second trimester pregnancy which ended in abortion; the "labour" of second trimester abortion; and the subsequent bodily transition. The paper has two key aims: Firstly, to make visible these experiences, and to consider how they relate to dominant sociocultural narratives of pregnancy; and secondly, to explore the concept of "liminality" as one means for interpreting them. Our findings contribute to informing future research, policy and practice around second trimester abortion. They highlight the need to maintain efforts to reduce silences around abortion and improve equity of access.
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Affiliation(s)
- Carrie Purcell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, UK
| | | | | | - Lisa M McDaid
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, UK
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22
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Webber K, Grivell RM. Cervical ripening before first trimester surgical evacuation for non-viable pregnancy. Cochrane Database Syst Rev 2015; 2015:CD009954. [PMID: 26559875 PMCID: PMC9271321 DOI: 10.1002/14651858.cd009954.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Medications or mechanical dilators are often used to soften and dilate the cervix prior to surgical evacuation of the uterus for non-viable pregnancy, or miscarriage. The majority of miscarriages occur in the first trimester. The aim of cervical ripening is to reduce the possibility of injury to the uterus and cervix and improve the surgical ease of the procedure. Cervical ripening agents can have adverse effects and it is uncertain as to whether these risks outweigh the benefits of their use. OBJECTIVES To systematically review the benefits and harms of using cervical ripening agents prior to surgical evacuation of non-viable pregnancy prior to 14 weeks' gestation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015) and reference lists of retrieved papers. SELECTION CRITERIA Randomised controlled trials (published in full-text form, or as abstracts only), which assessed the use of pharmacological or mechanical agents to ripen the cervix in women undergoing dilation and curettage or vacuum aspiration for non-viable pregnancy at less than 14 weeks' gestation were eligible for inclusion. Cluster-randomised controlled trials and trials using a cross-over design were not eligible for inclusion.Unpublished randomised controlled trials and quasi-randomised trials would have been eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data were checked for accuracy. MAIN RESULTS We included nine trials with 469 women. A diverse set of medications and regimens were studied in these trials, making the comparisons available for meta-analysis limited. The comparisons draw data from six trials with 383 participants. All trials were relatively small and had several aspects of unclear risk of bias with few of this review's outcomes reported. Due to this, no data from three trials were able to be used despite them meeting inclusion criteria.We carried out four comparisons: isosorbide mononitrate or dinitrate compared with misoprostol; misoprostol compared with placebo; chemical dilation (use of medications) compared with mechanical dilation; and any cervical preparation compared with placebo.None of the included studies reported data on the review's primary outcome: cervical or uterine injury (perforation, laceration, creation of a false passage).No clear difference was shown between isosorbide compounds and misoprostol for the outcome need for manual cervical dilation (average risk ratio (RR) 0.76, 95% confidence interval (CI) 0.10 to 5.64; three trials, 150 women; Tau² = 2.11; I² = 69%), however the data were heterogenous. In terms of adverse effects, misoprostol was associated with more vomiting (RR 0.11, 95% CI 0.01 to 0.85; two trials, 120 women), however there were no clear differences between isosorbide compounds and misoprostol in relation to other reported adverse effects (headache, nausea or hypotension). The dosing regimens differed in terms of dose, number of administrations and route of administration in the different trials. Mechanical (Dilapan-S hygroscopic) dilators performed similarly to chemical dilators in a single trial (65 women) that measured difficulty in cervical dilation, excessive bleeding and adverse effects.Misoprostol was shown to be more effective than placebo for cervical ripening (reduced need for manual cervical dilation) (RR 0.14, 95% CI 0.08 to 0.26; one trial, 120 women), and surgical time was reduced when misoprostol