Management Of Termination Research Articles

Management of childbearing with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders: A scoping review and expert co-creation of evidence-based clinical guidelines.

To co-create expert guidelines for the management of pregnancy, birth, and postpartum recovery in the context of hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD). Scoping Review and Expert Co-creation. United Kingdom, United States of America, Canada, France, Sweden, Luxembourg, Germany, Italy, and the Netherlands. Co-creators (n = 15) included expertise from patients and clinicians from the International Consortium on the Ehlers-Danlos syndromes and Hypermobility Spectrum Disorders, facilitated by the Ehlers-Danlos Society. A scoping review using Embase, Medline, the Cochrane Central Register of Controlled Trials and CINHAL was conducted from May 2022 to September 2023. Articles were included if they reported primary research findings in relation to childbearing with hEDS/HSD, including case reports. No language limitations were placed on our search, and our team had the ability to translate and screen articles retrieved in English, French, Spanish, Italian, Russian, Swedish, Norwegian, Dutch, Danish, German, and Portuguese. The Mixed Methods Appraisal Tool was used to assess bias and quality appraise articles selected. The co-creation of guidelines was based on descriptive evidence synthesis along with practical and clinical experience supported by patient and public involvement activities. Primary research studies (n = 14) and case studies (n = 21) including a total of 1,260,317 participants informed the co-creation of guidelines in four overarching categories: 1) Preconceptual: conception and screening, 2) Antenatal: risk assessment, management of miscarriage and termination of pregnancy, gastrointestinal issues and mobility, 3) Intrapartum: risk assessment, birth choices (mode of birth and intended place of birth), mobility in labor and anesthesia, and 4) Postpartum: wound healing, pelvic health, care of the newborn and infant feeding. Guidelines were also included in relation to pain management, mental health, nutrition and the common co-morbidities of postural orthostatic tachycardia syndrome, other forms of dysautonomia, and mast cell diseases. There is limited high quality evidence available. Individualized strategies are proposed for the management of childbearing people with hEDS/HSD throughout pregnancy, birth, and the postpartum period. A multidisciplinary approach is advised to address frequently seen issues in this population such as tissue fragility, joint hypermobility, and pain, as well as common comorbidities, including dysautonomia and mast cell diseases.

Court Injunctions Plague Union‐Free Efforts

The recent case of National Labor Relations Board v. HSA Cleaning, Inc., Civil Action No. 23‐2994 (D.N.J. July 6, 2023), demonstrates how legal compliance during union campaigns is an inexact science. In HSA, it was alleged that in March 2022, the cleaning contractor's employee, Luis Varela, spoke as a representative of coworkers to voice management concerns about, among other things, mistreatment by management and threats of termination. A few months later, union representatives met with Varela and others in an organizing effort. Thereafter, Varela became more involved in organizing activities, including discussion about circulating a petition to gather employee support for union representation.

Audit of Ireland's first manual vacuum aspiration service.

Manual vacuum aspiration (MVA) is a safe and effective alternative option for the management of first-trimester miscarriage, termination of pregnancy, or retained pregnancy tissue. Ireland's first MVA clinic was set up in the Rotunda Hospital in April 2020. To identify the number of women who have undergone MVA since establishing our service, to assess the efficacy and safety of MVA in that service, and to develop local Irish studies that further support the safety of MVA, adding to the international body of evidence. With the approval and assistance of the Clinical Audit Committee, we obtained a log of all patients who underwent MVA in the first 18 months of the service. We performed a retrospective electronic chart review using Maternal and Newborn Clinical Management System. We collected the data and preformed a descriptive analysis. In total, 86 women underwent MVA, 85 (98.8%) of which were successfully completed. There were no immediate procedural complications, inter-hospital transfers, or emergency electric vacuum aspiration (EVA) required. We obtained an incomplete evacuation rate of 4.7% (n = 4). We have demonstrated that the MVA service in the Rotunda Hospital is a safe, effective management option with advantages for both the patient and the healthcare system. We recommend consideration for provision of funding and resources to enable expansion of this service nationally in order to give women greater autonomy of choice in the management of early pregnancy complications and termination of pregnancy.

