Obstetric outcome of second trimester antenatal bleeding

Objective: To evaluate the clinical significance of vaginal bleeding in pregnant women between 14th and 22th gestational weeks.

Methods: This retrospective case–control study was conducted between September 2010 and December 2013. Two-hundred nineteen pregnant women with vaginal bleeding between 14th and 22th gestational weeks were compared with 325 pregnant women without vaginal bleeding for their maternal and early neonatal outcomes.

Results: Mean gestational age and birth weight of study group were significantly different from those of the control group respectively (37.9?±?2.8 versus 38.9?±?1.4 and 3071?±?710 versus 3349?±?446 for groups p?<?0.001). Vaginal bleeding between 14th and 22th gestational weeks had increased risk of having preterm birth (PB) and preterm premature rupture of membranes (PPROM) (OR: 10.8, 95% CI: [4.5–26.1]; OR: 12.0, 95% CI: [3.5–40.6], respectively). Gestational diabetes mellitus (GDM) and polyhydramnios ratio in the study group was significantly higher than the control respectively (4.1% versus 1.2%, p?=?0.031; 1.9% versus 0%, p?=?0.025).

Conclusion: Pregnant women with vaginal bleeding was a significantly risk factor for PB, PPROM, GDM, and polyhydramnios. Consequently, these pregnancies should be closely followed up for maternal and fetus complications.     

An advanced second trimester tubal pregnancy: Case report

BackgroundLack of early ultrasound examination and proper antenatal care in rural areas explain why most ectopic pregnancies are presented to our center only after they become disturbed. However, this is almost always restricted to the first trimester.CaseA middle aged woman presented with acute abdomen and hemodynamic instability was admitted at our emergency department. History revealed an unexpected definite period of amenorrhea of 18 weeks and 2 days duration and pregnancy test was found positive. Ultrasound examination showed hemoperitoneum and a right large adnexal swelling with a viable fetus inside and as such immediate exploration was decided. Laparotomy revealed profound intra-abdominal and pelvic blood collection and an advanced right tubal pregnancy with intact gestational sac. Right salpingectomy was done and the patient had a smooth postoperative course until being discharged.ConclusionAccording to this case, tubal pregnancy should always be considered even in the second trimester if the clinical presentation is relevant, and ultrasound examination is mandatory to identify pregnancy location.     

Randomized comparison of second trimester pregnancy termination utilizing saline moistened or dry misoprostol

Objective The aim of this randomized prospective study was to compare efficacy and side effects of saline moistened misoprostol with dry misoprostol, administered 800 μg intravaginally every 6 h up to a maximum of 3 doses in 24 h for second trimester pregnancy termination. Materials and methods A total of 81 women seeking termination of second trimester pregnancy (55 fetal death, 17 fetal structural anomaly, 5 chromosomal abnormality, 4 other reasons) were randomly assigned to one of two treatment groups: (1) intravaginal non-moistened (dry) misoprostol in group A (n = 40) or (2) misoprostol moistened with 3 ml of saline in group B (n = 41). Results All of the patients in either group aborted within 48 h (100% success rate). Delivery was achieved in a median (interquartile range) of 13 (40) h with the group A protocol and 12 (36) h with the group B protocol (P = 0.652). Delivery with first dose, delivery within 12 h and delivery within 24 h were similar (P > 0.05) in group B (34.1, 87.5 and 60%, respectively) and group A (25, 82.9, 46.3, respectively). Both treatment regimens were tolerable and with similar side effects. Conclusion Misoprostol moistened with saline was not more effective than dry misoprostol for second trimester pregnancy termination.     

