Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013-4

Abortion Return Rates and Wait Times Before and After Texas' Executive Order Banning Abortion During COVID-19

Objectives. To assess the associations between the executive order that Texas governor Greg Abbott issued on March 22, 2020, postponing procedures deemed not immediately medically necessary, and patients' access to abortion care in Texas. Methods. We used 17 515 individual-level patient records from 13 Texas abortion facilities for matched periods in 2019 and 2020 to examine differences in return rates for abortion after completion of a state-mandated ultrasound and median wait times between ultrasound and abortion visits for those who returned. Results. Patients were less likely to return for an abortion if they had an ultrasound while the executive order was under effect (82.8%) than in the same period in 2019 (90.4%; adjusted odds ratio = 2.06; 95% confidence interval = 1.12, 3.81). Compared with patients at or before 10.0 weeks' gestation at ultrasound, patients at more than 10 weeks' gestation had higher odds of not returning for an abortion or, if they returned, experienced greater wait times between ultrasound and abortion visits. Conclusions. Texas' executive order prohibiting abortion during the COVID-19 pandemic disrupted patients' access to care and disproportionately affected patients who were past 10 weeks' gestation. (Am J Public Health. 2024;114(10):1013-1023. https://doi.org/10.2105/AJPH.2024.307747).

Comparing transcervical balloon with osmotic dilators for cervical preparation prior to procedural abortion: A noninferiority randomized trial

OBJECTIVES

This study aimed to compare cervical preparation with transcervical balloon to osmotic dilators for second-trimester procedural abortions.

STUDY DESIGN

We performed an unblinded, randomized, noninferiority trial of people undergoing second-trimester procedural abortion at 18 + 0 to 23 + 6 weeks' gestation. We randomized participants to either overnight osmotic dilators (Dilapan-S) or transcervical balloon (Foley). Both groups received overnight mifepristone and preprocedural misoprostol. We powered the study on mean difference in procedure duration, a noninferiority limit of 5 minutes. We compared preprocedure cervical dilation and the need for additional dilation and, using a 100-point visual analog scale, measured physician satisfaction and ease of procedure, and participant pain and satisfaction.

RESULTS

We recruited 32 participants at a single academic center. Although procedure time (minutes) was similar (balloon: 22.6 ± 8.9 vs Dilapan-S: 22.4 ± 12.8, p = 0.96), noninferiority was not met (mean difference, 0.2 minutes; 95% CI, -7.8 to 8.2). Cervical dilation >2 cm was more likely after Dilapan-S (100% vs 62.5%, p = 0.02). Placement was well tolerated with similar time (minutes) for insertion (balloon: 4.8 ± 1.0, Dilapan-S: 5.1 ± 2.3, p = 0.64) and maximum pain (median) with insertion (balloon 39 [5-78], Dilapan-S: 39 [0-100], p = 0.92). Pain immediately postinsertion was higher for Dilapan-S (33 [0-100] vs 18 [0-50], p = 0.046) and similar for maximum pain overnight, participant satisfaction, and likelihood to recommend. Complications were minor and similar between groups (p = 0.60).

CONCLUSION

While significantly more people with transcervical balloon required mechanical dilation, the difference in operative time was clinically negligible. The transcervical balloon was well tolerated and acceptable by participants.

IMPLICATIONS

Clinicians experienced in mechanical dilation may consider a transcervical balloon as a lower-cost tool for second-trimester abortion cervical preparation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT05099991.

Spontaneous Pregnancy After the Removal of Long-Term Retained Laminaria

We report the case of a woman with laminaria retention up to six years, followed by spontaneous pregnancy after the removal by hysteroscope of the intrauterine retained laminaria. A 26-year-old woman (G1P0) visited our hospital with complaints of prolonged menstrual bleeding, dyspareunia, and infertility. She had a history of dilatation and evacuation (D&E) at nine weeks of gestation six years earlier. A transvaginal ultrasound showed an artifact, and hysteroscopy revealed a long foreign body, which was suspected to be a laminaria retained after the prior abortion. In the hysteroscopic surgical procedure, the laminaria was cut, and the two halves were excised using resectoscope electrodes and hooked to the electrodes for removal. Thereafter, a year later, she conceived spontaneously and gave birth to a baby by cesarean delivery due to the arrest of labor progress. We are the first to present a pregnant case after the removal of a six-year retained laminaria.

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

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.

Cervical preparation for second-trimester procedural abortion

PURPOSE OF REVIEW

To review the evidence-informed options for cervical preparation prior to second-trimester dilation and evacuation (D&E).