49 Comparative study of manual vacuum aspiration syringe versus electrical suction for management of miscarriage and abortion

Introduction: Surgical management of miscarriage and termination of pregnancies constitute a major workload in Indian Hospitals and up to 40% of pregnancies can end up in miscarriage or abortion. The majority being performed under General anaesthesia (GA) which results in increased costs and more blood loss. Methods like Manual Vacuum aspiration (MVA) syringe would provide safe alternative. We compared MVA syringe made by IPASTM use compared to electrical vacuum suction for duration of procedure, blood loss and surgical complications.

Clinical analysis of pregnancy termination in 167 pregnant women with cardiovascular disease during the first and second trimester

Objective: To study the risk assessment, method selection and clinical management of pregnancy termination during the first and second trimester of pregnant women with cardiovascular disease. Methods: This study focused on pregnant women with cardiovascular diseases who were admitted to Beijing Anzhen Hospital during the first and second trimester of pregnancy from January 2016 to September 2019, to summarize their clinical characteristics, reasons and methods of pregnancy termination, management and outcomes. Results: Among 167 pregnant women, 119 cases (71.3%, 119/167) were in early pregnancy and 48 cases (28.7%, 48/167) were in middle pregnancy. The reasons for termination of pregnancy were cardiovascular disease (109 cases; 65.3%, 109/167), unwanted pregnancy (54 cases; 32.3%, 54/167) and other reasons (4 cases). Vacuum aspiration was performed in 98 cases and forceps curettage was performed in 19 cases, medical abortion was performed in 2 cases in early pregnancy. There was no change in cardiac function after pregnancy termination and all survived in early pregnancy. In the second trimester, 16 cases were induced by intraamniotic injection of ethacridine, 2 cases by water balloon, 1 case by oxytocin intravenous drip, and 29 cases by hysterotomy delivery. The ratio of patients with hysterotomy delivery with cardiac function grade Ⅲ-Ⅳ was significantly higher than that in the patients with vaginal labor induction in the second trimester [79% (23/29) vs 4/19; P<0.01]; the ratio of pregnancy risk grade Ⅳ-Ⅴ was also significantly higher [100% (29/29) vs 14/19; P=0.007]. The mean length of hospital stay of patients with hysterotomy delivery was significantly longer than that in the patients with vaginal labor induction [(7.1±3.4) vs (2.4±1.8) days; P<0.01]. Cardiac function was improved in 4 patients induced by ethacridine and rapid recovery without serious complications. Cardiac function decreased in 5 cases and 1 case died on the first day after hysterotomy delivery. Conclusions: Pregnancy risk assessment should be conducted as early as possible in patients with cardiovascular disease. If it is not suitable to continue the pregnancy, terminate pregnancy as early as possible to reduce the risk. Pregnancy termination methods and analgesic methods should be selected according to different gestational age and complications. The indications for hysterotomy delivery should not be relaxed at will, so as to minimize trauma and hemodynamic changes. After the termination of pregnancy, contraceptive measures should be implemented and the next treatment plan should be guided.

Perspectives on self-managed abortion among providers in hospitals along the Texas\u2013Mexico border

BackgroundFollowing self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking.MethodsThe study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents’ roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach.ResultsMost of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available.ConclusionsTreatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.

Recommendations and practical management of pregnant women with COVID-19: A scoping review

