Audit of the effectiveness of cervical preparation with Dilapan prior to late second-trimester (20-24 weeks) surgical termination of pregnancy

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.

Comparison of surgical versus medical termination of pregnancy between 13-20 weeks of gestation in Ethiopia: A quasi-experimental study

Background

Dilation and evacuation is a method of second trimester pregnancy termination introduced recently in Ethiopia. However, little is known about the safety and effectiveness of this method in an Ethiopian setting. Therefore, the study is intended to determine the safety and effectiveness of dilation and evacuation for surgical abortion as compared to medical abortion between 13–20 weeks’ gestational age.

Methods

This is a quasi-experimental study of women receiving second trimester termination of pregnancy between 13–20 weeks. Patients were allocated to either medical or surgical abortion based on their preference. A structured questionnaire was used to collect demographic information and clinical data upon admission. Procedure related information was collected after the procedure was completed and before the patient was discharged. Additionally, women were contacted 2 weeks after the procedure to evaluate for post-procedural complications. The primary outcome of the study was a composite complication rate. Data were collected using Open Data Kit and then analyzed using Stata version 14.2. Univariate analyses were performed using means (standard deviation), or medians (interquartile range) when the distribution was not normal. Multiple logistic regression was also performed to control for confounders.

Results

Two hundred nineteen women chose medical abortion and 60 chose surgical abortion. The composite complication rate is not significantly different among medical and surgical abortion patients (15% versus 10%; p = 0.52). Nine patients (4.1%) in the medical arm required additional intervention to complete the abortion, while none of the surgical abortion patients required additional intervention. Median (IQR) hospital stay was significantly longer in the medical group at 24 (12–24) hours versus 6(4–6) hours in the surgical group p<0.001.

Conclusion

From the current study findings, we concluded that there is no difference in safety between surgical and medical methods of abortion. This study demonstrates that surgical abortion can be used as a safe and effective alternative to medical abortion and should be offered equivalently with medical abortion, per the patient’s preference.

Society of Family Planning clinical recommendations: Cervical preparation for dilation and evacuation at 20-24 weeks' gestation

Although only 1.3% of abortions in the United States are between 20 and 24 weeks' gestation, these procedures are associated with elevated risks of morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20-24 weeks' gestation reduces procedural risk. For this gestational range, at least one day of cervical preparation with osmotic dilators is recommended before D&E. The use of overnight osmotic dilators alone is sufficient for most D&Es at 20-24 weeks' gestation. Dilapan-S® dilators require a shorter time to achieve maximum dilation, may be more effective than laminaria and may increase the likelihood of success on the first D&E attempt. The use of adjunctive mifepristone administered one-day pre-operatively at the time of osmotic dilator placement, should be considered because evidence demonstrates that it makes D&E subjectively easier at 20-24 weeks without increasing side effects. While older studies suggest that two-days of serial osmotic dilators provide greater dilation than one day of dilators, adjunctive mifepristone may be comparable to a second day of dilators. Adjunctive misoprostol administered on the day of D&E does not appear to affect initial cervical dilation and procedure time and compared with mifepristone is associated with more side effects, such as pain and nausea. Using overnight mifepristone and same-day misoprostol without osmotic dilators at 20-24 weeks' gestation lengthens D&E procedure time and appears to increase immediate complications, at least among less experienced providers. Some evidence shows the feasibility of same-day cervical preparation before D&E at 20-24 weeks using Dilapan-S® with adjunctive misoprostol or serial repeat dosing of misoprostol, but same-day preparation should be limited to providers with significant experience with these regimens. The Society of Family Planning recommends preoperative cervical preparation before D&E at 20-24 weeks' gestation. Further studies are needed to clarify the best means of preparing the cervix in order to minimize abortion complications and improve outcomes in this gestational range.

Buccal misoprostol plus laminaria for cervical preparation before dilation and evacuation at 21-23 weeks of gestation: a randomized controlled trial

OBJECTIVE

To describe the effectiveness of buccal misoprostol as an adjunct to laminaria for cervical ripening before later second-trimester abortion by dilation and evacuation (D&E).

METHODS

A randomized, double-blinded, placebo-controlled trial of 196 women undergoing D&E between 21 and 23 weeks of gestation. Subjects had overnight laminaria and 400 mcg buccal misoprostol or placebo 3-4 h before the abortion. We used logarithmic transformation of the primary outcome--D&E procedure duration--to achieve a normal distribution.

RESULTS

Mean D&E duration was 1.7 min shorter with misoprostol (p=.02). The median duration was 9.7 versus 10.4 min in the misoprostol and placebo groups, respectively (p=.09). Cervical dilation was slightly greater with misoprostol (median 75 mm vs. 73 mm, p=.04); however, physicians did not find the misoprostol D&Es easier to complete. Half of subjects reported severe pain after misoprostol vs. 11% with placebo (p<.001).

CONCLUSION

Adjuvant buccal misoprostol results in slightly shorter D&Es at the cost of more side effects.