RECENT FINDINGS

As abortion restrictions increase and the number of abortion clinics and providers decreases, pregnant people are facing more barriers to abortion access. Those in need are now often required to travel for second-trimester abortion care, only to be faced with additional restrictions, such as mandatory waiting periods. Cervical preparation is recommended prior to D&E and takes time for effect. Given the increasing time required to obtain an abortion, patients and providers may prefer same-day cervical preparation to decrease the total time required. Options for same-day cervical preparation include misoprostol alone with single or serial doses, and misoprostol combined with osmotic dilators or transcervical balloon (Foley catheter). Same-day preparation may require additional clinical space to accommodate people after initiation of cervical preparation to manage side-effects and timing of the abortion. Overnight options are also used and more frequently later in the second trimester. Overnight options include mifepristone, osmotic dilators, and transcervical balloon and are often combined with same-day misoprostol. Medication alone preparation is well tolerated and effective in the second trimester, with the addition of mechanical methods with advancing gestation. With many options and combinations being safe and effective, providers can be dynamic and alter approach with supply shortages, adjust to different clinical settings, consider patient medical and surgical factors, and accommodate provider and patient preferences.

SUMMARY

Multiple pharmacologic and mechanical options have been shown to be safe and effective for cervical preparation prior to D&E. Consideration for multiple factors should influence the method of cervical preparation and methods may vary by patient, provider and setting.

Medication Abortion: A Comprehensive Review

This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.

Second-trimester Abortion

In 2019, the US Centers for Disease Control reported that 7% of abortions were performed after 13 weeks of pregnancy, a small proportion of all terminations. However, the need for second-trimester abortions will increase commensurate with restrictions to access nationwide. Second-trimester abortions are performed with medications or through a procedure. Health care practitioners serving persons at risk of pregnancy should understand how abortions are performed and how to deliver evidence-based postabortion care. The purpose of this article is to provide a foundation for caring for individuals before, during, and after second-trimester abortion.

Vaginal Bleeding Before 20 Weeks Gestation

Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.

A case of asymptomatic uterine incarceration in a patient undergoing dilation and evacuation

Uterine incarceration is a rare pregnancy complication that occurs when the uterine fundus becomes trapped beneath the sacral promontory. We present a case of incarceration in a patient seeking dilation and evacuation and a discussion of strategies for uterine reduction and cervical preparation.

Acute complications with same-day versus overnight cervical preparation before dilation and evacuation at 14 to 16 weeks

OBJECTIVE

Evaluate if same-day cervical preparation is associated with a clinically acceptable complication rate compared with overnight osmotic dilators for dilation and evacuation (D&E).

STUDY DESIGN

This retrospective, noninferiority, cohort study compared complication rates for same-day versus overnight cervical preparation with D&E between 14 and 16 weeks gestation. Cervical preparation was achieved with misoprostol, osmotic dilators, or both. Our primary outcome was the acute complication rate, defined as: hemorrhage (≥500 mL); hospitalization or hospital transfer; transfusion; or unplanned procedure occurring within 24 hours of the index procedure. Secondarily we evaluated nonmajor (re-aspiration, suture repair of cervical laceration, uterine tamponade, or emergency department only transfer) and major (transfusion, uterine artery embolization, abdominal surgery, or hospital admission) complications separately. Inverse probability of treatment weighting using the propensity score was used to perform an adjusted analysis, taking into account age, ethnicity, clinic location, insurance, gestational age, gravidity, and prior pregnancy outcomes.

RESULTS

We analyzed 1,319 subjects (n = 864 same-day, n = 455 overnight). Same-day cervical preparation patients were more likely to have Medicaid and a prior vaginal delivery. In both unadjusted and adjusted analyses, acute complication rates for same-day were noninferior to overnight preparation (unadjusted 0.93% vs 1.98%, difference of -1.05%, CI: -2.48% to 0.38%; adjusted difference -0.50%, CI: -1.45 to 0.44%). Only one major complication in the same-day group, a cervical laceration resulting in hemorrhage requiring transfusion, occurred in the entire sample.

CONCLUSIONS

In this retrospective review, same-day cervical preparation was noninferior to overnight preparation for D&E between 14 and 16 weeks gestation, both with low complication rates.

IMPLICATIONS

For early second trimester dilation and evacuation, same-day cervical preparation should be considered a safe alternative to overnight cervical preparation.

Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States

Importance

Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade.

Objective

To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity.

Design, Setting, and Participants

Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022.

Exposures

Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8.

Main Outcomes and Measures

Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation.

Results

Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend).

Conclusions and Relevance

Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.

Obstetric Outcomes after Perforation of Uterine Cavity

We aimed to evaluate the pregnancy characteristics and obstetric outcomes in patients after perforation of the uterus. Study design: A retrospective cohort study was conducted and included all patients who were diagnosed with uterine perforation and treated in a tertiary referral medical center between the years 1996 and 2018. Up to two deliveries after perforations were investigated. Results: During the study period, 51 women were diagnosed with uterine perforation during gynecological procedures, including intrauterine device (IUD) insertion. The mean age of patients at the time of diagnosis was 27.9 (±4.7) years. The majority, 76.5% (n = 39), experienced perforation during IUD insertion, and 23.5% (n = 12) of the patients experienced perforation during surgical procedures. Most of the patients were multiparous or grand multiparous, 45.8. % (n = 22) and 39.6% (n = 19) respectively. Anteflexed uterus was found in 86.4% of the patients (n = 38). Five patients (9.8%) had pelvic abscesses after the IUD insertion. A total of 50 patients had 71 deliveries subsequent to uterine perforation. One patient experienced intrauterine fetal death due to fetal malformations. One patient experienced uterine rupture. No other major obstetric complications were noted. Conclusions: Uterine perforation may be associated with adverse obstetric outcomes. The possibility of uterine rupture must be considered while managing the deliveries of patients after uterine perforation. Moreover, a larger cohort and further studies are needed to establish an association between uterine perforation and adverse outcomes of the subsequent deliveries.