ObjetivoRecopilar recomendaciones y evidencias en el manejo práctico de las gestantes con infección por COVID-19 para clarificar pautas de atención obstétrica ante esta nueva enfermedad.MétodoScope review a partir de búsqueda bibliográfica en bases de datos nacionales e internacionales en ciencias de la salud (PubMed/Medline, Biblioteca Virtual en Salud, SciELO, Cochrane y CUIDEN) y sitios web y adicionalmente mediante sistema de «bola de nieve». Se utilizaron los términos MeSH: «COVID-19», «Pregnancy», «Delivery, Obstetric», «Pregnant Women» y «Maternal». Como límites en la búsqueda se seleccionaron los idiomas español e inglés. No se establecieron límites en referencia al año de publicación o el tipo de artículo.ResultadosSe detectaron un total de 49 documentos y artículos, de los cuales 27 fueron analizados, utilizándose 18 y desechándose 9 que no contenían recomendaciones prácticas. Las recomendaciones fueron agrupadas en 10 temáticas: prevención de la infección en la embarazada; prevención de la infección en el personal sanitario que atiende a la embarazada; forma de presentación y severidad en la embarazada; transmisión materno-fetal (vertical y perinatal); control materno-fetal de la gestante con COVID-19; control de la gestante grave por COVID-19; tratamiento de la gestante con COVID 19; manejo y vía de finalización del parto; resultados neonatales en mujeres con COVID-19, y lactancia materna.ConclusionesFalta una evidencia sólida que sustente muchas de las recomendaciones para la mujer gestante respecto a la COVID-19, ya que están basadas en la experiencia previa con las infecciones provocadas por los virus SARS-CoV y MERS-CoV. Se necesitan nuevos estudios que confirmen la idoneidad de muchas de las recomendaciones y pautas de actuación en el caso concreto de la mujer gestante y la COVID-19.

P03.06: Management of medical termination of pregnancy (MToP) up until the 7th week of gestation in the Czech Republic

P03.06: Management of medical termination of pregnancy (MToP) up until the 7th week of gestation in the Czech Republic

Method selection and perioperative management of termination of pregnancy during the first and second trimester of pregnancy with severe cardiovascular disease

Objective: To summarize and analyze the methods of termination of pregnancy in the first and second trimester of pregnancy with severe cardiovascular disease. Methods: A retrospective analysis of 27 cases of termination of pregnancy in the first and second trimester of pregnancy in Beijing Anzhen Hospital from January 1, 2016 to December 30, 2017. All of these pregnant women were pregnancy complicated with severe cardiovascular disease in grade Ⅴ pregnancy risk. Results: (1) The age of 27 pregnant women was 22-40 years, gestational age was 6-27 weeks; cardiac function grade before induced labor was: 5 cases of grade Ⅱ, 15 cases of grade Ⅲ, 7 cases of grade Ⅳ. The cardiovascular diseases included ventricular septal defect in 9 cases, simple atrial septal defect in 3 cases, patent ductus arteriosus in 2 cases, tetralogy of Fallot in 2 cases, rheumatic valvular disease in 1 case,arrhythmia-paroxysmal atrial velocity in 2 cases, cardiomyopathy in 2 cases, hypertensive cardiopathy in 2 cases, primary pulmonary hypertension in 1 case, tissue disease complicated with pulmonary hypertension 1 case, hyperthyroid heart disease in 1 case, coronary heart disease in 1 case. Among them, 21 cases were complicated with pulmonary hypertension, and 5 cases with Eisenmenger syndrome. (2) Methods of termination of pregnancy: in 27 cases, eight cases of vacuum curettage, and 2 cases of forceps curettage under general anesthesia without intubation; rivanol intraamniotic induction of labor in 1 case; and hysterotomy delivery in 16 cases (11 cases were treated with continuous epidural anesthesia, 1 case was treated with combined spinal and epidural anesthesia, 4 cases were treated with spinal anesthesia) . (3) After termination of pregnancy, one patient with severe primary pulmonary hypertension at 19 weeks of gestation died on the 1st day postoperative. No significant changes in cardiac function were observed in other patients before and after termination of pregnancy, and all of them survived. Conclusions: In patients with severe cardiovascular disease, termination of pregnancy after pregnancy may result in maternal death even at the second trimester of pregnancy.It is strongly recommended that such patients undergo pre-pregnancy assessment and fertility counseling.If visiting doctor after pregnancy, we should organize a multidisciplinary consultation as soon as possible to assess the risk of continuing pregnancy and give medical advice. If the risk of pregnancy is high, we should terminate the pregnancy as early as possible, after making a suitable treatment plan. During termination of pregnancy, temporary or permanent contraception may be taken if the condition permits.