Induction of hepatic granulopoiesis due to chorioamnionitis during the second trimester of development

Objective: To detect post mortem changes in fetal hematopoiesis consistent with infection from liver examination alone. Study design: We investigated the immunohistochemical expression of Glycophorin C, Neutrophilic elastase, and CD34, in the hepatic parenchyma from fetuses miscarried as a result of chorioamnionitis (caused by Chlamydia trachomatis) and correlated them with the equivalent from fetuses after voluntary abortion (gestational age: 16th, 20th, and 24th weeks). Results: A statistically significant difference was found in the Neutrophilic elastase positive cells to the advantage of cases with chorioamnionitis over voluntary abortions (24th week: P=0.0001, t-test) and also at the level of total hematopoiesis (20th and 24th week: P=0.041 and 0.004, respectively, t-test). There was no quantitative difference between the two settings at the level of erythropoiesis in the three examined periods. Conclusions: Fetal infection can be diagnosed from the liver alone. After detection of changes in fetal hematopoiesis indicative of infection, examination of additional specimens of placenta and membranes will document the diagnosis of chorioamnionitis.     

Vaginal misoprostol for second-trimester pregnancy termination after one previous cesarean delivery

Objective

To determine the safety and efficacy of using misoprostol vaginally for second-trimester abortion in women with a single previous cesarean delivery.

Method

This prospective observational study was carried out at a university hospital in Egypt with 50 pregnant women with 1 previous cesarean delivery; a gestation of at least 16 weeks but less than 20 weeks (group 1) or 20 or more weeks (group 2); and a need to terminate the pregnancy. The regimen was 4 doses of 200 μg of misoprostol applied vaginally every 4 hours daily, with a 12-hour nightly rest from misoprostol applications, until contractions appeared but not for more than 72 hours. The primary outcome was the induction-to-abortion interval.

Results

There were no cases of uterine rupture. Abortion within the study protocol occurred in 45 of the 50 women, for a 90% success rate. There was no significant difference in the induction-to-abortion interval between the 2 groups.

Conclusion

Inducing abortion with lower misoprostol doses appear to be safe and effective throughout the second trimester in women with a single previous cesarean delivery. Larger randomized trials are needed to validate these results.     

Women's experiences after an induced second trimester abortion

Objective

to describe women's experiences of an abortion in the second trimester.

Design

qualitative design using semi-structured interviews.

Setting/participants

six women were interviewed after a second trimester abortion.

Methods

the women were interviewed in person after they were discharged from the hospital. Interviews were recorded, transcribed, and then analysed using qualitative content analysis.

Findings

four categories were identified: to consider and accept the decision; to lack understanding about the abortion procedure; to be in need of support and information; to have memories for life. Findings show that information and support during the whole abortion process is important. Women found it difficult to make the decision and going through abortion left memories for life.

Conclusion

information and support is of great importance for women in this vulnerable situation. The need for further support points out the need to have follow-up contacts with women after an induced second trimester abortion.     

Mifepristone combined with misoprostol versus intra-amniotic injection of ethacridine lactate for the termination of second trimester pregnancy: a prospective, open-label, randomized clinical trial

Objectives

To compare the effectiveness and safety of mifepristone/misoprostol versus intra-amniotic injection of ethacridine lactate for the termination of second trimester pregnancy.

Study design

210 women requesting voluntary termination of pregnancies at between 16 and 24 weeks of gestation were randomly assigned into two groups. Group 1 (MM) received a single oral dose of 200 mg mifepristone and, 36-48 h later, 400 μg of misoprostol vaginally, with up to three additional oral doses of 400 μg misoprostol every 12 h. Group 2 (EL) received an intra-amniotic injection of 100 mg ethacridine lactate. The primary outcome was successful abortion rate. Secondary outcomes included the difference in the induction-to-abortion interval and the frequency of adverse events.

Results

Both MM and EL regimens were effective, with successful abortion rates of 96.19% and 94.29%, respectively (P = 0.746). The complete abortion rates were 68.57% and 70.48%, respectively. The induction-to-abortion interval was longer in the MM group than in the EL group (50.57 ± 6.80 h vs. 43.02 ± 8.74 h, respectively, P < 0.001). Both treatments were safe, although there was a significant difference in rates of gastrointestinal and fever adverse events between the two groups.

Conclusions

Both MM and EL regimens were effective with high success rates and were safe for the termination of second trimester pregnancy.     

Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy.

OBJECTIVES: To determine the perinatal outcome associated with severe chronic hypertension (SCH) in pregnancies of > or =20 weeks' gestation. METHODS: A retrospective analysis of data obtained prospectively of patients with SCH (> or =160/110 mmHg) who were hospitalized and delivered during a 5-year period. Each patient received intensive monitoring of the clinical status throughout the hospitalization (mother, fetus and neonates). Antihypertensive drugs were used for blood pressure > or =160/110 mmHg, glucocorticoids for pregnancies of 24-34 weeks and magnesium sulfate for women with superimposed pre-eclampsia (SPE). The main outcome measures were fetal and neonatal deaths, fetal growth restriction (FGR), major neonatal complications and length of stay in the neonatal intensive care unit (NICU). RESULTS: Of 154 women studied, 78% developed SPE and the mean week's gestation at delivery was 34.5+/-4.6. The average birth weight was 2329+/-1011 g. and the FGR was 18.5%. Four patients had a dead fetus at the time of admission, eight during the hospitalization and there were six neonatal deaths resulting in perinatal mortality of 11.4%. Thirty-eight babies were admitted to the NICU, average stay was 14.8 days. The most common contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. CONCLUSIONS: This study found that the neonatal outcomes in pregnancy with SCH are better than the historical experience, but preterm deliveries, cesarean section, SPE, abruptions and total perinatal mortality remains very high.     

选择性减胎术在中期妊娠的应用

目的　探讨选择性减胎术在中期妊娠的应用及其注意事项。　方法　对 19例多胎妊娠孕妇在妊娠 12～ 2 5周行选择性减胎术。其中双胎 6例 ,三胎 11例 ,四胎、六胎各 1例。在超声引导下经腹向胎儿心内或胸腔内注入高浓度的氯化钾。　结果　 6例双胎除 1例单绒毛膜双胎外均获减胎成功 ;11例三胎 ,除 1例减胎后计划生育引产 ,1例单卵三胎外 ,9例中 7例减胎成功 ,2例减胎后流产 ;1例四胎减胎成功 ;1例六胎减胎后流产。　结论　选择性减胎术可成功应用于妊娠中期 ,母亲无严重的并发症 ,但有一定的流产率。如果减胎术前能排除单卵双胎或单卵三胎 ,或能选择近宫底的妊娠囊进行减胎 ,或能将被减胎儿的羊水抽尽 ,或推迟减胎的时间 ,可能会降低流产率。     

Human amniotic fluid stem cells have better potential in early second trimester of pregnancy and can be reprogramed to iPS

Objective

To study the difference of amniotic fluid stem cell potential at different gestational age.

Use of misoprostol for the termination of second trimester pregnancies

Surgical termination of pregnancy is of high risk for the woman’s health and safe medical ways are required. The use of prostaglandins may substantially reduce this risk. The efficacy and safety of misoprostol as a medication for the termination of the second trimester pregnancies were studied. During a 15-month period ninety-eight healthy pregnant women (13–24 weeks) wishing to terminate their pregnancy due to medical reasons participated voluntarily in this study. Misoprostol was administered 400 μg per os and 400 μg vaginally. Dose was repeated every 6 hours until adequate contractions and cervical ripening were achieved. Outcome measures included successful termination rates, mean expulsion time and side effects of the medication. The efficacy of the method was as high as 91.8% (90/98 cases 95%, CI 86–97%). Mean expulsion time was 10.2 h (range 3–23.4 h) for primigravida and 9.2 h (range 2.5–22.2 h) for multigravida. In 9 cases (9.2%) placenta remnants and in 8 (8.2%) placenta retention were found. Most common side effect was shivering in 17.3% of cases, vomiting and nausea (10.2%), headache and dizziness (7.1%), abdominal pain (79.6%), while diarrhea was noticed in 4.1%. The high efficacy and low incidence of side effects make misoprostol a useful alternative method for medical termination of second trimester pregnancies. Received: 6 October 2000 / Accepted: 22 January 2001     