Pain, Side Effects, and Abortion Experience Among People Seeking Abortion Care in the Second Trimester

Background:

There is limited documentation about pain and side effects associated with dilation and evacuation (D&E) abortion, yet, pain and side effects are important factors that can affect a client's abortion experience. In 2016, Hope Clinic for Women, an independent abortion clinic in Illinois, altered its cervical preparation protocols before D&E to reduce the total time of the abortion process and improve the client experience. This analysis addresses the gap in data on client experience of abortion in the later second trimester by evaluating pain, side effects, and acceptability by gestational age.

Methods:

Abortion clients obtaining services at the clinic between March 2017 and June 2018 were eligible to participate if they had viable singleton pregnancies of 16–23.6 weeks' gestation, spoke English, and were at least 18 years old. Eligible participants completed a two-part survey about their abortion experience.

Results:

We found that respondents seeking abortion care at later gestations in the second trimester were more likely to report pain during their abortions. We did not find any association between side effects and gestational age.

Conclusion:

Although most respondents were prepared for the pain they experienced, some reported experiencing more pain than they expected, and more effective pain relief was commonly reported as a way to improve the service. More research on patient experiences of later abortion is needed, particularly on experiences of pain and options for pain management.

Cervix Surgical uterine evacuation in patients with two cervices: a case series

OBJECTIVES

To describe the clinical circumstances, surgical approach, intraoperative challenges, and outcomes of patients with two cervices undergoing uterine evacuation for spontaneous, incomplete, or induced abortion at our institution.

STUDY DESIGN

We used diagnostic and procedure codes related to uterine anomalies and uterine evacuation to identify patients with cervical duplication who underwent uterine evacuation at Penn Medicine from January 2008 to December 2020.

RESULTS

We identified fifteen patients with cervical duplication in whom we performed uterine evacuations during nineteen pregnancies. We describe in detail each patient's first pregnancy with uterine evacuation at our institution, of which providers performed eleven in the first trimester and four in the second trimester. Ten patients had a known diagnosis of cervical duplication prior to pregnancy. Five patients did not have a diagnosis of cervical duplication prior to pregnancy and providers newly made this diagnosis intraoperatively either at our institution or referring clinics. Providers at outside institutions referred three patients to our institution for incomplete procedures. At our institution, one patient had a procedure notable for a major complication. Eight other cases were notable for surgical challenges including difficulty placing osmotic dilators, difficulty identifying the correct cervix for local anesthesia, and contralateral cervical and uterine horn instrumentation.

CONCLUSIONS

This case series suggests surgical abortion in patients with two cervices is rare, but generally safe. The majority of patients did not have major complications, despite presenting a variety of unique procedural challenges. Surgical providers were sometimes the first to make the diagnosis of a second cervix.

Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective

The majority of abortions are performed early in pregnancy, but later abortion accounts for a large proportion of abortion-related morbidity and mortality. People who need this care are often the most vulnerable-the poor, the young, those who experience violence, and those with significant health issues. In settings with access to safe care, studies demonstrate significant declines in abortion-related morbidity and mortality. This review focuses on evidence-based practices for induced abortion beyond 13 weeks' gestation and post-abortion care in both high- and low-resource settings. We also highlight key programmatic issues to consider when expanding the gestational age for abortion services.

Foley catheter and misoprostol for cervical preparation for second-trimester surgical abortion

OBJECTIVE

Document the effectiveness and safety of Foley balloon catheter and misoprostol use for cervical preparation before a same-day dilation and evacuation (D&E).

STUDY DESIGN

We conducted a retrospective medical records review of adult patients with viable pregnancies at 18 weeks 0 days to 21 weeks 6 days gestation who received a same-day D&E at an Alabama clinic using a 30-cc Foley balloon catheter and misoprostol for cervical preparation from January 2016 through December 2017. Patients received misoprostol 800 mcg buccally at the time of Foley placement and then every 4 hours until the physician deemed that dilation/effacement was adequate to proceed with a D&E. We extracted patient demographics, pregnancy and medical history, and preoperative, intraoperative, and postoperative data. We primarily evaluated effectiveness (D&E completion within one procedure day). Our secondary outcomes included safety, time between misoprostol and procedure start time, length of D&E, recovery time, and number of doses of misoprostol provided.