Gradual vs entire sponsorship termination

PurposeThe few studies on the effects of a sponsorship termination do not consider the effects of different exit options on consumers’ attitudes toward the exiting sponsor. To fill this gap, the purpose of this paper is to investigate the effects of the extent of the exit (gradual vs entire) as well as the timing of the announcement (early vs late) on consumers’ attitudes. Moreover, this research considers the mediating role of the perceived abandonment of the sponsored party.Design/methodology/approachThis research uses an experimental study (n=204). Data were collected among supporters of a German second division soccer team.FindingsThe results emphasize that the extent of the exit as well as the timing of the announcement influences consumers’ attitudes. They develop negative attitudes toward the withdrawing sponsor, especially when the sponsor exits entirely instead of gradually and announces the decision late instead of early. Furthermore, the results reveal that the perceived abandonment of the sponsored party mediates the effect of the extent of exit on attitudes.Practical implicationsThe results help to formulate several exit options for the withdrawing sponsor that will help to minimize the possible negative effects on their brand. Specifically, the author recommends a gradual exit as well as an early announcement of the decision to prevent negative effects on the sponsor brand.Originality/valueThis study expands the research on the effects of a sponsorship termination on consumers’ attitudes toward the sponsor brand. Specifically, it is the first study that considers several aspects regarding the sponsor management of a sponsorship termination as important determinants of consumers’ attitudes.

466: Improved safety of second trimester dilation and evacuation versus induction of labor in the management of fetal demise or termination

466: Improved safety of second trimester dilation and evacuation versus induction of labor in the management of fetal demise or termination

Ending a sponsorship relationship: consumers’ responses toward a forced versus a chosen exit

ABSTRACTResearch question: Sponsorship relationships can be categorized into a beginning, an ongoing, and an ending phase. Although all of these phases can be consequential for the sponsoring brand, past research mainly focuses on the beginning phase and the management of existing sponsorships, and only a few studies examine the effects of ending a sponsorship relationship. The present study addresses this gap by exploring how two types of exit (chosen vs. forced) and the exit consequences (few vs. extensive) influence consumers’ evaluations of the sponsor brand.Research methods: This research uses an experimental study (N = 202). Data were collected among supporters of a German second division soccer team.Results and findings: The results reveal that consumers’ attitudes are negatively affected when the sponsor’s exit is freely chosen (vs. forced). These effects are moderated by the exit’s consequences. The detrimental effect of a chosen exit is particularly strong when the exit has extensive (vs. few) negative consequences for the sponsored property. The findings further show that the interaction of the type of exit (chosen vs. forced) and the exit’s consequences on consumers’ attitudes is mediated by the perceived abandonment of the sponsored property.Implications: We contribute to the literature by expanding knowledge about the effects of a sponsorship termination on consumers’ attitudes toward the sponsor brand. The present study highlights the effects of different types of exit on consumers’ attitudes and identifies the explanatory mechanisms underlying these effects. Furthermore, our research offers several practical recommendations regarding the management of sponsorship termination.

Second Trimester Medical Termination of Pregnancy with Combined Intracervical and Intravaginal Misoprostol: Comparative Analysis with Intravaginal Misoprostol—A Pilot Study

Intravaginal placement of misoprostol has been used extensively to terminate second trimester pregnancies. Intracervical misoprostol is an alternative method of termination of pregnancy for women in this period of gestation. To assess the efficacy and safety of combined intracervical and intravaginal misoprostol in the management of mid-trimester medical termination of pregnancy and to compare it with intravaginal misoprostol. In this IRB approved prospective study, twenty-two women (mean age 25.4±3.2 years, range 23-32 years; mean BMI 22.3±3.4kg/m(2); mean parity 2.1±1.4, average gestational age 17.9±2.4 weeks) underwent second trimester termination of pregnancy at our institution. Patient cohort was randomized into two treatment protocols depending on the drug used and route of administration. Induction-abortion interval, need for surgical evacuation, completeness of abortion and side effects if any were documented. Mean induction-abortion interval for intravaginal group and combination group was comparable (t=7.9±1.8 and 6.5±3.5h, respectively). Three patients required surgical evacuation for incomplete abortion (n=2 after vaginal misoprostol and one after intracervical-intravaginal misoprostol). Number of patients aborting within 6h was more in the intracervical-intravaginal group (36.3%). Patients with intracervical misoprostol complained of abdominal pain more often than those in other groups. Excessive bleeding and uterine rupture was not seen in any patient. Intracervical misoprostol is an effective method of medical treatment of second trimester pregnancy failure. Its short induction to abortion interval and acceptable safety profile makes induction via the cervical route acceptable for second trimester abortion.

