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.     

Uterine rupture: differences between a scarred and an unscarred uterus

OBJECTIVES: This study aimed to compare risk factors, site of rupture, and outcome of uterine rupture among patients with a scarred versus an unscarred uterus.Study design We conducted a comparison between all cases of uterine rupture (n=53) in women with a scarred versus an unscarred uterus, occurring between January 1988 and July 2002. RESULTS: During the study period, there were ruptures among 26 patients with a scarred uterus and 27 patients without a uterine scar. No significant differences were noted between the scarred and unscarred groups while comparing risk factors such as birth order, birth weight, hydramnios, oxytocin induction, diabetes, and malpresentation. The main site of involvement in both groups was the lower uterine segment representing 92.6% of the ruptures in the unscarred group and 92.3% of the ruptures in the scarred uterus group. Cervical involvement was significantly more common among patients without a previous uterine scar (33.3% vs 7.7%; odds ratio [OR]=6.0, 95% CI, 1.16-31.23, P=.04). Conversely, uterus corpus involvement did not differ between the groups. Perinatal mortality did not differ between the groups. In addition, no significant differences were noted regarding maternal morbidity such as the need for hysterectomy, blood transfusion, or length of hospitalization. CONCLUSION: Although cervical involvement was significantly more prevalent in the rupture of an unscarred uterus, no significant differences in maternal or perinatal morbidity were noted between rupture of a scarred versus an unscarred uterus.     

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.     

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.     

Current and potential methods for second trimester abortion

Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.     

Spontaneous rupture of the unscarred uterus

Objective: By presentation of cases of spontaneous (nontraumatic) ruptures of previously intact uteri, we sought to emphasize important aspects of this rare and dangerous event.Study design: Two case presentations of oxytocin-associated unscarred uterine rupture and review of pertinent literature are used to study risk factors and accompanying clinical characteristics.Results: Both spontaneous ruptures of previous unscarred uteri were associated with low-dose oxytocin augmentation, bradycardia, and uterine hyperstimulation monitor patterns and occurred at the onset of the second stage of labor.Conclusion: Because of its rarity, further investigation of spontaneous uterine rupture will depend on case presentations where the associated events listed are noted and uterine hyperstimulation, fetal bradycardia, and second-stage onset are proved or disproved as valid clinical associations.     

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.     

The predictive nature of uterocervical angles in the termination of second trimester pregnancy

Aim: To establish how useful and the predictive capacity of uterocervical angles (UCA) in the termination of second trimester pregnancies.

Material and methods: This prospective cohort study was conducted at a tertiary center with a total of 120 singleton pregnancies delivered between 14 and 24 gestational weeks. Before the beginning of misoprostol induction, patients were screened for both cervical length (CL) and uterocervical angles (UCA). The UCA is defined as an angle constructed by the measurement of the cervical canal and lower uterine segment. The study population was subdivided into four groups; successful and failed terminations at the end of 24?hours of induction and successful and failed terminations at the end of 48?hours of induction. We decided to further evaluate our study population based on their UCAs, and placed them into four categories; UCA ≥95°, UCA <95°, UCA ≥105°, and UCA <105°.

Results: In the 24-hour time frame group, the mean UCA was 105.50?±?15.38 degrees in the successful termination group and was 100.22?±?11.12 degrees in the failed group (p?=?.001). In the 48-hour time frame group, the mean UCA was 104.19?±?13.51° in the successful termination group and was 93.52?±?7.84° in the failed group (p?=?.007). The mean hour of induction was shortest in the UCA ≥105° group.

Conclusions: Regardless of the time frames, patients who had successful terminations had a broader angle, less amount of misoprostol use and shorter duration of induction as compared to the failed termination groups. What do the results of this study add? The uterocervical angle has never been measured in second trimester pregnancies to predict the timing of termination. Our study demonstrated the useful application of this ultrasonographic finding in the prediction of successful second trimester terminations.

Trial registration: ClinicalTrials.gov identifier: NCT03220607.     