RESULTS

Two hundred and ninety patient charts met our review criteria - all of whom had a complete abortion in one day. Only one safety incident, a cervical laceration, occurred (0.3% of all procedures). The median time between Foley placement and first misoprostol dose and the procedure start was 7.2 hours (2.9-12.6 hours; interquartile range [IQR] 6.2-8.4 hours); median procedure length was 12 minutes (2-40 minutes; IQR 10-15 minutes); and median recovery time 14 minutes (4-89 minutes; IQR 14-16 minutes). Most patients needed two doses of misoprostol (n = 258, 89%), and 11 (4%) needed three doses; 21 (7%) patients needed one dose of misoprostol.

CONCLUSION

Patients in the mid-second trimester can effectively and safely undergo cervical preparation with a Foley balloon catheter and misoprostol to facilitate completion of same-day D&E.

IMPLICATIONS

Foley balloon catheter use with misoprostol for cervical preparation for second-trimester abortion (the Robinson Foley protocol) is effective and safe and can be completed in one day when used by an experienced physician.

Successful dilation and evacuation for second trimester conjoined twin: a case report and review of the literature

Background

Conjoined twins are a rare clinical event occurring in about 1 per 250,000 live births. Though the prognosis of conjoined twins is generally low, there is limited evidence as to the optimal method of pregnancy termination, particularly in cases of advanced gestational age. We report a successful dilation and evacuation (D&E) done for conjoined twins at 22 weeks of gestation.

Case presentation

A 20-year-old primigravid woman was diagnosed with a conjoined, thoraco-omphalopagus twin pregnancy after undergoing a detailed two-dimensional (2D) fetal ultrasound anatomic scanning. Assessment and counseling were done by a multidisciplinary team. The team discussed the prognosis and options of management with the patient. The patient opted for termination of pregnancy. Different options of termination were discussed and the patient consented for D&E, with the possibility of reverting to hysterotomy in case intraoperative difficulty was encountered. A 2-day cervical preparation followed by D&E was done under spinal anesthesia and ultrasound guidance.

Conclusion

In this patient, D&E was done successfully without complications. Adequate cervical preparation, pain control, and ultrasound guidance during the procedure are critical for optimal outcomes. A literature review of methods of pregnancy termination for conjoined twins in the second trimester revealed 75% delivered vaginally through medical induction while 18% underwent cesarean section. Only one other report described successful D&E for conjoined twins after 20 weeks. D&E can be safely performed for carefully selected cases of conjoined twins beyond 20 weeks’ gestations avoiding the need for induction or hysterotomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-02815-4.

Mechanical dilation to remove incarcerated laminaria during a second trimester abortion

Cervical preparation with laminaria reduces complications with 2nd trimester dilation and evacuation. During a surgical abortion at 22 weeks, we could not remove laminaria manually or with ring forceps due to laminaria "dumbbelling" [1]. Without pushing laminaria into the uterus, we mechanically dilated the cervix and removed the incarcerated laminaria.

Oral sedation for pain with cervical dilator placement: a randomized controlled trial

Objective

Assess oral sedation versus placebo for pain control with cervical dilator placement.

Study design

We randomized participants presenting for dilation and evacuation to lorazepam 1 mg/oxycodone 5 mg or placebo 45 min before cervical dilator placement. Our primary outcome was median visual analog scale (VAS) pain score after dilator placement using a 100-mm VAS. We used our outcome data to calculate median pain score changes from baseline to better reflect pain score differences between study groups. Planned sample size was 30 participants per group, for a total of 60.

Results

We randomized 27 participants; 9 received sedation and 11 placebo. Median pain score increase from baseline to last dilator placement was 20 [interquartile range (IQR) 8–29] and 31 (IQR 15–81) in the oral sedation and placebo groups, p = .16.

Conclusion

We were unable to enroll our desired sample size, and our sample is underpowered to make any conclusions. Our results suggest that oral sedation may provide some benefit for pain relief with dilator insertion and indicate that further research might be worthwhile especially in settings that do not routinely provide these analgesics.

Implications

We had difficulty with study recruitment because many patients desired oral sedation for pain management for cervical dilator placement and declined randomization. Randomized trials of pain management with a placebo arm may find recruitment challenging especially if default clinical care already includes a pain management option that patients would have to opt out of.

Leukocytosis during cervical preparation with osmotic dilators for dilation and evacuation

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.

Management of Postabortion Complications for the Emergency Medicine Clinician

Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.

Cervical priming before surgical abortion between 14 and 24 weeks: a systematic review and meta-analyses for the National Institute for Health and Care Excellence-new clinical guidelines for England

OBJECTIVE

This study aimed to determine the optimal cervical priming regimen before surgical abortion between 14⁺⁰ and 24⁺⁰ weeks' gestation.

DATA SOURCES

Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, published in English after 1985, that compared (1) mifepristone, misoprostol, and osmotic dilators against each other, alone or in combination; (2) different doses of mifepristone and misoprostol; (3) different intervals between priming and abortion; or (4) different routes of administration of misoprostol were included.

