Factors influencing the duration of late first and second-trimester termination of pregnancy with prostaglandin derivates

Complication rate after termination of pregnancy for fetal defects

OBJECTIVES

To assess the risk of complications in women undergoing termination of pregnancy (TOP) for fetal defects and to examine the impact of gestational age on the complication rate.

METHODS

This was a retrospective study of women with a singleton pregnancy undergoing TOP at the University Hospital of Tübingen, Germany, between 2018 and 2021. TOP was performed by experienced operators according to the national protocol; dilatation and curettage (D&C) or evacuation (D&E) was used in the first and early second trimesters and induction was used later in pregnancy. The following were considered to be significant procedure-related complications: blood loss of more than 500 mL, uterine perforation, need for blood transfusion, allergic reaction, creation of a false passage (via falsa), systemic infection, readmission to hospital, any unplanned surgical procedure, such as repeat D&C/D&E or hysterectomy, and maternal death.

RESULTS

The search of the hospital database identified 416 pregnancies that met the study criteria. Median maternal and gestational age at termination were 34.1 years and 17.4 weeks, respectively. In the first, second and third trimesters, respectively, 84 (20.2%), 278 (66.8%) and 54 (13.0%) pregnancies were terminated, for which D&C or D&E was used in 80 (95.2%), 21 (7.6%) and 0 (0.0%) cases. Seventy-seven (18.5%) women had at least one previous Cesarean section and 169 (40.6%) had at least one previous spontaneous delivery. Overall, 95 (22.8%) women had complications during or after TOP. A significantly higher complication rate was noted for terminations performed later in pregnancy. The median gestational age at termination was 16.6 weeks in women who did not experience complications and 20.7 weeks in those with complications (P < 0.001). The respective complication rates in the first, second and third trimesters were 6.0%, 27.0% and 27.8%.

CONCLUSION

In women undergoing TOP for fetal defects, the risk of complications increases with advancing gestational age. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Factors Influencing the Duration of Termination of Pregnancy for Fetal Anomaly with Mifepristone in Combination with Misoprostol

This study's aim was to determine relevant factors that influence the time interval between first induction and fetal expulsion in late termination of pregnancy (TOP) and TOP after previous feticide for severe fetal malformation with a mifepristone-misoprostol regime. This retrospective study included 913 TOPs from a single tertiary care referral center. In 197 out of 913 TOPs, a previous feticide had been performed due to advanced gestational age (after 22 + 0 weeks of gestation). Induction was accomplished using 600 mg mifepristone followed by 400 μg misoprostol. The interval between first induction with misoprostol and fetal expulsion was examined. Univariate and multivariate logistic regression analysis were used to predict an induction interval of 12 h or less. The median gestational age at induction of labor was 18.9 weeks of pregnancy. In 487 (53.3%) cases women delivered within 12 h; in 344 (37.7%) cases the induction interval was between 12 h and 36 h. In 82 (9%) cases induction took longer than 36 h. Factors that were significantly associated with a delivery duration of <12 h were a lower gestational age at induction (OR 0.87; 95% CI 0.84-0.89; p < 0.001) and a history of at least one previous vaginal delivery (OR 1.57; 95% CI 1.20-2.05; p < 0.001). Factors that had no impact included previous cesarean section, performing feticide before induction and maternal age. Maternal BMI showed a non-significant trend.

[Factors Associated with Prolonged Duration of Labor in Medical Termination of Pregnancy in the 2nd and 3rd Trimesters]

OBJECTIVE

In the context of a medical termination of pregnancy, prolonged labor may accentuate the difficulty of women's experience and increase the risk of associated complications. The factors associated with prolonged labor are not known. Reducing the duration of labor could limit these complications. Determining the relevant factors associated with prolonged labor defined as a delay between the onset of induction and delivery greater than or equal to 12hours and comparing the complications rates between the two groups.

METHOD

We conducted a retrospective study at Port Royal Maternity Hospital from 2017 to 2019, including medical terminations of pregnancy by vaginal delivery in the 2nd and 3rd trimesters for fetal or maternal reasons.

RESULTS

Two hundred twenty-seven patients were included and divided into two comparative groups based on the duration of labor: labor <12h (n=173) and labor ≥12h (n=54). The mean maternal age was 33.7 years. Forty-four percent of patients were nulliparous, 15.8 % had a history of cesarean section. The average gestational age was 20+2 weeks of gestation. The average duration of labor was 9.7hours. The duration of labor was greater than 24hours in 3% of cases (7/227). Advanced gestational age (22+3 vs. 20+5 p=0,04) and nulliparity (p=0.01) were associated with prolonged labor. Two other intermediate factors, not independent of the duration of labor, were significant: long time to rupture of membranes (239min vs. 427min p<0,01) and an unfavorable Bishop score at rupture (p=0,003). In both groups, the complications were placental retention and the occurrence of fever during labor.

