Laminaria Tents Research Articles

Cervical preparation with laminaria tents improves induction-to-delivery interval in second- and third-trimester medical termination of pregnancy

Background The purpose of our study was to determine whether cervical preparation with laminaria tents would improve the procedure of second- and third-trimester medical termination of pregnancy (TOP) in terms of duration of abortion and hospitalization. Study A retrospective comparative study of two historical periods of women undergoing second- and third-trimester medical TOP at a single tertiary care center from September 2004 to December 2006 was conducted. During Period A, patients received oral mifepristone and vaginal misoprostol, while during Period B, laminaria tents were added. Main outcome measures included initiation-to-delivery (ITD) time, induction-to-delivery interval and hospitalization time. Results Of 186 eligible women, 174 were enrolled in the study: 91 patients during Period A and 83 patients during Period B. The ITD time was reduced during Period B compared to Period A (43.2±6.2 h and 48.5±13.2 h, respectively; p=.001). Similarly, the induction-to-delivery interval was significantly shorter during Period B (7.5 h) compared to Period A (12.7 h; p=.001). A significant reduction in total hospital stay was observed during Period B (3 days) versus Period A (4 days; p<.001). Conclusion Cervical preparation with laminaria tents significantly shortens the duration of medical TOP that uses mifepristone–misoprostol without adverse events or serious complications.

Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation

Roughly 11% of induced abortions in the United States are performed after 14 weeks of gestation, most commonly by dilation and evacuation (D&E). For a D&E procedure, the cervix must be dilated sufficiently to allow passage of operative instruments and products of conception without injuring the uterus or cervical canal. Preoperative preparation of the cervix reduces the risk of cervical laceration and uterine perforation. The cervix may be prepared with osmotic dilators, prostaglandin analogues, or both. Osmotic dilators currently available in the United States include Dilapan-S™, Lamicel ®, and laminaria. Laminaria tents are made from dehydrated seaweed and require 12–24 h to achieve greatest dilation. The synthetic products, Dilapan-S™ and Lamicel ®, achieve maximum effect within 6 h. Dilapan-S™ achieves greater dilation than the others and, thus, requires fewer dilators to be placed but may be more difficult to remove. For same day procedures, Dilapan-S™ and Lamicel ® are preferable to laminaria. A single set of one to several dilators is usually adequate for D&E before 20 weeks of gestation. Additional sets over 1–2 days may be needed in challenging cases. Misoprostol, a prostaglandin analogue, is sometimes used instead of osmotic dilators; however, the data to support such use are limited. Misoprostol is inferior to overnight dilation with laminaria for cervical priming prior to D&E. Misoprostol use as an adjunct to overnight osmotic dilation is only marginally beneficial for priming beyond 16 weeks and does not truly demonstrate any benefit before 19 weeks of gestation. Limited data demonstrate the safety of misoprostol prior to D&E in patients with a uterine scar. The Society of Family Planning recommends preoperative cervical preparation to decrease the risk of complications when performing a D&E prior to 20 weeks of gestation. The three currently available osmotic dilators (laminaria, Lamicel ®, and Dilapan-S™) are safe and effective for this use. Since no single protocol has been found to be superior, clinical judgment is warranted when selecting a method of preoperative cervical preparation.

Medical treatment for early fetal death (less than 24 weeks).

