Second-trimester Dilation Research Articles

Creation and initial assessment of a second-trimester uterine model.

Training for obstetrics and gynecology residents in second-trimester dilation and evacuation (D&E) procedures is extremely limited despite the Accreditation Council for Graduate Medical Education mandating all residents to receive abortion training. Simulation-based training improves surgical competence, but no second-trimester uterine models exist. The purposes of this study were to create a realistic, low-cost model and to assess the prototype. A uterine model was created with 6 silicone cervixes of varying texture and dilations that are interchangeable. The uterus is neoprene and opens to allow for objects to be placed within it for extraction. At a national meeting, experienced D&E surgeons assessed the prototype by using the model and then completing a questionnaire. Twenty-one expert surgeons completed the questionnaires. Participants rated the prototype as "useful" or "very useful" for teaching extraction skills and for training in general. Subjects agreed this represented a clinical scenario they were likely to encounter and the model allowed for practicing the necessary steps for performing D&Es. The model cost approximately $35 to fabricate. Expert surgeons believe that this model accurately and realistically replicates a second-trimester uterus and cervix. This prototype may be used in simulation environments to train obstetrics and gynecology residents.

Safety of deep sedation without intubation in late second-trimester dilation and evacuation

Safety of deep sedation without intubation in late second-trimester dilation and evacuation

Availability and characteristics of abortion training in US ob-gyn residency programs: a national survey

ObjectiveTo assess the availability and characteristics of abortion training in US ob-gyn residency programs. MethodsWe surveyed fourth-year residents at US residency programs by email regarding availability and type of abortion training, procedural experience and self-assessed competence in abortion skills. We conducted multivariable, ordinal logistic regression with general estimating equations to determine individual-level and resident-reported, program-level correlates of quantity of uterine evacuation procedures done during residency. ResultsThree hundred sixty-two residents provided data, representing 161 of the 240 residency programs contacted. Access to training in elective abortion was available to most respondents: 54% reported routine training—where abortion training was routinely scheduled; 30% reported opt-in training—where training was available but not routinely integrated; and 16% reported that elective abortion training was not available. Residents in programs with routine elective abortion training and those who intended to do abortions before residency did a greater number of first-trimester manual uterine aspiration and second-trimester dilation and evacuation procedures than those without routine training. Similarly, routine, integrated training, even for indications other than elective abortion, correlated with more clinical experience (all p<.01, odds ratio and confidence interval shown below). ConclusionThere is a strong independent relationship between routine training and greater clinical experience with uterine aspiration procedures.

Efficacy of mifepristone for cervical priming for second-trimester surgical termination of pregnancy

ObjectiveTo determine whether mifepristone plus misoprostol was as effective as misoprostol with or without laminaria (depending on gestational age) for cervical preparation for second-trimester termination of pregnancy. MethodsA retrospective cohort study was carried out among women who underwent surgical termination between 14 and 19+6weeks of pregnancy. Those who received preoperative mifepristone were compared with those who did not. The study group received mifepristone plus misoprostol before dilation and evacuation of the uterus between May 2008 and September 2011. The comparison (non-mifepristone) group received misoprostol with or without laminaria between January 2005 and April 2008. ResultsThere was no difference between the groups in terms of difficulty of cervical dilation, with an overall relative risk for moderate–difficult dilation in the mifepristone group of 0.91 (95% confidence interval, 0.49–1.68). There was no difference between the groups with regard to complications arising from the procedure. ConclusionMifepristone is effective for cervical priming prior to second-trimester dilation and evacuation in both multiparous and primiparous women, without an increase in complication rates.

542: Availability of dilation and evacuation training at maternal-fetal medicine fellowships

542 Availability of dilation and evacuation training at maternal-fetal medicine fellowships Melissa Rosenstein, Jody Steinauer, Aaron Caughey, Jennifer Kerns University of California, San Francisco, Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA, Oregon Health and Science University, Obstetrics & Gynecology, Portland, OR OBJECTIVE: To describe the availability of second-trimester dilation and evacuation (DE 38% of respondents are located in the Northeast, 30% in the South/Southwest, 18% in the Midwest, and 15% in the West. The availability of DE 7 programs (18%) offer routine training, 12 programs (30%) offer organized optional training, and16 programs (40%) do not have formalized training opportunities but allow fellows to participate in D&Es that are occasionally performed. Five programs (13%) have no D&E training available. Fellowship directors at programs without formalized routine or optional training opportunities are more likely to report that a majority of their fellows pursue D&E training (8/21 vs 4/19, p 0.07). CONCLUSION: SomeformofD&Etraining isavailableatmostof theMFM fellowship sites participating in this survey. Program directors report that many fellows are motivated to acquire skills in D&E, and expanding these training opportunities could be beneficial to MFM fellows.