was used (mean difference (MD) -3.15, 95% CI -3.59 to -2.70; one trial, 120 women). However, compared to placebo, misoprostol, was associated with more abdominal pain (RR 29.00, 95% CI 1.77 to 475.35; one trial, 120 women), although no clear differences in the risk of other adverse effects (nausea, vomiting, headache or fever) were observed between groups.There was no clear differences between chemical dilation and mechanical dilators for the outcomes: difficulty in cervical dilation, excessive bleeding or adverse effects.Compared with placebo, any cervical preparation reduced the need for manual cervical dilatation (average RR 0.25, 95% CI 0.07 to 0.89; two trials, 168 women; Tau² = 0.67; I² = 81%), and reduced surgical time (MD -2.55, 95% CI -3.67 to -1.43, two trials, 168 women; Tau² = 0.63; I² = 96%).None of the included trials reported on the review's other secondary outcomes, including: injury to bladder or bowel, miscarriage/preterm birth in a subsequent pregnancy, analgesia use after administration of ripening agent but before surgery, or analgesia use after surgery. AUTHORS' CONCLUSIONS This review found no evidence to evaluate cervical ripening prior to first trimester surgical evacuation for miscarriage for reducing the rate of cervical or uterine injury, however, this may be because these outcomes are very rare. Cervical preparation was shown to reduce the need for manual cervical dilatation compared with placebo.Misoprostol and isosorbide mononitrate and dinitrate were similarly effective in ripening the cervix, however there was more vomiting with misoprostol. Mechanical (Dilapan-S hygroscopic) dilators performed similarly to chemical dilators.The nine studies included in this review were small and the methodological quality of the trials was mixed, and for the most part, not well-described; thus any conclusions drawn from the data included in this review must be treated with caution. Consequently, large, high-quality trials are required to determine whether the benefits of this treatment outweigh the risks. Further research should be powered to assess the rate of cervical and uterine injury between interventions. Future research should also guide clinicians in deciding whether the benefits of reduced manual cervical dilatation outweigh the risks of adverse effects associated with these agents (nausea, vomiting, headache, fever, diarrhoea and pain). Women's satisfaction and outcomes of future pregnancies should also be assessed.
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Affiliation(s)
- Kylie Webber
- Women's and Children's HospitalDepartment of Perinatal Medicine72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Rosalie M Grivell
- The University of Adelaide, Women's and Children's HospitalDiscipline of Obstetrics and Gynaecology, Robinson Research Institute72 King William RoadAdelaideSouth AustraliaAustraliaSA 5006
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Programmed intermittent epidural bolus versus continuous epidural infusion for pain relief during termination of pregnancy: a prospective, double-blind, randomized trial. Int J Obstet Anesth 2015; 25:37-44. [PMID: 26431778 DOI: 10.1016/j.ijoa.2015.08.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 07/07/2015] [Accepted: 08/23/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pain is a major concern during medical abortion but no evidence-based recommendations for optimal analgesia during medical termination of pregnancy are available. We compared two methods of epidural analgesia during second trimester termination of pregnancy, with the primary aim of assessing the incidence of motor block. METHODS Women were randomly assigned to receive continuous epidural infusion (CEI Group; n=52) or programmed intermittent epidural bolus (PIEB Group; n=52). Assessment of motor block was performed every hour. Patients with a modified Bromage score <6 were considered to have motor block. RESULTS Motor block occurred more frequently in the CEI Group compared with the PIEB Group (46.2% vs. 5.8%, P<0.001). Pain scores were low and comparable between groups. Patients in the CEI Group experienced nausea more frequently than those in the PIEB Group (34.6% vs. 13.5%, P=0.022). The degree of satisfaction was higher in the PIEB Group compared with the CEI Group. CONCLUSIONS During second trimester termination of pregnancy in our patient groups, a programmed intermittent epidural bolus technique was associated with less motor block and greater patient satisfaction than continuous epidural infusion. Both techniques had similar analgesic efficacy.