In most pregnancies that miscarry, arrest of embryonic or fetal development occurs some time (often weeks) before the miscarriage occurs. Ultrasound examination can reveal abnormal findings during this phase by demonstrating anembryonic pregnancies or embryonic or fetal death. Treatment before 14 weeks has traditionally been surgical but medical treatments may be effective, safe, and acceptable, as may be waiting for spontaneous miscarriage. To assess the effectiveness, safety and acceptability of any medical treatment for early pregnancy failure (anembryonic pregnancies or embryonic and fetal deaths before 24 weeks). We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2005). Randomised trials comparing medical treatment with another treatment (e.g. surgical evacuation), or placebo, or no treatment for early pregnancy failure. Quasi-random studies were excluded. Data were extracted unblinded. Twenty four studies (1888 women) were included. Vaginal misoprostol hastens miscarriage (complete or incomplete) when compared with placebo: e.g. miscarriage less than 24 hours (two trials, 138 women, relative risk (RR) 4.73, 95% confidence interval (CI) 2.70 to 8.28), with less need for uterine curettage (two trials, 104 women, RR 0.40, 95% CI 0.26 to 0.60) and no significant increase in nausea or diarrhoea. Lower-dose regimens of vaginal misoprostol tend to be less effective in producing miscarriage (three trials, 247 women, RR 0.85, 95% CI 0.72 to 1.00) with similar incidence of nausea. There seems no clear advantage to administering a 'wet' preparation of vaginal misoprostol or of adding methotrexate, or of using laminaria tents after 14 weeks. Vaginal misoprostol is more effective than vaginal prostaglandin E in avoiding surgical evacuation. Oral misoprostol was less effective than vaginal misoprostol in producing complete miscarriage (two trials, 218 women, RR 0.90, 95% CI 0.82 to 0.99). Sublingual misoprostol had equivalent efficacy to vaginal misoprostol in inducing complete miscarriage but was associated with more frequent diarrhoea. The two trials of mifepristone treatment generated conflicting results. There was no statistically significant difference between vaginal misoprostol and gemeprost in the induction of miscarriage for fetal death after 13 weeks. Available evidence from randomised trials supports the use of vaginal misoprostol as a medical treatment to terminate non-viable pregnancies before 24 weeks. Further research is required to assess effectiveness and safety, optimal route of administration and dose. Conflicting findings about the value of mifepristone need to be resolved by additional study.

A Randomized Trial of Laminaria Tents Versus Vaginal Misoprostol for Cervical Ripening in First Trimester Surgical Abortion

Objective: To compare the use of laminaria tents with misoprostol for cervical ripening prior to first trimester surgical abortion.Method: In a prospective, open-label, randomized trial, 70 women were assigned to have either insertion of a 3 mm intracervical laminaria tent or vaginal misoprostol 200 µg on the day prior to suction dilatation and curettage (D&C). Cervical dilatation and operating time were measured at the time of D&C; the surgeon subjectively rated the ease of dilatation. The women were interviewed just prior to the D&C with regard to pain, vaginal bleeding, and dilator preference.Results: Laminaria produced significantly (P < 0.001) greater pre-abortion dilatation of the cervix (34.8 Pratt ± 6.2) than did misoprostol (28.4 Pratt ± 5.8). There was no demonstrable difference in ease of dilatation or operating time. Women randomized to use of laminaria reported significantly more pain on insertion than did those who received misoprostol (P < 0.001). Conversely, misoprostol was associated with more vaginal bleeding (P < 0.01). Pain following insertion was similar in each group. Two patients aborted completely after misoprostol alone. Overall, the stated patient preference for cervical dilator was more likely to be misoprostol (P < 0.01).Conclusions: Laminaria tents are more effective cervical dilators than vaginal misoprostol when inserted the day prior to suction D&C. Vaginal misoprostol insertion is more comfortable, although it is associated with an increased risk of vaginal bleeding and may abort the pregnancy. Patient preference favours misoprostol. In patient-centred care, both laminaria and misoprostol are suitable options for cervical preparation prior to suction D&C.

Medical abortion in combination with laminaria for first-trimester termination of pregnancy

Oral treatment with 600 mg of mifepristone, followed by 400 mg of misoprostol, has been used for early abortion by hundreds of thousands of women, with success rates ranging from 92 to 97% up to the 49th day of pregnancy w1,2x. Poor cervical dilation may prevent expulsion of gestational tissue, thereby increasing the rates of failure and prolonged heavy bleeding. Laminaria tents have been reported to obviate some of the trauma attributed to forced cervical dilation w3x. We hypothesized that, combined with medical abortion, laminaria use facilitated gestational tissue passage by enhancing cervical dilation. Our study population consisted of 38 women seeking medical abortion within the first 49 days of pregnancy. Each received 600 mg of mifepristone (Apano; Lotus, Taiwan) and, 36–48 h later, 400 mg of misoprostol (Cytotec; Searle, England). The women were randomly assigned to receive medical abortion with laminaria (group A) or without laminaria (group B) at the time of mife-

Laminaria dilatation and evacuation for pregnancies with mid-trimester premature rupture of membranes: a retrospective cohort study

