Second-trimester Medical Abortion Research Articles

Duration of Induction of Labor for Second-Trimester Medication Abortion and Adverse Outcomes.

To evaluate the relationship between duration of labor during second-trimester medication abortion and adverse outcomes. We conducted a retrospective cohort study including all individuals with a singleton gestation undergoing second-trimester medication abortion without evidence of advanced cervical dilation, rupture of membranes, or preterm labor at four centers. The primary exposure was duration of labor (ie, hours spent from receiving misoprostol to fetal expulsion). The primary outcome was composite morbidity, defined as uterine rupture, need for blood transfusion, clinical chorioamnionitis, intensive care unit admission, or need for readmission. We performed bivariate and multivariate negative binomial analyses. A post hoc subgroup analysis was performed to assess for the risk of the primary outcome by gestational age. We performed tests of homogeneity based on history of uterine scarring and parity. Six hundred eighty-one individuals were included. The median duration of labor was 11 hours (interquartile range 8-17 hours). One hundred thirty-one (19.2%) experienced the primary outcome. When duration of labor was evaluated continuously, a longer duration of labor was associated with an increased frequency of morbidity (adjusted β=0.68, 95% CI, 0.32-1.04). When duration of labor was evaluated categorically, those experiencing the highest quartile of duration (ie, 17 hours or more) had a statistically higher risk for experiencing morbidity compared with individuals in all other quartiles (adjusted relative risk 1.99, 95% CI, 1.34-2.96). When we focused on components of the composite outcome, clinical chorioamnionitis was significantly different between those experiencing a longer duration and those experiencing a shorter duration of labor (26.2% vs 10.6%, P<.001). On subgroup analysis, gestational age was not associated with the risk of composite morbidity. Tests of homogeneity demonstrated no significant difference in the risk for morbidity among individuals with a history of uterine scarring or based on parity. Duration of labor was independently associated with risks for adverse maternal outcomes during second-trimester medication abortion, specifically clinical chorioamnionitis.

24-Hour Compared With 12-Hour Mifepristone-Misoprostol Interval for Second-Trimester Abortion: A Randomized Controlled Trial.

To compare 24-hour and 12-hour mifepristone-to-misoprostol intervals for second-trimester medication abortion. We conducted a prospective randomized controlled trial. Participants were allocated to receive mifepristone either 24 hours or 12 hours before misoprostol administration. The primary outcome was the time from the first misoprostol administration to abortion (induction time). Secondary outcomes included the time from mifepristone to abortion (total abortion time); fetal expulsion percentages at 12, 24, and 48 hours after the first misoprostol dose; side effects proportion; and pain and satisfaction scores. A sample size of 40 per group (N=80) was planned to compare the 24- and 12-hour regimens. Eighty patients were enrolled between July 2020 and June 2023, with 40 patients per group. Baseline characteristics were comparable between groups. Median induction time was 9.5 hours (95% CI, 10.3-17.8 hours) and 12.5 hours (95% CI, 13.5-20.2 hours) in the 24- and 12-hour interval arms, respectively (P=.028). Median total abortion time was 33.0 hours (95% CI, 34.2-41.9 hours) and 24.5 hours (95% CI, 25.7-32.4 hours) in the 24- and 12-hour interval groups, respectively (P<.001). At 12 hours from misoprostol administration, 25 patients (62.5%) in the 24-hour arm and 18 patients (45.0%) in the 12-hour arm completed abortion (P=.178). At 24 hours from misoprostol administration, 36 patients (90.0%) in the 24-hour arm and 30 patients (75.0%) in the 12-hour arm had complete abortion (P=.139). The need for additional medication or surgical treatment for uterine evacuation, pain scores, side effects, and satisfaction levels were not different between groups. A 24-hour mifepristone-to-misoprostol regimen for medication abortion in the second trimester provides a median 3-hour shorter induction time compared with the 12-hour interval. However, the median total abortion time was 8.5-hours longer in the 24-hour interval regimen. These findings can aid in shared decision making before medication abortion in the second trimester. ClinicalTrials.gov, NCT04160221.

