Midtrimester Abortion Research Articles

GESTATION, BIRTH-WEIGHT, AND SPONTANEOUS ABORTION IN PREGNANCY AFTER INDUCED ABORTION: Report of Collaborative Study by W.H.O. Task Force on Sequelæ of Abortion

The outcome of pregnancy in 7228 women from eight European cities was studied. In two of the three city clusters, there was a significantly higher risk of adverse outcome in terms of either mid-trimester spontaneous abortion, preterm delivery, or low-birth-weight infant among women whose only previous pregnancy had been surgically terminated than among primigravidæ or women whose only previous pregnancy had ended in live birth. In one city cluster in which surgical termination was accomplished both by conventional dilatation and curettage and by vacuum aspiration (V.A.), an increased risk of short gestation was noted for V.A., but the overall total risk of adverse outcome was not significantly increased. In the third city cluster, in which surgical termination was nearly entirely by V.A., induced abortion was not associated with any increased risk of adverse pregnancy outcome. The effects of spontaneous abortion on the subsequent pregnancy are similar to those of induced abortion.

Termination of second trimester pregnancy with intraamniotic administration of 16-phenoxy-ω-tetranor-PgE2-methylsulfonamide (SHB 286) alone and combined with oxytocin and calcium gluconate

Midtrimester abortion was succesfully induced within 30 hours in 62 out of 90 patients by intraamniotic administration of 16-phenoxy-ω-17,18,19, 20-tetranor-prostaglandine-E2-methylsulfonamide. The Pg-analogue was tested in 5 groups of patients which received 1,2 or 3 mg. In group IV, 2 mg of the analogue was combined with oxytocin. In group V, 3 mg of the analogue was combined with 2.75 grams of calcium gluconate. The success rate was significantly influenced by the amount of the drug administered. Side effects were minimal. Multiparous women respond better to the therapy than nulliparous patients. The combination with oxytocin was more effective than the Pg-analogue alone and the combination of sulprostone with calcium gluconate was 87% succesful within 30 hours and 100% succesful within 36 hours.

Use of intra- and extra-amniotic prostaglandins for the termination of pregnancies — Report of multicentric trial in India

The Indian Council of Medical Research initiated a, multicentric trial with prostaglandins in 1976 to assess the safety and efficacy of their use in midtrimester abortions, PGF 2αand 15-Me-PGF 2α were compared using the intra-amniotic (I.A.) route, 15-Me-PGF 2α was also evaluated by extra-amniotic (E.A.) route. With intra-amniotic instillation, success rate was 88.1 per cent with PGF 2α and 93.0 per cent with 15-Me-PGF 2α within 48 hours and by the extra-amniotic route it was 78.1 per cent within 36 hours. The mean induction-abortion interval was 19 hours with I.A. and 14.8 hours with E.A. Abortions were complete in 48.8 per cent of the women following I.A. PGF 2α, 56.0 per cent following I.A. 15-Me-PGF 2αand only 23.0 per cent following E.A. administration. Vomiting and diarrhoea were the most commonly reported side effects. Cervical injuries were 4.7 per cent with I.A. PGF 2α, 1.4 per cent with I.A. 15-Me-PGF 2α and only 0.6 per cent with E.A. route.

Arachidonic acid in amniotic fluid after extra-amniotic instillation of rivanol for midtrimester abortion

Free arachidonic acid was measured by gas liquid chromatography in amniotic fluid in 13 women during induction of midtrimester abortion. The abortions were induced by extraamniotic instillation of 0.1% Rivanol. Serial sampling of amniotic fluid were performed through a trans-abdominal catheter up to 22 hrs. Free, total arachidonic acid showed a significant increase from 26±8 ng/ml to 293±102 ng/ml at 22 hrs. The percentage of free arachidonic acid in total free fatty acids increased significantly from 2.2±0.5 to 6.1±1.6% during the same time. The C results suggest a selective release of arachidonic acid during Rivanol-induced abortion.

