Laminaria, induced fetal demise and misoprostol in late abortion.

OBJECTIVES: To analyze and determine the safety and effectiveness of induced fetal demise as an adjunctive method in outpatient abortion for patients with advanced pregnancies and to evaluate the independent effect of intrauterine misoprostol administered after amniotomy in late abortion. METHODS: During a 9-year period, 1677 abortions were performed for patients whose pregnancies ranged from 18 through 34 menstrual weeks in an outpatient facility. Of these, 832 were performed by one physician. Techniques for performing all the abortions included induction of fetal demise by intrauterine fetal injection of digoxin and/or hyperosmolar urea, serial multiple laminaria treatment of the cervix, amniotomy, oxytocin induction of labor, and assisted delivery or surgical evacuation of the fetus and placenta. In the last 411 of the 832 patients whose abortions were performed by one physician, misoprostol was placed in the lower uterine segment following amniotomy in order to enhance labor induction, cervical ripening, and fetal expulsion. RESULTS: Of the entire group of 1677 cases, the median gestational age was 22 menstrual weeks. The median procedure time for all cases was 10 min. Measured median blood loss was 125 ml. Blood loss and procedure time increased with length of gestation, but these were not affected by misoprostol. There were three major complications (0.2%) in the overall series. Among patients seen by one physician (N=832), amniotomy-to-procedure time was shorter by 26 min for patients receiving misoprostol, and there was 27% more variability in amniotomy-to-procedure time among patients not receiving misoprostol. Complication rates for patients receiving misoprostol were the same as for those not receiving misoprostol. There were no major complications in the 832 patients seen by one physician, no uterine rupture or perforations, and no cervical lacerations. CONCLUSIONS: Outpatient abortion may be performed safely from 18 through 34 menstrual weeks using combined surgical and medical procedures. Use of intrauterine post-amniotomy misoprostol was associated with reduced amniotomy-to-procedure time and reduced variability in the amniotomy-to-procedure time.