Mifepristone and second trimester pregnancy termination for fetal abnormality in Western Australia: Worth the effort

Objective:  To determine the impact on the process of second trimester medical termination for fetal abnormality following the introduction of adjunctive mifepristone in an Australian tertiary hospital.
Methods:  All second trimester medical terminations for fetal abnormality between July 2006 and June 2009 were prospectively identified. Two temporal therapeutic cohorts were created: the first (1 July 2006 to 31 December 2007) using vaginal misoprostol alone and the second (1 January 2008 to 30 June 2009) using mifepristone priming prior to the administration of misoprostol. The primary outcome was to evaluate the impact of mifepristone priming upon the duration of pregnancy termination.
Results:  During the study period, 388 women with prenatally recognised fetal anomalies between 14 and 24 weeks gestation underwent medical termination: 189 with misoprostol alone and 199 with mifepristone priming followed by misoprostol. There was no difference between the groups for maternal age, parity or prior caesarean delivery. The median abortion duration was 15.5 h (interquartile ranges (IQR) 11.2–22.7) in the misoprostol group and 8.6 h (IQR 5.6–13.8) in the mifepristone primed group ( P  < 0.001). In both the groups, nulliparity and advancing gestation were associated with a significant prolongation of the abortion interval. Duration of hospitalisation was significantly longer in the misoprostol alone group (31.5 h (27–48.9) vs 27.2 h (22–31.5), misoprostol vs mifepristone priming, respectively, P  < 0.001).
Conclusions:  The introduction of mifepristone priming prior to second trimester medical termination with misoprostol has resulted in a significant reduction in the duration of the termination procedure and length of inpatient stay. These observed benefits of mifepristone provide objective support for the decision to permit use of this medication in Australia.     

Uterine rupture of cesarean scar related to spontaneous abortion in the first trimester

We report the case of a 31-year-old Japanese female diagnosed by transvaginal ultrasonography to have a spontaneous uterine rupture in the first trimester. Her condition was complicated by diabetes mellitus type 1. Her previous pregnancy had resulted in an emergency cesarean section by transverse incision of the lower uterine segment with single-layer suture at 37(+4) weeks of gestation. Transvaginal ultrasonography displayed both a gestational sac located in the anterior lower uterine segment and a defect in the uterine wall located at the site of the previous cesarean delivery scar. Pelvic magnetic resonance imaging showed that the uterine muscle layer was discontinuous and the gestational sac was almost outside the uterine cavity, accompanied by mild hemorrhaging within the endometrial cavity. The defect in the lower uterine wall was round in shape and was 3 cm in diameter. Since uterine ruptures can occur during all gestational periods, it is important to pay attention to the uterine wall where any cesarean incision was previously made.     

Effects of a prolonged, 72 hours,interval between mifepristone and gemeprost in second trimester termination of pregnancy: a retrospective analysis

Objective: To evaluate if the 72 hours interval between mifepristone and gemeprost has a similar efficacy compared to the 48 hours interval for second trimester termination of pregnancy

Study Design: Two-hundred and fifteen consecutive pregnant women, admitted to our hospital, for second trimester TOP, were included in this retrospective analysis. Standard protocol was followed for all patients. On the first day of the procedure oral mifepristone 200?mg was administered. After 72 (group A, n?=?78) or 48 hours (group B, n?=?113) women were admitted for administration of gemeprost 1?mg pessary as per protocol. The induction to abortion time was defined as the interval between the insertion of the first gemeprost pessary and the expulsion of the fetus.

Results: There are no significant differences in the number of pessaries in the two groups. The induction to abortion interval was longer in group A than in group B. Twenty-one women required surgical evacuation of the uterus for retained placenta or incomplete abortion without difference between groups.

Conclusion: A 48-hours interval between mifepristone and gemeprost leads to better results than a 72-hours interval, with a shorter abortion length and represents the elective method for second trimester TOP.     

One- and two-day mifepristone-misoprostol intervals for second trimester termination of pregnancy between 13 and 16 weeks of gestation

Objective

To compare the efficacy of 1-day and 2-day mifepristone and misoprostol intervals for second trimester termination of pregnancy between 13 and 16 weeks.

Methods

A prospective randomized cohort study of 100 women who underwent voluntary termination between 13 and 16 weeks of gestation. Patients were randomly assigned to receive 200 mg of oral mifepristone, followed 1 day (group 1) or 2 days (group 2) later by 600 μg of vaginal misoprostol. All patients received 400 μg of oral misoprostol every 6 hours for a maximum of 2 doses. Main outcome measure was successful abortion rate at 24 hours after the start of misoprostol treatment. Secondary outcome measures were induction-to-abortion interval and frequency of adverse events.