Patient travel time and distance for second-trimester dilation and evacuation in the Intermountain West

Patient travel time and distance for second-trimester dilation and evacuation in the Intermountain West

Fetal Intracardiac Potassium Chloride Injection to Expedite Second-Trimester Dilation and Evacuation

Objective: To determine whether potassium chloride (KCl)-induced feticide prior to termination by dilation and evacuation (D&E) improves surgical outcome. Methods: We conducted a retrospective study of women who underwent second-trimester (13 0/7 to 23 6/7 weeks) D&E at an urban university-based hospital between January 2000 and July 2010. Women were divided into 3 cohorts: (1) D&E for termination of pregnancy after feticide, (2) D&E without feticide, and (3) D&E for spontaneous pregnancy loss. We compared maternal characteristics, various perioperative variables, and surgical outcomes for all 3 groups. Anesthesia time was used as a surrogate for operative time in the primary outcome. Results: We analyzed 128 pregnancies (group 1: n = 23, group 2: n = 53, group 3: n = 52). Baseline maternal characteristics did not differ among the 3 groups. Anesthesia time was longest in the termination with KCl group (group 1: 116.9 min vs. group 2: 94.5 min and group 3: 90.3 min, p = 0.004), however, the effect was mitigated after controlling for fetal size (p = 0.176). There was no difference in blood loss (p = 0.968). Complications were uncommon, however, cervical lacerations were more common in the termination with KCl group (2 vs. 0 and 0, p = 0.010). Conclusion: Presurgical feticide with KCl was not associated with shorter anesthesia time. The decision to perform feticide should be based on other considerations, such as patient preference.

Cervical preparation for second trimester dilation and evacuation.

Abortion during the second trimester of pregnancy accounts for 10-15% of abortions performed worldwide. Dilation and evacuation (D&E) is the preferred method of second-trimester abortion in most parts of the developed world. Cervical preparation is recommended for dilation and curettage (D&C) after 12 weeks gestation and is standard practice for D&E beyond 14 weeks gestation. Prostaglandins, osmotic dilators, and Foley balloon catheters have been used and studied as cervical preparation prior to second-trimester D&E. However, no consensus exists as to which cervical preparation method is superior with regards to safety, procedure time, need for additional dilation, ability to perform the procedure, or patient and provider acceptability. Despite the fact that the advent of osmotic dilation has improved the safety of the D&E procedure during the second trimester, it is unclear whether a certain type of osmotic dilator is superior to another or whether osmotic dilation with adjuvant prostaglandin is superior to osmotic dilation alone or to prostaglandins alone. This review evaluates cervical preparation methods for second-trimester surgical abortion with respect to differences in procedure time, dilation achieved, need for additional dilation, complications, ability to complete the procedure, patient pain scores, and patient and provider acceptability and satisfaction. We searched for trials of cervical preparation prior to second-trimester D&E. We included all randomized controlled trials that compared osmotic, mechanical, antiprogesterone, prostaglandin, or other medical agents of cervical preparation for second-trimester surgical abortion from 14-24 weeks of gestation. Data were abstracted by two authors and data entry was verified by a third author. Mean difference and Peto Odds Ratio were calculated. Osmotic dilators were found to be superior to prostaglandins with respect to cervical dilation throughout the second trimester and with respect to procedure time within the early second trimester. Addition of prostaglandins to osmotic dilators was not found to increase cervical dilation, except after 19 weeks gestation, however, no impact was seen on procedure time. Addition of Mifepristone to misoprostol was found to improve cervical dilation, yet increase procedure time and frequency of pre-procedural expulsions. Two-day cervical preparation was found to produce greater cervical preparation than one-day, but had no impact on procedure time. Serious complication rates or ability to complete the procedure did not differ significantly between any of the preparation methods reviewed. Cervical preparation with osmotic dilators and/or misoprostol before second-trimester D&E is safe and effective. Osmotic dilators appear to provide superior cervical dilation when compared to prostaglandins alone or when combined with prostaglandins, however this difference in cervical dilation does not appear to result in differences in procedure time or complication rates. There does not appear to be clear clinical benefit from two days of cervical preparation compared to one-day prior to second-trimester D&E below 19 weeks gestational duration. Mifepristone plus misoprostol was associated with high rates of pre-procedural expulsions and does not appear to be a useful method of cervical preparation before second-trimester dilation and evacuation. Same-day procedures appear to be a safe and reasonable option in the early second trimester, however, more research is needed to assess the effectiveness and safety of same-day procedures in the later second trimester.