Objective: To assess the efficacy and risk of chorioamnionitis with laminaria tents and uterine evacuation in patients with mid-trimester premature rupture of membrane (MPROM). Study Design: A retrospective cohort study of 34 women, admitted between January 1995 and May 1999 with confirmed mid-trimester (14–23 weeks) PROM and 34 controls matched for gestational age, undergoing elective termination. All women underwent cervical dilatation by the use of laminaria tents followed by uterine evacuation (D∝E). Perioperative complications were retrieved from the medical records and long-term ones by telephone questionnaire. Results: Apart from one case requiring a change in antibiotic, no short- or long-term complications were reported. Although, in 8 out of 19 study cases (42%) endocervix culture was positive. The number of laminaria tents used was similar in both groups. The future pregnancy rate was higher in the study group but included four early spontaneous abortions and one ectopic pregnancy. Conclusion: Evacuation of uterus following cervical dilatation by laminaria tents in patients presenting with MPROM is safe, and probably not associated with future adverse pregnancy outcome.

Toxic shock syndrome after laminaria insertion

BACKGROUND: Laminaria tents used to facilitate surgical abortion are rarely associated with significant infectious morbidity. CASE: A parous woman in midpregnancy had laminaria placed in her cervix followed by a second set after 24 hours. Eight hours later, she presented with dyspnea, hives, fever, tachycardia, and hypotension. Antibiotic treatment was initiated and a dilation and evacuation procedure was performed. Amniotic membrane cultures showed a heavy growth of Staphylococcus aureus with staphylococcal enterotoxin C expression, compatible with toxic shock syndrome. CONCLUSION: Laminaria cervical dilation might be associated with toxic shock syndrome.

Toxic Shock Syndrome After Laminaria Insertion

In Brief BACKGROUND Laminaria tents used to facilitate surgical abortion are rarely associated with significant infectious morbidity. CASE A parous woman in midpregnancy had laminaria placed in her cervix followed by a second set after 24 hours. Eight hours later, she presented with dyspnea, hives, fever, tachycardia, and hypotension. Antibiotic treatment was initiated and a dilation and evacuation procedure was performed. Amniotic membrane cultures showed a heavy growth of Staphylococcus aureus with staphylococcal enterotoxin C expression, compatible with toxic shock syndrome. CONCLUSION Laminaria cervical dilation might be associated with toxic shock syndrome. Laminaria used for cervical dilation might be associated with toxic shock syndrome.

Mechanical methods for induction of labour.