METHODS

Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were meta-analyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no significant heterogeneity (I²<50%), random effects models were used for moderate heterogeneity (I²≤50% and <80%), and evidence was not pooled when there was high heterogeneity (I²≥80%). Subgroup analyses were undertaken based on parity where available. The overall quality of the evidence was assessed using Grades of Recommendation Assessment, Development, and Evaluation.

RESULTS

A total of 15 randomized controlled trials (N=2454) were included and showed decreased difficulty of procedure and/or increased cervical dilation and decreased patient acceptability with regimens that included dilators compared with those that did not include dilators; increased preoperative expulsion of the pregnancy with sublingual misoprostol and mifepristone compared with sublingual misoprostol alone; increased difficulty of procedure with dilators and misoprostol compared with dilators and mifepristone; decreased difficulty of procedure with dilators and mifepristone compared with dilators alone; and increased cervical dilation when dilators were placed the day before abortion compared with the same day.

CONCLUSION

Considered alongside clinical expertise, the published data support the use of osmotic dilators, misoprostol, or mifepristone before abortion for pregnancies at 14⁺⁰ to 16⁺⁰ weeks' gestation; osmotic dilators or misoprostol for pregnancies at 16⁺¹ to 19⁺⁰ weeks' gestation; and osmotic dilators alone or with mifepristone for pregnancies at 19⁺¹ to 24⁺⁰ weeks' gestation. The effectiveness of pharmacologic agents alone beyond 16⁺⁰ weeks' gestation and the optimal timing of dilator placement remain important questions for future research.

Factors associated with abortion at 12 or more weeks gestation after implementation of a restrictive Texas law

OBJECTIVE

To examine factors associated with obtaining abortion at 12 or more weeks gestation in Texas after implementation of a restrictive law.

STUDY DESIGN

In this retrospective cohort study, we collected data from eight Texas abortion clinics that provided services at 12 or more weeks gestation from April 1, 2015 to March 30, 2016, after a restrictive abortion law enacted in November 2013 shuttered many of the state's clinics. We examined factors associated with obtaining in-clinic abortion services between 3-11 versus 12-24 weeks gestation including patient race-ethnicity, income level, and driving distance to the clinic using chi-square tests and calculating odds ratios. We further subcategorized abortion between 15-24 weeks to determine who may be most affected by a Texas law banning dilation and evacuation (D&E).

RESULTS

Among 24,555 in-clinic abortions, 19.2% (n = 4,714) occurred at 12 or more weeks gestation. Compared to patients who obtained care between 3-11 weeks, those who obtained care at 12 or more weeks were more likely to be Black than White (OR 1.18; 95% CI 1.05-1.31), live ≤110% of the federal poverty level than have higher income (OR 2.09; 95% CI 1.94-2.26), and drive 50+ miles than 1-24 miles to obtain care (OR 1.25; 95% CI 1.15-1.38). These associations remained for those obtaining care between 15-24 weeks. Even after adjusting for race-ethnicity and driving distance, low-income patients had greater odds of obtaining care in between 15-24 weeks (aOR 1.52; 95% CI 1.21-1.91).

CONCLUSIONS

Patients obtaining abortion at 12 or more weeks gestation in Texas are more likely to be Black, low-income, and travel far distances to obtain in-clinic care.

IMPLICATIONS

In Texas, patients who are Black, low-income, and travel the farthest are more likely to obtain in-clinic abortion between 15-24 weeks gestation, commonly performed via D&E. If Texas Senate Bill 8 (SB8) banning D&E goes into effect, these patients may be prevented from obtaining care.

A double-blind randomized trial comparing lidocaine spray and placebo spray anesthesia prior to cervical laminaria insertion

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.

Dilation and evacuation after preterm premature rupture of membranes with abdominal cerclage in situ

For women with a history of cervical insufficiency, treatment with transvaginal (TV) or abdominal (TA) cerclage is often recommended; however management of pregnancy complications necessitating uterine evacuation in the second trimester are challenging. We present a patient at 17 weeks 3 day gestation with preterm premature rupture of membranes, and chorioamnionitis with an abdominal cerclage in situ. She desired uterine evacuation via dilation and evacuation. This case report reviews the clinical considerations for uterine evacuation in the second trimester in patients with an abdominal cerclage in situ and discusses options for cervical preparation prior to dilation and evacuation for this unique patient population.

Mifepristone and misoprostol compared to osmotic dilators for cervical preparation prior to surgical abortion at 15-18 weeks' gestation: a randomised controlled non-inferiority trial

OBJECTIVE

Cervical preparation is recommended prior to second-trimester surgical abortion. Osmotic dilators are an effective means to prepare the cervix, but require an additional procedure and may cause discomfort. We compared cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators.

