1
|
Zambrano Guevara LM, Buckheit C, Kuller JA, Gray B, Dotters-Katz S. Evidence Based Management of Labor. Obstet Gynecol Surv 2024; 79:39-53. [PMID: 38306291 DOI: 10.1097/ogx.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Importance Induction of labor (IOL) is a common obstetric intervention. Augmentation of labor and active management of the second stage is frequently required in obstetric practice. However, techniques around labor and induction management vary widely. Evidence-based practice regarding induction and labor management can reduce birth complications such as infection and hemorrhage and decrease rates of cesarean delivery. Objective To review existing evidence on IOL and labor management strategies with respect to preparing for induction, cervical ripening, induction and augmentation, and second stage of labor techniques. Evidence acquisition Review of recent original research, review articles, and guidelines on IOL using PubMed (2000-2022). Results Preinduction, pelvic floor training and perineal massage reduce postpartum urinary incontinence and perineal trauma, respectively. Timely membrane sweeping (38 weeks) can promote spontaneous labor and prevent postterm inductions. Outpatient Foley bulb placement in low-risk nulliparous patients with planned IOL reduces time to delivery. Inpatient Foley bulb use beyond 6 to 12 hours shows no benefit. When synthetic prostaglandins are indicated, vaginal misoprostol should be preferred. For nulliparous patients and those with obesity, oxytocin should be titrated using a high-dose protocol. Once cervical dilation is complete, pushing should begin immediately. Warm compresses and perineal massage decrease risk of perineal trauma. Conclusion and relevance Several strategies exist to assist in successful IOL and promote vaginal delivery. Evidence-based strategies should be used to improve outcomes and decrease risk of complications and cesarean delivery. Recommendations should be shared across interdisciplinary team members, creating a model that promotes safe patient care.
Collapse
Affiliation(s)
- Linda M Zambrano Guevara
- Resident, New York University Langone Health, Department of Obstetrics and Gynecology, New York, NY
| | - Caledonia Buckheit
- Former Resident, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC; Physician, Kamm McKenzie OBGYN, Raleigh, NC
| | | | - Beverly Gray
- Associate Professor, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Sarah Dotters-Katz
- Associate Professor, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| |
Collapse
|
2
|
Shimels T, Getnet M, Shafie M, Belay L. Comparison of mifepristone plus misoprostol with misoprostol alone for first trimester medical abortion: A systematic review and meta-analysis. Front Glob Womens Health 2023; 4:1112392. [PMID: 36970118 PMCID: PMC10038101 DOI: 10.3389/fgwh.2023.1112392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
ObjectiveTo compare mifepristone plus a misoprostol-combined regimen with misoprostol alone in the medical abortion of first trimester pregnancy.MethodsAn internet-based search of available literature was performed using text words contained in titles and abstracts. PubMed/Medline, Cochrane CENTRAL, EMBASE, and Google scholar were used to locate English-based articles published until December 2021. Studies fulfilling the inclusion criteria were selected, appraised, and assessed for methodological quality. The included studies were pooled for meta-analysis, and the results were presented in risk ratio at a 95% confidence interval.FindingsNine studies comprising 2,052 participants (1,035 intervention and 1,017 controls) were considered. Primary endpoints were complete expulsion, incomplete expulsion, missed abortion, and ongoing pregnancy. The intervention was found to more likely induce complete expulsion irrespective of gestational age (RR: 1.19; 95% CI: 1.14–1.25). The administration of misoprostol 800 mcg after 24 h of mifepristone pre-treatment in the intervention group more likely induced complete expulsion (RR: 1.23; 95% CI: 1.17–1.30) than after 48 h. The intervention group was also more likely to experience complete expulsion when misoprostol was used either vaginally (RR: 1.16; 95% CI: 1.09–1.17) or buccally (RR: 1.23; 95% CI: 1.16–1.30). The intervention was more effective in the subgroup with a negative foetal heartbeat at reducing incomplete abortion (RR: 0.45; 95% CI: 0.26–0.78) compared with the control group. The intervention more likely reduced both missed abortion (RR: 0.21; 95% CI: 0.08–0.91) and ongoing pregnancy (RR: 0.12; 95% CI: 0.05–0.26). Fever was less likely to be reported (RR: 0.78; 95% CI: 0.12–0.89), whereas the subjective experience of bleeding was more likely to be encountered (RR: 1.31; 95% CI: 1.13–1.53) by the intervention group.ConclusionThe review strengthened the theory that a combined mifepristone and misoprostol regimen can be an effective medical management for inducing abortions during first trimester pregnancy in all contexts. Specifically, there is a high-level certainty of evidence on complete expulsion during the early stage and its ability to reduce both missed and ongoing pregnancies.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019134213, identifier CRD42019134213.
