Laminaria use in midtrimester abortions induced by intra-amniotic prostaglandin F2alpha with urea and intravenous oxytocin.

A laminaria tent was used as an adjunct during midtrimester abortion to attempt to shorten the injection-abortion interval without adversely affecting the frequency of infection, hemorrhage, failed abortion, or cervical laceration. Eighty patients, between 14 and 20 weeks' gestation and desiring pregnancy termination, were randomized into three groups. Abortion was initiated by an intra-amniotic infusion of 20 mg of prostaglandin F2alpha and 80 gm of hyperosmolar urea in Ringer's lactate (135 ml total volume), followed by oxytocin infused intravenously at 333 mU/min. Group I (N = 28) received no additional therapy; Group II (N = 23) had laminaria placed at the time of the abortifacient injection and removed 4 hours later; Group III (N = 29) had laminaria placed 4 hours prior to inejction and removed at the time of injection. The injection-abortion intervals in these three groups were 17.76, 20.80, and 12.96 hours, respectively. This study illustrates that a laminaria tent palced 4 hours prior to injection is significantly more effective than a laminaria tent placed at the time of injection, and produces a shorter mean injection-abortion interval than that in patients receiving no laminaria. Furthermore, laminaria augmentation results in no demonstrable increase in the frequency of serious complications.     

Cervicovaginal fistula: an apparent increased incidence with prostaglandin F2alpha

A rare but difficult to treat complication of midtrimester abortion is cervicovaginal fistula. It has been reported as a consequence of criminal, spontaneous, and induced abortions with either laminaria, Hegar dilatation, puncture of the ovum, or by injection of soap. This condition was recently reported as a consequence of intraamniotic hypertonic saline or prostaglandin (PG) instillation. At the Women's Hospital in Los Angeles, 5291 midtrimester abortions with intraamniotic instillation of hypertonic saline had been performed since the advent of elective abortion. There were 4 cases of central cervical rupture (cervicovaginal fistula) for a net incidence of 1:1000. 3 out of 373 intraamniotic PGF2alpha-treated patients developed cervical fistula for an incidence 10 times higher than saline abortion. Other studies confirm this finding. If all such studies are combined, the net incidence is 9 in 678 cases or 1.3%. High risk patients include those who are pregnant for the 1st time, are less than 21 years old, and are treated with hypertonic saline augmented by oxytocin. The fistula may occur with intraamniotic PGF2alpha alone, but the incidence is greater in patients receiving PGs and oxytocin together. A recurring feature is a moderate to severe cramping pain without cervical response even before oxytocin is started. The use of mechanical dilatation of the cervix with the introduction of either laminaria tents or Foley catheters is suggested for primigravid patients receiving hypertonic saline and intravenous oxytocin augmentation. If cervical spasm is the mechanism of action of PGF2alpha, initial insertion of laminaria should be considered with all primigravid patients. Further study of a larger series should be done to elucidate the role of PGs in the development of cervicovaginal fistula. 7 case reports are presented.     

Management of failures following extra-amniotic terminations

In 35 out of 162 women who had their pregnancies terminated (11-15 weeks' gestation) by extraamniotic procedures, the primary procedure failed to expel the fetus at the end of 72 hours. A second procedure for the failed cases utilized the following methods: laminaria tents followed by curettage in 15 cases, dilatation and curettage in 6, extraamniotic instillation 9, extraamniotic of 20% saline in 3, intravenous oxytocin in 2. Selection of procedure of each case depended on size of uterus, state of the cervix and infection. Complications experienced by the patients included perforation of the uterus, infection, incomplete abortion, and vomiting. Routine antibiotics were given to the patients. The following observations were noted: 1) laminaria tents followed by curettage is an efficient method; disadvantages are infrequent unaavailability and costs of the tent; 2) dilatation and curettage is a quick method, but it requires formal anesthesia and tends to result in greater blood loss; 3) disadvantages of extraamniotic prostaglandin are that it results in complete abortions, has too many side effects and is unavailable in India; 4) extraamniotic saline and intravenous oxytocin appear promising but necessitate further investigation.     

Experience with midtrimester abortion.

The midtrimester abortion program at a large community hospital was evaluated. During the 3-year study, 1839 patients aborted in the midtrimester by intraamniotic injection of hypertonic saline, prostaglandin F2alpha or a combination of saline and prostaglandin F2alpha. The method, using a combination of saline and prostaglandin F2alpha together with intracervical laminaria, showed significant reduction in the number of failures (4.3 to 1.0%), reduction in the injection-abortion interval from 33.9 to 14.6 hours, shortening of the hospital stay from 2 1/2 to 1 1/3 days, minimum incidence of live abortions (0.9%), infrequent need for oxytocin to effect delivery (7.7%); and low rates of hemorrhage (1.5%) and fever (2.8%). The main disadvantage was an increased rate of incomplete abortions (32.3%), which could be reduced to 27% by patient selection.     