STUDY DESIGN

A randomised, controlled, non-inferiority trial was performed to compare cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators in women undergoing surgical abortion between 15 and 18 weeks gestation. The medication group (n=29) received mifepristone 200 mg orally 24 hours prior to uterine evacuation and misoprostol 400 μg buccally 2 hours before the procedure. The dilator group (n=20) underwent osmotic dilator insertion 24 hours prior to the procedure. The primary outcome was total procedure time, from insertion to removal of the speculum. Secondary outcomes included operative time (from intrauterine instrumentation to speculum removal), initial cervical dilation, nausea, pain, ease of procedure, and whether participants would choose the same modality in the future.

RESULTS

For mean total procedure time, medication preparation (14.0 min, 95% CI 12.0-16.1) was not inferior to dilators (14.3 min, 95% CI 11.7 to 16.8, p<0.001). Mean operative time and ease of procedure were also similar between groups. More women in the medication group than the dilator group would prefer to use the same method in the future (86% vs 30%, p=0.003).

CONCLUSION

Prior to surgical abortion at 15-18 weeks, use of mifepristone and misoprostol did not result in longer procedure times than overnight osmotic dilators.

TRIAL REGISTRATION NUMBER

NCT01462.

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

OBJECTIVE

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.

INTENDED USERS

Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.

TARGET POPULATION

Women with an unintended or abnormal first or second trimester pregnancy.

EVIDENCE

PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.

VALUES

The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

The use of an osmotic dilator for induction of miscarriage in patients with the second trimester missed miscarriage

AIM

The aim of this study was to assess the outcomes of combined use of dilapan-S and pharmacological induction of miscarriage with mifepristone and misoprostol versus mifepristone and misoprostol only in patients with a second-trimester pregnancy loss.

MATERIALS AND METHODS

Our study included 74 patients with a second-trimester antenatal death who were randomized into two groups to receive pharmacological induction of miscarriage combined with intracervical insertion of dilapan-S (n = 37) or pharmacological induction of miscarriage only (n = 37). Efficacy endpoints included: blood loss volume, length of time between the procedure initiation and complete miscarriage, and the number of complications.

RESULTS

The use of dilapan-S together with mifepristone and misoprostol for induction of miscarriage in the second trimester in women with antenatal fetal death reduced the time from the start of the procedure to complete miscarriage by 1.98-fold. However, the use of dilapan-S did not significantly reduce the odds of such post-procedural complications as hematometra and retention of the products of conception in the uterus (p = .2501).

CONCLUSIONS

Combined management of antenatal pregnancy loss in the second trimester including intracervical insertion of dilapan-S and conventional induction with miscarriage may be considered a valuable clinical strategy. However, future studies should focus on ways to prevent postprocedural complications in this group of women.

A factorial-design randomized controlled trial comparing misoprostol alone to Dilapan with misoprostol and comparing buccal to vaginal misoprostol for same-day cervical preparation prior to dilation & evacuation at 14 weeks 0 days-19 weeks 6 days gestation

OBJECTIVES

To compare procedure times following same-day cervical preparation using misoprostol 400 mcg alone or misoprostol 400 mcg plus hygroscopic dilators for dilation and evacuation (D&E) before 20 weeks gestation and to compare side effects of buccal and vaginal misoprostol administration.

STUDY DESIGN

We randomized women undergoing D&E at 14 weeks 0 days-19 weeks 6 days gestation to receive (1) hygroscopic dilators or not and (2) buccal or vaginal misoprostol using a 2 × 2 factorial design. We assessed two primary outcomes: (1) total procedure time, defined as time to insert hygroscopic dilators plus D&E time, and (2) side effects of misoprostol 4-6 h after initiation of cervical preparation using a 5-point Likert scale assessing nausea, emesis, diarrhea, chills and cramps.

RESULTS

We randomized 163 women and 161 completed the study. We completed all procedures in one day. Mean total procedure time was 14.0 and 10.8 min. with and without hygroscopic dilators (difference 3.2 minutes, 95% CI 1.7, 4.6). Mean D&E procedure time was 0.7 (95% CI -0.8, 2.1) min longer without hygroscopic dilators. Initial cervical dilation was 15.6 and 11.7 mm with and without hygroscopic dilators (difference 3.9 mm, 95% CI 3.1, 4.8). Participants receiving buccal misoprostol reported less chills (1.9) than women receiving vaginal misoprostol (2.3), p = 0.04.

CONCLUSIONS

Hygroscopic dilators with misoprostol requires more time and increases cervical dilation without shortening D&E time when used for cervical preparation 4-6 h prior to D&E before 20 weeks. Women receiving vaginal misoprostol may have more chills compared to buccal misoprostol.

IMPLICATIONS

Adding hygroscopic dilators to misoprostol for same day D&E procedures at less than 20 weeks gestation increases total intervention time without reducing D&E time and is less favored by patients. Clinical judgment requires balancing relative effectiveness with patient preference. Further studies should evaluate the side effect profile of vaginal misoprostol.