Collapse
Affiliation(s)
- Tariku Shimels
- Research Directorate,St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Correspondence: Tariku Shimels
| | - Melsew Getnet
- Research Directorate,St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mensur Shafie
- Department of Pharmacology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Lemi Belay
- Department of Obstetrics and Gynaecology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| |
Collapse
|
3
|
Low V, Choo SN, Huang Z. Reasons for termination of pregnancy in mid-trimester: A single-centre experience. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:343-345. [PMID: 33990823 DOI: 10.47102/annals-acadmedsg.2020607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Valerie Low
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | | | | |
Collapse
|
4
|
Benson LS, Stevens J, Micks EA, Prager SW. Leukocytosis during cervical preparation with osmotic dilators for dilation and evacuation. SAGE Open Med 2021; 9:2050312120986731. [PMID: 33489232 PMCID: PMC7809630 DOI: 10.1177/2050312120986731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives: To describe leukocytosis trends during cervical preparation with osmotic dilators for second-trimester dilation and evacuation procedures, and to determine whether there is a difference in leukocytosis seen with laminaria versus Dilapan-S. Methods: We conducted a retrospective cohort study of 986 women presenting for dilation and evacuation from April 2008 through March 2009 at an outpatient clinic network. We included all procedures at ⩾14 weeks’ gestation where laminaria or Dilapan-S dilators were used for overnight dilation. All women had routine white blood cell testing during the study period. Results: There was a median increase of 2.4 × 103/μL white blood cell count (95% confidence interval 2.2–2.7 × 103/μL) from beginning of cervical preparation to the day of procedure (95% confidence interval and p value). Women receiving laminaria (n = 805) versus Dilapan-S (n = 181) had a greater increase in white blood cell count from baseline (median increase 2.7 versus 1.2 × 103/μL, p < 0.001), including when adjusting for age, gestational age, parity, baseline white blood cell count, and number of dilators placed. Conclusion: There is increased leukocytosis during the course of cervical preparation with osmotic dilators, and this is increased with use of laminaria versus Dilapan-S. Rates of clinically recognized infection in second-trimester abortion are low regardless of dilator type used.
Collapse
Affiliation(s)
- Lyndsey S Benson
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Jordan Stevens
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Sarah W Prager
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Kapp N, Lohr PA. Modern methods to induce abortion: Safety, efficacy and choice. Best Pract Res Clin Obstet Gynaecol 2020; 63:37-44. [DOI: 10.1016/j.bpobgyn.2019.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 10/22/2019] [Accepted: 11/25/2019] [Indexed: 12/01/2022]
|
7
|
Abstract
Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.
Collapse
|
8
|
McNamara B, Russo J, Chaiken S, Jacobson J, Kerns J. A qualitative study of digoxin injection before dilation and evacuation. Contraception 2018; 97:515-519. [PMID: 29477630 DOI: 10.1016/j.contraception.2018.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We sought to qualitatively understand patients' experiences with digoxin as a step before dilation and evacuation (D&E). STUDY DESIGN We recruited English-speaking women from one abortion health center where digoxin is routinely used before D&E. We interviewed participants one to three weeks after the D&E about physical and emotional experiences with digoxin and understanding of its purpose. Using grounded theory, we analyzed transcripts iteratively, identifying themes from interviews; we stopped recruitment when we reached thematic saturation. RESULTS We conducted 20 interviews and participants described mixed experiences. Three overarching themes from the qualitative interviews were: (1) physical and emotional discomfort; (2) varied understanding of digoxin's purpose and effects; and (3) reassurance. Most participants described significantly negative experiences with digoxin; however, many participants also described positive aspects of the injection intermingled with those negative experiences. CONCLUSIONS Participants' experiences with digoxin before D&E were both polarized and nuanced. While participants were largely clear about digoxin's action, they were much less clear about the reason for its use. IMPLICATIONS Both the clinical purpose for and patients' experiences with digoxin before D&E are complicated. Providers who continue to use digoxin should consider patient preferences in how they offer digoxin, and consider tools to ensure patient understanding.
