Misoprostol For Second-trimester Abortion Research Articles

Outpatient medical management of later second trimester abortion (18–23.6 weeks) with procedural evacuation backup: A large case series

ObjectiveDocument the clinical outcomes of an outpatient medical management with procedural evacuation backup procedure for abortions between 18 weeks zero days to 23 weeks six days gestation. Study designWe conducted a retrospective medical records review of adult patients who received mifepristone and repeated misoprostol for second trimester abortion with procedural evacuation backup at an Arizona clinic between October 2017 and November 2021. We extracted patient demographics; pregnancy and medical history; and preoperative, intraoperative, and postoperative data. We assessed abortion outcomes, including procedure timing, mode of completion (medication alone or medications and procedural evacuation), and safety. ResultsAll 359 patients had a complete abortion with 63.5% of patients completing with medication alone and 36.5% with procedural evacuation backup. The median time from first dose of misoprostol to fetal expulsion was six hours, among those who completed the abortion with medications alone. Of those who received procedural evacuation as backup, the median time for procedural evacuation was 10 minutes. The vast majority of patients (99.4%) did not have any adverse events. Two safety incidents (0.6%) occurred, a broad right ligament tear and a uterine rupture. ConclusionPatients in one outpatient setting safely and effectively received medical management of second trimester abortion with procedural evacuation backup, and two thirds completed with medications alone. ImplicationsOutpatient settings may consider medical management of abortion between 18 and 24 weeks with procedural evacuation back-up as a safe, effective, and manageable second trimester abortion option. Additional research is needed on patient experience and satisfaction.

Complication rates of dilation and evacuation and labor induction in second-trimester abortion for fetal indications: A retrospective cohort study

ObjectiveTo compare complication rates of dilation and evacuation (D&E) to mifepristone and misoprostol labor induction for second trimester abortion for fetal indications. Study designWe performed a retrospective cohort study comparing complication rates with D&E and labor induction abortion for fetal indications at 14 weeks 0 days through 23 weeks and 6 days gestation between January 1, 2009, and August 31, 2017. We extracted demographic, procedural, and outcome data, focusing specifically on complications of maternal hemorrhage, infection, emergency department visit, hospital readmission, retained tissue requiring dilation and curettage (D&C), manual placental removal, or thromboembolism. We compared complication rates between the D&E and induction groups using univariate and multivariate analyses. ResultsWe included outcomes from 75 (48%) D&E and 81 (52%) labor induction abortions. We identified any complication in 1 (1%) and 7 (7%) of patients, respectively (p = 0.12). The only complication in the D&E group was hemorrhage with an estimated blood loss of 1000 mL not requiring transfusion. Labor induction complications included retained tissue requiring manual removal (n = 2) or D&C (n = 1) and hemorrhage (n = 2). ConclusionThere was no difference in complication rates between the D&E group and the labor induction group. ImplicationsThis study compared outcomes between D&E and labor induction using mifepristone and misoprostol for second trimester abortion. Our complication rate for labor induction using mifepristone and misoprostol, and particularly our rate of retained placenta requiring D&C, was lower than what has been previously reported for second trimester labor induction termination using other methods. This study suggests there is a benefit for the routine use of mifepristone with misoprostol for second trimester labor induction. Additionally, the low rate of major complications in this study for both D&E and labor induction further validates the safety of both procedures for second trimester abortion.