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Shaw KA, Shaw JG, Hugin M, Velasquez G, Hopkins FW, Blumenthal PD. Adjunct mifepristone for cervical preparation prior to dilation and evacuation: a randomized trial. Contraception 2015; 91:313-9. [DOI: 10.1016/j.contraception.2014.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 11/26/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022]
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Fox MC, Krajewski CM. Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013-4. Contraception 2014; 89:75-84. [PMID: 24331860 DOI: 10.1016/j.contraception.2013.11.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
For a dilation and evacuation (D&E) procedure, the cervix must be dilated sufficiently to allow passage of operative instruments and products of conception without injuring the uterus or cervical canal. Preoperative preparation of the cervix reduces the risk of cervical laceration and uterine perforation. The cervix may be prepared with osmotic dilators, pharmacologic agents or both. Dilapan-S™ and laminaria are the two osmotic dilators currently available in the United States. Laminaria tents, made from dehydrated seaweed, require 12-24 h to achieve maximum dilation. Dilapan-S™, made of synthetic hydrogel, achieves significant dilation within 4 h and is thus preferable for same-day procedures. A single set of one to several dilators is usually adequate for D&E before 20 weeks' gestation. Misoprostol, a prostaglandin E1 analogue, is sometimes used instead of osmotic dilators. It is generally regarded as safe and effective; however, misoprostol achieves less dilation than overnight osmotic tents. The literature supports same-day cervical preparation with misoprostol or Dilapan-S™ up to 18 weeks' gestation. As the evidence regarding alternative regimens increases, highly experienced D&E providers may consider same-day regimens at later gestations utilizing serial doses of misoprostol or a combination of osmotic and pharmacologic agents. Misoprostol use as an adjunct to overnight osmotic dilation is not significantly beneficial before 19 weeks' gestation. Limited data demonstrate the safety of misoprostol before D&E in patients with a prior cesarean delivery. Mifepristone, a progesterone receptor antagonist, is also effective for cervical preparation prior to D&E, although data to support its use are limited. The Society of Family Planning recommends preoperative cervical preparation to decrease the risk of complications when performing a D&E. Since no single protocol has been found to be superior in all situations, clinical judgment is warranted when selecting a method of cervical preparation.
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers. SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK.
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Gayford K, Grivell RM. Cervical ripening before first trimester surgical evacuation for non-viable pregnancy. Cochrane Database Syst Rev 2012. [DOI: 10.1002/14651858.cd009954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fetopathologic examination for early termination of pregnancy: dogma or necessity? Am J Obstet Gynecol 2011; 205:467.e1-9. [PMID: 21871598 DOI: 10.1016/j.ajog.2011.06.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 03/07/2011] [Accepted: 06/13/2011] [Indexed: 11/23/2022]
Abstract
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.
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Lavoué V, Vandenbroucke L, Grouin A, Briand E, Bauville E, Boyer L, Lemeut P, Bernard O, Poulain P, Morcel K. [Medical abortion from 12 through 14 weeks' gestation: a retrospective study with 126 patients]. J Gynecol Obstet Hum Reprod 2011; 40:626-632. [PMID: 21741780 DOI: 10.1016/j.jgyn.2011.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 05/23/2011] [Accepted: 06/03/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To assess the efficacy of medical abortion performed according to a single protocol from 12 through 14 weeks. STUDY DESIGN Retrospective observational study of medical abortions from 12 through 14 weeks performed from January 2007 through March 2009. The protocol combined 600 mg de mifepristone orally, followed 48 h later by 400 μg of misoprostol, administered orally, and repeated after 3h, four times a day (during two days), if patient did not begin to abort. Outcome measures were the abortion rate, the rate of complication, the rate of manual uterine revision or vacuum aspiration, the time of expulsion and the misoprostol dose. RESULTS The study included 126 medical abortions. The abortion rate was 98% and the secondary manual revision or vacuum aspiration rate was 41%. The mean time to expulsion was 10.4 (±8.8)h, and the mean misoprostol dose 1040 (±420) μg. Higher parity was significantly correlated with shorter time to expulsion (P=0.02). CONCLUSION Medical abortion was consistently effective from 12 through 14 weeks but with high rate of secondary manual revision or vacuum aspiration.
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Affiliation(s)
- V Lavoué
- Service d'obstétrique, CHU Anne-de-Bretagne, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex 2, France.