A double-blinded randomized trial of same-day Dilapan-S vs. overnight laminaria for cervical preparation before surgical abortion between 14 and 18 weeks' gestation

To determine whether same-day Dilapan-S is inferior to overnight laminaria for cervical preparation before early second-trimester dilation and evacuation (D&E).

The effects of vasopressin injection on uterine artery blood flow during dilation and evacuation

This study was undertaken to determine whether vasopressin decreases uterine artery blood flow and blood loss in early second-trimester surgical abortions (dilation and evacuation). Randomized, double blind, placebo-controlled trial of a saline paracervical block with or without vasopressin before dilation and evacuation. Uterine artery pulsatility index and blood loss were measured. Demographics were similar in both groups (mean gestational age 16.8 weeks, SD 1.7). Of 35 randomly assigned patients, Doppler waveforms were adequate in 28 patients (vasopressin, n = 13; placebo, n = 15). The mean difference in uterine artery pulsatility index before and after injection between groups was not significantly different (P = .14). Procedural blood loss was no different. Paracervical vasopressin compared to placebo injection did not result in significant changes in uterine artery pulsatility index in early second-trimester dilation and evacuation procedures.

Retained Fetal Parts After Elective Second-Trimester Dilation and Evacuation

Extrusion of fetal parts into the abdomen after second-trimester pregnancy termination is rare. We report a case of extrusion of fetal parts into the broad ligament at the time of second-trimester pregnancy termination that remained undetected for 10 days. In cases of perforation during second-trimester pregnancy termination, meticulous evaluation of the abdomen and pelvis with ultrasonography or computerized tomography should be performed if complete fetal evacuation cannot be confirmed.

Cervical preparation using laminaria with adjunctive buccal misoprostol before second-trimester dilation and evacuation procedures: A randomized clinical trial

This study was undertaken to determine whether buccal misoprostol improves cervical preparation achieved with laminaria before second-trimester dilation and evacuation procedures. A randomized, double blind, placebo-controlled trial of preoperative cervical preparation with overnight laminaria and either buccal placebo or 400 microg buccal misoprostol approximately 90 minutes before second-trimester surgical abortion. Block randomization was used to provide balanced enrollment into 2 separate gestational age study groups: early (13-15(6/7)) and mid (16-20(6/7)) second trimester. Surgeons tested maximal cervical dilation by inserting the largest dilator that could be passed through the cervical os without force. Subject demographics and preprocedure symptoms were tracked. Groups were similar in regard to age, gravity, parity, delivery type, and gestational age. Data were analyzed from 125 women in the 13 to 15(6/7) (30 misoprostol, 32 placebo) and 16 to 20(6/7) (31 misoprostol, 32 placebo) gestational age groups. Overall, misoprostol treatment did not improve the initial mean dilation achieved with laminaria alone in either the 13 to 15(6/7) (46.0 fr +/- 5.0; placebo 45.0 fr +/- 6.2, P = .68) or 16 to 20(6/7) (50.9 fr +/- 5.6, placebo 48.9 fr +/- 5.2, P = .16) groups. However, a subanalysis of gestations 19 weeks or more demonstrated significantly greater dilation in the misoprostol group (53.6 fr fr +/- 5.3, placebo 48.5 fr +/- 5.0, P = .01). Subjects receiving misoprostol reported significantly more cramping than those receiving placebo (13-15(6/7) weeks misoprostol 25/30, 83%; placebo 17/32, 53%, P = .02; 16-20(6/7) week misoprostol 25/31, 81%, placebo 16/32, 50%, P = .02). Cervical dilation with laminaria is augmented by 400 microg buccal misoprostol in gestations 19 weeks or more, but not in earlier gestations. Misoprostol causes more abdominal cramping.