Mechanical methods were the first methods developed to ripen the cervix or to induce labour. Devices which were used include various type of catheters and of laminaria tents, introduced into the cervical canal or into the extra-amniotic space. Mechanical methods were never completely abandoned, but were substituted by pharmacological methods during recent decades. Potential advantages of mechanical methods, compared with pharmacological methods, may include simplicity of preservation, lower cost and reduction of the side effects. However, special attention should be paid to contraindications (e.g. low-lying placenta), risk of infection and maternal discomfort when inserting these devices. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology. To determine the effects of mechanical methods for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment, prostaglandins (vaginal, intracervical, misoprostol) and oxytocin. The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched April 2001. The criteria for inclusion were the following: (1) clinical trials comparing mechanical methods used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate or unclear method for allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions. A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data will be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman. In total, 58 studies were considered; 45 studies have been included and 13 were excluded. Studies generally included women with unfavourable cervix and intact membranes. Comparing mechanical methods with placebo/no treatment, only one study with 48 participants reported on vaginal delivery not achieved in 24 hours (69% with mechanical methods versus 77% with placebo/no treatment; relative risk (RR) 0.90; 95% confidence interval (CI): 0.64-1.26). Hyperstimulation with fetal heart rate changes was not reported. The risk of caesarean section, reported in six studies including 416 women, was similar between groups (34%; RR 1.00; 95% CI: 0.76-1.30). There were no reported cases of severe neonatal and maternal morbidity. Comparing mechanical methods with vaginal PGE2, only one trial (109 women) reported on vaginal delivery not achieved in 24 hours (73% versus 42%; relative risk (RR) 1.74; 95% CI: 1.21-2.49). Compared with intracervical PGE2, only one trial (100 women) reported on vaginal delivery not achieved in 24 hours (68% versus 40%; relative risk (RR) 1.70; 95% CI: 1.15-2.51). Compared with with misoprostol, the effectiveness of mechanical methods was similar (34% versus 30%; relative risk (RR) 1.15; 95% CI: 0.80-1.66). The use of mechanical method reduced the risk of hyperstimulation with fetal heart rate changes when compared with prostaglandins: vaginal PGE2 (0% versus 6%; RR 0.14; 95% CI: 0.04-0.53), intracervical PGE2 (0% versus 1%; RR 0.21; 95% CI: 0.04-1.20) and misoprostol (4% versus 9%; RR 0.41; 95% CI: 0.20-0.87). There was no difference in the risk of caesarean section between mechanical methods and prostaglandins. Serious neonatal (three cases) and maternal morbidity (one case) were infrequently reported. When compared with oxytocin, use of mechanical methods reduced the risk of caesarean section (4 trials; 198 women; 17% versus 32%; RR 0.55; 95% CI: 0.33-0.91). The likelihood of vaginal delivery in 24 hours and of hyperstimulation with fetal heart rate changes was not reported. There were no reported cases of serious maternal morbidity and severe neonatal morbidity was not reported. These results are similar whatever specific mechanical method was used, except with extra-amniotic infusion. When comparing extra-amniotic infusion with any prostaglandins, women were more likely to not achieve vaginal delivery within 24 hours (57% versus 42%; RR 1.33; 95% CI: 1.02-1.75), the risk of caesarean section was increased (31% versus 22%; RR 1.48; 95% CI: 1.14-1.90), without a reduction of the risk of hyperstimulation. There is insufficient evidence to evaluate the effectiveness, in terms of likelihood of vaginal delivery in 24 hours, of mechanical methods compared with placebo/no treatment or with prostaglandins. The risk of hyperstimulation was reduced when compared with prostaglandins (intracervical, intravaginal or misoprostol). Compared to oxytocin in women with unfavourable cervix, mechanical methods reduce the risk of caesarean section. There is no evidence to support the use of extra-amniotic infusion.

Hypersensitivity reactions following laminaria placement

Laminaria tents are commonly placed intracervically prior to elective termination of pregnancy. Three women, each of whom had undergone at least one previous abortion in which a laminaria was utilized, developed hypersensitivity reactions following laminaria placement. The reactions included urticaria, angioedema and respiratory distress. All responded to removal of the laminaria and administration of either diphenhydramine, prednisone, inhaled bronchodilators or subcutaneous epinephrine. One of the women subsequently underwent skin testing and was positive to laminaria. Patients undergoing laminaria placement may manifest a Type I reaction, IgE-mediated sensitivity. Providers should counsel patients with histories of multiple previous laminaria insertions about this possibility, have alternative methods of cervical dilation available, and be able to promptly recognize and treat reactions when they occur.

Comparative Study of Cervical Laminar Tents prior to Extra-Amniotic Injection of Ethacridine Lactate (Rivanol) and a Condom-Nelathon Catheter Method for Second-Trimester Pregnancy Interruption in Vietnam

Objective: To determine whether the regimen for termination of second-trimester pregnancies using laminaria tents 12–24 h prior to extra-amniotic ethacridine lactate (Rivanol) instillation, is more effective in shortening the insertion-expulsion interval than the presently used method of abortion induction by a condom/Nelathon catheter. Design: A prospective randomised comparative study was performed at Uong Bi General Hospital in Quang Ninh Province, Vietnam, on 91 women undergoing pregnancy termination in the second trimester. Interventions: The subjects were randomly allocated to 2 treatment groups, receiving either the Nelathon catheter-condom method (n = 50) or by insertion of a laminaria tent into the cervical canal for preinduction, 13–29 h before extra-amniotic instillation of ethacridine lactate (n = 34). Seven subjects were not pretreated with the laminaria tent. Main Outcome Measures: The insertion-expulsion intervals and the incidence of side effects were assessed. Results: The mean insertion-expulsion interval in the 2 groups was not significantly different (mean 27.5 ± 16.1 and 26.4 ± 16.4 h, respectively), calculating the insertion-expulsion interval from the start of active treatment, i.e. from the instillation of Rivanol or insertion of the Nelathon catheter and condom, until expulsion of the fetus. Conclusions: The laminaria-Rivanol method for pregnancy interruption is not more advantageous than the existing Nelathon catheter-condom method. Simple, successful and cost-effective methods in achieving second-trimester abortion in the Vietnamese context have therefore to be identified and tested.