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Chambers DG, Willcourt RJ, Laver AR, Baird JK, Herbert WY. Comparison of Dilapan-S and laminaria for cervical priming before surgical pregnancy termination at 17-22 weeks' gestation. Int J Womens Health 2011; 3:347-52. [PMID: 22114527 PMCID: PMC3220316 DOI: 10.2147/ijwh.s25551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Indexed: 11/23/2022] Open
Abstract
Methods: A retrospective analysis of medical records of three consecutive cohorts of women. All cohorts received a digoxin feticide injection on Day 1. Two cohorts were treated with laminaria, cohort A of 151 women over 1–2 days and cohort B of 52 women over 1–3 days, and cohort C of 151 women was treated with Dilapan-S over 1–3 days. Results: Adequate cervical priming for dilatation and evacuation (D&E) on Day 2 was achieved in 98% of the Dilapan-S cohort and 56% of cohort A and 40% of the cohort B laminaria cohorts. Return to theater for D&E 3–4 hours after dilator insertion on Day 2 occurred in 62.3% of Dilapan-S cohort C and 9.3% of cohort A and 4% of cohort B laminaria cohorts (P = 0.001). A mean D&E theater time of 19 minutes for laminaria cohort A was reduced by 10.1% in the Dilapan-S cohort C (P = 0.02). The incidence of unscheduled overnight delivery outside the clinic was 0% for Dilapan-S and 1.3% for cohort A and 3.8% for cohort B laminaria cohorts (P = 0.14). Conclusion: Dilapan-S osmotic dilators are superior to laminaria in producing more cervical priming and dilatation in a shorter time. This enables 17–22 week D&E procedures to be carried out in fewer days and in shorter theater times. They also eliminate the risk of an unscheduled overnight delivery outside the clinic.
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Affiliation(s)
- Dennis G Chambers
- The Queen Elizabeth Hospital, Pregnancy Advisory Centre, Woodville Park, Adelaide, South Australia, Australia
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Whitley KA, Trinchere K, Prutsman W, Quiñones JN, Rochon ML. Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes. Am J Obstet Gynecol 2011; 205:386.e1-7. [PMID: 22083061 DOI: 10.1016/j.ajog.2011.07.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Revised: 06/15/2011] [Accepted: 07/15/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of the study was to determine the optimal procedure for midtrimester uterine evacuation. STUDY DESIGN This was a retrospective cohort study of women undergoing midtrimester uterine evacuation by prostaglandin induction or dilation and evacuation (D&E). Primary outcome was composite complication, defined as any of the following: infection, need for additional surgery, unexpected admission or readmission, serious maternal morbidity, and/or maternal death. RESULTS Two hundred twenty patients met inclusion criteria: 94 D&E and 126 induction. D&E was associated with less composite complications (15% vs 28%, P = .02), which persisted in adjusted analysis (adjusted odds ratio, 0.38; 95% confidence interval, 0.15-0.99; P = .05). Women in the induction group had higher rates of retained placenta requiring curettage (22% vs 2%, P = .01), whereas cervical injury was more common in the D&E group (5% vs 0%, P = .01). Median length of stay was significantly shorter in the D&E group (5.7 hours vs 28.4 hours, P < .001). CONCLUSION Midtrimester D&E is associated with fewer complications than prostaglandin induction.
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Surgical and medical second trimester abortion in South Africa: a cross-sectional study. BMC Health Serv Res 2011; 11:224. [PMID: 21929811 PMCID: PMC3196698 DOI: 10.1186/1472-6963-11-224] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 09/19/2011] [Indexed: 11/10/2022] Open
Abstract
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.
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A randomized comparative study on vaginal administration of acetic acid-moistened versus dry misoprostol for mid-trimester pregnancy termination. Arch Gynecol Obstet 2011; 285:311-6. [PMID: 21735193 DOI: 10.1007/s00404-011-1949-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Accepted: 06/08/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Absorption and effectiveness of vaginally administered misoprostol tablets may vary according to the medium in which it is placed. This study was directed to compare the outcomes of vaginal administrations of acetic acid-moistened misoprostol tablets with those of dry tablets for induction of second-trimester abortion. METHODS A randomized comparative trial where 322 women at 13-20 weeks gestation, requiring medical abortion, were randomly assigned to vaginal administration of either acetic acid-moistened or dry misoprostol tablets with a dose schedule of 400 μg three-hourly, up to a maximum five doses over 24 h. The same doses were repeated for another 24 h in nonresponders. Primary outcome measure was complete abortion rate at 24 and 48 h, and the secondary outcome measures were induction-abortion interval, failure rate and side effects. A difference of 15% in success rates at 24 h was used to calculate the sample size required with a power of 0.8 at the 5% significance level. RESULTS No statistically significant differences in the complete abortion rates were observed at 24 h (70.95 vs. 68.71%, P = 0.675) and at 48 h (86.49 vs. 84.35%, P = 0.604) when both groups were compared. The difference in mean induction-abortion interval was also statistically insignificant between the groups (12.5 ± 1.6 vs. 12.8 ± 1.5 h, P = 0.97). Other outcome measures were also comparable in both groups. CONCLUSION Moistening misoprostol tablets with 5% acetic acid before vaginal application creates no difference in outcomes when compared with those after the vaginal application of dry tablets for the termination of second-trimester pregnancy.