Pregnancy outcomes after removal of osmotic dilators in patients who presented for second-trimester abortion

OBJECTIVE

The objective was to report pregnancy outcomes and potentially related complications among 13 patients who had osmotic dilators placed for second-trimester dilation and evacuation (D&E) followed by subsequent removal with the intention to continue their pregnancies.

STUDY DESIGN

We reviewed billing and scheduling data between 2005 and 2017 to identify the total number of women seen for D&E and to identify the individuals who had dilators placed without a subsequent scheduled dilation and evacuation. We then performed chart reviews to determine pregnancy outcomes.

RESULTS

Between 2005 and 2017, we treated 2532 patients who presented for second-trimester abortions by D&E and received osmotic dilators for cervical preparation. Twenty (0.8%) of these women had cervical dilators removed with the intention of continuing their pregnancies. We could obtain outcome data for 13 of these pregnancies; one of these women ultimately elected to have an abortion. Eight of the remaining 12 women (66%) experienced complications which included premature preterm rupture of membranes, preterm delivery, maternal infection and hemorrhage. Six (50%) pregnancies ended in spontaneous abortion or fetal or neonatal death.

CONCLUSION

Continuation of pregnancy after placement and removal of osmotic dilators may increase the risk of adverse pregnancy outcomes.

IMPLICATIONS

Of the women who had outcome data available, 50% who had cervical dilators removed experienced spontaneous abortion or fetal or neonatal death. Conservatively assuming that all women lost to follow-up had healthy pregnancies, 30% of women experienced fetal or neonatal death and 40% had an adverse pregnancy outcome.

Chronic Pelvic Pain and Infertility Resulting from Unrecognized Retained Laminaria

BACKGROUND

In 2013, the abortion rate in the United States was found to be 200 abortions per 1,000 live births. Of these, the CDC estimates that nearly 49% were performed using unsafe measures. Even when these procedures are safely performed, patients are at risk for immediate or delayed complications. In second-trimester terminations, mechanical dilation with an osmotic dilator is common to allow for delivery of the fetus. The Japanese seaweed Laminaria japonica is used to achieve this purpose.

CASE

A 28-year-old primigravida presented with chronic pelvic pain and infertility. She had irregular menstrual cycles and reported scant yellow discharge. A transvaginal ultrasound revealed an abnormally appearing endometrium with an elongated structure suspicious for a foreign body. The patient reported a voluntary termination of pregnancy twelve years earlier, for which laminaria were placed prior to the dilation and extraction. She underwent an operative hysteroscopy confirming our suspicion for retained laminaria. The pathology report demonstrated chronic severe endometritis and plant based material.

CONCLUSION

Retained laminaria are associated with chronic pelvic pain and chronic infertility. Since they can be difficult to detect on conventional imaging, proper counting prior to insertion and after removal is an essential physician responsibility.

Update on second-trimester surgical abortion

PURPOSE OF REVIEW

To review the recent literature on surgical second-trimester abortion, with specific attention to cervical preparation techniques.

RECENT FINDINGS

Confirming previous studies, a recent retrospective observational cohort study, including 54 911 abortions, estimated the total abortion-related complication rate to be 0.41% for second-trimester or later procedures. Cervical preparation is known to reduce risks associated with second-trimester dilation and evacuation (D&E). When considering adjuncts to osmotic dilators for cervical preparation prior to D&E after 16 weeks, both misoprostol and mifepristone are effective alone and in combination or as adjuncts to osmotic dilators. Misoprostol consistently has been shown to cause more pain and cramping than placebo, but is an effective adjunct to osmotic dilators after 16 weeks. Although mifepristone has fewer side-effects, at its current price, it may not be as cost-effective as misoprostol.

SUMMARY

Second-trimester abortion is safe. The use of mifepristone and misoprostol for second-trimester abortion has improved safety and efficacy of medical and surgical methods when used alone or in combination and as adjuncts to osmotic dilators. An important aspect of D&E, cervical preparation, is not a one-size-fits-all practice; the approach and methods are contingent on patient, provider and setting and should consider all the evidence-based options.

State of family planning

Family planning and reproductive health services are uniquely impacted by policy and politics in the United States. Recent years have witnessed an unprecedented number of abortion restrictions, and research funding has decreased in related areas. Despite this, both the science and the implementation of improved family planning and abortion methods have progressed in the past decade. This article reviews the current state of family planning, as well as technologies and patient care opportunities for the future.

Misoprostol 1 to 3 h preprocedure vs. overnight osmotic dilators prior to early second-trimester surgical abortion

OBJECTIVES

We sought to compare the effectiveness of at least 1 h of 400 mcg of buccal misoprostol to overnight osmotic dilators for early second-trimester surgical abortion cervical preparation.

DESIGN

We conducted a retrospective cohort study, reviewing 145 consecutive charts to compare procedure duration for women who received 400 mcg of buccal misoprostol at least 1 h preprocedure vs. overnight osmotic dilators before dilation and evacuation between 14 weeks, 0 days and 15 weeks, 6 days' gestation. Primary outcome was procedure duration and secondary outcomes included maximum mechanical dilator size, estimated blood loss and side effects.