The Effect of Intra-Amniotic Prostaglandin F2α on Anterior Pituitary Hormone Release During Midtrimester Abortion

The effect of intra-amniotic administration of prostaglandin F2alpha (PGF2alpha) on pituitary hormone release was studied in women undergoing midtrimester abortion. Serum prolactin (PRL), growth hormone (GH), thyrotropin (TSH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were measured prior to and at 15-minute intervals for 2 hours following intra-amniotic administration of 40 gm of urea alone, 20 mg of PGF2alpha and 40 gm of urea, or an equal volume of normal saline. Serum PRL levels were significantly higher at sampling times from 15 through 120 minutes when both PGF2alpha and urea were administered than after saline or urea alone. The elevation in serum GH following PGF2alpha and urea was not significantly greater than for urea alone. The GH response in the women receiving normal saline was significantly less than for the two groups of women receiving the abortifacients. These results indicate that the GH response was related to the stress effects of the abortifacients. There was no difference in the TSH, LH, and FSH responses for the three groups. These results suggest that PGF2alpha selectively causes pituitary release of PRL in women during midtrimester pregnancy.

Second trimester abortion with 5% intraamniotic saline--a pilot study.

The risk of hypernatremia and related postabortion complications resulting from the intraamniotic administration of a 20-25% hypertonic saline solution, a widely used procedure all over the world, prompted this trial of 5% saline. Midtrimester abortion was induced in 150 women with a 5% saline solution administered intraamniotically at the National Medical College, Calcutta, India, from August 1974 to October 1975. The abortion was complete within 48 hours in 90% of the cases. All the fetuses were delivered dead. In one case, hysterotomy was performed because of severe bleeding. The immediate complication rate was 36% (12% serious). The follow-up complication rate was 2%. One patient died on the seventh postabortal day due to severe, uncontrolled septicemia. The authors conclude that because this procedure is simple and low cost and because it reduces the risk of hypernatremia it should be a welcome addition to service programs in developing countries.

Bacteriologic culture results obtained before and after elective midtrimester urea abortion

Twenty patients undergoing elective midtrimester abortion by urea amnioinfusion had bacteriologic culture data obtained before and after the procedure. Despite the presence of pathogens in the vagina and cervix prior to the procedure, only 20% of patients exhibited endometrial growth following abortion. Factors that seem to favor such endometrial growth include increased injection-abortion intervals and the requirement for curettage to manage incomplete abortion.

A Randomized Study of 12-mm and 15.9-mm Cannulas in Midtrimester Abortion by Laminaria and Vacuum Curettage

We evaluated the adequacy of a new large-bore vacuum cannula system for midtrimester abortion by randomly allocating patients to be treated with a standard 12-mm vacuum system or the new 15.9-mm system. Cervical dilataion was accomplished by overnight placement of laminaria tents. Blood loss was similar for the two treatment groups and was significantly greater at gestational ages 17 to 18 weeks than for abortions at 16 weeks or less. Operating time was slightly less in the large-cannula group. When the 12-mm cannula was used beyond 13 weeks' gestation, forceps were usually needed to empty the uterus completely. The large-cannula system was able to empty the uterus through 16 weeks, but at 17 and 18 weeks it offered no advantage over the smaller system and forceps were always needed. Complications were minimal. We caution against forcible cervical dilatation to 16 mm and urge the use of laminaria instead. Our findings, together with published reports of the safety of late dilatations and evacuation, would appear to justify wider clinical trials by experienced investigators.

Midtrimester Abortion With Prostaglandin and Hypertonic Saline—A Comparative Study

This study was conducted in Baroda, India, to evaluate and compare the safety and effectiveness of intraamniotic prostaglandin F2alpha (PGF2alpha) and 20% saline augmented with intravenous oxytocin for terminating 200 pregnancies of 14 to 20 weeks' gestation. While there was no method failure among the group treated with saline, ten method failures were reported for patients treated with the PGF2alpha. The rate of incomplete abortions was significantly lower for the group treated with saline (19.4%) than it was for the group treated with the PGF2alpha (33.7%). The administration of oxytocin after fetal expulsion did not reduce the rate of incomplete abortion. The mean instillation-to-abortion time was significantly lower with saline than with PGF2alpha. The incidence of gastrointestinal side effects and excessive bleeding (less than 200 ml) during the procedure was significantly higher for patients treated with PGF2alpha than for those treated with saline.