Lamicel is More Effective in Preparing the Cervix for Midtrimester Termination of Pregnancy than Laminaria Japonicum

Laminaria tents are often used prior to prostaglandin termination of midtrimester pregnancy to reduce the induction-abortion interval. Natural laminaria suffers from a number of disadvantages and, recently, a synthetic form Lamicel (Cabot Medical, PA), has been produced. Uncontrolled evaluation has suggested that it is effective for dilating the cervix but scepticism remains because Lamicel does not exert radial force on the cervical canal. One hundred women who requested abortion between 12 and 24 weeks of pregnancy were studied. They were randomly divided into group A who had a Lamicel inserted for 6 hours and group B who had a laminaria tent inserted for 8 hours. The cervical dilatation was assessed at the end of this period and the patients were then given up to 6 injections of sulprostone at 4-hourly intervals. All patients in Group A aborted, but 7 of those in Group B did not. The mean cervical dilatation in Group A was 7.47 +/- 1.46 mm compared with 4.71 +/- 1.76 mm in Group B (p less than 0.001). The mean induction-abortion interval in Group A was also significantly shorter (p less than 0.05) than that in Group B: 11.79 +/- 7.24 hours compared with 12.51 +/- 6.52 hours in Group B (excluding 7 patients who failed to abort in Group B). The results of the study suggest that the degree of cervical dilatation that can be achieved using Lamicel is significantly greater than that by laminaria tents.     

Laminaria tent for diagnostic and operative hysterectomy

Laminaria tents were inserted in 300 nonpregnant women to induce cervical dilation before diagnostic or operative hysteroscopy. All laminaria tents were inserted without anesthesia following uterine sounding. Diagnostic hysteroscopic procedures were performed with a 5.0 mm hysteroscope with video monitoring within 2-3 hours after insertion of the laminaria tent. Minimal analgesia was used. Operative procedures were performed approximately 24 hours after insertion of the laminaria tent with a 9 mm operative resectoscope. There were no complications with the use of the laminaria tent, such as infections or bleeding, but a few patients complained of mild menstrual-like lower abdominal discomfort. In all cases, the laminaria tent resulted in a softening and dilation of the cervix, which facilitated the passage of the diagnostic and operative hysteroscope.     

Oxytocin augmentation of saline abortion

53 patients undergoing second trimester saline abortion were given either 20 units or 100 units of oxytocin per 500 ml of 5% dextrose solution 12 hours after saline instillation. Mean abortion time (30.67 hours, 20 units; 27.66 hours, 100 units) was 11-14 hours less than a control group of 26 patients who did not receive oxytocin (41.26 hours). The smaller dose is as effective as the larger dose and should prove safer for patients undergoing saline abortion.     

Clostridial sepsis after abortion with PGF2alpha and intracervical laminaria tents--a case report.

A case of clostridial endomyometritis and sepsis necessitating total abdominal hysterectomy which occurred 12 hours following abortion induced with intraamniotic administration of prostaglandin F2 alpha and laminaria tent insertion is discussed. Cultures from cervical, blood, and surgical specimens all yielded Clostridium perfringens. Intrauterine contamination with this microorganism most likely followed the insertion of laminaria tents through the cervical os, which was colonized with C. perfringens. Since C. perfringens may be present in the microflora of the lower female genital tract, great care must be taken to cleanse this area prior to intracervical laminaria tent insertion.     

Does the hygroscopic property of the laminaria tent imply a risk for ascending infection in legal abortions? A microbiological study

In 53 women admitted for first-trimester abortion, the cervical canal was dilated with laminaria tents prior to vacuum aspiration. Before insertion of the tents, endocervical specimens were taken for microbiological investigations, including Chlamydia trachomatis, and both aerobic and anaerobic microorganisms. The laminaria tents, widened by their hygroscopic properties, were removed just before the vacuum aspiration and sent for cultivation of aerobic and anaerobic microorganisms. The Gram-positive aerobic cocci, Staph. epidermidis, Strept. faecalis and Strept. agalactiae as well as Escherichia coli and Klebsiella/Enterobacter were the most frequent microorganism among the aerobic isolates from the endocervices as well as from the laminaria tents. These microorganisms were identified on the tents in greater numbers than in the cervices. Staph. aureus was isolated from three laminaria tents, but only one of these 3 women was proved to be primarily colonized endocervically. Among the anaerobes, Bacteroidaceae followed by peptococci and peptostreptococci were the predominant genera found in the cervix as well as on the removed laminaria tents. These three groups of anaerobic microorganisms were found markedly less frequently on the laminaria tents than in the endocervix. On the other hand, Strept. intermedius, another anaerobe of possible enteric origin, was recovered from 9 laminaria tents but not in the cervices. Since no cases of clinically verified endometritis/salpingitis were registered in the present study it is concluded that the risk of a pelvic inflammatory disease (PID) due to the laminaria tent is negligible as long as the laminaria treatment does not exceed 24 hours.     