Impact of midtrimester dilation and evacuation on subsequent pregnancy outcome

Objective: This study was undertaken to evaluate the impact of second-trimester dilation and evacuation (D&E) on subsequent pregnancy outcome. Study Design: Medical record review of 600 patients undergoing midtrimester (14-24 weeks) D&E from 1996 to 2000 and evaluation of subsequent pregnancy outcome. Mann Whitney U , Spearman rho, and χ2 tests were used in statistical analysis with a P value <.05 considered significant. Results: Ninety-six subsequent pregnancies were identified, including 12 first-trimester spontaneous abortions, 1 second-trimester fetal death, 1 ectopic pregnancy, and 5 elective terminations. Seventy-seven pregnancies resulted in the delivery of a live-born infant at a median gestational age of 39.0 weeks. Five pregnancies (6.5%) were complicated by spontaneous preterm birth. Patients delivered preterm had an earlier gestational age at D&E (18.0 vs 20.0 weeks, P =.02) and a trend toward less preoperative cervical dilation (2.0 vs 3.0 cm, P =.09) than patients delivered at term. Conclusion: Second-trimester D&E is not a risk factor for midtrimester pregnancy loss or spontaneous preterm birth. Preterm delivery in future gestations appears less likely when greater preoperative cervical dilation is achieved with laminaria, possibly because of a decrease in cervical trauma. ( Am J Obstet Gynecol 2002;187:882-5.)

Second-Trimester Dilatation of the Internal Os and a History of Prior Preterm Birth

Second-Trimester Dilatation of the Internal Os and a History of Prior Preterm Birth

Second-trimester dilatation of the internal Os and a history of prior preterm birth

Second-trimester dilatation of the internal Os and a history of prior preterm birth

Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial

Objective: To examine the efficacy of digoxin for decreasing operative time, difficulty, and pain of late second-trimester surgical abortions. Methods: We performed a randomized, double-masked, placebo-controlled trial of intra-amniotic digoxin for second-trimester dilation and evacuation (D&E) involving 126 consecutive women at an inner-city public hospital. Eligible women had gestational ages of 20–23.1 weeks, spoke English or Spanish, and were at least 16 years old. Digoxin (1 mg) or saline was injected intra-amniotically 24 hours before the procedure, at cervical laminaria insertion. The primary outcome was procedure duration. Sample size was based on 80% power to detect a difference of 3.5 minutes between groups. Results: The two groups were similar in demographic factors, obstetric histories, and gestational duration. The average gestational length was 22.5 weeks. There was no difference in procedure duration (mean ± standard deviation) between groups (placebo 14.7 ± 7.0, digoxin 15.4 ± 8.0). There were no differences in blood loss estimated by surgeons, pain scores, procedure difficulty scores, or complications between groups. Vomiting was significantly more common in those who received digoxin (placebo 3.1%, digoxin 16.1%). Most subjects (91%) reported that they preferred their fetuses were dead before the abortions. Conclusion: Although digoxin did not increase efficacy of late second-trimester abortion, patient preference might justify its use.

Success rate of cytogenetic analysis at the time of second-trimester dilation and evacuation