CONCLUSION

Two main factors affecting labor duration were identified in this study (term and nulliparity). This knowledge could allow women to be better informed about the expected time of labor and the potential associated risks.

Incidence and contributing factors for uterine rupture in patients undergoing second trimester termination of pregnancy in a large tertiary hospital - a 10-year case series

INTRODUCTION

Uterine rupture is a rare complication in second trimester termination of pregnancy (TOP) with an overall incidence of up to 1.1%. There are concerns that patients with previous caesarean section(s) were at an increased risk of uterine rupture. However, there is no published data in our local population to date. This study aims to identify the incidence and contributing factors for uterine rupture in women undergoing TOP in Singapore.

STUDY DESIGN

This is a retrospective review of all women who had TOP between 14⁺⁰ weeks to 23⁺⁶ weeks gestation from January 2005 to December 2014 in a large tertiary hospital. Patients' characteristics and details of TOP were retrieved from pre-existing hospital databases. The gestation age and dose of gemeprost used were retrieved from an internal hospital audit conducted from December 2012 to July 2016.

RESULTS

A total of 3385 patients underwent TOP from 2005 to 2014. An estimated 339 patients had a scarred uterus. Seven cases of uterine rupture were identified, with an overall incidence of 0.21% (7/3385). The incidence of uterine rupture in patients with scarred uterus was 2.1% (7/339). Contributing factors identified included higher mean dose of abortifacient, usage of multiple abortifacients and methods, advanced gestation age and short interval between last caesarean section and current TOP.

CONCLUSION

Second trimester TOP on scarred uterus warrants careful usage of abortifacient with minimal cumulative dosage and should be carried out in early second trimester gestation whenever feasible. Prostaglandin analogues appeared to be safe for TOP in unscarred uteruses.

Mifepristone and misoprostol is safe and effective method in the second-trimester pregnancy termination

PURPOSE

The second-trimester medical abortions constitute 10-15 % of all induced abortions worldwide, but are responsible for two-thirds of major abortion related complications. During the last decade, medical methods for the second-trimester-induced abortion have been become safer and more accessible. The aim of this study is to evaluate factors affecting clinical effectiveness of the second-trimester medical terminations using mifepristone and misoprostol combination.

METHODS

In this retrospective observational study, 142 consecutive women underwent medical abortion on 12-24 weeks of gestation. Clinical data were collected from Oulu University Hospital patients' records for the period between January 2008 and June 2011. The associations between patient characteristics and different outcomes were evaluated using the standard statistical test for correlation.

RESULTS

The majority (92 %) of women aborted successfully within 24 h and were considered as day cases with small complication rate, as compared to hospitalized patients. In nulliparous patients, the time for complete abortion was longer than in other groups (P < 0.0019). Nulliparous women and women with gestation more than 16 weeks required opiate analgesia more often (P = 0.003 and <0.001, respectively).

CONCLUSION

Women with previous live births aborted more often within 8 h than women with no previous births. Mifepristone and misoprostol is safe and effective method for the second-trimester pregnancy termination. The second-trimester medical abortion can be provided by a nurse-midwife with the back-up of a gynecologist.

Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies

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.

Comparison of two misoprostol regimens for mid-trimester pregnancy terminations after FIGO's misoprostol dosage recommendation in 2012

OBJECTIVE

To compare the safety and efficacy of two misoprostol regimens for mid-trimester pregnancy terminations.

METHODS

Retrospective analysis of 263 cases of pregnancy terminations with misoprostol between 12 and 24 weeks was performed. Group 1 (total 129 patients) consisted of patients who were given 200 mcg vaginal misoprostol every 4 h until the abortion, whereas Group 2 patients (total 134 patients) were given misoprostol as in International Federation of Gynecology and Obstetrics's (FIGO) 2012 recommendation. In case of a previous cesarean section doses were halved in both groups. Primary outcomes of the study were the time to abortion and the total drug dose used. Secondary outcome was the rate of complications.

RESULTS

Total dose and time to abortion did not differ between the groups. As for complications, one patient (%0.8) in group 1 developed HELLP syndrome and had hysterotomy. One patient (%0.8) in group 2 had uterine rupture and had total hysterectomy. Two patients in both groups considered failure of induction and terminated with surgery (hysterotomy). Groups did not show difference in induction failure rates.