Results

The 24-hour successful abortion rate was similar between groups 1 and 2 (47 [94%] vs 50 [100%]; P = 0.241). The mean misoprostol-to-abortion interval was also similar (7.0 ± 3.0 vs 6.8 ± 4.3 hours; P = 0.744). Among the 86 patients for whom histological examination of the products of conception was performed, retained chorionic villi rates were higher in the 1-day regimen group compared with the 2-day regimen group (46.2% [18/39] vs 29.8% [14/47]; P < 0.001).

Conclusion

A 2-day mifepristone-misoprostol interval resulted in fewer incomplete abortions than a 1-day interval for second trimester termination of pregnancy between 13 and 16 weeks.     

Mifepristone and misoprostol versus Dilapan and sulprostone for second trimester termination of pregnancy

Objective. To compare two methods for second trimester termination of pregnancy: mifepristone and misoprostol versus Dilapan® and sulprostone.

Methods. This was a randomized study involving 16 patients with a singleton live fetus with congenital malformations or genetic disorders. Eight patients were treated with 200 mg mifepristone orally followed by 200 μg misoprostol vaginally 3 hourly and eight patients received a sulprostone infusion after cervical dilatation with Dilapan.

Results. Mifepristone and misoprostol had a mean induction interval of 17.8 hours and sulprostone and Dilapan 20.9 hours. The mean induction interval did not differ significantly. Mean hospital stay was shorter in the patients treated with misoprostol: 2.1 vs. 3.3 days (p = 0.02) with a 95% confidence interval of ?2.1 to 0.3.

Conclusion. Mifepristone and misoprostol did not reduce the induction interval significantly compared to the sulprostone and Dilapan treatment for second trimester pregnancy termination. Hospital admission was significantly shorter in patients treated with mifepristone and misoprostol.     

Sublingual misoprostol 100 microgram versus 200 microgram for second trimester abortion: a randomised trial

Objectives To compare the efficacy of repeated doses of 100 μg vs. 200 μg misoprostol given sublingually for induction of second trimester abortion.

Methods One hundred and sixty-two women at 15–22 weeks' gestation were randomized to receive every 2 h either 100 μg (group 1; n = 81) or 200 μg (group 2; n = 81) misoprostol sublingually. The primary outcome measure was the abortion rate within 24 h. The secondary outcome measures were the induction-abortion interval, the total misoprostol dose required, and side effects of the regimen.

Results There was no significant difference between the two groups with regard to the abortion rates within 12 h (43.2% in group 1 vs. 48.1% in group 2; p = 0.52; relative risk [RR]: 0.81; 95% confidence interval [CI]: 0.4–1.5) and 24 h (92.6% in group 1 vs. 91.4% in group 2; p = 0.77; RR: 1.11; 95% CI: 0.37–3.6). The induction-abortion intervals in the two groups were of similar length (885 minutes in group 1 vs. 912 minutes in group 2; p = 0.72). When the total dose of misoprostol was compared between the two groups, women belonging to group 2 on average had received significantly more misoprostol than those in group 1 (1274 ± 592 μg [7 ± 3 doses] vs. 614 ± 432 μg [6 ± 4 doses], respectively; p = 0.000).

Conclusions Sublingual administration of repeated doses of 100 μg misoprostol for abortion induction appears to be equally effective to that of repeated doses of 200 μg.     

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     

Spontaneous uterine rupture at a non-cesarean section scar site caused by placenta percreta in the early second trimester of gestation: A case report

ObjectivesRisk factors for placenta percreta are placenta previa and prior cesarean delivery. Placenta percreta–induced ruptures at non-cesarean sites are very rare, particularly in the early second trimester.Case reportA 30-year-old woman with a prior cesarean delivery was brought to our emergency department at 17 weeks' gestation for sudden-onset consciousness loss and generalized convulsions. Hypovolemic shock was identified. Computed tomography scans suggested uterine rupture and massive ascites, r/o hemoperitoneum. Emergency exploratory laparotomy revealed a ruptured hole over the left uterine fundus with protruding placental tissue; placenta percreta was impressed. An intact intrauterine sac was dissected and removed. The placenta was removed and hysterorrhaphy was completed.ConclusionPlacenta percreta is dangerous and is rarely seen in the early second trimester. Uterine rupture should always be kept in mind in pregnant woman with acute abdomen associated with hypovolemic shock, even in those of early pregnancy without scarred uterus. Routine sonographic examination of placentation, even in early second trimester, should be emphasized.