Efficacy and acceptability of 15(S)-15-methyl-prostaglandin E2-methyl ester for midtrimester pregnancy termination

This study attempts to modify the prostaglandin method to reduce untoward side effects and to test its acceptability and efficacy. 30 healthy women (20 primigravidas and 10 multiparas) 13 to 36 years old, between the 5th and 21st weeks of gestation participated in the study. Baseline clinical and laboratory data were collected. 12 primigravidas were inserted with 1 to 4 laminaria tents. Ampicillin was administered orally every every 6 hours. 8 primigravidas and 10 multiparas comprised the control group. Ethanol was administered intravenously in all 30 patients. 20 control patients of a following series received 5% dextrose without alcohol. A threshold dose was established at 3 mcg of 15(S)-ME-PGE2 per 100 lbs of body weight. The dose was calculated individually for each patient and injected at 1 hour interval into the deltoid muscle in 17 patients and into the gluteus in 13. The dose was increased by 1 to 2 mcg/hour toward the end of induction. There were no failures: 28 complete abortions (93%) and only 2 incomplete abortions (7%). Mean induction-to-abortion time was 12 hours 14 minutes in multiparas and 18 hours 23 minutes in primigravidas. Use of laminaria tents reduced abortion time for primigravida to 9 hours 29 minutes, which was even shorter than that for multiparas. Mean prostaglandin dose required for complete abortion in all patients was 63 mcg; in multiparas, 61 mcg. Use of laminaria tents halved the total dose needed in primigravidas from 81 to 44 mcg (p 0.05). The incidence of diarrhea in this series was significantly reduced from 3 episodes to 0.9 episode per induction (p 0.05). The results of this study are encouraging and suggest that the prostaglandin derivative may be used intravenously for induction of labor at term.     

A comparison of prostaglandin E2 pessaries and laminaria tents for ripening the cervix before termination of pregnancy

Forty primigravid women aged 15-45 years were randomly allocated to receive either an intravaginal pessary of 3 mg prostaglandin E2 (PGE2) or an intracervical 5-mm laminaria tent (LT) 12-16 h before termination of pregnancy at 6-14 weeks gestation. The degree of dilatation of the cervix at operation and its resistance to further dilatation during the procedure were assessed by a 'blind' operator. Laminaria tents were more effective in achieving dilatation and softening of the cervix than were PGE2 pessaries and in 40% of women no further dilatation was necessary. There were no associated side-effects or complications. A cervical tear occurred in two of 20 patients treated with PGE2 pessaries and all 20 required further dilatation of the cervix. Laminaria tents provide a simple, safe, acceptable and effective means of 'ripening' the cervix prior to termination of early pregnancy.     

Midtrimester abortion using prostaglandin F2alpha, oxytocin, and laminaria

This study combined the use of preinjection laminaria, intravenous oxytocin, and 15 mg of intra-amniotic prostaglandin (PG) F2alpha in order to demonstrate a potentially improved procedure for 2nd trimester abortion. 20 patients, aged 18-27, were between the 16-20 weeks gestation, and were free of intercurrent medical or obstetrical problems. 7 of the 20 were nulliparae. A laminaria was inserted into the cervix the evening before the injection of PG. In the morning an intravenous infusion was begun using 50 units of oxytocin in 500 ml of 5% dextrose and 0.9% sodium choloride at a rate of 150 ml/hour. The amniocentesis was performed and when a free flow of clear amniotic fluid was obtained 15 mg. of PGF2alpha was injected into the amniotic cavity. Different concentrations of oxytocin were administered if contractions were increasingly painful or not. Results of the experiment were that: 1) all patients aborted within 24 hours of the prostaglandin injection, 2) the median injection-to-abortion interval was 7 hours and 25 minutes; primigravidae aborted with a median time of 15 hours 20 minutes; and multiparous patients aborted in 6 hours 20 minutes; 3) only 9 patients requested analgesia medication; 4) the average blood loss was 150-200 nl; 1 patient had a postabortion hemorrhage greater than 500 ml; 5) 3 patients underwent sharp curettage for suspected retained secundines; 6) vomiting occurred in 6 patients, 3 of whom had emesis once; and 7) no diarrhea was encountered during the study. This study demonstrates that this procedure fulfills 3 strict criteria for success, as follows: 1) single injection technic, 2) consistent abortion within 24 hours, and 3) minimal side effects.     