Placement of an intrauterine device within 48 hours after second-trimester medical abortion: a randomized controlled trial

BackgroundInternational guidelines recommend placement of intrauterine devices immediately after second trimester medical abortion, but evidence concerning the optimal time for intrauterine device placement is lacking from clinical trials. ObjectiveWe aimed to investigate effectiveness, safety, and acceptability of intrauterine device placement within 48 hours, compared with placement at two to four weeks after second trimester medical abortion. We hypothesized that intrauterine device placement within 48 hours would be superior compared with placement at two to four weeks after the abortion, in terms of the proportion of intrauterine device use after six months, with maintained safety and acceptability. Study DesignIn this open-label, randomized, controlled, superiority trial, we recruited participants at eight abortion clinics in Sweden. Eligible participants were ≥18 years, requesting medical abortion with gestation ≥85 days and opting for use of a post abortion intrauterine device. Participants were randomized (1:1) to intrauterine device placement either within 48 hours of complete abortion (intervention) or after 2 to 4 weeks (control). Our primary outcome was self-reported use of an intrauterine device after 6 months. Secondary outcomes included expulsion rates, pain at placement, adverse events and complications, acceptability, and subsequent pregnancies and abortions. Differences in non-normal continuous variables were analyzed with the Mann-Whitney U-test and differences in dichotomous variables with the chi square or Fisher’s exact tests. A P value <.05 was considered statistically significant. Group differences are presented by modified intention-to-treat and per protocol analyses. ResultsBetween January 2019, and June 2022, we enrolled 179 participants, of whom 90 were assigned to intervention and 89 to control. Enrolment was prematurely stopped after an interim analysis exceeded a predefined intrauterine device expulsion rate of 20%. By modified intention-to-treat, use of intrauterine device after 6 months was 50.7% (34/67) in the intervention group compared to 71.6% (48/67) in the control group (proportion difference 20.9%; 95% confidence interval 4.4%-35.9%; P=.02). The intrauterine device expulsion rate was 30.1% (22/73) in the intervention group versus 2.9% (2/70; P <.001) in the control group. Other adverse events were rare and patient acceptability was high in both groups. ConclusionIntrauterine device placement within 48 hours after second trimester medical abortion was non-superior in terms of the proportion of intrauterine device use after 6 months when compared with placement after 2 to 4 weeks. Placement within 48 hours after second trimester abortion can be used in selected individuals after counselling on expulsion risk.

24-Hour Compared With 12-Hour Mifepristone–Misoprostol Interval for Second-Trimester Abortion: A Randomized Controlled Trial [ID 2683386

INTRODUCTION: We aimed to compare 24- and 12-hour mifepristone to misoprostol intervals for second-trimester medical abortion. METHODS: This was a prospective randomized controlled trial. Women were allocated to receive mifepristone either 24 or 12 hours before misoprostol administration. The primary outcome was time from mifepristone administration to fetal expulsion and from first misoprostol administration to fetal expulsion. RESULTS: Eighty women were enrolled between July 2020 and June 2023, 40 women per group. Baseline characteristics were comparable between groups. Median time from mifepristone to fetal expulsion was 33.0 and 24.5 hours in the 24- and 12-hour interval groups, respectively (P&lt;.001). Median time from first misoprostol dose to fetal expulsion was 9.5 and 12.5 hours in the 24- and 12-hour interval arms, respectively (P=.028). At 12 hours from misoprostol administration, 25 (62.5%) and 18 (45.0%) of women in the 24- and 12-hour arms completed abortion (P=.178). At 24 hours from misoprostol administration, 36 (90.0%) and 30 (75.0%) in the 24- and 12-hour arms had complete abortion (P=.139). Need for additional medical and/or surgical treatment for uterine evacuation were comparable between groups. Pain scores, side effects, and satisfaction levels were similar in both groups. CONCLUSION: A 12-hour mifepristone-to-misoprostol regimen for medical abortion in the second trimester provides an 8.5-hour shorter mifepristone-to-fetal-expulsion rate compared with the 24-hour interval. However, misoprostol-to-fetal-expulsion time is 3 hours longer in the 12-hour interval regimen. Medical regimen success rate, side effects, and satisfaction levels are also similar. These findings can aid in shared decision-making prior to medical abortion in the second trimester.