Collapse
Affiliation(s)
- Blair McNamara
- Yale University School of Medicine, New Haven, CT 06520, USA.
| | - Jennefer Russo
- Planned Parenthood of Orange and San Bernardino Counties, Orange, CA 92866, USA
| | | | - Janet Jacobson
- Planned Parenthood of Orange and San Bernardino Counties, Orange, CA 92866, USA
| | - Jennifer Kerns
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA 94110, USA
| |
Collapse
|
9
|
Abstract
Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1-3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4-6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.
Collapse
|
10
|
Velipasaoglu M, Ayaz R, Senturk M, Arslan S, Tanir HM. Analgesic effects of acetaminophen, diclofenac and hyoscine N-butylbromide in second trimester pregnancy termination: a prospective randomized study. J Matern Fetal Neonatal Med 2016; 29:3838-42. [DOI: 10.3109/14767058.2016.1148134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Melih Velipasaoglu
- Department of Obstetrics and Gynecology, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Reyhan Ayaz
- Department of Obstetrics and Gynecology, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Metin Senturk
- Department of Obstetrics and Gynecology, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Samet Arslan
- Department of Obstetrics and Gynecology, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Huseyin Mete Tanir
- Department of Obstetrics and Gynecology, School of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| |
Collapse
|
11
|
When Timing Is Everything: Are Placental MRI Examinations Performed Before 24 Weeks' Gestational Age Reliable? AJR Am J Roentgenol 2015; 205:685-92. [DOI: 10.2214/ajr.14.14134] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
12
|
Hoopmann M, Hirneth J, Pauluschke-Fröhlich J, Yazdi B, Abele H, Wallwiener D, Kagan KO. Influence of Mifepristone in Induction Time for Terminations in the Second and Third Trimester. Geburtshilfe Frauenheilkd 2014; 74:350-354. [PMID: 25076791 DOI: 10.1055/s-0033-1360361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 12/19/2013] [Accepted: 01/14/2014] [Indexed: 10/25/2022] Open
Abstract
Termination of pregnancy after the first trimester is generally carried out by medical induction. Question: The aim of this study is to investigate the effect of mifepristone before administration of the prostaglandin derivative on induction time. Material and Methods: We analysed 333 medically indicated terminations after the first trimester under the terms of § 218 a Para. 2 of the German Criminal Code, in which the prostaglandin derivatives misoprostol, gemeprost or dinoprostone were administered with or without pre-treatment with 600 mg of mifepristone. The time interval between the initial administration of prostaglandin and delivery was investigated. Using uni- and multivariate regression analysis, the effect of maternal age, body mass index, gravidity and parity, previous Caesarean sections, gestational age and the induction regimen on the induction time were analysed. Results: The average induction time was significantly shortened with mifepristone (15.1 ± 11.9 hours with mifepristone vs. 25.3 ± 24.2 hours without mifepristone [p < 0.001]). The combination of mifepristone and misoprostol was most frequently used and proved to be the most effective regimen, reducing the induction period to 13.6 ± 10.3 hours. Besides pre-treatment with mifepristone, gestational age and a history of delivery without Caesarean section were significant influencing factors in reducing the induction time. Conclusion: The induction interval can be significantly shortened by the prior administration of mifepristone. The combination of mifepristone and misoprostol or gemeprost is the most effective regimen for the medical termination of pregnancy.