Update on second-trimester surgical abortion

To review the recent literature on surgical second-trimester abortion, with specific attention to cervical preparation techniques. Confirming previous studies, a recent retrospective observational cohort study, including 54 911 abortions, estimated the total abortion-related complication rate to be 0.41% for second-trimester or later procedures. Cervical preparation is known to reduce risks associated with second-trimester dilation and evacuation (D&E). When considering adjuncts to osmotic dilators for cervical preparation prior to D&E after 16 weeks, both misoprostol and mifepristone are effective alone and in combination or as adjuncts to osmotic dilators. Misoprostol consistently has been shown to cause more pain and cramping than placebo, but is an effective adjunct to osmotic dilators after 16 weeks. Although mifepristone has fewer side-effects, at its current price, it may not be as cost-effective as misoprostol. Second-trimester abortion is safe. The use of mifepristone and misoprostol for second-trimester abortion has improved safety and efficacy of medical and surgical methods when used alone or in combination and as adjuncts to osmotic dilators. An important aspect of D&E, cervical preparation, is not a one-size-fits-all practice; the approach and methods are contingent on patient, provider and setting and should consider all the evidence-based options.

Laparoscopic Management of Uterine Rupture After Early Second-Trimester Medical Abortion in a Patient With a Prior Cesarean Section

Study ObjectiveTo show the possibility of laparoscopic management of uterine rupture. DesignVideo with explanations. SettingIn the medical management with misoprostol for termination of pregnancy at any time the risk of uterine rupture may be possible. The risk is likely higher in women with a previous uterus surgery. In a systematic review of available studies, the risk of rupture was .28% among women with a prior cesarean delivery who were undergoing second-trimester misoprostol-induced abortion, meaning if 414 women with a history of cesarean delivery were given misoprostol for second-trimester abortion, 1 would experience uterine rupture. Uterine rupture has only been reported 3 times in first-trimester abortion and only once managed via laparoscopy: a missed abortion reported in 2005, a case of a ruptured unscarred uterus in a women undergoing medical abortion, and a case of a delayed miscarriage at 8 weeks’ gestation after misoprostol managed by laparotomy and sharp curettage. InterventionsTotal laparoscopic management in a patient with uterine tear after misoprostol treatment. ConclusionEarly second-trimester medical abortions with misoprostol can cause uterine rupture. In hemodynamically stable cases, total laparoscopic management is possible approach.

Vaginal Misoprostol only Versus Vaginal Misoprostol Preceded by Preinduction Cervical Ripening by Vaginal Misoprostol in Second Trimester Abortion

Vaginal Misoprostol only Versus Vaginal Misoprostol Preceded by Preinduction Cervical Ripening by Vaginal Misoprostol in Second Trimester Abortion

A prospective double-blinded, randomized, placebo-controlled trial on the use of letrozole pretreatment with misoprostol for second-trimester medical abortion

Background The aim of this randomized trial was to evaluate the abortion rate of combined regimen of letrozole and misoprostol in second-trimester abortion. Study Design This was a randomized, double-blinded, placebo-controlled trial of 130 women requesting legal termination of pregnancy at gestational age between 12 and 20 weeks. Letrozole 7.5 mg or placebo were given for 3 days, followed by misoprostol 400 mcg vaginally every 3 h up to a maximum of five doses on the third day. Results The abortion rate in 24 and 48 h were similar for the letrozole and placebo groups (24 h: 93.8% vs. 90.8%, respectively, p=.718; 48 h: 98.5% vs. 95.4%, respectively, p=.496). The median induction-to-abortion interval was also similar for the letrozole and placebo groups (9.6 h vs. 10.6 h, p=.145). All the side effects were comparable between the two groups. Conclusion The use of letrozole pretreatment (7.5 mg daily for 3 days) with misoprostol in second-trimester abortion does not significantly improve the abortion rate of the misoprostol-only regimen.