Hyperosmolar urea for elective midtrimester abortion: Experience in 1,913 cases

Intra-amniotic hyperosmolar urea (59.7 per cent) augmented by intravenous oxytocin (332 mμ per minute), prostaglandin F2α (20 mg.), prostaglandin F2α (10 mg.), or prostaglandin F2α (5 mg.) was utilized for 1,913 patients requesting elective midtrimester abortion. Injection-abortion intervals ranging from 13.70 to 21.49 hours were achieved with failure rates of 0.7 to 6.7 per cent. Despite frequent pre-existing medical conditions, the complication rate compared favorably with those of other methods for terminating midtrimester pregnancy such as saline amnioinfusion or dilatation and evacuation.

Influence of induced abortion on gestational duration in subsequent pregnancies.

We studied the effect of previous induced and spontaneous abortion on gestational duration in subsequent pregnancies in 12 obstetric departments in the Netherlands. Only primiparae were studied. Of 504 women who had had a previous induced abortion, 18 (3.6%) delivered before 32 weeks' gestational age. Forty of 1313 women with a history of spontaneous abortion (3.0%) and 259 of 12 678 women with no history of abortion (2.1%) also delivered before 32 weeks. The differences between the three groups were not significant. In the Netherlands there are no significant indications that spontaneous midtrimester abortions or premature deliveries are caused by a previous induced abortion.

Mid-trimester abortion induced by intravaginal administration of prostaglandin F 2α-methylester suppositories

Mid-trimester abortion was successfully induced in 28 of 31 patients by administration of vaginal prostaglandin F 2α-methylester. A suppository containing 1.5 mg was given every three hours. Two of the patients who failed to abort needed a D & C after 24 and 30 hours. In the third patient “ballooning” of the lower uterine segment was observed. The mean induction-abortion interval was 15.6 ± 1.1 hours. The mean dose was 8.5 mg. The patients were mostly primiparous women between 13 and 32 years with a mean age of 19.5 years. In 8 patients abortion was incomplete and surgical intervention was required to remove the placenta. Only one patient had an estimated blood loss exceeding 250 ml (approx. 1000 ml) which required transfusion. The most frequently encountered side effects were sleepiness and gastrointestinal disturbances (despite premedication with anti-emetic and anti-diarrheal agents). Postabortion lactorrhea is a seldom mentioned but real side effect of Pg-induced abortion. In general the side effects were minimal and never required termination of therapy. Midtrimester abortion with intravaginal PgF 2α-methylester suppositories appears to offer a valid alternative to the presently available techniques.

Limitations of a single extra-amniotic injection of prostaglandins in viscous gel to induce midtrimester abortion.

A dose-response study using PGE2 in a viscous gel has been undertaken for induction of midtrimester abortion. A direct relationship was found between the time to abortion and the dose administered. However, even using PGE2 3.5 mg induced uterine activity was noticed to subside in a significant number of women after approximately 6 h. For routine management it is suggested that PGE2 3.5 mg be injected and followed by repeat doses 6 h later with removal of the injecting catheter on each occasion.

Evaluation of a balloon dilator to augment midtrimester abortion

A new balloon-type cervical dilating device (CDD) was inserted just after intra-amniotic infusion of a combination of prostaglandin F2α and hypertonic saline in an effort to shorten the interval from infusion to abortion. The CDD has both dilator and anchor balloons which are inflated with normal saline after insertion into the cervical canal. The infusion-to-abortion interval was shorter in patients with the CDD dilator inflated (14.6 ± 2.1 hours) than in those with both dilating and anchor balloons inflated or in those aborting without the device in place at all (23.0 ± 1.7 and 18.8 ± 1.0 hours, respectively).

The effects of longacting paracervical block anesthesia on the abortifacient efficacy of intra‐amniotic pgf2α and hypertonic saline