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

For a dilation and evacuation (D&E) procedure, the cervix must be dilated sufficiently to allow passage of operative instruments and products of conception without injuring the uterus or cervical canal. Preoperative preparation of the cervix reduces the risk of cervical laceration and uterine perforation. The cervix may be prepared with osmotic dilators, pharmacologic agents or both. Dilapan-S™ and laminaria are the two osmotic dilators currently available in the United States. Laminaria tents, made from dehydrated seaweed, require 12-24 h to achieve maximum dilation. Dilapan-S™, made of synthetic hydrogel, achieves significant dilation within 4 h and is thus preferable for same-day procedures. A single set of one to several dilators is usually adequate for D&E before 20 weeks' gestation. Misoprostol, a prostaglandin E1 analogue, is sometimes used instead of osmotic dilators. It is generally regarded as safe and effective; however, misoprostol achieves less dilation than overnight osmotic tents. The literature supports same-day cervical preparation with misoprostol or Dilapan-S™ up to 18 weeks' gestation. As the evidence regarding alternative regimens increases, highly experienced D&E providers may consider same-day regimens at later gestations utilizing serial doses of misoprostol or a combination of osmotic and pharmacologic agents. Misoprostol use as an adjunct to overnight osmotic dilation is not significantly beneficial before 19 weeks' gestation. Limited data demonstrate the safety of misoprostol before D&E in patients with a prior cesarean delivery. Mifepristone, a progesterone receptor antagonist, is also effective for cervical preparation prior to D&E, although data to support its use are limited. The Society of Family Planning recommends preoperative cervical preparation to decrease the risk of complications when performing a D&E. Since no single protocol has been found to be superior in all situations, clinical judgment is warranted when selecting a method of cervical preparation.

Cervical preparation for second trimester dilation and evacuation

BACKGROUND

Abortion during the second trimester of pregnancy accounts for 10-15% of abortions performed worldwide. Dilation and evacuation (D&E) is the preferred method of second-trimester abortion in most parts of the developed world. Cervical preparation is recommended for dilation and curettage (D&C) after 12 weeks gestation and is standard practice for D&E beyond 14 weeks gestation. Prostaglandins, osmotic dilators, and Foley balloon catheters have been used and studied as cervical preparation prior to second-trimester D&E. However, no consensus exists as to which cervical preparation method is superior with regards to safety, procedure time, need for additional dilation, ability to perform the procedure, or patient and provider acceptability. Despite the fact that the advent of osmotic dilation has improved the safety of the D&E procedure during the second trimester, it is unclear whether a certain type of osmotic dilator is superior to another or whether osmotic dilation with adjuvant prostaglandin is superior to osmotic dilation alone or to prostaglandins alone.

OBJECTIVES

This review evaluates cervical preparation methods for second-trimester surgical abortion with respect to differences in procedure time, dilation achieved, need for additional dilation, complications, ability to complete the procedure, patient pain scores, and patient and provider acceptability and satisfaction.

SEARCH STRATEGY

We searched for trials of cervical preparation prior to second-trimester D&E.

SELECTION CRITERIA

We included all randomized controlled trials that compared osmotic, mechanical, antiprogesterone, prostaglandin, or other medical agents of cervical preparation for second-trimester surgical abortion from 14-24 weeks of gestation.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and data entry was verified by a third author. Mean difference and Peto Odds Ratio were calculated.

MAIN RESULTS

Osmotic dilators were found to be superior to prostaglandins with respect to cervical dilation throughout the second trimester and with respect to procedure time within the early second trimester. Addition of prostaglandins to osmotic dilators was not found to increase cervical dilation, except after 19 weeks gestation, however, no impact was seen on procedure time. Addition of Mifepristone to misoprostol was found to improve cervical dilation, yet increase procedure time and frequency of pre-procedural expulsions. Two-day cervical preparation was found to produce greater cervical preparation than one-day, but had no impact on procedure time. Serious complication rates or ability to complete the procedure did not differ significantly between any of the preparation methods reviewed.

AUTHORS' CONCLUSIONS

Cervical preparation with osmotic dilators and/or misoprostol before second-trimester D&E is safe and effective. Osmotic dilators appear to provide superior cervical dilation when compared to prostaglandins alone or when combined with prostaglandins, however this difference in cervical dilation does not appear to result in differences in procedure time or complication rates. There does not appear to be clear clinical benefit from two days of cervical preparation compared to one-day prior to second-trimester D&E below 19 weeks gestational duration. Mifepristone plus misoprostol was associated with high rates of pre-procedural expulsions and does not appear to be a useful method of cervical preparation before second-trimester dilation and evacuation. Same-day procedures appear to be a safe and reasonable option in the early second trimester, however, more research is needed to assess the effectiveness and safety of same-day procedures in the later second trimester.

Audit of short term outcomes of surgical and medical second trimester termination of pregnancy

Background

As comparisons of modern medical and surgical second trimester termination of pregnancy (TOP) are limited, and the optimum method of termination is still debated, an audit of second trimester TOP was undertaken, with the objective of comparing the outcomes of modern medical and surgical methods.

Methods

All cases of medical and surgical TOP between the gestations of 13 and 20 weeks from 1st January 2007 to 30th June 2008, among women residing in the local health board district, a tertiary teaching hospital in an urban setting, were identified by a search of ICD-10 procedure codes (surgical terminations) and from a ward database (medical terminations). Retrospective review of case notes was undertaken. A total of 184 cases, 51 medical and 133 surgical TOP, were identified. Frequency data were compared using Chi-squared or Fischer's Exact tests as appropriate and continuous data are presented as mean and standard deviation if normally distributed or median and interquartile range if non-parametric.

Results

Eighty-one percent of surgical terminations occurred between 13 to 16 weeks gestation, while 74% of medical terminations were performed between 17 to 20 weeks gestation. The earlier surgical TOP occurred in younger women and were more often indicated for maternal mental health. Sixteen percent of medical TOP required surgical delivery of the placenta. Evacuation of retained products was required more often after medical TOP (10%) than after surgical TOP (1%). Other serious complications were rare.

Conclusion

Both medical and surgical TOP are safe and effective for second trimester termination. Medical TOP tend to be performed at later gestations and are associated with a greater likelihood of manual removal of the placenta and delayed return to theatre for retained products. This case series does not address long term complications.