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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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Second-trimester abortion care for those with complex medical conditions. Curr Opin Obstet Gynecol 2022; 34:359-366. [PMID: 36036465 DOI: 10.1097/gco.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF THE REVIEW This review focuses on patients who are most likely to experience morbidity associated with second trimester abortion care and risk mitigation strategies. RECENT FINDINGS Prior cesarean birth, particularly multiple prior cesarean births, is the most significant risk factor associated with complications during second trimester abortion because of increased risks of hemorrhage, with or without placenta accreta spectrum (PAS), and distorted anatomy, which increases the risk of uterine perforation. Recent data suggests that first trimester ultrasound findings may be predictive of PAS, including multiple lacunae, abnormal uteroplacental interface, and hypervascularity. Multiple common medications interact with mifepristone and are therefore contraindicated; ulipristal shares mifepristone's selective progesterone receptor modulator activity but does not share the same metabolic pathway. Recent data suggests ulipristal may be an effective adjunct for cervical preparation, avoiding potentially mifepristone's drug-drug interactions. Those ending a pregnancy due to severe early-onset hypertensive disorders have a high rate of clinically significant thrombocytopenia: platelet transfusion is recommended for those with platelets <50 000 per cubic millimeter. SUMMARY Pregnant people presenting for care in the second trimester may have conditions that make an abortion more technically or medically complex. Clinicians can mitigate much of this increased risk with preprocedural planning, and appropriate intra-operative preparedness.
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Zhan J, Xing A, Tan X. Complete cervical inversion and nearly inappropriate stitching with cesarean section during the second stage of labor: a case report. J Int Med Res 2021; 49:300060521999522. [PMID: 33730903 PMCID: PMC8165849 DOI: 10.1177/0300060521999522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cesarean section is a common obstetric operation and an important method for saving the
lives of mothers and their neonates in dangerous situations. Nevertheless, cesarean
section has a higher risk and might have more complications compared with natural
delivery. A reasonable choice of delivery method is important for maternal and neonatal
health. The incidence of complications after cesarean section for mothers and neonates
during the second stage of labor significantly increases compared with planned cesarean
section. During the second stage of labor, the fetal head is deep in the pelvic cavity. If
a cesarean section is performed at this stage, it is prone to causing complications,
including difficult delivery of the fetal head, delayed uterine incision, and massive
hemorrhage, which seriously threaten the health of the mother and her neonate. For the
first time, we report a case of cesarean section after complete opening of the uterine
orifice, which led to almost mistakenly suturing the cervix to the uterus. This report
will hopefully help surgeons anticipate such incidents during cesarean section in the
future.
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Affiliation(s)
- Jun Zhan
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Aiyun Xing
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Xi Tan
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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Alshehri KA, Ammar AA, Aldhubabian MA, Al-Zanbaqi MS, Felimban AA, Alshuaibi MK, Oraif A. Outcomes and Complications After Repeat Cesarean Sections Among King Abdulaziz University Hospital Patients. Mater Sociomed 2019; 31:119-124. [PMID: 31452637 PMCID: PMC6690310 DOI: 10.5455/msm.2019.31.119-124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/05/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Cesarean section (CS) is a surgical procedure that often saves the lives of both the mother and the baby, while a previous CS is one of the main indications for cesarean delivery in current pregnancy. AIM Our aim was to determine the surgical and obstetrical outcomes and complication for the mother and the neonate after 4 or more CSs and compare it with mothers who had less than 4 previous CSs. METHODS This case-control study was conducted by reviewing the records of all women who underwent multiple CSs from 2013 to 2018. Our study group comprised of 394 women who had 4 or more CSs, and our control group comprised of similar number of women who had previous history of two or three CSs. RESULTS A total of 788 patients were enrolled in our study. We found that adhesions were the most common complications in our study group with a considerable increase in number of both moderate and severe adhesions in the study group compared to the controls with p-value of <0.001. CONCLUSION Increasing number of CSs leads to an increase of the complications risk. Among the complications, adhesions were the most common in our study group, followed by intraoperative bleeding.