A comparative study was conducted to evaluate the effects of repeated, longacting paracervical blocks on the abortifacient efficacy of intraamniotic prostaglandin F2alpha (PGF2alpha)-40 mg initially and an additional 20 mg after 24 hours--and hypertonic saline augmented with intravenous oxytocin, for patients at 16 to 20 weeks' gestation. Patients were randomly assigned to the 2 abortion procedures, and one half (50) of the patients induced with each procedure received serial, longacting paracervical blocks. For those patients aborted with saline, the rates of complications, side effects, incomplete abortion, and cumulative abortion were similar for patients whether they did or did not receive paracervical blocks. Among the PGF2alpha-treated patients who were administered paracervical blocks, there was a significant reduction in the rates of gastrointestinal side effects and incomplete abortion and a significant differences in the cumulative abortion rates. Within 32 hours of the initial PGF2alpha, instillation, 98% of the patients who received paracervical blocks aborted compared to 70% of those who did not receive paracervical blocks. Although the cumulative abortion rates of PGF2alpha-treated patients with paracervical blocks and saline-treated patients were similar, the rate of incomplete abortion for the PGF2alpha-treated patients was significantly lower. Additional studies will be necessary to evaluate the safety and advantages of using paracervical block anesthesia as an adjunct to midtrimester abortion procedures.

Uterine rupture: A complication of midtrimester abortion

The intraamniotic injection of prostaglandin F2alpha and/or hypertonic saline may be associated with serious uterine and cervical trauma. Multiparity and superimposed uterotonic stimulation by oxytocin are generally thought to be contributory. A patient is described who failed to abort vaginally after an uneventful intraamniotic infusion of prostaglandin F2 alpha in combination with hypertonic saline; 48 hours later she evacuated the uterine contents into the peritoneal cavity through a rent in the uterine fundus. The uterine rupture occurred even though there had been no uterotonic stimulation by oxytocin.

Catecholamines during therapeutic abortion induced with intra-amniotic prostaglandin F2α

Serial plasma, amniotic fluid, and urine samples were analyzed for epinephrine (E) and norepinephrine (NE) in eight subjects during midtrimester abortion induced by intra-amniotic prostaglandin F2α (PGF2α). After PGF2α administration, plasma E increased and there was no change in plasma NE levels. Amniotic fluid levels of E and NE decreased initially. During the course of abortion the mean level of E in the amniotic fluid increased after fetal distress and decreased after fetal death, indicating that the midtrimester fetus may respond to stress by the urinary excretion of E. The maternal urinary excretion rates of both E and NE increased following PGF2α. The observation that mean plasma levels and urinary excretion rate changes correlated better with the course of abortion and uterine contractility rather than with the time of PGF2α administration was consistent with the hypothesis that the catecholamine response may be due to the stress of labor rather than to the PGF2α per se.

Intra-amniotic urea and prostaglandin F2α for midtrimester abortion: Clinical and laboratory evaluation

The clinical management of the elective midtrimester abortion continues to be unsatisfactory as judged by either national mortality or morbidity rates. This report documents the results of a randomized series of 16 midtrimester abortions induced by either intra-amniotic hyperosmolar urea and 5 mg. of prostaglandin F2α (PGF2α) or intra-amniotic hyperosmolar urea alone. Pertinent clinical characteristics and biochemical determinations were compared between these two groups. A series of 150 patients were then treated with urea and 5 mg. of PGF2α. The clinical results of this series of patients are presented and compared with a previous group who had urea and 10 mg. of PGF2α. These studies demonstrate that 5 mg. of PGF2α with 80 Gm. of urea achieves injection-abortion intervals that are less than 24 hours.

Detachment of the uterine cervix in association with induced midtrimester abortion

Detachment of the uterine cervix in association with induced midtrimester abortion

Vaginal administration of 15(s)15-methyl prostaglandin F 2α methyl ester for induction of mid-trimester abortion

A clinical trial with 15(S)15-methyl prostaglandin F 2α methyl ester for termination of second trimester abortion is described. The compound was administered vaginally by means of 1.5-mg suppositories and this dose was repeated every three hours until the patient aborted or up to 24 hours. Twenty-nine patients were studied. Lomotil tablets were administered to reduce gastro-intestinal side effects. A success rate of 96.5% was obtained. Approximately 76% of the patients aborted within 18 hours. The mean induction-abortion interval was 12.5 hours, with no significant difference between primigravidae and multigravidae. The abortion was complete in 17.9%. The incidence of vomiting and diarrhoea was high, 3.6 and 3.9 episodes per patient, respectively. Further studies with a lower dose of 15(S)15-methyl prostaglandin methyl ester vaginal suppositories may prove to be just as effective but with a more acceptable frequency of gastro-intestinal side effects.