Comparison of induction-to-expulsion interval during second-trimester medication abortion in pregnancies with anencephaly and other congenital anomalies compared to those without anomalies: A retrospective cohort study

To investigate whether induction to expulsion interval during second-trimester medication abortion in pregnancies complicated by anencephaly or other fetal anomalies is prolonged compared to pregnancies without fetal anomalies STUDY DESIGN: This was a retrospective cohort study of women who had second-trimester medication abortion at St. Paul's Hospital Millennium Medical College (Addis Ababa, Ethiopia). We assigned subjects to one of three groups based on fetal diagnosis: 1) anencephaly group 2) other congenital anomaly group 3) no anomaly group. Data were collected by reviewing patients' charts. We used SPSS version 23 to analyze the data. Simple descriptive analysis and Chi-squared test were performed as appropriate. A total of 303 women had second trimester medication at 14-28 weeks, of which 58 had anencephaly, 19 had congenital anomalies other than anencephaly, and the remaining 226 had no fetal anomalies. There was no difference in induction to expulsion interval among the groups. The mean induction to expulsion interval was 18.4 hours in the anencephaly group vs, 19.4 hours in the other congenital anomaly group vs. 19.2 hours in those without anomaly (p-value=0.924). The 24-hours non-expulsion rate was also comparable among the groups, with 5.25% rate of non-expulsion in the anencephaly group vs 15.8% in the other congenital anomaly group vs 11.15 % in the no anomaly group, (p-value=0.594). In multivariable regression analysis after controlling for parity, the 24-hour non-expulsion rate was not significantly different. In this study, pregnancies undergoing second-trimester medication abortion for fetal anomalies had comparable induction to expulsion interval and 24-hour expulsion rates compared to those who had the same procedure for other or no anomalies. Second-trimester medication abortion procedure length in pregnancies complicated by anencephaly is similar to those pregnancies without anomalies. All data generated or analyzed during this study are included in this published article.

Abortion Opt-in Experience in Third-Year Clerkship.

Despite the public health imperative that all medical practitioners serving reproductive-aged women know the components of abortion care and attain competency in nondirective pregnancy options counseling, exposure to abortion care in US medical school education remains significantly limited. Florida International University Herbert Wertheim College of Medicine offers an opt-in clinical exposure to abortion care during the obstetrics and gynecology clerkship. During clerkship orientation, students watched a recorded presentation reviewing components of abortion care and emphasizing that participating students may increase or decrease involvement at any time without explanation. Students opting in completed a form specifying their desired level of involvement for each component as "yes," "no," or "not sure." Of 350 clerkship students over 23 6-week rotations, 98 (28%) chose to opt in, with opt-in form data available for 90 students. Ninety students chose to observe counseling for first- and second-trimester surgical abortion and medical abortion. Seven students used the option "no" for history taking and examine second trimester fetal parts. Twenty-four students marked "not sure" for participating in evacuation of first-trimester pregnancy. This educational intervention proved feasible and offers an opportunity for students to have experiential learning about abortion care in an inclusive, respectful manner. This experience may be incorporated into undergraduate and graduate medical education. Providing learners the opportunity for exposure to abortion care improves their overall medical education and will impact the care they provide as future clinicians.

Second-Trimester Medical Abortion with Misoprostol Preceded by Two Sequential Doses of Mifepristone: An Observational Study.

Based upon the pharmacokinetics of mifepristone, we postulated that repeating a dose after its half-life period may potentiate its abortifacient effect. We administered mifepristone (200mg) on days one and two, and misoprostol on day three (200 or 400μg, vaginally, six-hourly, upto three doses in 12h) in 100 women (intervention group). We compared their outcome with that of another 100 women who received the one-dose mifepristone regimen (mifepristone on day one and misoprostol on day three) during the months immediately preceding the study period (historical controls). The mean age, parity and gestation (18weeks) were similar in the two groups. On day three (before initiating misoprostol), cervix admitted one finger in significantly more women in the intervention group (36 versus 8% in historical controls; p = 0.001). All women aborted successfully in the two groups. The IAI of the intervention group was significantly shorter than the IAI of historical controls (10.45 vs 13.75h; p = 0.013), and the misoprostol requirement was also significantly lower (mean 434 vs 500μg among historical controls, p = 0.04). Second-trimester medical abortion using two sequential doses of mifepristone followed by misoprostol reduced the IAI and misoprostol requirement without adding any extra days to the existing regimen. Further randomized studies can assess if the 'two-dose' mifepristone regimen is more efficient than the 'one-dose' regimen.