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Affiliation(s)
- Khalid A Alshehri
- College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed A Ammar
- College of Medicine, Jeddah University, Jeddah, Saudi Arabia
| | | | | | - Ahyad A Felimban
- College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Motaz K Alshuaibi
- College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ayman Oraif
- Department of Obstetrics and Gynecology, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Estimated versus measured blood loss during dilation and evacuation: an observational study. Contraception 2018; 97:451-455. [PMID: 29410259 DOI: 10.1016/j.contraception.2018.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare estimated versus measured blood loss at the time of dilation and evacuation (D&E). STUDY DESIGN We measured blood loss for all D&E procedures between 16 and 24 weeks at one abortion clinic over 9 months. We weighed all blood-containing items and measured blood captured in the D&E tray. Providers recorded estimated blood loss before weighing or measuring blood. We compared median measured blood loss (MBL) and estimated blood loss (EBL) for each gestational week. RESULTS We measured blood loss in 371 of the 534 D&Es in the study period; we excluded 163 procedures because of failure to measure blood loss or contamination with amniotic fluid. Included and excluded procedures had similar median EBLs. Median EBL differed significantly from MBL for each week gestation from 16 to 24 weeks (p≤.001 for all comparisons); MBL was approximately twice as high as EBL for each gestational week. EBL and MBL increased with increasing gestation, as did the difference between EBL and MBL. CONCLUSION Providers consistently and significantly underestimate blood loss at the time of D&E. D&E providers may want to consider using a new heuristic for estimating blood loss. IMPLICATIONS Providers significantly underestimate blood loss at the time of D&E. Future research should confirm these findings (particularly at 22-24 weeks gestation), evaluate the efficacy of interventions to improve estimations of blood loss, and determine best practices for decreasing blood loss.
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Andrikopoulou M, Lavery JA, Ananth CV, Vintzileos AM. Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies. Am J Obstet Gynecol 2016; 215:177-94. [PMID: 27018469 DOI: 10.1016/j.ajog.2016.03.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/16/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The aim of this systematic review and metaanalysis was to determine the efficacy and safety of cervical ripening agents in the second trimester of pregnancy in patients with previous cesarean delivery. STUDY DESIGN Data sources were PubMed, EMBASE, CINAHL, LILACS, Google Scholar, and clinicaltrials.gov (1983 through 2015). Eligibility criteria were cohort or cross-sectional studies that reported on efficacy and safety of cervical ripening agents in patients with previous cesarean delivery. Efficacy was determined based on the proportion of patients achieving vaginal delivery and vaginal delivery within 24 hours following administration of a cervical ripening agent. Safety was assessed by the risk of uterine rupture and complications such as retained placental products, blood transfusion requirement, and endometritis, when available, as secondary outcomes. Of the 176 studies identified, 38 met the inclusion criteria. Of these, 17 studies were descriptive and 21 studies compared the efficacy and safety of cervical ripening agents between patients with previous cesarean and those with no previous cesarean. From included studies, we abstracted data on cervical ripening agents and estimated the pooled risk differences and risk ratios with 95% confidence intervals. To account for between-study heterogeneity, we estimated risk ratios based on underlying random effects analyses. Publication bias was assessed via funnel plots and across-study heterogeneity was assessed based on the I(2) measure. RESULTS The most commonly used agent was PGE1. In descriptive studies, PGE1 was associated with a vaginal delivery rate of 96.8%, of which 76.3% occurred within 24 hours, uterine rupture in 0.8%, retained placenta in 10.8%, and endometritis in 3.9% in patients with ≥1 cesarean. In comparative studies, the use of PGE1, PGE2, and mechanical methods (laminaria and dilation and curettage) were equally efficacious in achieving vaginal delivery between patients with and without prior cesarean (risk ratio, 0.99, and 95% confidence interval, 0.98-1.00; risk ratio, 1.00, and 95% confidence interval, 0.98-1.02; and risk ratio, 1.00, and 95% confidence interval, 0.98-1.01; respectively). In patients with history of ≥1 cesarean the use of PGE1 was associated with higher risk of uterine rupture (risk ratio, 6.57; 95% confidence interval, 2.21-19.52) and retained placenta (risk ratio, 1.21; 95% confidence interval, 1.03-1.43) compared to women without a prior cesarean. However, the risk of uterine rupture among women with history of only 1 cesarean (0.47%) was not statistically significant (risk ratio, 2.36; 95% confidence interval, 0.39-14.32), whereas among those with history of ≥2 cesareans (2.5%) was increased as compared to those with no previous cesarean (0.08%) (risk ratio, 17.55; 95% confidence interval, 3.00-102.8). Funnel plots did not demonstrate any clear evidence of publication bias. Across-study heterogeneity ranged from 0-81%. CONCLUSION This systematic review and metaanalysis provides evidence that PGE1, PGE2, and mechanical methods are efficacious for achieving vaginal delivery in women with previous cesarean delivery. The use of prostaglandin PGE1 in the second trimester was not associated with significantly increased risk for uterine rupture among women with only 1 cesarean; however, this risk was substantially increased among women with ≥2 cesareans although the absolute risk appeared to be relatively small.