Is tissue an issue? Current practice and opinion in Western Australia for routine histopathology on products of conception.

An anonymous questionnaire-based survey was used to determine current practices and opinions of senior health professionals working in Western Australian (WA) hospitals performing gynaecological procedures, regarding the routine use of histopathology for products of conception (POC) obtained either from the surgical management of miscarriage or termination of pregnancy. Sixty-one senior health professionals completed the survey. Tissue histopathology on POC was routinely requested for miscarriage and termination of pregnancy (TOP) by 87 and 59% of respondents, respectively. Respondents listed the main reasons for requesting routine histopathology as avoidance of misdiagnosis, medico-legal and quality assurance. There were inconsistent practices among WA health professionals regarding sending POC for histopathology; 63% of gynaecology head of departments recommend the introduction of state or national guidelines for the use of histopathology in the surgical management of miscarriages or terminations of pregnancy.

Pregnancy Loss Managed by Cervical Dilatation and Curettage Increases the Risk of Spontaneous Preterm Birth

Women with a history of 1 or 2 miscarriages or terminations of pregnancy have not been considered to be at risk of adverse pregnancy outcomes in subsequent pregnancies. However, few studies have examined the association between previous pregnancy loss and adverse pregnancy outcomes in subsequent pregnancies; results in the available studies are mixed. It has been suggested that previous use of cervical dilatation and curettage (D&C) for management of first-trimester miscarriage or termination may adversely affect outcomes in subsequent pregnancies. The aim of this prospective cohort study was to determine whether women with a previous miscarriage or termination of pregnancy are at increased risk of spontaneous preterm birth and to determine whether any increased risk is associated with previous use of cervical D&C. Prospective data were obtained for 5575 healthy nulliparous women with singleton pregnancies who were enrolled from 2004 to 2011 in the Screening for Pregnancy Endpoints (SCOPE) study. The primary study outcome was spontaneous preterm birth (spontaneous onset of preterm labor or preterm premature rupture of membranes resulting in preterm birth at less than 37 weeks’ gestation). Secondary outcomes examined included preterm premature rupture of membrane, small for gestational age, birth weight, placental abruption, and preeclampsia. Comparison groups were women with previous pregnancy loss (miscarriage or termination) and women with no previous pregnancy loss (control). Among the 5575 women in the study, 4331 (78%) had no previous pregnancy loss, 974 (17.5%) had 1 early previous pregnancy loss, 249 (4.5%) had 2, and 21 (0.5%) had 3 or 4 losses. A single pregnancy loss was not associated with a significant increase in adverse pregnancy outcomes, whereas 2 to 4 previous losses had an increased risk of spontaneous preterm birth (adjusted odds ratio [aOR], 2.12; 95% confidence interval [CI], 1.55–2.90) and/or placental abruption (aOR, 2.30; 95% CI, 1.36–3.89) compared with no previous pregnancy loss. The use of cervical D&C to manage a single previous miscarriage or termination of pregnancy was associated with an increased risk of spontaneous preterm birth (aOR,1.64; 95% CI, 1.08–2.50; 6% absolute risk and aOR, 1.83; 95% CI, 1.35–2.48; 7% absolute risk, respectively) compared with no previous pregnancy loss. In contrast, use of a nonsurgical method for management of a single previous miscarriage or termination did not increase the risk of adverse outcomes in a subsequent pregnancy (aOR, 0.86 [95% CI, 0.38–1.94; 3.4% absolute risk]; and aOR, 0.87 [95% CI, 0.69–1.12; 3.8% absolute risk], respectively). These findings indicate that a single pregnancy loss managed by cervical D&C is associated with an increased risk of spontaneous preterm birth and/or placental abruption. In contrast, a single pregnancy loss managed nonsurgically does not increase the risk, but 2 to 4 losses are associated with increased risk. Further prospective studies are needed to confirm these data and to determine whether nonsurgical management in this population should be preferable to surgical treatment.

