Update on second-trimester surgical abortion

Missouri's Abortion law: Access to care for Patients with Lethal Fetal Anomalies at a Midwest Tertiary care Center

OBJECTIVES

Missouri passed an 8-week gestational age abortion in August 2019. The objective of this study was to compare distance and time from referral to evaluation between patients who continued their pregnancy and those who terminated in patients with severe and lethal fetal anomalies and estimate the impact of the Missouri gestational age abortion ban on distance to abortion care in this patient population.

METHODS

This is a retrospective cohort study of patients seen at the Washington University in St. Louis (WUSTL) Fetal Care Center (FCC) with a severe or lethal fetal anomaly between July 2018 and June 2019. Patient characteristics including gestational age at referral and distance traveled to the FCC were compared between patients who underwent abortion and who continued their pregnancies.

RESULTS

From July 2018 to June 2019, 463 patients were seen in the Fetal Care Center and 13% (60/463) were diagnosed with severe or lethal fetal anomalies comprising the study population for this analysis. Of these, 21 (35%) patients underwent an abortion, and 39 (65%) patients continued their pregnancy. Patients who underwent abortion were referred at a significantly earlier gestational age (median 19 weeks [IQR 17, 20 weeks] v. 20 weeks [IQR 18, 24 weeks]), p = 0.04. There was a statistically significant difference between the median latency time between patients who underwent an abortion and who continued their pregnancy (median 8 days [IQR 4,13 days] v. 14 days [IQR 9, 22 days], p < 0.01).

CONCLUSION

Patients with severe or lethal fetal anomalies are often evaluated at later gestational ages, which may preclude their access to abortion services.

Termination of pregnancy in the second trimester - the course of different therapy regimens

OBJECTIVES

To compare two prostaglandin analogs and two application intervals between mifepristone and the prostaglandin analog administration on the time to abortion in second trimester termination of pregnancy. Other endpoints were live birth rate and fetal lifetime after expulsion.

METHODS

Retrospective data of 373 abortions performed were evaluated. Four medical induction subgroups and two feticide subgroups were considered. The definition criteria of the subgroups were the choice of administered prostaglandin analog (misoprostol vs. sulprostone) and the time interval between mifepristone and prostaglandin analog administration (48 vs. 24 h). The outcome parameters were the time to complete uterine evacuation (TCUE), the live birth rate and duration of fetal life.

RESULTS

In the misoprostol subgroups, the median TCUE was 1.6 h longer in the 24-h group than in the 48-h group (p=0.950). In the sulprostone subgroups, the median TCUE was 1.9 h shorter in the 24-h group than in the 48-h group (p=0.950). The median TCUE was shorter for sulprostone than for misoprostol in all six subgroups (p<0.001). The rate of fetal live births ranged between 13.6 and 15.9% within the medical induction subgroups (p=0.969). The median fetal lifetime was slightly shorter in the sulprostone groups than in the misoprostol groups (p=0.563).

CONCLUSIONS

Both application intervals and prostaglandin analogs are similarly effective. The therapy regime should be adapted to the personal preferences of the woman, the situational and clinical conditions.

Foley catheter for cervical preparation prior to second trimester dilation and evacuation: A supply-based alternative for surgical abortion: A case series

OBJECTIVE

To document the use of Foley catheter as an alternative to osmotic dilators for cervical preparation before second trimester dilation and evacuation at a tertiary setting in Ethiopia.

METHODS

This is a retrospective case series conducted at St. Paul's Hospital Millennium Medical College (Ethiopia) from April 1, 2021 to August 30, 2021. Forty-three cases of dilation and evacuation (D&E) in which overnight intra-cervical Foley catheter placement was used to prepare the cervix were reviewed. Data were analysed using SPSS version 23 and simple descriptive statistics were applied to analyze the clinical characteristics of study subjects and procedure outcomes. Percentages and frequencies were used to present the findings.

RESULTS

The calculated median gestational age was 21.4(17-24.2) weeks. Around 40%(17/43) of cases had cervical dilation of 3 to 4 cm, with another 33% (14/43) achieving cervical dilation of 1.5 to 2.5 cm. Additional dilation during the procedure was required only in 12 cases (28%) prior to D&E procedure. In 36 cases (84%), the procedure was attended by family planning fellow.

CONCLUSION

Cervical preparation using overnight Foley catheter before second-trimester D&E resulted in majority of the cases requiring no additional dilation immediately prior to D&E procedure. Where osmotic dilators are not available, Foley catheter can be an alternative method to prepare the cervix prior to D&E procedures.

IMPLICATIONS

In the absence of osmotic dilators, Foley catheter can be used as an alternate, and readily available means of cervical preparation for second trimester D&E procedures.

Incidence of uterine rupture in second-trimester abortion with gemeprost alone compared to mifepristone and gemeprost

OBJECTIVES

To compare uterine rupture rates in women having a medical abortion receiving gemeprost alone to those receiving mifepristone plus gemeprost.

STUDY DESIGN

We reviewed the records of women undergoing medical abortion at 13 0/7-23 6/7 weeks from January 2007 to December 2014 at a single center in Italy. Prior to January 2011, we used gemeprost 1 mg vaginally every 3 h up to a maximum of five doses. After January 2011, we added mifepristone 200 mg orally 24 h prior to the same gemeprost protocol. The primary outcome of the study was the incidence of uterine rupture. We compared the outcome between women receiving gemeprost alone with the combination of gemeprost and mifepristone.

RESULTS

One thousand and sixty-one (58.5%) and 753 (41.5%) women underwent medical abortion in the gemeprost-alone and the gemeprost/mifepristone groups, respectively. Five (0.47%) uterine ruptures occurred in the gemeprost and four uterine ruptures occurred in the gemeprost/mifepristone groups, respectively (0.53%) (p=.89). All uterine ruptures occurred in women with prior cesarean delivery.

CONCLUSIONS

We rep orted no difference in the incidence of uterine rupture between the gemeprost-alone and gemeprost and mifepristone groups.

IMPLICATIONS

Uterine rupture is a rare complication of second-trimester medical abortion with gemeprost. Use of mifepristone prior to gemeprost does not affect this risk.

Update on second trimester medical abortion

PURPOSE OF REVIEW

To review recent literature on second trimester abortion with medical methods.

RECENT FINDINGS

Across studies published in the recent past, it is apparent that women prefer shorter procedures and procedure times. Several randomized controlled trials have confirmed adding mifepristone to the second trimester medication abortion regimen results in shorter abortion intervals from first misoprostol administration to complete fetal expulsion. A study of simultaneous administration of mifepristone and misoprostol yielded shorter mean 'total' abortion times, presenting several logistical advantages. Recent studies on the continuous dosing of misoprostol have produced critical evidence to support continued dosing until expulsion. These studies had a more practical design compared with previous protocols that capped the number of misoprostol doses.

SUMMARY

Second trimester surgical abortion is well tolerated and increasingly expeditious. Further research is needed to refine second trimester medical abortion methods, specific to the mifepristone, misoprostol dosing interval. A 12-hour mifepristone to misoprostol interval may be the optimal interval balancing patient preferences and logistical considerations. Pragmatic dosing, including continuous dosing of misoprostol, could yield results that better inform clinical guidelines and reduce burden on patient, provider, and health facility.