Could second-trimester medical abortion be offered as a day service? Assessing the feasibility of a 1-day outpatient procedure using pooled data from six clinical studies

Outpatient medical management of later second trimester abortion (18-23.6 weeks) with procedural evacuation backup: A large case series

Objective

Document the clinical outcomes of an outpatient medical management with procedural evacuation backup procedure for abortions between 18 weeks zero days to 23 weeks six days gestation.

Study design

We conducted a retrospective medical records review of adult patients who received mifepristone and repeated misoprostol for second trimester abortion with procedural evacuation backup at an Arizona clinic between October 2017 and November 2021. We extracted patient demographics; pregnancy and medical history; and preoperative, intraoperative, and postoperative data. We assessed abortion outcomes, including procedure timing, mode of completion (medication alone or medications and procedural evacuation), and safety.

Results

All 359 patients had a complete abortion with 63.5% of patients completing with medication alone and 36.5% with procedural evacuation backup. The median time from first dose of misoprostol to fetal expulsion was six hours, among those who completed the abortion with medications alone. Of those who received procedural evacuation as backup, the median time for procedural evacuation was 10 minutes. The vast majority of patients (99.4%) did not have any adverse events. Two safety incidents (0.6%) occurred, a broad right ligament tear and a uterine rupture.

Conclusion

Patients in one outpatient setting safely and effectively received medical management of second trimester abortion with procedural evacuation backup, and two thirds completed with medications alone.

Implications

Outpatient settings may consider medical management of abortion between 18 and 24 weeks with procedural evacuation back-up as a safe, effective, and manageable second trimester abortion option. Additional research is needed on patient experience and satisfaction.

[Medical strategy for abortions between 14 and 16 weeks of gestation]

OBJECTIVE

To adapt the protocols for the management of voluntary termination of pregnancy following the new law extending the practice to 16 weeks of gestation.

MATERIAL AND METHOD

A systematic review of the literature in French and English concerning the management of patients requesting medically induced abortion was performed on PubMed, Cochrane Library and on the recommendations of international learned societies.

RESULTS

The efficacy of the medical method is greater than 95% when the protocols are adapted to the gestational age. The combination of mifepristone and misoprostol currently represents the "gold standard" of drug-based management. Mifepristone 200mg is sufficient, followed 24 to 48hours later by misoprostol 800μg administered sublingually or buccally. After the first dose, 400μg should be administered every 3hours buccally or sublingually until expulsion. Adverse effects (digestive and thermoregulatory disorders) during medical abortion are usually mild and short-lived. An anti-emetic treatment should be proposed as a prophylactic measure. For pain, ibuprofen is the analgesic treatment of choice, with the addition of level 2 analgesics if necessary.

CONCLUSION

Medical abortion is a safe and effective method up to 16 weeks of gestation, provided that the protocols, which differ according to gestational age, are respected. Women must be informed of the advantages and disadvantages of the methods according to the term and the side effects, which will allow them to choose the method that fits them best.

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.

Evaluation of shorter mifepristone to misoprostol intervals for second trimester medical abortion: a retrospective cohort study

OBJECTIVES

To assess shorter mifepristone-misoprostol intervals compared to current guidelines for second trimester medical abortion on total abortion time (mifepristone to fetal expulsion) and induction time (first misoprostol to fetal expulsion).

METHODS

This retrospective cohort study included women who elected for a second trimester medical abortion with mifepristone and misoprostol at an academic tertiary medical center in the United States from January 2008 to June 2018. We abstracted times of mifepristone administration, first dose of misoprostol, and fetal expulsion from the medical record. We assessed outcomes based on the shorter intervals <12 h and 12 to 24 h compared to the guideline mifepristone-misoprostol interval (24-48 h).

RESULTS

The study population included eighty-nine women, 47, 28, and 14 women in the <12 h, 12 24 h, guideline (24-48 h) groups, respectively. The cohort had a median gestational age of 22^0/7 weeks (range: 15^0/7-27^0/7) and parity of 1 (range: 0-5) with no differences observed between groups. Total abortion times were 20.7 h (range: 3.7-46.9), 30.6 h (16.7-48.0), and 42.8 h (32.7-62.6), respectively (p < 0.001). Induction times were 12.9 h (range: 1.2-36.6), 11.7 h (2.0-35.2), and 9.3 h (5.3-16.5), respectively. Fetal expulsion within 12 h of first misoprostol dose occurred in 22 (47%), 14 (50%), and 9 (64%), respectively (p = 0.52).

CONCLUSIONS

Shorter mifepristone-misoprostol intervals (less than 24 h) significantly decrease the total abortion time while maintaining a clinically similar induction time.

IMPLICATIONS

Shortening the mifepristone-misoprostol interval in second trimester medical abortion significantly decreases the total abortion time which may be preferable to some women or health systems.

Feasibility of a hospital outpatient day procedure for medication abortion at 13-18 weeks gestation: Findings from Nepal

OBJECTIVES

To evaluate the safety, acceptability and feasibility of a one-day outpatient medication abortion service at gestations 13-18 weeks.

STUDY DESIGN

Open-label prospective study in which participants received mifepristone 200 mg orally to swallow at home or at the clinic followed 24 h later by misoprostol 400 mcg buccally. They presented to the outpatient clinic 24-48 h after mifepristone for misoprostol 400 mcg buccally every three hours (no maximum dose). The primary outcome was successful abortion without transfer to overnight inpatient care. Secondary outcomes included time to abortion from initial misoprostol dose, safety, additional interventions and side effects.

RESULTS

We enrolled 230 women from December 2017 to November 2018. Approximately nine of ten (n = 206, 89.6%) achieved a successful abortion without transfer to overnight care. Twenty-four were transferred to overnight inpatient care; of these 18 were to manage a complication, five for incomplete abortion and two by choice. Among these 24, three women experienced an SAE. The median time to successful abortion from time of the first misoprostol dose was 7.2 h (range: 0.75-92.3), with an average of three misoprostol doses. Most participants expelled the fetus and the placenta at or around the same time; median time between fetal and placental expulsion was 15 minutes (range: 0-4.5 h). Fifteen participants (6.6%) received more than five misoprostol doses and were transferred to inpatient care. Administration of more than five doses of misoprostol was associated with nulliparity. Provision of antibiotics (27.9%, n = 64), manual removal of placenta (15.3%, n = 35), uterotonics (4.4%, n = 10) and surgical interventions (4.4%, n = 10) were also reported. About one in four participants experienced nausea, vomiting and chills; fever was infrequent (2.5%, n = 5).

CONCLUSIONS

For gestations 13-18 weeks, an outpatient day process for medication abortion is safe, effective and feasible.

IMPLICATIONS

Medication abortion in 13 - 18 weeks need not be limited to inpatient care; nine of ten cases can be managed as an outpatient day service.

Current and potential methods for second trimester abortion

Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.