RESULTS

Sixty-four women (44.1%) received buccal misoprostol (mean 1.6 h), and 81 women (55.9%) received overnight osmotic dilators. Groups did not differ regarding mean gestational age or gynecologic history. All procedures in both groups were completed. Procedure duration was not significantly different between the misoprostol and osmotic dilator groups (median 11.0 min vs. 10.0 min, p=.22), even after multivariable linear regression (p=.17). The mean total cervical preparation duration was 1.6 h for women in the misoprostol group compared to 20.3 h in the osmotic dilator group (p<.001). Secondary outcomes did not differ between groups.

CONCLUSIONS

We found that at least 1 h of preprocedure misoprostol decreased the duration of cervical preparation for early second-trimester procedures performed by an experienced surgeon.

IMPLICATIONS

In this small, retrospective review, at least 1 h of preprocedure buccal misoprostol decreased the duration from cervical preparation initiation to procedure completion in early second-trimester procedures performed by an experienced surgeon. These results should be considered as a pilot evaluation, and further prospective study is needed to further clarify whether this short interval could be applied in general practice.

Experimental comparison of properties of natural and synthetic osmotic dilators

PURPOSE

The in vitro study compares natural and synthetic osmotic dilators in selected parameters influencing their clinical efficacy.

METHODS

Diameters of Laminaria and synthetic dilators (Dilapan-S and Dilasoft) were measured in dry state, during free swelling in isotonic solution and during swelling against a force. Three aspects were evaluated-diameter increase, speed of action and consistency of action.

RESULTS

The maximum diameter increase of 3 and 4-mm Dilapan-S was 3.6 and 3.3 times, of Dilasoft 3.2 and 3.1 times, respectively. For Laminaria, it was 2.9 and 2.7 times. The difference between synthetic dilators and Laminaria was statistically significant (p < 0.01). Synthetic dilators also swelled faster. Under applied counter force, synthetic dilators increased their diameter more than Laminaria (+3.6 mm for Dilapan-S, +3.8 mm for Dilasoft, +1.2 mm for Laminaria; p < 0.01) and achieved faster expansion. Synthetic dilators also showed significantly higher consistency between samples in all experiments.

CONCLUSIONS

Synthetic dilators compared to Laminaria reached higher maximum diameters, acted faster, were more consistent and were able to expand against force three times more. The results support clinical observations that synthetic dilators are more suitable and preferable for same-day D&E procedure and that fewer synthetic dilators are needed to achieve the same effect.

Laminaria vs. vaginal misoprostol for cervical preparation before second-trimester surgical abortion: a randomized clinical trial

OBJECTIVE

To compare the efficacy and tolerability of vaginal misoprostol and laminaria for cervical preparation before second-trimester surgical abortion.

STUDY DESIGN

We performed a prospective, randomized trial comparing midnight administration of misoprostol 600 mcg vaginally to midnight placement of laminaria, before surgical abortions among women at 13-20 weeks of gestation. The primary outcome was preoperative cervical dilation. Secondary outcomes were the need for further dilation, procedure duration and difficulty, immediate complications and side effects.

RESULTS

Eighty-four women were randomized, with a median gestational age of 16.5 weeks. The mean time interval between misoprostol and laminaria placement and dilatation and evacuation initiation was 11.0±2.9 and 11.2±2.0h, respectively (p=.17). Cervical dilation was not greater in the laminaria group as compared to the misoprostol group (12.8 vs. 12.4mm, respectively; p=.32). No difference was demonstrated regarding the need for additional dilation or the difficulty of the procedure. Procedures performed after laminaria insertion were 1 min longer (median 11 vs. 10 min, p=.04). Participants found laminaria placement more uncomfortable than vaginal misoprostol placement. Other than pain, additional side effects occurred only in the misoprostol group, primarily nausea and vomiting. One participant in the misoprostol group experienced fetal expulsion during the night before the intended procedure.

CONCLUSION

Either vaginal misoprostol or laminaria provides adequate dilation for second-trimester surgical abortion. Laminaria causes more pain at insertion and misoprostol causes more side effects.

IMPLICATIONS STATEMENT

We found that cervical preparation in an inpatient setting for approximately 11h with misoprostol 600 mcg vaginally is comparable to 11h of laminaria. However, given the potential for spontaneous expulsion and more side effects with misoprostol, laminaria is likely a better general option in such a setting.

Prevalence and risk factors of inadequate cervical dilation following laminaria insertion in second-trimester abortion--case control study

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.

Hypersensitivity to laminaria: a case report and review of literature

We report a case of laminaria hypersensitivity treated with diphenhydramine and corticosteroids. A literature review identified 10 previously reported cases, with 8 recognized as anaphylaxis, and good outcomes with corticosteroids and antihistamines despite limited epinephrine utilization. Laminaria hypersensitivity is likely IgE mediated with an increased anaphylaxis risk with prior exposure.