Objective: The aim of this study was to determine the success rate of cytogenetic analysis from specimens obtained at the time of second-trimester termination of pregnancy by dilation and evacuation. Study Design: All second-trimester dilation and evacuations performed by a single practitioner at a single institution from 1993 through 1995 were evaluated to pick out those patients in whom biopsy specimens were submitted for cytogenetic analysis. The main outcome studied was the ability to obtain karyotype results for these specimens. Results: Cytogenetic studies were performed on 258 dilation and evacuation specimens with a median gestational age of 18 weeks (range 13-25 weeks). The indications for termination were fetal aneuploidy (n = 88, 34%), sonographically diagnosed fetal malformations (n = 82, 32%), intrauterine fetal death (n = 67, 26%), oligohydramnios or premature rupture of membranes (n = 16, 6%), and others (hematologic and metabolic disorders, n = 5, 2%). Successful karyotyping was achieved for 99% of specimens obtained at second-trimester dilation and evacuation, with 3 failures of growth (1% failure rate). The failures included a 14-week molar pregnancy, an 18-week fetus with Dandy-Walker malformation, and a 19-week intrauterine fetal death. Of the samples obtained in cases of intrauterine fetal death, 99% (66/67) provided adequate cytogenetic information. Conclusions: Karyotyping for abnormal second-trimester pregnancies and intrauterine fetal deaths at the time of a dilation and evacuation procedure has a success rate nearing 100%. In contrast to previous reports, our data indicate that it is unnecessary to perform pretermination invasive karyotyping in patients with abnormal second-trimester pregnancies or intrauterine fetal death who elect to undergo dilation and evacuation. Chromosome analysis at the time of termination of pregnancy by dilation and evacuation reduces patient discomfort, risk of infection, and cost while still providing reliable and vital cytogenetic information for future genetic counseling. (Am J Obstet Gynecol 1998;179:957-61.)

Laminaria versus Dilapan osmotic cervical dilators for outpatient dilation and evacuation abortion: Randomized cohort comparison of 1001 patients

Our purpose was to compare the clinical experience in using Dilapan osmotic dilator and Laminaria japonicum as overnight osmotic cervical dilators in second-trimester dilation and evacuation abortion with respect to measurable outcome variables, including complication rates. A cohort comparison was performed of 1001 patients receiving alternate preoperative treatment with either osmotic dilator after initial randomization until this number had been reached in the series. Few significant differences were found in the two cohorts with respect to blood loss, procedure times, and overall complication rates. However, patients receiving the Dilapan dilator were at least twice as likely to experience problems in cervical dilation or problems resulting from poor dilation or disintegration of the device than were patients receiving Laminaria japonicum. Although more patients receiving laminaria experienced amniotic fluid embolism or disseminated intravascular coagulation syndrome, these problems could not be attributed to the type of osmotic dilator used. Both osmotic dilators are acceptable for use in overnight dilation in this procedure, but the Dilapan dilator is more likely to disintegrate, retract, or present minor problems associated with poor dilation.

Randomised trial of hypan versus gemeprost in cervical preparation prior to second trimester termination of pregnancy

The findings of a preliminary study of women undergoing second-trimester dilatation and evacuation for pregnancy termination suggest that hypan produces better cervical preparation than the more commonly used prostaglandin gemeprost. All 50 subjects were between 15-20 weeks' gestation. The 25 women who were randomly assigned to the gemeprost group had a 1 mg vaginal pessary inserted in the posterior fornix 4-6 hours before abortion; an additional 1 mg pessary was inserted 2-4 hours before the procedure in nulliparous women. The 25 women in the hypan group had either a 3 x 55 mm dilator (15-17 weeks' gestation) or a 4 x 65 mm dilator (18-20 weeks' gestation) inserted in the cervix 24 hours pre-operatively. The mean pre-dilatation cervical diameter was significantly greater (p 0.0001) in the hypan group (14.5 mm) than the gemeprost group (8.7 mm). Also significantly greater (p 0.01) was the mean post-dilatation cervical diameter: 19.3 mm for hypan compared to 17.1 for gemeprost. Dilatation was rated as easy by 21 women in the hypan group compared to only 10 in the gemeprost group. In the hypan group, 24 women reported no pre-operative pain and 23 experienced no post-operative pain; in the gemeprost group, these numbers were 15 and 14, respectively. There were 4 cases of pre-operative bleeding among gemeprost acceptors but none in the hypan group. Finally, at the 6-week follow-up, 1 patient in the gemeprost group reported she had required evacuation of retained products of conception and 1 woman in the hypan group had been treated with antibiotics for a urinary tract infection. Although hypan, unlike gemeprost, requires insertion by a trained physician or nurse, its substantially lower cost, better cervical preparation, and lack of side effects justify its more widespread use.

Safety of Local Versus General Anesthesia for Second-Trimester Dilatation and Evacuation Abortion

United States Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Division of Reproduction Health, Atlanta, Georgia