Fear of childbirth after medical vs surgical abortion. Population-based register study from Finland.

To evaluate the effect of method of induced abortion and other abortion-associated variables on the incidence of fear of childbirth in subsequent pregnancy. This population-based register study cohort includes all nulliparous women with their first pregnancy ending in an induced abortion in 2000-2015 and subsequent pregnancy with live singleton delivery between 2000 and 2017 (n=21479). Data were derived from three national registers maintained by the Finnish Institute for Health and Welfare. We divided the study population in three cohorts: (a) medical and (b) surgical abortion during first trimester (≤84days of gestation), and (c) medical abortion during second trimester (85-168days of gestation). Primary outcome measures were the incidence of registry-identified fear of childbirth and cesarean delivery related to it. The overall incidence of fear of childbirth was 5.6% (n=1209). Altogether, 19.2% (n=4121) of women underwent cesarean delivery. The odds were elevated especially for elective cesarean delivery (odds ratio [OR] 9.30, 95% CI 7.95-10.88, P<.001) in women with fear of childbirth. In multivariable analysis, the odds for fear of childbirth (adjusted OR [aOR] 0.80, 95% CI 0.68-0.94) and cesarean delivery (aOR 0.66, 95% CI 0.84-0.90) were decreased in women with a history of first-trimester medical abortion compared with those with first-trimester surgical abortion. Second-trimester medical abortion had no effect on the odds for fear of childbirth (aOR 1.04, 95% CI 0.71-1.50). Maternal age of 30-39years and interpregnancy interval over 2years were additional risk factors for both fear of childbirth and cesarean delivery, but surgical evacuation of uterus after the abortion was not. One first- or second-trimester medical abortion does not increase the odds for fear of childbirth, and cesarean delivery related to it in subsequent pregnancy when compared with first-trimester surgical abortion. Older maternal age and longer interpregnancy interval emerged as risk factors for fear of childbirth.

Determinants of Second-Trimester Safe Termination of Pregnancy in Public Health Facilities of Amhara Region, Northwest Ethiopia: An Unmatched Case-Control Study

Background. Second-trimester medical abortion is the termination of pregnancy between 13 and 28 weeks of gestational age. Although the majority of abortions are performed in the first trimester, 10–15% of terminations of pregnancies have taken place in the second trimester globally. Objective. To identify the determinant factors of second-trimester safe termination of pregnancy in public health facilities of the Amhara region, northwest Ethiopia. Methods. An institution-based unmatched retrospective case-control study conducted from 01/10/2019–30/02/2020. A systematic random sampling technique was used to select 119 cases and 238 controls. An interviewer-administered questionnaire was used to collect the data. A binary logistic regression model was fitted to identify determinant factors. The odds ratio with 95% CI was computed to assess the strength and significance of the association between dependent and independent variables. Result. Rural resident (adjusted odds ratio (AOR) = 1.9; 95% CI 1.07–3.25), irregular menses (AOR = 1.8; 1.06–3.13), had no known symptoms of pregnancy (AOR = 1.9; (95% CI 1.06–3.46)), not knowing the abortion law (AOR = 3.0; (95% CI 1.63–5.60)), low level of education (1st–8th grade) (AOR = 2.7; (95% CI 1.06–6.60), opposition against abortion care (AOR = 2.6; (1.22–5.42)), delayed referral (AOR = 10.1 (95% CI 4.02–29.18)), and not undertaking pregnancy test (AOR = 2.2; (95% CI (1.21–4.04)) were determinants of second-trimester safe termination of pregnancy. Conclusion. Women being rural residents, irregular menses, not undertaking pregnancy test, not knowing the abortion law, low-level educational status, delayed referral, no knowledge about signs and symptoms of pregnancy, and opposition of safe abortion were determinants of second-trimester safe termination. The Regional Health Bureau and Health Facilities should give emphasis to women living in rural areas, and they should increase awareness towards abortion law and sign and symptoms of pregnancy and encourage female education.

