Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases.

OBJECTIVE: To assess the effectiveness of a regimen comprising mifepristone followed by a combination of the vaginal and oral administration of misoprostol for mid-trimester medical termination of pregnancy. DESIGN: Retrospective analysis of prospectively collected data in women undergoing mid-trimester medical termination of pregnancy. SETTING: Aberdeen Royal Infirmary, Scotland. SAMPLE: A consecutive series of 500 women with pregnancies of 13-21 weeks of amenorrhea undergoing legally induced abortion in one Scottish NHS hospital. METHODS: Each woman received a single oral dose of mifepristone 200 mg and 36-48 h later vaginal misoprostol 800 microg. Three hours following the first dose of misoprostol, 400 microg doses were administered orally at three hourly intervals, to a maximum of four doses. Success was defined as abortion occurring with five doses of prostaglandin, or within 15 h of administration of the first dose of prostaglandin. RESULTS: Ninety-seven percent aborted successfully. The median dose of misoprostol required was 1200 microg and the median induction-to-abortion interval after first prostaglandin administration was 6.5 h. The median number of doses of misoprostol required to induce abortion, and the induction-to-abortion interval, was statistically significantly higher among women at gestations 17-21 weeks than among those at 13-16 weeks (P = 0.0001). A total of 9.4% required surgical evacuation of the uterus under general anaesthesia and 66.4% of the women were managed as day cases. CONCLUSIONS: The combination of oral mifepristone 200 mg followed by vaginally and orally administered misoprostol provides a noninvasive and effective regimen for second trimester termination of pregnancy.     

Misoprostol for termination of mid-trimester post-Caesarean pregnancy

OBJECTIVE: To evaluate the efficacy and safety of PGE1 analogue, misoprostol, for inducing abortion or labour during mid-trimester in women who have had a prior Caesarean section (one or more). STUDY DESIGN: Women who had to undergo termination of pregnancy between 13 and 26 weeks of gestation for various indications and who had at least one previous Caesarean section were studied over a period of two and a half years. The standard regimen for misoprostol in all the cases was 400 microg up to 20 weeks of gestation and 200 microg for pregnancies longer than 20 weeks, either vaginally or sublingually every six hours (up to maximum 24 h). A contemporaneous cohort of women undergoing the same procedure for similar indications but without scarred uteri served as control. RESULTS: Eighty women in the study group underwent termination procedures for unwanted pregnancy, missed abortion, fetal anomaly or fetal death. The median induction-abortion interval was 16.4 h (10-21 h) and did not differ much from that in women without previous Caesarean delivery (median: 15.6 h; range 9.6-20 h), P > 0.05. Misoprostol was found to be safe in our cohort of post-Caesarean women and there was no case of scar rupture or dehiscence. No significant differences in rates of incomplete abortions, blood loss or sepsis were detected in the study group compared to the control group. CONCLUSION: The use of misoprostol for mid-trimester pregnancy termination is not contraindicated in women with Caesarean scar and is effective and comparable with those in women without scarred uteri.     

Intra-amniotic injection of oxytetracycline hydrochloride for termination of mid-trimester pregnancy

Seventy-eight women underwent induced mid-trimester abortion. Fifty-two women aborted after an intra-amniotic injection of 1 g oxytetracycline hydrochloride. The control group comprised 16 women who received an intra-amniotic injection of hypertonic saline and 9 women with prostaglandin F2 alpha. All but 2 women aborted after one injection. Thirty-five women of the oxytetracycline hydrochloride group received intravenous oxytocin after the appearance of uterine contractions, 17 did not. The mean injection abortion interval in the women who received intravenous oxytocin was 38.6 +/- 2.7 h, whereas in the group without oxytocin it was 31.3 +/- 2.3 h. There is no statistically significant difference between these two groups (p less than 0.2). The mean injection abortion interval in the hypertonic saline group was 18.4 +/- 2.2 h. In the F2 alpha group it was 13.2 +/- 1.3 h. There is no statistically significant difference between hypertonic saline and prostaglandins (p less than 0.2). The mean injection abortion interval is significantly shorter in the F2 alpha and hypertonic saline groups as compared to the oxytetracycline hydrochloride group (p less than 0.001). It is advisable therefore to use oxytetracycline hydrochloride only in cases when the use of F2 alpha or hypertonic saline is contraindicated.     