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Affiliation(s)
- Maria Andrikopoulou
- Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY.
| | - Jessica A Lavery
- Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Cande V Ananth
- Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY
| | - Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY
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Kaplanoglu M, Bulbul M, Kaplanoglu D, Bakacak SM. Effect of multiple repeat cesarean sections on maternal morbidity: data from southeast Turkey. Med Sci Monit 2015; 21:1447-53. [PMID: 25989945 PMCID: PMC4450602 DOI: 10.12659/msm.893333] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/25/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Cesarean section (CS) is one of the most common obstetric procedures worldwide and an increased rate of cesarean section has been observed in recent studies. Maternal and fetal mortality and morbidity associated with cesarean section is an important health problem worldwide. This requires the evaluation of the effect of repeated cesarean delivery on maternal morbidity. MATERIAL/METHODS A total of 2460 patients who underwent delivery by CS at a center in southeast Turkey between January 2012 and January 2014 (24 months) were included in the study. The patients were divided into 5 groups according to the number of CSs, and the maternal and neonatal outcomes of the groups were retrospectively evaluated. RESULTS A statistically significant difference was found between the groups in terms of maternal age, education level, time of hospitalization, operating time, the presence of dense adhesions, bowel and bladder injury, the presence of placenta previa, hysterectomy, blood transfusion requirements, and need for intensive care (p<0.05). Placenta previa (OR, 11.7; 95% CI, 2.6-53.2) and placenta accreta (OR, 12.2; 95% CI, 3.9-37.8) were found to be important risk factors in terms of the need for hysterectomy. No statistically significant difference was found between the groups for gestational age at birth, birth weight, fifth-minute APGAR score, preoperative and postoperative hemoglobin levels, uterine rupture, wound infection, wound dehiscence, placenta accreta, maternal death, and endometritis (p>0.05). A total of 4 or more CSs was identified as the critical level for most of the major complications. CONCLUSIONS An increasing number of CSs is accompanied by serious maternal complications. Four or more CSs are of especially critical importance. Decreasing the number of cesarean sections is required to decrease relevant complications. Vaginal birth after CS is an option that should be recommended to the patient.
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Affiliation(s)
- Mustafa Kaplanoglu
- Department of Obstetric and Gynecology, Adiyaman University School of Medicine, Adiyaman, Turkey
| | - Mehmet Bulbul
- Department of Obstetric and Gynecology, Adiyaman University School of Medicine, Adiyaman, Turkey
| | - Dilek Kaplanoglu
- Department of Obstetric and Gynecology, Adiyaman University School of Medicine, Training and Education Hospital, Adiyaman, Turkey
| | - Suleyman Murat Bakacak
- Department of Obstetric and Gynecology, Kahramanmaras Sutcu Imam University School of Medicine, Kahramanmaras, Turkey
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Ben-Ami I, Stern S, Vaknin Z, Smorgick N, Schneider D, Halperin R. Prevalence and risk factors of inadequate cervical dilation following laminaria insertion in second-trimester abortion--case control study. Contraception 2015; 91:308-12. [PMID: 25575873 DOI: 10.1016/j.contraception.2014.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 12/24/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective was to explore the prevalence of and risk factors for inadequate cervical dilation following insertion of a single set of laminaria in women scheduled for dilation & evacuation (D&E) at 14-24 weeks' gestation. STUDY DESIGN We retrospectively reviewed all cases of women who underwent pregnancy termination by D&E at 14-24 weeks' gestation between January 2003 and December 2013. All cases in which the surgical procedure was cancelled due to failure to achieve adequate cervical dilation after a single set of laminaria inadequate cervical dilation were included. The control group was women who underwent D&E following adequate cervical dilation after a single set of laminaria, and were matched according to gestational week in a ratio of 1:3. RESULTS The overall dilation failure rate was 3.2%, with 4.0% among the induced-abortion patients and 1.5% among the patients with fetal demise (p=.002). Patients who had inadequate cervical dilation had lower rates of gravidity (p=.002) and previous spontaneous vaginal delivery (p<.001), along with higher rates of primigravidity, nulliparity (p<.001), previous cesarean section/s (p=.041), previous abdominal surgeries (p=.001) and previous cervical procedures (p=.003), compared to controls. A multivariable logistic regression analysis revealed two risk factors for inadequate cervical dilation following laminaria insertion, namely, previous cesarean section (p=.002) and previous cervical procedure (p<.001), whereas increased gravidity was found to protect against inadequate cervical dilation (p=.002). CONCLUSIONS Previous cesarean section/s, cervical procedures and primigravidity were found to be risk factors for failure to achieve adequate cervical dilation after a single set of laminaria. Women who are scheduled for D&E, and in whom one of these risk factors exists, might benefit from additional interventions to achieve better cervical preparation.
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Affiliation(s)
- Ido Ben-Ami
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University.
| | - Sharon Stern
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - Zvi Vaknin
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - Noam Smorgick
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - David Schneider
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - Reuvit Halperin
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
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BEN-AMI IDO, FUCHS NOGA, SCHNEIDER DAVID, PANSKY MOTY, HALPERIN REUVIT. Coagulopathy associated with dilation and evacuation for second-trimester abortion. Acta Obstet Gynecol Scand 2011; 91:10-15. [DOI: 10.1111/j.1600-0412.2011.01296.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Effect of Prior Cesarean Delivery on Risk of Second-Trimester Surgical Abortion Complications. Obstet Gynecol 2010; 115:760-764. [DOI: 10.1097/aog.0b013e3181d43f42] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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