CONCLUSIONS

We respect the presence of dose recommendation stated by the FIGO and found similar results with our recent protocol. Other misoprostol regimens used worldwide should also be compared with this guideline in order to improve its efficacy.

Influence of Mifepristone in Induction Time for Terminations in the Second and Third Trimester

Termination of pregnancy after the first trimester is generally carried out by medical induction. Question: The aim of this study is to investigate the effect of mifepristone before administration of the prostaglandin derivative on induction time. Material and Methods: We analysed 333 medically indicated terminations after the first trimester under the terms of § 218 a Para. 2 of the German Criminal Code, in which the prostaglandin derivatives misoprostol, gemeprost or dinoprostone were administered with or without pre-treatment with 600 mg of mifepristone. The time interval between the initial administration of prostaglandin and delivery was investigated. Using uni- and multivariate regression analysis, the effect of maternal age, body mass index, gravidity and parity, previous Caesarean sections, gestational age and the induction regimen on the induction time were analysed. Results: The average induction time was significantly shortened with mifepristone (15.1 ± 11.9 hours with mifepristone vs. 25.3 ± 24.2 hours without mifepristone [p < 0.001]). The combination of mifepristone and misoprostol was most frequently used and proved to be the most effective regimen, reducing the induction period to 13.6 ± 10.3 hours. Besides pre-treatment with mifepristone, gestational age and a history of delivery without Caesarean section were significant influencing factors in reducing the induction time. Conclusion: The induction interval can be significantly shortened by the prior administration of mifepristone. The combination of mifepristone and misoprostol or gemeprost is the most effective regimen for the medical termination of pregnancy.

[Misoprostol in case of termination of pregnancy in the second and third trimesters. Trials]

Termination of pregnancies (TOP), in the second and third trimesters, require feasibility to induce labour with unfavorable cervix. Combination therapy is then usually necessary. Misoprostol use is out of marketing authorization in obstetrics but is widely used for many years in TOP in the 2nd and 3rd trimesters of pregnancy. Most randomized trials comparing misoprostol to other molecules available for TOP (gemeprost, dinoprostone, sulprostone) show that misoprostol is at least as effective with fewer side effects often especially if using adapted doses and routes of administration. Sometimes, products with a marketing authorization have been used with caution due to adverse effects more or less reported with misoprostol. There is, however, no conclusive evidence in the literature showing the superiority of a dose or route of administration of misoprostol compared to another. However, sublingual and oral seem to be preferred by patients than the vaginal route which remains the most evaluated and effective route. In summary, the use of vaginal misoprostol is the first-line treatment in medical abortion in the 2nd and third trimester, in combination with at least 200mg of mifepristone 36 to 48 hours before, at a dose of 400 μg every 4 to 6 hours. However, its use must be given with caution in cases of uterine scar, but cannot be forbidden for the sole justification of not having a marketing authorization. It will nevertheless warrant information to patients and allow a reduction at least half doses. The multi-scarred uterus still justifies a lower starting dose in the minimum effective doses (100 μg or less) as a corollary, increased induction-expulsion delay. The risk-benefit balance must be discussed with the patient. The agent without any pharmacological action solely or in combination (laminar dilapans, Foley catheter or double balloon) is particularly interesting in the case of uterine scar or maternal vascular risk but requires further evaluation by other research with adequate power and methodology before recommending for systematic routine use.

Mifepristone followed by misoprostol or oxytocin for second-trimester abortion: a randomized controlled trial

OBJECTIVE

To compare two methods for induction of second-trimester abortion after priming the cervix with mifepristone.

METHODS

This was a randomized prospective trial carried out between January 2009 and February 2012. The participants were healthy women between 14 and 24 weeks of gestation with missed miscarriage or need for termination of pregnancy. All participants received oral 200 mg mifepristone and, after 36 hours, after randomization, were given either a high-concentration oxytocin drip (maximal dose of 150 milli-international units/min) for up to 36 hours or 800 micrograms misoprostol vaginally followed by 400 micrograms oral misoprostol every 3 hours with a maximum of four oral doses. If expulsion of the fetus was not achieved, another 200 mg mifepristone was administered and another course of misoprostol was delivered as described previously. The primary outcome measure was success expulsion of the fetus in 36 hours since starting on uterotonic agent. Secondary outcomes included time until expulsion of the fetus and rate of adverse outcomes.