Collapse
Affiliation(s)
- M Hoopmann
- Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| | - J Hirneth
- Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| | | | - B Yazdi
- Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| | - H Abele
- Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| | - D Wallwiener
- Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| | - K O Kagan
- Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| |
Collapse
|
13
|
Weisman PS, Kashireddy PV, Ernst LM. Pathologic diagnosis of achondrogenesis type 2 in a fragmented fetus: case report and evidence-based differential diagnostic approach in the early midtrimester. Pediatr Dev Pathol 2014; 17:10-20. [PMID: 24144387 DOI: 10.2350/13-02-1305-oa.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
As a group, lethal genetic skeletal disorders (GSDs) usually result in death within the perinatal period. Because lethal GSDs are often ultrasonographically detectible by early midtrimester, dilation and evacuation (D&E) is the method of choice for elective termination of pregnancy in many institutions. However, because the diagnosis of the lethal GSDs relies heavily upon radiologic examination of fetal remains, reaching an accurate diagnosis in this setting can be challenging. We report an autopsy case of a fetus delivered by D&E at 15 4/7 weeks gestation with radiologic, histologic, and genetic findings compatible with achondrogenesis type 2 and discuss an evidence-based differential diagnostic approach to lethal GSDs terminated by early midtrimester D&E.
Collapse
Affiliation(s)
- Paul S Weisman
- Department of Pathology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | |
Collapse
|
14
|
Umbilical cord transection to induce fetal demise prior to second-trimester D&E abortion. Contraception 2013; 88:712-6. [DOI: 10.1016/j.contraception.2013.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 11/22/2022]
|
15
|
Mifepristone followed by misoprostol or oxytocin for second-trimester abortion: a randomized controlled trial. Obstet Gynecol 2013; 122:815-820. [PMID: 24084539 DOI: 10.1097/aog.0b013e3182a2dcb7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare two methods for induction of second-trimester abortion after priming the cervix with mifepristone. METHODS This was a randomized prospective trial carried out between January 2009 and February 2012. The participants were healthy women between 14 and 24 weeks of gestation with missed miscarriage or need for termination of pregnancy. All participants received oral 200 mg mifepristone and, after 36 hours, after randomization, were given either a high-concentration oxytocin drip (maximal dose of 150 milli-international units/min) for up to 36 hours or 800 micrograms misoprostol vaginally followed by 400 micrograms oral misoprostol every 3 hours with a maximum of four oral doses. If expulsion of the fetus was not achieved, another 200 mg mifepristone was administered and another course of misoprostol was delivered as described previously. The primary outcome measure was success expulsion of the fetus in 36 hours since starting on uterotonic agent. Secondary outcomes included time until expulsion of the fetus and rate of adverse outcomes. RESULTS Success rates in the mifepristone-misoprostol and mifepristone-oxytocin arms were 100% (70/70 patients) and 95.8% (69/72), respectively (relative risk 1.043, 95% confidence interval 0.99-1.10, P=.13). Time until fetal expulsion was shorter in the mifepristone-misoprostol arm (7.0 ± 4.9 hours compared with 11.3 ± 7.4 hours, P<.001). However, the rate of adverse effects in the misoprostol group was higher than in the oxytocin group. Factors associated with a shorter time until expulsion were missed miscarriage compared with therapeutic abortion, increased ultrasonographic gestational age, and increased parity. CONCLUSION The two regimens studied had comparable efficacy for induction of second-trimester abortion; however, the mifepristone-oxytocin regimen has a longer time until expulsion but with fewer side effects. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00784797. LEVEL OF EVIDENCE : I.
Collapse
|
16
|
Tocce K, Sheeder JL, Edwards LJ, Teal SB. Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation. Contraception 2013; 88:706-11. [PMID: 24034581 DOI: 10.1016/j.contraception.2013.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study evaluates the feasibility, efficacy and safety of transvaginal digoxin administration to induce fetal demise prior to dilation and evacuation. STUDY DESIGN This descriptive report from a single center involves a large case series of dilations and evacuations (D&Es) ranging from 18 to 22 weeks of gestation. Transvaginal feticidal injection with digoxin was attempted in 1640 cases; intrafetal, intraamniotic and combined (intrafetal and intraamniotic) injections were administered. Digoxin dosage ranged from 0.5 to 3.0 mg, with the majority receiving 1.0 mg. Cases were reviewed to determine feasibility, efficacy and adverse events. RESULTS Successful completion of transvaginal injection occurred in 98.5% (1637/1662) of eligible cases, and 1596 cases were evaluable for fetal demise. Demise occurred by the time of D&E in 99.4% of all cases; 99.7% of intrafetal injections resulted in fetal demise. Doses ≥1 mg were equally effective (98.1%-99.6%) regardless of injection site (intraamniotic, combined intrafetal/intraamniotic or intrafetal). Doses <1.0 mg were less successful at inducing demise if not administered intrafetally (p<.001). Rates of ruptured membranes (4.1%), chorioamnionitis (0.49%) and extramural deliveries (0.12%) were low. Patients who experienced complications were more likely to be of greater gestational age and have had a previous cesarean section. CONCLUSIONS Transvaginal digoxin administration is feasible, effective and safe. IMPLICATION STATEMENT This study demonstrates the feasibility, effectiveness and safety of transvaginal digoxin administration in a large clinical cohort. Future studies will be needed to determine if this method of administration improves patient satisfaction and outcomes when compared to transabdominal feticidal injections.
