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Chandrasekaran S, Ruggiero S, Goodrick G. Outpatient medical management of later second trimester abortion (18-23.6 weeks) with procedural evacuation backup: A large case series. Contracept X 2024; 6:100104. [PMID: 38515629 PMCID: PMC10950721 DOI: 10.1016/j.conx.2024.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 03/23/2024] Open
Abstract
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.
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Bettahar K, Koch A, Deruelle P. [Medical strategy for abortions between 14 and 16 weeks of gestation]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:735-740. [PMID: 36183986 DOI: 10.1016/j.gofs.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- K Bettahar
- Service de gynecologie obstetrique, CHU de Strasbourg, 1, place de l'Hôpital, BP 426, site du CMCO, 67091 Strasbourg cedex, France.
| | - A Koch
- Service de gynecologie obstetrique, CHU de Strasbourg, 1, place de l'Hôpital, BP 426, site du CMCO, 67091 Strasbourg cedex, France.
| | - P Deruelle
- Service de gynecologie obstetrique, CHU de Strasbourg, 1, place de l'Hôpital, BP 426, site du CMCO, 67091 Strasbourg cedex, France.
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Cohen MA, Kapp N, Edelman A. Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective. Clin Obstet Gynecol 2021; 64:460-474. [PMID: 34323228 DOI: 10.1097/grf.0000000000000631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Megan A Cohen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | | | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
- Ipas, Chapel Hill, North Carolina
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Ruggiero S, Brandi K, Mark A, Paul M, Reeves MF, Schalit O, Blanchard K, Key K, Chandrasekaran S. Access to later abortion in the United States during COVID-19: challenges and recommendations from providers, advocates, and researchers. Sex Reprod Health Matters 2020; 28:1774185. [PMID: 32460663 PMCID: PMC7887955 DOI: 10.1080/26410397.2020.1774185] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
| | - Kristyn Brandi
- Assistant Professor, Department of Obstetrics, Gynecology, and Women's Health, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Alice Mark
- Medical Director, National Abortion Federation, Washington, DC, USA
| | - Maureen Paul
- Consultant, Ibis Reproductive Health, Cambridge, MA, USA
| | - Matthew F Reeves
- Executive Director, DuPont Clinic, Washington, DC, USA.,Adjunct Associate Professor of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Odile Schalit
- Executive Director, Brigid Alliance, New York, NY, USA
| | | | - Katherine Key
- Project Manager, Ibis Reproductive Health, Cambridge, MA, USA
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Henkel A, Lerma K, Blumenthal PD, Shaw KA. Evaluation of shorter mifepristone to misoprostol intervals for second trimester medical abortion: a retrospective cohort study. Contraception 2020; 102:327-331. [PMID: 32592800 DOI: 10.1016/j.contraception.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/26/2022]
Abstract
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 220/7 weeks (range: 150/7-270/7) 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.
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Affiliation(s)
- Andrea Henkel
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA.
| | - Klaira Lerma
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Paul D Blumenthal
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Kate A Shaw
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
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Feasibility of a hospital outpatient day procedure for medication abortion at 13-18 weeks gestation: Findings from Nepal .. Contraception 2019; 100:451-456. [PMID: 31491379 DOI: 10.1016/j.contraception.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/21/2019] [Accepted: 08/26/2019] [Indexed: 11/24/2022]
Abstract
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.
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Lerma K, Blumenthal PD. Current and potential methods for second trimester abortion. Best Pract Res Clin Obstet Gynaecol 2019; 63:24-36. [PMID: 31281014 DOI: 10.1016/j.bpobgyn.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Klaira Lerma
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA.
| | - Paul D Blumenthal
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA
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