The relationship between fetal gender and pregnancy outcome

Background Genesis 3:16 is the passage usually quoted by those who believe women have been cursed to give birth in pain. God punished Eve that she will have increased (painful) labor, after she was beguiled by the serpent and ate the forbidden fruit of knowledge. The Lord God said “I will greatly multiply your pain in childbearing; in pain you shall bring forth children”. Nevertheless, the word translated as “children” is the Hebrew word “banim” which means “boys”. Indeed, most interpreters translated boys as children. Yet, there is gaining scientific evidence that the gender does matter. Objective The present Editorial will discuss gender differences in perinatal medicine. Conclusions Male gender is an independent risk factor for adverse pregnancy outcome. Further research including endocrine and immunological tests is needed to clarify gender differences in birth outcome.     

Lack of coagulation defects after the intraamniotic instillation of ethacridine (Rivanol) for second trimester abortion

Summary Second trimester abortion was induced by the intraamniotic infusion of ethacridine. Coagulation studies revealed no change in 10 cases. It is felt that the intraamniotic use of ethacridine is probably safe.Dedicated to Gordon Watkins Douglas at the occasion of his 65th birthday with respect and dedication     

Operator experience reduces the risk of second trimester amniocentesis-related adverse outcomes

Objective

To investigate the impact of operator experience on amniocentesis-related adverse outcomes.

Study design

Retrospective study of mid-trimester amniocenteses performed by the same operator on singleton pregnancies in a single private institution during 1994–2007. Outcomes were hemorrhagic or dark amniotic fluid aspiration, insufficient volume aspiration, repeated puncture and fetal loss. Rates were estimated annually, as well as for every 10% of procedures up to the total number. The association of each outcome with epidemiological aspects was also examined.

Results

In total, 5913 amniocenteses were performed. The overall rate of adverse outcomes was 5.4%. The total adverse outcome rate reduced from 10.2% in the first 10% of cases to 3.0% in the last 10% (P = .001). The rate of hemorrhagic fluid gradually decreased from 4.4% to 1.5% (P = .05) over the same intervals. The fetal loss rate was also reduced from 0.5% during the first half to 0.3% in the second half of the study period (P = NS). Logistic regression analysis indicated no significant correlations between adverse outcomes with any of epidemiological parameters of women undergoing amniocentesis.

Conclusion

Operator experience has a beneficial impact on preventing procedure-related adverse outcomes.     

Pregnancy in a non-communicating rudimentary horn: a cause of failed medical and surgical management of second trimester pregnancy loss

Objectives: We present the management of a case of failed medical and surgical management of second trimester pregnancy loss due to pregnancy in a non-communicating rudimentary horn.

Case: A 16-week intrauterine fetal death singleton pregnancy was referred to us after failed medical and surgical termination of pregnancy. Ultrasound confirmed the diagnosis and showed minimal blood clots and fluid in the pouch of Douglas. Laparoscopy showed a soft, enlarged right uterine horn not communicating with the cervix and containing the pregnancy, and a left uterine horn communicating with the cervix and showing a posterior wall perforation. The procedure was converted to laparotomy, and the right uterine horn and adjacent tube were excised. The patient made an uneventful recovery and was discharged after 3 days.

Conclusion: Pregnancy in a non-communicating horn is rare and usually presents with serious complications. Any case of failed medical termination of pregnancy after repeated doses of misoprostol should be carefully assessed to exclude the possibility of uterine anomalies (especially in a primigravida), before proceeding with dilatation and evacuation to minimise the risk of complications.     

Silent rupture of unscarred uterus: an unusual presentation at second trimester abortion

Rupture of unscarred uterus during the second trimester is rare. A case of ruptured uterus in a multiparous woman is presented. To our knowledge, this might be the first reported case in the English literature of uterine rupture during second trimester termination of pregnancy using ethacridine lactate. This case is also rare as uterine rupture is presented with an insidious course rather than acute, thus delaying the diagnosis.