Second trimester termination of pregnancy with gemeprost: a review of 306 cases

AIM: Prostaglandin analogues provide an effective method for induction of abortion in the second trimester of pregnancy. The clinical outcome and the risk of complications were evaluated in a group of women having a medical termination of pregnancy with gemeprost. METHODS: Three-hundred and six women undergoing second trimester termination of pregnancy, between January 1998 and July 2002 in our center, were studied. All women were given 1 mg vaginal gemeprost every 3 h up to a maximum of 3 doses in the first 24 hours. If the abortion did not occur within the first 24 hours after initiation of treatment, they were given a 2(nd) course of gemeprost. Outcome measures included failure of the 1st course of gemeprost, length of hospital stay after expulsion of conceptus, heavy blood loss with or without necessity of uterine packing or blood transfusion, and failure of induction. RESULTS: There was a significant difference, with better results in women with previous deliveries (vaginal or abdominal), as to the failure to abort after the 1(st) course of PG (P<0.01). Length of hospital stay, complications and failure of induction were independent from parity. Twelve (3.9%) women failed to abort with gemeprost and required other methods for abortion. CONCLUSIONS: The study confirms the efficacy of gemeprost for mid-trimester termination of pregnancy, although it is a risky and costly procedure, requiring hospitalisation and is associated with higher complication rate than the first trimester surgical abortion.     

Progesterone inhibition in mid-trimester termination of pregnancy: physiological and clinical effects

Summary. A double-blind, placebo controlled clinical trial was conducted to assess the clinical and physiological effects of'epostane', a progesterone synthesis inhibitor, in mid-trimester prostaglandin termination of pregnancy. Mean peripheral progesterone levels had fallen by 74% after 72 h in the patients treated wtih epostane. The mean induction abortion interval in the treatment group was 490 (SD 271) min, compared with 1432 (SD 640) min in the control group. Intrauterine pressure recording demonstrated increased sensitivity to prostaglandin E2 after epostane treatment but no change in oxytocin sensitivity. The clinical implications of facilitated induction of abortion are discussed.     

A safe and effective method of termination of mid-trimester pregnancy

Different techniques and abortifacients are being used to perform abortions during the 2nd trimester of pregnancy. These include the use of hypertonic saline, prostaglandins, hypertonic urea and glucose, mannitol, and rivanol, yet none of them are ideal and safe. This study was conducted in an effort to determine a safe, effective, and easy method of abortion during the midtrimester of pregnancy. 225 cases of pregnancy between 12-20 weeks were selected randomly from those admitted to the NRS Medical College Hospital in Calcutta, India for abortion., A full history was taken, and a thorough clinical examination was performed with particular attention to cardiovascular, respiratory, and renal conditions. The patients were divided into 2 groups. The 125 women in Group 1 were administered 150-200 ml of 20% urea in 2% saline and half million units of crystalline penicillin were introduced by a Foley's catheter extraamniotically. In the 200 patients in Group 2, 150-200 ml of 30% urea in 2% saline was introduced in the same manner extraamniotically. Penicillin was not given in these cases. Instead, when there was a need of reinstillation after 48 hours, oxytetracyclin 250 mg was given every 6 hours orally for 3-4 days. Antiseptic dressings were applied and light diet was given in the morning. An intramuscular injection of Triflupromazine (Siquil) 20 mg was given half an hour before instillation. Syntocinon 5 units was injected subcutaneously in Group 1 cases and intramuscularly in Group 2 cases every 4 hours starting soon after instillation until abortion. If the placenta failed to abort within half an hour or there was delay in the process of abortion by more than 4 hours, Syntocinon drip was started intravenously with 40 drops/minute. After complete expulsion of conceptus, ergometrine 0.5 mg was given intramuscularly. The follow-up was performed after 6 weeks and 3 months or earlier if there was any complication. Of 225 cases, 102 (45%) were below age 20 and 14.6% were below 16 years. 104 of the cases were nulliparous. Of the 121 multigravida, only 4 had 1 previous induced abortion and 1 had 2 induced abortions previously. 41% were married, 31% were unmarried, and the remainders were widowed or separated from their husbands. 70% of the cases were above 14 weeks, and 20% were between 12-14 weeks. Mean induction/abortion time was less (28 hours) in pregnancies above 14 weeks than in those below 14 weeks. The success rate was about 98% and no difference was found between the 2 groups. The success rate within 48 hours was more (88%) in Group 2 cases than in Group 1 cases (80.8%). Only 2 cases in each group went beyond 72 hours. The cumulative success rate within 72 hours was 96% in each group. The most common complication was incomplete abortion which happened in 23% cases in Group 1 and in 25% cases in Group 2.     

Progesterone inhibition in mid-trimester termination of pregnancy: physiological and clinical effects

A double-blind, placebo controlled clinical trial was conducted to assess the clinical and physiological effects of 'epostane', a progesterone synthesis inhibitor, in mid-trimester prostaglandin termination of pregnancy. Mean peripheral progesterone levels had fallen by 74% after 72 h in the patients treated wtih epostane. The mean induction-abortion interval in the treatment group was 490 (SD 271) min, compared with 1432 (SD 640) min in the control group. Intrauterine pressure recording demonstrated increased sensitivity to prostaglandin E2 after epostane treatment but no change in oxytocin sensitivity. The clinical implications of facilitated induction of abortion are discussed.     