Pregnancy loss managed by cervical dilatation and curettage increases the risk of spontaneous preterm birth

Do women with a previous miscarriage or termination of pregnancy have an increased risk of spontaneous preterm birth and is this related to previous cervical dilatation and curettage? A single previous pregnancy loss (termination or miscarriage) managed by cervical dilatation and curettage is associated with a greater risk of SpPTB. Miscarriage affects ∼20% of pregnancies and as many as a further 20% of pregnancies undergo termination. We utilized data from 5575 healthy nulliparous women with singleton pregnancies recruited to the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study performed between November 2004 and January 2011. The primary outcome was spontaneous preterm birth (defined as spontaneous preterm labour or preterm premature rupture of membranes (PPROM) resulting in preterm birth <37 weeks' gestation). Secondary outcomes included PPROM, small for gestational age, birthweight, pre-eclampsia and placental abruption. Women with previous pregnancy loss (miscarriage or termination) were compared with those with no previous pregnancy loss. There were 4331 (78%) women who had no previous pregnancy loss, 974 (17.5%) who had one early previous pregnancy loss, 249 (4.5%) who had two and 21 (0.5%) who had three or four losses. Women with two to four previous losses, but not those with a single loss, had an increased risk of spontaneous preterm birth (adjusted OR 2.12; 95% CI 1.55, 2.90) and/or placental abruption (adjusted OR 2.30; 95% CI 1.36, 3.89) compared with those with no previous pregnancy. A single previous miscarriage or termination of pregnancy where the management involved cervical dilatation and curettage was associated with an increased risk of spontaneous preterm birth (adjusted OR 1.64; 95% CI 1.08, 2.50; 6% absolute risk and adjusted OR 1.83; 95% CI 1.35, 2.48; 7% absolute risk, respectively) compared with those with no previous pregnancy losses. This is in contrast with women with a single previous miscarriage or termination managed non-surgically who showed no increase risk (adjusted OR 0.86; 95% CI 0.38, 1.94; 3.4% absolute risk and adjusted OR 0.87; 95% CI 0.69, 1.12; 3.8% absolute risk, respectively). Although every effort was made to record accurate previous pregnancy data, it was not feasible to confirm the history and management of previous pregnancy loss by hospital records. This may have introduced recall bias. This large prospective cohort study of healthy nulliparous women has demonstrated that women with either a previous miscarriage or termination of pregnancy were at increased risk of spontaneous preterm birth if they were managed by procedures involving cervical dilatation and curettage. However, overall, women with a single pregnancy loss did not have an increased risk of having any other of the adverse pregnancy outcomes examined. In contrast, two to four previous pregnancy losses were associated with an increased risk of having a pregnancy complicated by spontaneous preterm birth and/or placental abruption. Research is required to determine whether non-surgical management of miscarriage or termination of pregnancy should be advocated over surgical treatment. New Zealand: New Enterprise Research Fund, Foundation for Research Science and Technology; Health Research Council; Evelyn Bond Fund, Auckland District Health Board Charitable Trust. Australia: Premier's Science and Research Fund, South Australian Government. Ireland: Health Research Board. Leeds: Cerebra Charity, Carmarthen. Manchester: National Health Service NEAT Grant; Manchester Biotechnology and Biological Sciences Research Council; University of Manchester Proof of Concept Funding. King's College London: Guy's and St Thomas' Charity. King's College London and Manchester: Tommy's-The Baby Charity. N/A.