Intra-cardiac lidocaine administration to induce fetal demise before late second-trimester abortion: Retrospective review.

To determine the efficacy and safety of intra-cardiac lidocaine administration to induce fetal demise before second-trimester medication abortion in a teaching hospital in Addis Ababa, Ethiopia. We performed a retrospective chart review to collect selected sociodemographic and clinical information. All patients who received fetal intra-cardiac lidocaine between January 1, 2019 and April 30, 2019 were included in the study. Fetal demise was considered successful if achieved within 24hours after fetal intra-cardiac lidocaine administration. We analyzed the data using SPSS version 20. We used frequency tables to describe the data and performed a multivariable analysis to determine associations between variables. A total of 80 fetuses were given intra-cardiac lidocaine.The mean gestational age was 23+1 weeks (range 21+0 -27+5 weeks). Twenty-four hours after lidocaine administration 76 (95%) pregnancies showed negative fetal cardiac activity. Fetuses at gestational ages of 21-23+6 weeks were five times more likely to have negative cardiac activity compared with those with gestational ages between 24 and 28weeks (P=0.001). Two women developed nausea, vomiting, and a metallic taste, but no serious adverse events were reported. Intra-cardiac lidocaine is effective at inducing fetal demise before late second-trimester medication abortion with no associated serious adverse events or complications.

Risk of surgical evacuation and risk of major surgery following second-trimester medical abortion in Denmark: A nationwide cohort study

ObjectiveThe primary objectives were to (1) identify risk factors for surgical evacuation following medical termination of second-trimester pregnancies in Denmark and (2) assesses if these risk factors were able to explain the a priori observed variation in risk of surgical evacuation among Danish hospitals and the a priori observed decline in risk throughout time. The secondary objective was to estimate the risk of major surgery following second-trimester medical abortion. Study designWe conducted a nationwide cohort study including all pregnancies terminated with mifepristone/misoprostol in second trimester in women aged 15–49 years through the period 2006–2017 in Denmark. All included pregnancies were followed for eight weeks from induction. Data were retrieved from national health registers. Multiple logistic regression provided adjusted odds ratios (ORs) of surgical evacuation with 95% confidence intervals (CI). Risk of major surgery was assessed and reported descriptively. ResultsOf 5702 abortions, 2934 (52%) underwent surgical evacuation. The proportion of surgical evacuations decreased linearly from 72% in 13th gestational week to 17% in week 22 (p < 0.001). Compared to 25–29-year-olds, a reduced risk of surgical evacuation was observed in the youngest age group, 15–19 years (OR 0.77; 95% CI 0.61–0.99), while the risk among women aged 30–49 years did not differ significantly from the reference group. Compared to nulliparas, women with a history of only vaginal deliveries with spontaneous delivery of placenta had a decreased risk of surgical evacuation, OR 0.79 (95% CI 0.68–0.92).The OR of surgical evacuation varied from 0.05 (95% CI 0.02–0.15) to 2.38 (95% CI 1.71–3.31) among the hospitals (Copenhagen University Hospital as the reference) and declined significantly throughout the study period (OR for one-year increase in calendar time 0.82; 95% CI 0.81–0.84).Of the 5702 abortions, ten (0.2%) underwent major surgery following medical induction, including one laparoscopy, three hysterotomies, five laparotomies, and one hysterectomy. ConclusionRisk of surgical evacuation of second-trimester medical abortions decreased with increasing gestational age and was reduced in women aged 15–19 years as well as in women with a history of only vaginal deliveries with spontaneous delivery of the placenta. However, these risk factors could not explain the significant variation in risk of surgical evacuation among hospitals and the decline in risk by time, suggestive of an unwarranted variation in risk of surgical evacuation following second-trimester medical termination of pregnancy in Denmark. Major surgery following medical induction was uncommon. ImplicationRisk of surgical evacuation following medical termination of second-trimester pregnancy declined by calendar time and varied among Danish hospitals. Risk factors for surgical evacuation could not explain the difference by time and site of induction, suggestive of an unwarranted variation in the risk of surgical evacuation following second-trimester medical abortions in Denmark.