A Randomized Controlled Trial of Laminaria, Oral Misoprostol, and Vaginal Misoprostol Before Abortion

In Brief Objective To compare the efficacy and acceptability of oral misoprostol, vaginal misoprostol, and laminaria tents for cervical dilation before surgical abortion. Methods We conducted a randomized, double-blind, placebo-controlled trial comparing oral misoprostol 400 μg, vaginal misoprostol 400 μg, and one medium laminaria for dilating the cervix over 4 hours before surgical abortion. The study sample consisted of 106 women at 7–14 weeks' gestation who presented to San Francisco General Hospital requesting abortion. The primary outcome was the amount of cervical dilation measured by Pratt dilators. Secondary outcomes were the proportion of subjects needing further manual dilation, difficulty of dilation, duration of the procedure, blood loss, and side effects. Results The vaginal-misoprostol group had a significantly greater mean dilation (28.0 mm) than the oral misoprostol group (24.2 mm; P < .05) and a greater mean dilation than the laminaria group (25.9 mm), although this difference did not reach significance. Women who received laminaria reported significantly more pain at the time of placement (85.7% reported at least “a little” pain) compared with women who received misoprostol by either route (28.9% of oral-misoprostol and 34.0% of vaginal-misoprostol subjects reported “a little” pain; P < .01). The proportion of subjects who required further manual dilation, ease of dilation, duration of the procedure, and blood loss were not significantly different among the groups. There was no difference in side effects during the 4-hour waiting period among the three groups, and gastrointestinal side effects were rare in all groups. Conclusion Vaginal misoprostol is superior to oral misoprostol and is an acceptable alternative to laminaria tents for cervical dilation before surgical abortion in pregnancies of 7–14 weeks' gestation. It is inexpensive and easy to administer, and achieves equal or greater dilation with less pain on insertion and no increase in side effects compared with laminaria. Vaginal misoprostol is an acceptable alternative to laminaria and is superior to oral misoprostol for cervical dilation before surgical abortion at 7–14 weeks' gestation.

A randomized controlled trial of laminaria, oral misoprostol, and vaginal misoprostol before abortion

Objective: To compare the efficacy and acceptability of oral misoprostol, vaginal misoprostol, and laminaria tents for cervical dilation before surgical abortion. Methods: We conducted a randomized, double-blind, placebo-controlled trial comparing oral misoprostol 400 μg, vaginal misoprostol 400 μg, and one medium laminaria for dilating the cervix over 4 hours before surgical abortion. The study sample consisted of 106 women at 7–14 weeks’ gestation who presented to San Francisco General Hospital requesting abortion. The primary outcome was the amount of cervical dilation measured by Pratt dilators. Secondary outcomes were the proportion of subjects needing further manual dilation, difficulty of dilation, duration of the procedure, blood loss, and side effects. Results: The vaginal-misoprostol group had a significantly greater mean dilation (28.0 mm) than the oral misoprostol group (24.2 mm; P < .05) and a greater mean dilation than the laminaria group (25.9 mm), although this difference did not reach significance. Women who received laminaria reported significantly more pain at the time of placement (85.7% reported at least “a little” pain) compared with women who received misoprostol by either route (28.9% of oral-misoprostol and 34.0% of vaginal-misoprostol subjects reported “a little” pain; P < .01). The proportion of subjects who required further manual dilation, ease of dilation, duration of the procedure, and blood loss were not significantly different among the groups. There was no difference in side effects during the 4-hour waiting period among the three groups, and gastrointestinal side effects were rare in all groups. Conclusion: Vaginal misoprostol is superior to oral misoprostol and is an acceptable alternative to laminaria tents for cervical dilation before surgical abortion in pregnancies of 7–14 weeks’ gestation. It is inexpensive and easy to administer, and achieves equal or greater dilation with less pain on insertion and no increase in side effects compared with laminaria.