How to manage unresponsiveness to misoprostol in failed second trimester pregnancy termination

To present the experience of management of second trimester pregnancy termination by misoprostol after failure to abort within 48 h of its use. A retrospective, cohort descriptive study was carried out in the Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University Thailand between 1998 and 2010. All women at 14-28 weeks of gestation who failed to abort using misoprostol within 48 h were included. Management of failed pregnancy termination among these women is described here. Of a total of 680 women undergoing termination of pregnancy, 68 (10%) failed to abort. Mean maternal age was 28.71 years and mean gestational age was 19.91 weeks. Further management after failure included additional administration of misoprostol only (19.1%), modified condom balloon technique only (17.7%), modified condom balloon technique plus other methods (16.1%), while 47.1% needed only oxytocin as necessary. The mean interval between initiation of termination and delivery was 96.97 h. Failure of pregnancy termination using misoprostol can be successfully managed by introducing additional misoprostol, modified condom balloon technique and oxytocin infusion. These methods should be considered before proceeding to hysterotomy.

Organizational relationship termination competence: A conceptualization and an empirical test

Most firms are involved in a number of customer relationships that drain the firm's resources. However, many firms are hesitant to address this problem. This paper investigates customer relationship termination at the organizational level. We develop and analyze the organizational dimensions of organizational termination in order to improve our understanding of the management of termination. The impact of these termination dimensions on the percentage of unwanted customers is developed and tested using PLS on data gathered from a cross-sectional survey of more than 800 sales representatives. We find that a firm's percentage of unwanted customers decreases significantly as acceptance of termination increases, if the firm's definition of unwanted customers is well understood, and if a firm has clear termination routines. In addition, general focus on profitability and external constraints on relationship termination are found to significantly affect a firm's relationship termination competence. The findings suggest that managers should regard termination as a legitimate option in customer relationship management. In order to decrease the number of unwanted customers, managers must accept termination as a valid option, clearly define the types of customers that the organization does not want to serve, and implement termination routines within the organization.

Gravid hysterectomy following history of recurrent ruptured uterus: Case report

The risk of uterine rupture and its associated morbidities increases as the incidence of cesarean deliveries increases. There is little evidence guiding the management of pregnancy termination in patients with a history of uterine rupture. A 21-year-old woman with a history of a classical cesarean delivery and four subsequent uterine ruptures presented for termination of pregnancy at 17 weeks and 2 days. Ultrasound study noted anterior wall implantation of the placenta covering the classical cesarean scar as well as the subsequent cesarean section scars. A scheduled gravid hysterectomy was performed to complete the pregnancy termination and avoid recurrent uterine rupture. Pathological examination revealed marked attenuation and fibrosis of the anterior uterine wall with diffuse placenta accreta and focal placenta percreta justifying the decision for hysterectomy in this young patient. We therefore suggest that gravid hysterectomy rather than dilatation and evacuation should be considered for pregnancy termination in patients with history of recurrent uterine rupture and suspicion for abnormal placentation.

Second- and third-trimester management of medical termination of pregnancy and fetal death in utero after prior caesarean section

ObjectivesTo evaluate the results and risks of a protocol for second- and third-trimester termination of pregnancy after prior caesarean section. Study designThis is a retrospective study, conducted in a level 3 (university hospital) maternity unit between January 2001 and September 2008. 67 women with a history of caesarean section underwent second- and third-trimester termination of pregnancy. The protocol was administration of 600mg mifepristone the first day and application of laminaria tents the second day. One the third day, 48h after mifepristone, two 200μg tablets of misoprostol were given orally every 3h until delivery. Epidural analgesia was performed routinely. Complications analysed were uterine rupture, labour lasting over 12h, and bleeding requiring blood transfusion. ResultsDelivery was vaginal in 64 cases (95.5%), a median 4h 20min (P25: 3h 5min, P75: 7h 7min) after administration of misoprostol (median number of tablets 2; P25: 2, P75: 4). The median number of tablets of misoprostol was significantly higher for termination of pregnancy than for fetal death in utero (4 vs. 2; p=0.002). The rate of uterine rupture was 4.8% [95% CI: 1.2–14.2]. Bleeding during delivery requiring a transfusion occurred in 2 cases (3.0%; 95% CI: 0.5–11.3). ConclusionA high rate of vaginal delivery was achieved at low doses of misoprostol, with a short median induction-to-delivery interval, and a rate of uterine rupture higher than that observed during attempted vaginal delivery at term in a caesarean scar pregnancy. The rate of severe bleeding during delivery was low.