A prospective study of mifepristone and unlimited dosing of sublingual misoprostol for termination of second-trimester pregnancy in Uzbekistan and Ukraine

IntroductionWe aimed to assess the feasibility and acceptability of a second-trimester medical abortion regimen using mifepristone and sublingual misoprostol with no maximum number of misoprostol doses in Uzbekistan and Ukraine.MethodsThis...

Could second-trimester medical abortion be offered as a day service? Assessing the feasibility of a 1-day outpatient procedure using pooled data from six clinical studies

ObjectivesCurrent service delivery models for second-trimester medical abortion typically include routine inpatient admission and overnight stays. To assess the feasibility of a day-service model, we evaluated outpatient administration of abortion medications and analyzed the proportion of clients who could avoid an overnight stay. We also examined additional key elements of medical abortion care to evaluate the practicality of this model. Study designWe pooled data from six clinical studies of second-trimester medical abortion conducted by Gynuity over the past 10 years. We include 868 individuals receiving mifepristone–misoprostol abortion between 13 and 22 weeks’ gestation. ResultsAt 8 h post misoprostol initiation, 309/521 (59.3%) participants at 13-18 weeks' gestation had a successful abortion; by 10 h, 382/521 (73.3%) were successful. Taking the mifepristone at home lowered neither the efficacy of the method nor satisfaction with the experience. Nonphysician providers played a significant role in the provision of care. Needed interventions were relatively rare; serious complications were very rare. ConclusionsOur findings support the provision of second-trimester medical abortion in a day-clinic setting, especially at ≤18 weeks' gestation. Such a model could increase access to quality care in many settings. ImplicationsSecond-trimester medical abortion can safely and effectively be offered as a day service. Nonphysician providers are well suited to provide the majority of care. Developing guidelines for a 1-day model could increase access to quality care in many settings worldwide.

Incidence of uterine rupture in second-trimester abortion with gemeprost alone compared to mifepristone and gemeprost

ObjectivesTo compare uterine rupture rates in women having a medical abortion receiving gemeprost alone to those receiving mifepristone plus gemeprost. Study designWe reviewed the records of women undergoing medical abortion at 13 0/7–23 6/7 weeks from January 2007 to December 2014 at a single center in Italy. Prior to January 2011, we used gemeprost 1 mg vaginally every 3 h up to a maximum of five doses. After January 2011, we added mifepristone 200 mg orally 24 h prior to the same gemeprost protocol. The primary outcome of the study was the incidence of uterine rupture. We compared the outcome between women receiving gemeprost alone with the combination of gemeprost and mifepristone. ResultsOne thousand and sixty-one (58.5%) and 753 (41.5%) women underwent medical abortion in the gemeprost-alone and the gemeprost/mifepristone groups, respectively. Five (0.47%) uterine ruptures occurred in the gemeprost and four uterine ruptures occurred in the gemeprost/mifepristone groups, respectively (0.53%) (p=.89). All uterine ruptures occurred in women with prior cesarean delivery. ConclusionsWe rep orted no difference in the incidence of uterine rupture between the gemeprost-alone and gemeprost and mifepristone groups. ImplicationsUterine rupture is a rare complication of second-trimester medical abortion with gemeprost. Use of mifepristone prior to gemeprost does not affect this risk.

Management of physical pain during induced second-trimester medical abortions: a cross-sectional study of methodological quality and recommendations in local clinical practice guidelines at Swedish hospitals.