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Association between gestational age and induction-to-abortion interval in mid-trimester pregnancy termination using misoprostol. Eur J Obstet Gynecol Reprod Biol 2011; 156:140-3. [PMID: 21507550 DOI: 10.1016/j.ejogrb.2010.12.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 12/05/2010] [Accepted: 12/23/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The study was aimed to evaluate the effectiveness, outcome, and pain intensity of the vaginal administration of misoprostol for the induction of abortion between 13 and 24 gestational weeks. STUDY DESIGN A retrospective study was conducted at our tertiary medical center from January 2006 to December 2009 on 122 consecutive women who underwent termination of pregnancy (TOP) in the mid-trimester. They were given 400 mcg of vaginal misoprostol every 6h, up to four doses. The induction-to-abortion interval and the level of pain experienced during the process were assessed. Success was defined by the fetus being expelled within 48 h. RESULTS Vaginal misoprostol was effective in 84% (98/122) of patients. The median duration of the induction-to-abortion interval was 16 (5-48)h. The induction-to-abortion interval was correlated with gestational age, while inversely correlated with parity. A correlation was also found between gestational age and pain intensity at 12h from induction. CONCLUSION Misoprostol is safe and effective in mid-trimester abortion induction. The induction-to-abortion interval is shorter and abortion less painful with lower gestational age. Higher parity is also associated with shorter induction to abortion interval.
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Niinimäki M, Suhonen S, Mentula M, Hemminki E, Heikinheimo O, Gissler M. Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: population register based study. BMJ 2011; 342:d2111. [PMID: 21508042 PMCID: PMC3079960 DOI: 10.1136/bmj.d2111] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the risks of short term adverse events in adolescent and older women undergoing medical abortion. DESIGN Population based retrospective cohort study. SETTING Finnish abortion register 2000-6. PARTICIPANTS All women (n = 27,030) undergoing medical abortion during 2000-6, with only the first induced abortion analysed for each woman. MAIN OUTCOME MEASURES Incidence of adverse events (haemorrhage, infection, incomplete abortion, surgical evacuation, psychiatric morbidity, injury, thromboembolic disease, and death) among adolescent (<18 years) and older (≥ 18 years) women through record linkage of Finnish registries and genital Chlamydia trachomatis infections detected concomitantly with abortion and linked with data from the abortion register for 2004-6. RESULTS During 2000-6, 3024 adolescents and 24,006 adults underwent at least one medical abortion. The rate of chlamydia infections was higher in the adolescent cohort (5.7% v 3.7%, P < 0.001). The incidence of adverse events among adolescents was similar or lower than that among the adults. The risks of haemorrhage (adjusted odds ratio 0.87, 95% confidence interval 0.77 to 0.99), incomplete abortion (0.69, 0.59 to 0.82), and surgical evacuation (0.78, 0.67 to 0.90) were lower in the adolescent cohort. In subgroup analysis of primigravid women, the risks of incomplete abortion (0.68, 0.56 to 0.81) and surgical evacuation (0.75, 0.64 to 0.88) were lower in the adolescent cohort. In logistic regression, duration of gestation was the most important risk factor for infection, incomplete abortion, and surgical evacuation. CONCLUSIONS The incidence of adverse events after medical abortion was similar or lower among adolescents than among older women. Thus, medical abortion seems to be at least as safe in adolescents as it is in adults.