RESULTS

Success rates in the mifepristone-misoprostol and mifepristone-oxytocin arms were 100% (70/70 patients) and 95.8% (69/72), respectively (relative risk 1.043, 95% confidence interval 0.99-1.10, P=.13). Time until fetal expulsion was shorter in the mifepristone-misoprostol arm (7.0 ± 4.9 hours compared with 11.3 ± 7.4 hours, P<.001). However, the rate of adverse effects in the misoprostol group was higher than in the oxytocin group. Factors associated with a shorter time until expulsion were missed miscarriage compared with therapeutic abortion, increased ultrasonographic gestational age, and increased parity.

CONCLUSION

The two regimens studied had comparable efficacy for induction of second-trimester abortion; however, the mifepristone-oxytocin regimen has a longer time until expulsion but with fewer side effects.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00784797.

LEVEL OF EVIDENCE

: I.

Misoprostol versus High Dose Oxytocin and Laminaria in Termination of Pregnancy in Second Trimester Pregnancies

BACKGROUND

In 2 recent decades, found drug regimen to induce abortion that are more effective than surgery. Prostaglandins especially misoprostol, oxytocin and osmotic dilators such as laminaria use for termination but the best method is unknown. Therefore we aimed to assess the comparison between the Misoprostol regimen and the highly concentrated oxytocin with laminaria regimen in second trimester of pregnancy termination.

METHODS

In this randomized clinical trial, 100 women with gestational age 14 to 24 week coming to hospital due to termination of pregnancy in the absence of uterine contractions and items of exclusion criteria enrolled to study and randomly assign to 2 groups and received misoprostol (group 1) or oxytocin (group 2). Data collected with use of observation, examination and demographic checklist. In group 1, in admission time and then every 6 hour patients received 200 µgr misoprostol until start the pain or vaginal bleeding or abortion in 48 hr. in group 2, patients first received laminaria in cervix with duration of 6 hr and then oxytocin 50 unit in 500 cc normal saline in 3 hr. after 1 hr rest, oxytocin dosage elevated as multiple into 2 and continue until termination or maximum dose of 300 u in 500 cc normal saline. Data entered to SPSS software version 16 and analyzed with use of descriptive methods and also Chi-square and T-test.

RESULTS

In each group enrolled 50 women that approximately no different in baseline characteristic. Number of abortion in misoprostol group was more than oxytocin group (P<0.001) and duration of abortion also was shorter than oxytocin in misoprostol group (P<0.001). Side effects in 23 (46%) women in misoprostol group were seen but no side effect seen in oxytocin group. Complementally interventions was seen in 31 women (60%) in misoprostol group versus 32 women (62%) in oxytocin group but this difference was not significant (P>0.05).

CONCLUSION

This study demonstrated that misoprostol is effective than oxytocin in termination of pregnancy but with attention to limitation of this study include of limited abortion causes due to legal laws, additional studies on different doses of misoprostol and oxytocin due to achieve to suitable regimen with lower side effects recommended.

Control of uterine microenvironment by foxp3(+) cells facilitates embryo implantation

Implantation of the fertilized egg into the maternal uterus depends on the fine balance between inflammatory and anti-inflammatory processes. Whilst regulatory T cells (Tregs) are reportedly involved in protection of allogeneic fetuses against rejection by the maternal immune system, their role for pregnancy to establish, e.g., blastocyst implantation, is not clear. By using 2-photon imaging we show that Foxp3(+) cells accumulated in the mouse uterus during the receptive phase of the estrus cycle. Seminal fluid further fostered Treg expansion. Depletion of Tregs in two Foxp3.DTR-based models prior to pairing drastically impaired implantation and resulted in infiltration of activated T effector cells as well as in uterine inflammation and fibrosis in both allogeneic and syngeneic mating combinations. Genetic deletion of the homing receptor CCR7 interfered with accumulation of Tregs in the uterus and implantation indicating that homing of Tregs to the uterus was mediated by CCR7. Our results demonstrate that Tregs play a critical role in embryo implantation by preventing the development of a hostile uterine microenvironment.

To compare the methods of pregnancy termination for fetal abnormality in the first and second trimesters

Fetal abnormality is a major cause of termination of pregnancy and preservation of the fetus is important for confirmation of the diagnosis. Various regimes have been reported for termination of pregnancy for fetal abnormality in the first and the second trimesters. In this paper, we compare those regimes that allow preservation of the fetus, in terms of the efficacy in expulsion of the fetus, the factors and the side effects.