Uterine Rupture in Second-Trimester Misoprostol-Induced Abortion After Cesarean Delivery

To determine the risk of uterine rupture when using misoprostol for second-trimester abortion in women with a history of cesarean delivery. MEDLINE, EMBASE, CINAHL, LILACS, and the Cochrane Library were searched systematically for all articles published before September 2008. Sixty-three articles were found using the above data sources. I excluded case reports, narrative reviews or commentaries, studies that excluded women with a history of cesarean delivery, studies with unrelated outcomes, studies not conducted in humans, and studies that were not available in English. The remaining 16 studies that described misoprostol use for second-trimester abortion in women with a history of cesarean delivery were examined. The number of participants with and without cesarean delivery, regimen of medical abortion used, and cases of uterine rupture were reviewed. To estimate the risk of uterine rupture in women with prior cesarean delivery undergoing second-trimester abortion with misoprostol and number needed to harm, I pooled the results of all 16 studies. The risk of uterine rupture in women with prior cesarean delivery was 0.28% (95% confidence interval [CI] 0.08-1.00%). The risk of uterine rupture in women without prior cesarean delivery was 0.04% (95% CI 0.01-0.20%). Based on these risks, if 414 women with a history of cesarean delivery were given misoprostol for second-trimester abortion, one would experience uterine rupture. The risk of uterine rupture among women with a prior cesarean delivery undergoing second-trimester abortion using misoprostol is less than 0.3%. This may be acceptable to both patients and providers.

Comparison of vaginal and sublingual misoprostol for second trimester abortion: randomized controlled equivalence trial

To identify an effective misoprostol-only regimen for the termination of second trimester pregnancy, we compared sublingual and vaginal administration of multiple doses of misoprostol in a randomized, placebo-controlled equivalence trial. Six hundred and eighty-one healthy pregnant women requesting medical abortion at 13-20 weeks' gestation were randomly assigned within 11 gynaecological centres in seven countries into two treatment groups: 400 microg of misoprostol administered either sublingually or vaginally every 3 h up to five doses, followed by sublingual administration of 400 microg misoprostol every 3 h up to five doses if abortion had not occurred at 24 h after the start of treatment. We chose 10% as the margin of equivalence. The primary end-point was the efficacy of the treatments to terminate pregnancy in 24 h. Successful abortion within 48 h was also considered as an outcome along with the induction-to-abortion-interval, side effects and women's perceptions on these treatments. At 24 h, the success (complete or incomplete abortion) rate was 85.9% in the vaginal administration group and 79.8% in the sublingual group (difference: 6.1%, 95% CI: 0.5 to 11.8). Thus, equivalence could not be concluded overall; the difference, however, was driven by the nulliparous women, among whom vaginal administration was clearly superior to sublingual administration (87.3% versus 68.5%), whereas no significant difference was observed between vaginal and sublingual treatments among parous women (84.7% versus 88.5%). The rates of side effects were similar in both groups except for fever, which was more common in the vaginal group. About 70% of women in both groups preferred sublingual administration. Equivalence between vaginal and sublingual administration could not be demonstrated overall. Vaginal administration showed a higher effectiveness than sublingual administration in terminating second trimester pregnancies, but this result was mainly driven by nulliparous women. Fever was more prevalent with vaginal administration. Registered with International Standard Randomized Controlled Trial number ISRCTN72965671.

Applying the WHO Strategic Approach to Strengthening First and Second Trimester Abortion Services in Mongolia

Abortion was made legal on request in Mongolia in 1989, following the collapse of the socialist regime, and later bound by a range of regulations. Concerned about the high number of abortions and inadequate quality of care in abortion services, the Ministry of Health applied the World Health Organization's Strategic Approach to issues related to abortion and contraception in 2003. The aim was to develop policies and programmes to reduce unintended pregnancies, mitigate complications from unsafe abortion, and improve the quality of abortion and contraception services for all socio-economic groups, including adolescents. This paper describes the changes that arose from a strategic assessment, highlighting the introduction of mifepristone–misoprostol for second trimester abortion. The aim was to replace mini-caesarean section and intra-uterine injection of Rivanol (ethacridine lactate), so that second trimester abortions could take place earlier than at 20 weeks gestation. National standards and guidelines for comprehensive abortion care were developed, the national pre-service training curriculum was harmonised with the new guidelines, at least one-third of the country's obstetrician–gynaecologists were trained in manual vacuum aspiration and medical abortion, and three model comprehensive abortion care units were established to provide high quality services to women, high quality training for providers and serve as nodes for further scaling up.