Outcomes for subsequent pregnancy in women who have undergone misoprostol mid-trimester termination of pregnancy

In Australia, the most common method of mid-trimester termination of pregnancy (TOP) is by medical induction with the prostaglandin E 1 analog misoprostol. This study was undertaken to compare the pregnancy outcomes of women who had undergone a misoprostol mid-trimester TOP in their last pregnancy with those of a similar cohort of women without a history of misoprostol TOP. This study suggests a possibility that medical mid-trimester TOP with misoprostol increases the risk of preterm or very preterm delivery in a subsequent pregnancy but larger studies are needed to confirm or dismiss this.     

Methotrexate for the termination of early pregnancy: a toxicology review

A review of the toxicology of methotrexate combined with misoprostol for termination of early pregnancy found that. (1) methotrexate is teratogenic in both animals and humans, and (2) some data suggest that misoprostol maybe a human teratogen. The combined regimen of methotrexate and misoprostol fails to interruptpregnancyin about four per cent of cases. Serious congenital abnormalities have been observed in several of these continuing pregnancies. Because of possible risks to the woman's health and the potential birth of infants with severe congenital abnormalities if treatment fails and the pregnancy is carried to term, the use ofmethotrexate as a non-surgical method for first trimester termination of pregnancy cannot be recommended. This paper summarises the review and the Panel's comments.     

Association between gestational age and induction-to-abortion interval in mid-trimester pregnancy termination using misoprostol

Objective

The study was aimed to evaluate the effectiveness, outcome, and pain intensity of the vaginal administration of misoprostol for the induction of abortion between 13 and 24 gestational weeks.

Study design

A retrospective study was conducted at our tertiary medical center from January 2006 to December 2009 on 122 consecutive women who underwent termination of pregnancy (TOP) in the mid-trimester. They were given 400 mcg of vaginal misoprostol every 6 h, up to four doses. The induction-to-abortion interval and the level of pain experienced during the process were assessed. Success was defined by the fetus being expelled within 48 h.

Results

Vaginal misoprostol was effective in 84% (98/122) of patients. The median duration of the induction-to-abortion interval was 16 (5-48) h. The induction-to-abortion interval was correlated with gestational age, while inversely correlated with parity. A correlation was also found between gestational age and pain intensity at 12 h from induction.

Conclusion

Misoprostol is safe and effective in mid-trimester abortion induction. The induction-to-abortion interval is shorter and abortion less painful with lower gestational age. Higher parity is also associated with shorter induction to abortion interval.     

Repeat ectopic pregnancy: a study of 123 consecutive cases.

In a study of 1,330 ectopic pregnancies, 123 (9 per cent) patients experienced repeat tubal pregnancies. Of these 123 patients with repeat ectopics, 96 (78 per cent) were surgically sterilized with their second operative procedure. The remaining 27 potentially fertile patients have had nine pregnancies, but only three living children. Cornual wedge resection of the uterine tube predisposed in interstitial pregnancy and to rupture of the uterus in four cases. Four patients had three ectopic pregnancies each. Repair of the involved tube is usually technically possible following linear salpingotomy and should be done if future fertility is desired. If the patient does not desire future pregnancy, she should be sterilized to avoid the risk of repeat ectopic pregnancy.     

Prevalence of intrauterine adhesions after termination of pregnancy: a systematic review

Objectives: Termination of pregnancy (TOP) is one of the most performed interventions in women worldwide: approximately one in three women will have at least one TOP in their reproductive life. Intrauterine adhesions (IUAs) have been reported as a possible complication after TOP, but their prevalence has not been established, as women are not routinely evaluated. IUAs are associated with menstrual disturbances, infertility and obstetric complications.

Methods: We searched Ovid MEDLINE, Ovid EMBASE and CENTRAL from inception until November 2015 for studies evaluating women following TOP. We selected studies in which women were evaluated consecutively, independently of symptoms, by hysteroscopy or hysterosalpingography (HSG), for the presence of IUAs.

Results: After an extensive review of the literature, no studies were found that evaluated women after medical TOP and no randomised trials following surgical TOP. Only two prospective cohort studies were identified. In the first, IUAs were detected in 21.2% of women evaluated by hysteroscopy following first trimester surgical TOP; adhesions were moderate to severe in 48%. In the second, IUAs were detected in 16.2% of women evaluated by HSG after second trimester TOP by intra-amniotic prostaglandin induction followed by D&C; a pathologically wide internal cervical os was observed in 12%.

Conclusions: This systematic review suggests a link between TOP and adhesion formation, but, according to the scientific literature and despite new diagnostic facilities, the relationship between the methods of TOP and IUA formation remains unclear. Nevertheless, the reported frequency is in accordance with that found in women following D&C for miscarriage. Further research is required.