Collapse
Affiliation(s)
- Kristina Tocce
- University of Colorado Denver School of Medicine, Department of Obstetrics and Gynecology, Mail Stop 198-2 AO1, 12631 E. 17th Avenue, Room 4006, Aurora, CO 80045, USA.
| | | | | | | |
Collapse
|
17
|
Shuaib AA, Alharazi AH. Medical versus surgical termination of the first trimester missed miscarriage. ALEXANDRIA JOURNAL OF MEDICINE 2013. [DOI: 10.1016/j.ajme.2012.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Alia A. Shuaib
- Sana'a University, Faculty of Medicine, Obstetrics and Gynecology Department, Sanaa, Yemen
| | | |
Collapse
|
18
|
Ernst LM, Gawron L, Fritsch MK. Pathologic Examination of Fetal and Placental Tissue Obtained by Dilation and Evacuation. Arch Pathol Lab Med 2013; 137:326-37. [DOI: 10.5858/arpa.2012-0090-ra] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Dilation and evacuation (D&E) is an alternative method to induction of labor for pregnancy termination and intrauterine fetal demise, and it is the most common mode of second-trimester uterine evacuation in the United States. Many D&E specimens are examined in surgical pathology, and there is little information available in surgical pathology textbooks or the literature to assist pathologists in these examinations.
Objective.—To provide an overview of the D&E procedure, discuss related legal issues, provide guidelines for routine pathologic examination of D&E specimens, and demonstrate the importance of careful pathologic examination of D&E specimens.
Data Sources.—Case-derived material and literature review.
Conclusions.—Pathologic examination of D&E specimens has been understudied. However, the available literature and our experience support the fact that careful pathologic examination of D&E specimens can identify significant fetal and placental changes that can confirm clinical diagnoses or provide definitive diagnosis, assist in explaining the cause of intrauterine fetal demise, and identify unexpected anomalies that may provide further clues to a diagnostic syndrome or mechanism of anomaly formation.
Collapse
Affiliation(s)
- Linda M. Ernst
- From the Departments of Pathology (Drs Ernst and Fritsch) and Obstetrics and Gynecology (Dr Gawron), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lori Gawron
- From the Departments of Pathology (Drs Ernst and Fritsch) and Obstetrics and Gynecology (Dr Gawron), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael K. Fritsch
- From the Departments of Pathology (Drs Ernst and Fritsch) and Obstetrics and Gynecology (Dr Gawron), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
19
|
Transvaginal administration of intraamniotic digoxin prior to dilation and evacuation. Contraception 2012; 87:76-80. [PMID: 22959902 DOI: 10.1016/j.contraception.2012.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 07/13/2012] [Accepted: 07/27/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Transabdominal injection of digoxin into the amniotic fluid or fetus to induce fetal demise before dilation and evacuation (D&E) abortion has become common practice since the passage of the Partial-Birth Abortion Ban Act in 2007. STUDY DESIGN We performed a prospective study to assess the feasibility of transvaginal administration of intraamniotic digoxin the day before D&E. All women between 18 0/7 and 23 5/7 weeks of gestation seeking termination from December 2009 to May 2011 were approached for study participation. Women who declined participation were asked to identify their primary rationale. For women declining study participation, transection of the umbilical cord during D&E was performed to meet the requirements of the ban. RESULTS Over 18 months, 134 women met study entry criteria and 108 (81%) declined to participate. Of the 26 women who enrolled, 1.0 mg undiluted digoxin was successfully administered transvaginally in 24 (92%, 95% confidence interval 75%-99%). The most common reasons for declining participation were discomfort with preoperatively inducing fetal demise (37%) and desire to avoid a medically unnecessary medication (36%). CONCLUSIONS Transvaginal administration of digoxin is a feasible alternative to transabdominal administration to induce preoperative fetal demise. The majority of women decline digoxin administration when an alternative is available.