Induction of midtrimester abortion with intraamniotic urea, intravenous oxytocin and laminaria.

Midtrimester abortion was accomplished in 75 patients by the intraamniotic instillation of 80 g of urea and the intravenous administration of oxytocin. In 33 of the patients, laminaria tents were inserted into the cervix. No severe complication occurred; all fetuses were stillborn. A single urea instillation was effective in 94.6% of the patients. The mean instillation-abortion interval was significantly (p less than 0.02) shorter in patients with laminaria tents than in those without. The tents probably prevent cervical rupture in s-me patients. Significant but transient changes occurred in platelet count and blood urea nitrogen one hour after urea instillation. Surgical removal of the placenta was required in 18.7% of the 75 patients; infection occurred in 2.6%. The combined use of urea, oxytocin, and laminaria appears to be an effective and relatively safe method of inducing abortion during the second trimester.     

Cervical ruptures in midtrimester abortions

2 groups of patients are at risk of traumatic complication after midtrimester abortion: older multiparous women (uterine ruptures) and young primigravid women (cervical ruptures). While the occurrence of uterine ruptures in the former class can be reduced by selective use of abortifacient agents, and avoidance of amnioinfusions and intravenous oxytocin, the occurrence of cervical ruptures continues to be high. From May 1974 through May 1978, 780 women underwent midtrimester abortion by various techniques. 12 patients (1.5%) sustained cervical injuries, 11 of whom were nulliparous aged 16 to 25 years. Intra-amniotic and extra-ovular methods alike produced cervical injuries. The combined method of induction increases the likelihood of damaging the cervix. Oxytocic augmentation, however, does not appear to increase its incidence. Nor does a shorter induction-abortion interval, according to the evidence. Since laminaria tents did not prevent cervical injuries, none of the presently available methods offers any protection. Nevertheless, it may be that cervical injuries can be prevented if midtrimester abortions are undertaken between 13 and 15 weeks of pregnancy. Cervical ruptures can also go unnoticed and cause future obstetric problems; the authors therefore emphasize the importance of routine cervical inspection in all patients.     

Intra-amniotic prostaglandin F2alpha and urea for midtrimester abortion.

Intra-amniotic prostaglandin F2alpha, in doses of 2.5 to 20 mg, combined with 80 gm of urea, was an effective, safe, simple, and economical midtrimester abortifacient in 115 patients. The mean abortal time, 15.8 hours, was significantly less than that in prior series in which intra-amniotic hypertonic saline or urea was administered together with constant, intravenous oxytocin infusion. The use of intracervical laminaria tents did not shorten the abortal time. Only eight patients had not aborted within 30 hours; only two had not aborted within 36 hours; and only six received a second intra-amniotic injection. Operative removal of the placenta, when necessary, was accomplished under intravenous sedation in a treatment room. The incidence of infection, nausea, vomiting, and other complications was low.     

Assessment of Pain After Elective Abortion Relating to the Use of Misoprostol for Dilatation of the Cervix

ObjectiveOur objective was to compare the use of misoprostol to that of laminaria tents for dilatation of the cervix before a surgical elective abortion (EAB) during the first trimester, with regard to the pain caused (1) during insertion, for both methods, (2) immediately before the EAB, and (3) one hour after the procedure.MethodsOne hundred two women were recruited at Clinique de planification des naissances du Centre hospitalier universitaire de Québec, CHUL pavilion, between March 1, 2006 and March 1, 2007, for a tracking study. Fifty-three women were given 400 μg of misoprostol intravaginally, three to four hours before the EAB, and a laminaria tent was inserted in 49 women, 16 to 24 hours before the EAB. A visual analog scale was used to determine the pain score.ResultsOne hour after EAB, severe pain was reported in 6% of the participants who were given misoprostol. The pain score post-EAB was 3.8 times higher in women who were given misoprostol than in those who had a laminaria tent inserted (P = 0.004). The pain score during insertion of the dilatation method was 33 times higher with the laminaria tent than with misoprostol (P < 0. 001), and 30% of women who had a laminaria tent inserted felt severe pain.ConclusionWhile misoprostol may increase pain after EAB in a small percentage of women, it remains an efficient, easy to use, low-cost method for dilating the cervix before an EAB. It is one of the options that may be offered to women when a pre-EAB dilatation of the cervix is required, after discussing its benefits and disadvantages with them.     