The aim was to assess the methodological quality and describe recommendations for pain management in local clinical practice guidelines about induced second-trimester medical abortions at Swedish university and county hospitals. In 2017, Swedish university and county hospitals that provided abortion care in the second trimester of pregnancy were contacted (n = 29), and guidelines from 25 were received (university: n = 6, county: n = 19). Guideline quality was assessed according to two systematic instruments. Recommendations were systematically assessed regarding frequency and tools for pain measurement, prophylactic pharmacologic treatment, as needed pharmacologic treatment and nonpharmacologic treatment. Overall methodological quality was poor across both instruments, as the majority of the guidelines did not fulfil the investigated quality criteria. For pain measurements, no guideline recommended measurement frequency and four recommended specific measurement tools. Prophylactic pharmacologic treatment, described in 23 (92%) guidelines, included paracetamol (n = 23, 92%), anti-inflammatory drugs (n = 23, 92%) and opioids (n = 18, 72%). As needed pharmacologic treatment, described in 23 (92%) guidelines, included anaesthetics (n = 21, 84%), opioids (n = 21, 84%) and paracetamol (n = 1, 4%). Recommendations for as needed anaesthetics included paracervical block (n = 21, 84%), epidural analgesia (n = 16, 64%) and inhalation of nitrous oxide (n = 5, 20%). Nonpharmacologic treatments were recommended in nine (36%) guidelines. The findings indicate that local clinical practice guidelines about induced second-trimester medical abortions are of inadequate methodological quality and that a large majority lack recommendations concerning systematic pain measurements. Although most recommend prophylactic and as needed pharmacologic management, national inconsistencies exist in Sweden with regard to recommendations of epidural analgesia, nitrous oxide and nonpharmacologic methods. In Sweden, there is room for improvement in the development of these guidelines.

The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa

BackgroundIn South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings.MethodsWe derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013–2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars.ResultsD&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances.ConclusionD&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa’s reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs.

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods.

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care. Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs. Women with an unintended or abnormal first or second trimester pregnancy. PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched. The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request. IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

Investigation of a variable mifepristone to misoprostol interval for second trimester medical abortion

Current guidelines recommend an interval of at least 24-hours between mifepristone and misoprostol administration for second-trimester medical abortion. Reducing this interval, and subsequently the total abortion time, has the potential improve overall experience for women and better accommodate local facilities. This analysis aims to describe a shortened mifepristone-misoprostol interval and associated total abortion (mifepristone to fetal expulsion) and induction times (first dose of misoprostol to fetal expulsion).

Accompaniment of second-trimester abortions: the model of the feminist Socorrista network of Argentina

ObjectiveLegal restrictions on abortion access impact the safety and timing of abortion. Women affected by these laws face barriers to safe care that often result in abortion being delayed. Second-trimester abortion affects vulnerable groups of women disproportionately and is often more difficult to access. In Argentina, where abortion is legally restricted except in cases of rape or threat to the health of the woman, the Socorristas en Red, a feminist network, offers a model of accompaniment wherein they provide information and support to women seeking second-trimester abortions. This qualitative analysis aimed to understand Socorristas' experiences supporting women who have second-trimester medication abortion outside the formal health care system. Study designWe conducted 2 focus groups with 16 Socorristas in total to understand experiences accompanying women having second-trimester medication abortion who were at 14–24 weeks’ gestational age. We performed a thematic analysis of the data and present key themes in this article. ResultsThe Socorristas strived to ensure that women had the power of choice in every step of their abortion. These cases required more attention and logistical, legal and medical risks than first-trimester care. The Socorristas learned how to help women manage the possibility of these risks and were comfortable providing this support. They understood their work as activism through which they aim to destigmatize abortion and advocate against patriarchal systems denying the right to abortion. ConclusionSocorrista groups have shown that they can provide supportive, women-centered accompaniment during second-trimester medication abortions outside the formal health care system in a setting where abortion access is legally restricted. ImplicationsSecond-trimester self-use of medication abortion outside of the formal health system supported by feminist activist groups could provide an alternative model for second-trimester care worldwide. More research is needed to document the safety and effectiveness of this accompaniment service-provision model.

Second-trimester surgical and medical abortion practice in Canada in 2012: a national survey

Second-trimester surgical and medical abortion practice in Canada in 2012: a national survey