Two regimens of vaginal misoprostol in second trimester termination of pregnancy – a prospective randomised trial

The search continues for a safe, effective, and cheap method for mid-trimester termination of pregnancy. Misoprostol is a strong contender in this respect. The dose schedule of misoprostol is still not fixed. The objective of our present study was to compare the efficacy and adverse events of 2 dose regimens of vaginal misoprostol for second trimester termination. A prospective, randomised, controlled trial was undertaken in 138 women at 14-20 weeks gestation, in a teaching hospital. Subjects were randomised to receive either regime A: 400 microg of intravaginal misoprostol every 3 h, or regime B: loading dose of 600 microg, followed by 200 microg every 3 h. The main outcome measure was the success rate at 48 h, total dose required, induction-abortion interval, and adverse events. Data was analysed by Student's t-test, Mann-Whitney U-test, the chi-squared test or Fisher's exact test, using Statistica 6.0 software. There was no significant difference in the success rates at 24 and 48 h (Regime A: 97.18 and 98.59%; Regime B: 95.45 and 95.45%), and in mean induction-abortion interval (12.97 versus 12.13 h). However, mean misoprostol requirement was significantly higher for Regime A (1701.4 versus 1269.7 microg). The incidence of fever was significantly less in Regime B (32.4 versus 14.9%). Use of vaginal misoprostol for second trimester abortion had comparable efficacy with less drug requirement for the 600 microg loading dose followed by 200 microg 3-hourly regime compared to the 400 microg 3-hourly regime.

Misoprostol for Second-Trimester Pregnancy Termination in Women With a Prior Cesarean Delivery

To evaluate the use of misoprostol in second-trimester abortion in women with prior cesarean deliveries. A review of women with prior cesarean deliveries undergoing abortion at 14-28 weeks of gestation for a fetal anomaly over a 7.5-year period. Outcome data were compared with a contemporaneous cohort of women with unscarred uteri undergoing the same procedure. Misoprostol was used to induce abortion in all cases, and a variety of dosage regimens were used, the most frequent being 400 mug vaginally every 6 hours (71.3%). During the study period, 720 consecutive women underwent a second-trimester abortion for a fetal anomaly using misoprostol. One hundred one women (14%) had at least 1 prior cesarean delivery: 78 women had 1, 19 women had 2, and 4 women had 3 prior cesarean deliveries. Women with a prior cesarean birth were significantly older (30 years [interquartile range 26-35] versus 33 years [29-37], no cesarean delivery versus cesarean delivery, P = < .001) and of increased parity. The median gestational age at delivery was 19.4 weeks (interquartile range 18-20.7) versus 19.3 weeks (17.7-21), no cesarean delivery versus cesarean delivery, P = .48. The presence of a prior uterine scar did not impact upon abortion duration (16.6 hours [12.1-23.8] versus 14.5 hours [11.4-21.4], no cesarean delivery versus cesarean delivery, P = .07). No differences in blood loss, major hemorrhage, or blood transfusion occurred. There was no case of uterine rupture or hysterectomy. In second-trimester abortion, the use of misoprostol in women with prior cesarean delivery was not associated with an excess of complications compared with women with unscarred uteri. II-2.

Delivery of retained placenta by misoprostol in second trimester abortion

There are many methods available to terminate a viable second trimester pregnancy. After the fetus is completely delivered, retained placenta is a common occurrence during a second trimester abortion, which is usually managed by conventional curettage under general anesthesia. However, surgical removal of the placenta carries a risk of trauma, hemorrhage, postpartum infection, and complication with anesthesia. More recently, misoprostol has been administered via oral, vaginal and rectal routes to increase uterine contractility 1,2 . As normal vaginal anatomy is significantly changed immediately after delivery, and due to the potential risks of oral intake while undergoing general anesthesia, rectal administra-