Cervical Ripening

The purpose of this study was to evaluate the efficacy of adding laminaria tents to sequential intravaginal prostaglandin E₂ (PGE₂) gel for cervical ripening.

A prospective, randomized study was conducted from October 1994 to May 1995. Pregnant women with maternal or fetal indications for induction of labor at ≥37 weeks gestation and a Bishop score of ≤4 were eligible. Nineteen patients received laminaria tents in addition to 4 mg PGE₂ gel, while 25 patients received PGE₂ gel alone. After 4 hr, the laminaria tents were removed and the gel was continued in both groups at 4-hr intervals. Induction with oxytocin was initiated after a Bishop score of >5 was achieved.

The groups were comparable with respect to maternal age, parity, gestational age, reason for induction, and initial Bishop score. The addition of laminaria tents to sequential PGE₂ gel did not statistically improve the time to a favorable cervix (control group 12.7 ± 8.5 hr (95% CI, 9.1–16.3) and study group 10.9 ± 7.1 hr (95% CI, 7.5–14.3) (P = 0.59). The 6-hr difference from the time of the initial PGE₂ gel placement to delivery was not detected (control group 22.4 ± 11.2 hr, 95% CI 17–27 and study group 23.4 ± 13.1 hr, 95% CI 17–29.6 (P = 0.79). The combination approach of laminaria tents and PGE₂ gel did not have a significant impact on the vaginal delivery rate, with 28.0% of patients in the control group and 26.3% of patients in the study group undergoing cesarean section (P = 0.90). Maternal and neonatal complications were rare in both groups.

We had insufficient evidence to show that the addition of laminaria tents to PGE₂ gel improved cervical ripening, the induction to delivery interval, or the cesarean section rate in patients at term undergoing induction of labor.     

The influence of aspirin on the course of induced midtrimester abortion

Prostaglandins appear to mediate the uterine contractions of abortion and labor, and aspirin has been shown to be an inhibitor of prostaglandin synthesis. In this double-blind, placebo-controlled, prospective, and randomized study, aspirin was administered orally in doses of 600 mg. every 6 hours to patients undergoing induced midtrimester abortions with hyperosmolar urea and oxytocin augmentation. The mean injection-abortion interval was significantly prolonged by aspirin in nulliparous patients (aspirin 32.3 ± 3.3 hr. vs. placebo 21.5 ± 3.5 hr.) and no aspirin-treated nullipara aborted in less than 18 hours. There was no significant difference between treatment groups in the mean injection-abortion interval in the multiparous patients at the dose of aspirin used. The effectiveness of aspirin in the prolongation of the injection-abortion interval has potential therapeutic implications for the treatment of premature labor.     

A comparison of prostaglandin E2 pessaries and laminaria tents for ripening the cervix before termination of pregnancy

Summary. Forty primigravid womcn aged 15–45 years were randomly allocated to receive either an intravaginal pessary of 3 mg prostaglandin E, (PGE₂) or an intracervical 5-mm laminaria tent (LT) 12–16 h before termination of pregnancy at 6–14 weeks gestation. The degree of dilatation of the cervix a t operation and its resistance t o further dilatation during the procedure were assessed by a 'blind' operator. Laminaria tents were more effective in achieving dilatation and softening of the cervix than were PGE₂ pessaries and in 40% of women no further dilatation was necessary. There were no associated side-effects or complications. A cervical tear occurred in two of 20 patients treated with PGE₂ pessaries and all 20 required further dilatation of the cervix. Laminaria tents provide a simple. safe, acceptable and effective means of 'ripening' the cervix prior to termination of early pregnancy.     

Outcome of continued pregnancies after first- and second-trimester cervical dilatation by laminaria tents

In 21 pregnant women (seven in the first trimester and 14 in the second trimester), laminaria tents inserted for induction of elective abortion were removed after dilatation had been achieved, but upon the patient's request, the abortion was not carried out. Four patients again changed their minds and had uncomplicated induced abortion after reinsertion of the laminaria tents. Seventeen patients continued their pregnancies: Fourteen had term deliveries, two had premature deliveries, and one had a spontaneous abortion at 10 weeks' gestation, 2 weeks after laminaria removal. None of the patients suffered infectious morbidity, including three untreated patients with positive cervical cultures for chlamydia, who experienced normal pregnancies and deliveries.