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Affiliation(s)
- Maarit Niinimäki
- Department of Obstetrics and Gynecology, University Hospital of Oulu, Finland
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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; 117:1512-20. [DOI: 10.1111/j.1471-0528.2010.02712.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Lee VC, Ng EH, Ho P. Issues in second trimester induced abortion (medical/surgical methods). Best Pract Res Clin Obstet Gynaecol 2010; 24:517-27. [DOI: 10.1016/j.bpobgyn.2010.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 02/04/2010] [Indexed: 11/30/2022]
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Napolitano R, Thilaganathan B. Late termination of pregnancy and foetal reduction for foetal anomaly. Best Pract Res Clin Obstet Gynaecol 2010; 24:529-37. [PMID: 20350838 DOI: 10.1016/j.bpobgyn.2010.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 02/04/2010] [Indexed: 11/25/2022]
Abstract
Late termination of pregnancy is a relatively rare procedure accounting for approximately 1% of all registered terminations in England and Wales; however, with improving detection rates for foetal anomalies, this number is increasing. Surgical dilation and evacuation (D&E) appears to be a safe and cost-effective procedure as long as the clinical expertise exists to provide this service. Medical termination appears equally safe and is best undertaken with the combined use of mifepristone and misoprostol. Foeticide, when required, should be performed from 22 weeks' gestation using strong KCl administered either by cardiocentesis or by cordocentesis. All women should be offered a post-mortem and any other appropriate investigation to allow accurate counselling regarding future pregnancies. The issue of late selective foetal reduction for foetal abnormality is complicated by the need to balance the risks to the healthy co-twin of expectant management versus selective termination.
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Neilson JP, Gyte GML, Hickey M, Vazquez JC, Dou L. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane Database Syst Rev 2010:CD007223. [PMID: 20091626 PMCID: PMC4042279 DOI: 10.1002/14651858.cd007223.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable. OBJECTIVES To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks). SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009). SELECTION CRITERIA Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. MAIN RESULTS Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on 'deaths or serious complications'.Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on 'deaths or serious complications'. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.
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Affiliation(s)
- James P Neilson
- Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Gillian ML Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | - Martha Hickey
- The University of Melbourne, The Royal Women’s Hospital, Melbourne, Australia
| | - Juan C Vazquez
- Departamento de Salud Reproductiva, Instituto Nacional de Endocrinologia (INEN), Habana, Cuba
| | - Lixia Dou
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
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Mauelshagen A, Sadler LC, Roberts H, Harilall M, Farquhar CM. Audit of short term outcomes of surgical and medical second trimester termination of pregnancy. Reprod Health 2009; 6:16. [PMID: 19788764 PMCID: PMC2760505 DOI: 10.1186/1742-4755-6-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Accepted: 09/30/2009] [Indexed: 11/10/2022] Open
Abstract
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.
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Dickinson JE, Doherty DA. Optimization of third-stage management after second-trimester medical pregnancy termination. Am J Obstet Gynecol 2009; 201:303.e1-7. [PMID: 19632665 DOI: 10.1016/j.ajog.2009.05.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 04/26/2009] [Accepted: 05/22/2009] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Jan E Dickinson
- School of Women's and Infants' Health, The University of Western Australia, and The Women and Infants' Research Foundation, Perth, Western Australia
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Ben-Ami I, Schneider D, Svirsky R, Smorgick N, Pansky M, Halperin R. Safety of late second-trimester pregnancy termination by laminaria dilatation and evacuation in patients with previous multiple cesarean sections. Am J Obstet Gynecol 2009; 201:154.e1-5. [PMID: 19539892 DOI: 10.1016/j.ajog.2009.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 03/07/2009] [Accepted: 04/16/2009] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Ido Ben-Ami
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel
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Schwenkhagen A, Schaudig K. Antigestagene. GYNAKOLOGISCHE ENDOKRINOLOGIE 2008. [DOI: 10.1007/s10304-008-0268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Grossman D, Blanchard K, Blumenthal P. Complications after Second Trimester Surgical and Medical Abortion. REPRODUCTIVE HEALTH MATTERS 2008; 16:173-82. [DOI: 10.1016/s0968-8080(08)31379-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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