Collapse
|
20
|
Pazol K, Creanga AA, Zane SB. Trends in use of medical abortion in the United States: reanalysis of surveillance data from the Centers for Disease Control and Prevention, 2001-2008. Contraception 2012; 86:746-51. [PMID: 22770796 DOI: 10.1016/j.contraception.2012.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 05/17/2012] [Accepted: 05/30/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND With changing patterns and increasing use of medical abortion in the United States, it is important to have accurate statistics on the use of this method regularly available. This study assesses the accuracy of medical abortion data reported annually to the Centers for Disease Control and Prevention (CDC) and describes trends over time in the use of medical abortion relative to other methods. STUDY DESIGN This analysis included data reported to CDC for 2001-2008. Year-specific analyses included all states that monitored medical abortion for a given year, while trend analyses were restricted to states that monitored medical abortion continuously from 2001 to 2008. Data quality and completeness were assessed by (a) examining abortions reported with an unspecified method type within the gestational age limit for medical abortion (med-eligible abortions) and (b) comparing the percentage of all abortions and med-eligible abortions reported to CDC as medical abortions with estimates based on published mifepristone sales data for the United States from 2001 to 2007. RESULTS During 2001-2008, the percentage of med-eligible abortions reported to CDC with an unspecified method type remained low (1.0%-2.2%); CDC data and mifepristone sales estimates for 2001-2007 demonstrated strong agreement [all abortions: intraclass correlation coefficient (ICC)=0.983; med-eligible abortions: ICC=0.988]. During 2001-2008, the percentage of abortions reported to CDC as medical abortions increased (p<.001 for all abortions and for med-eligible abortions). Among states that reported medical abortions for 2008, 15% of all abortions and 23% of med-eligible abortions were reported as medical abortions. CONCLUSION CDC's Abortion Surveillance System provides an important annual data source that accurately describes the use of medical abortion relative to other methods in the United States.
Collapse
Affiliation(s)
- Karen Pazol
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health, Atlanta, GA 30341, USA.
| | | | | |
Collapse
|
21
|
Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion. Contraception 2012; 85:140-3. [DOI: 10.1016/j.contraception.2011.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
|
22
|
Chen QJ, Hou SP, Meads C, Huang YM, Hong QQ, Zhu HP, Cheng LN. Mifepristone in combination with prostaglandins for termination of 10–16 weeks’ gestation: a systematic review. Eur J Obstet Gynecol Reprod Biol 2011; 159:247-54. [DOI: 10.1016/j.ejogrb.2011.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 05/19/2011] [Accepted: 06/09/2011] [Indexed: 10/18/2022]
|
23
|
Termination of second-trimester pregnancy by mifepristone combined with misoprostol versus intra-amniotic injection of ethacridine lactate (Rivanol®): a systematic review of Chinese trials. Contraception 2011; 84:214-23. [DOI: 10.1016/j.contraception.2011.01.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 01/14/2011] [Accepted: 01/24/2011] [Indexed: 11/24/2022]
|
24
|
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.
Collapse
|
25
|
Current world literature. Curr Opin Obstet Gynecol 2010; 22:166-75. [PMID: 20216348 DOI: 10.1097/gco.0b013e328338c956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
26
|
Grimes DA, Stuart G. Abortion jabberwocky: the need for better terminology. Contraception 2010; 81:93-6. [DOI: 10.1016/j.contraception.2009.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 09/14/2009] [Indexed: 11/25/2022]
|
27
|
Hern WM. The evidence-based review of second-trimester abortion missed some important evidence. Am J Obstet Gynecol 2009; 201:e7-8; author reply e8. [PMID: 19683691 DOI: 10.1016/j.ajog.2009.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Accepted: 06/22/2009] [Indexed: 10/20/2022]
|
28
|
Hammond C. Reply. Am J Obstet Gynecol 2009. [DOI: 10.1016/j.ajog.2009.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|