Laminaria and sulprostone in second trimester pregnancy termination for fetal abnormalities

The efficacy and safety of intracervical placement of laminaria and intravenous prostaglandin E 2 (sulprostone) infusion for termination of second-trimester pregnancies with abnormal fetuses was investigated. One hundred and six pregnant women at 13–29 weeks' gestation with fetal anomalies underwent laminaria tent insertion into the cervical canal on admission. The next morning, Sulprostone infusion was started at a rate of 16 μg/h and increased by 16 μg/h every 30 min to induce uterine contractions. Induction-to-abortion time (IAT), success and complete abortion rates, and sulprostone-related side effects were registered. The overall success and complete abortion rates within 24 h were 91.5 and 80.2%, respectively. The mean IAT was 12.1±7.6 h. The incidence of nausea and/or vomiting was 17.9%, with 1.7 episodes per case. Diarrhea and fever (9.5%) were not common. Laminaria tent insertion plus sulprostone infusion was an effective and safe regimen for second-trimester termination of pregnancy with live fetuses.

The Acute Release of Maternal Prolactin by Instrumental Cervical Dilatation Simulates the Second Stage of Labor

We hypothesize that artificial stimulation of the cervix causes an acute secretion of maternal prolactin (PRL) that mimics PRL secretion during the second stage of human labor. Eighteen women scheduled for first-trimester therapeutic abortion had a blood sample drawn at the following times: before and after laminaria tent (LT) insertion for cervical ripening, 18-24 hours later upon entry in the procedure room, after LT removal, during instrumental cervical dilatation and uterine evacuation by suction curretage, soon after evacuation, and 1/2 hour and 1 hour after evacuation. Local cervical anesthesia, intravenous analgesics, and sedation were administered before the procedure. Blood serum was assayed for PRL, human chorionic gonadotropin (hCG), and estradiol. The initial PRL levels were 34 ng/mL +/- 4.2 standard error of the mean (SEM) and did not change after 18-24 hours of LT placement nor after LT removal. However, PRL increased significantly (t = 5.8; P = .00001) over basal levels by 204% +/- 15 at the time of instrumental dilatation and rose to 378% +/- 33 at 1/2 hour postevacuation. After 1 hour, PRL had declined to 173% +/- 10%. Serum levels of estradiol and hCG changed only after evacuation. Artificial stimulation of the cervix causes an immediate surge in PRL levels. We suggest that the acute increase in pituitary PRL secretion that occurs during the second stage of labor results from a neural signal from the cervix and not from endocrine changes associated with labor.

Intraoperative blood loss and gestational age at pregnancy termination

Objective: To establish the relationship of measured intraoperative blood loss to gestational age at pregnancy termination, and to determine which factors, if any, affect the risk of bleeding. Methods: A single-operator series of 363 consecutive women undergoing pregnancy termination between 5 and 24 weeks gestational age, as dated by ultrasound, was prospectively evaluated. All pregnancies under 13 weeks gestation were terminated by mechanical dilation and suction curettage without preoperative cervical ripening. All pregnancies between 13 and 24 weeks gestation were terminated by preoperative osmotic cervical dilation with laminaria tents and subsequent uterine evacuation by a combination of suction curettage, sharp curettage, and Bierer forceps extraction. All patients over 12 weeks gestation received a postoperative oxytocin infusion. Whenever possible, amniotic fluid and blood were collected and measured separately. Patients were excluded from the data analysis for pregnancy demise, PPROM, Potter’s syndrome, or inability to separate blood establish their relationship. After adjustment for gestational age, the results were analyzed to determine if blood loss was related to maternal age, smoking history, body habitus, or operative indication. Results: A curvilinear relationship between blood loss and gestational age was observed. Mean blood loss at 24 weeks exceeded 800 mL. After adjustment for gestational age, no factors significantly affected blood loss at dilation and aspiration of first trimester pregnancies. In those patients undergoing dilation and evacuation in the second trimester, both simple and stepwise regression analyses showed obesity (BMI ≥32.3) to be significantly associated with increased blood loss ( P < .05). Neither age, parity, previous cesarean section, nor smoking history were significantly associated with increased blood loss at dilation and evacuation. Conclusions: With advancing gestational age, intraoperative blood loss increases in curvilinear fashion. Termination providers should be advised that, although blood loss is unaffected by many factors, obese patients are at risk for increased bleeding at dilation and evacuation of pregnancies beyond 12 weeks gestation.

Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis

Objective: To determine whether laminaria tents are a safe and effective method of cervical dilatation in patients with a history of cervical stenosis and difficult ET. Design: Case reports describing two patients. Setting: Tertiary care, assisted reproduction practice. Patient(s): Two patients with cervical stenosis and a history of multiple failed cycles of IVF. Intervention(s): Laminaria tents were placed intracervically before ET. Main Outcome Measure(s): Presence of a gestational sac and fetal heartbeat on ultrasound. Result(s): Successful clinical pregnancies occurred in both patients after laminaria placement and ET. Conclusion(s): Laminaria tent cervical dilatation appears to be a safe and effective option to assist ET in patients with a history of cervical stenosis.

Abortion at 18–22 weeks by laminaria dilation and evacuation

To evaluate the complications of late second-trimester abortions (18-22 weeks) by laminaria dilation and evacuation, and the obstetric outcome of subsequent pregnancies. Dilation of the cervix was achieved by repeated laminaria tent replacement. Evacuation was carried out in the outpatient clinic using general anesthesia. After the first menstrual period, all patients were invited for examination and thereafter were asked to report the outcome of subsequent pregnancies. One hundred seventy-one late second-trimester abortions were performed. Cervical dilation was satisfactory in 158 women (92%). Operative sonography was required in nine (5%) women. One had uterine atony. Follow-up from 150 (88%) women indicated no infection, but one woman required repeat curettage for retained products of conception. There was no indication of cervical injury on cervical internal os measurements remote from abortion. Of the 50 patients who conceived and elected to continue the subsequent pregnancies, two had premature deliveries unrelated to cervical incompetence, and all others reached term. Late second-trimester termination by laminaria dilation and evacuation is safe and probably not associated with future adverse pregnancy outcome.

A comparison of misoprostol with and without laminaria tents for induction of second-trimester abortion

OBJECTIVE: Our purpose was to determine whether intracervical placement of laminaria tents would improve the effectiveness of the prostaglandin analog misoprostol for the elective termination of pregnancies in the second trimester. STUDY DESIGN: Sixty-eight women between 12 and 22 weeks of gestation with either an intrauterine fetal death ( n = 40) or medical or genetic indications for pregnancy termination ( n = 30) were randomized to receive 200 μg of misoprostol administered vaginally every 12 hours with or without intracervical placement of laminaria concurrently with the first dose of misoprostol. RESULTS: The rate of abortion 24 hours after initiation of treatment was 69.7% in the 33 women receiving misoprostol alone and 68.6% in the 35 women treated with misoprostol and laminaria. The abortion rates 48 hours after initiation of treatment were 84.8% and 91.4%, respectively, an insignificant difference. The complete abortion rate was also similar between women receiving misoprostol alone (39.3%) and the group receiving misoprostol and laminaria (37.5%). There were no significant differences in the incidence of fever, vomiting, diarrhea, or pain. The mean interval from initiation of treatment to abortion was also similar, 15.7 hours in those receiving misoprostol alone and 17.4 hours in those treated with misoprostol and laminaria. In both groups women who had live fetuses at the start of the procedure had a higher failure rate of abortion and a longer time interval to abortion than women whose fetus was dead. CONCLUSIONS: Laminaria tents inserted concurrently with the first dose of misoprostol do not significantly improve the abortifacient effect of vaginal misoprostol in the second trimester of pregnancy. (Am J Obstet Gynecol 1996;175:173-7.)

Cervical dilation from multiple laminaria tents used for abortion

To quantify the cervical dilation achieved from multiple medium-thick laminaria tents used for 16-26 hours in single applications before abortion. In a practice setting, cervical dilation was studied from all abortions done at greater than 8 weeks in which one or more medium-thick laminaria tents were used in a single application for 16-26 hours. Multiple regression analysis was used to quantify results. There was a positive linear regression of dilation against weeks of gestation for all numbers of tents. The more tents, the greater the dilation; the more weeks, the greater the dilation. Approximate cervical circumferential dilation from medium-thick laminaria tents under the constraints listed is provided by the formula: Pratt dilation = 12.36 + (2.35 x tents) + (1.79 x weeks).