Second-trimester Terminations Research Articles

Risk Factors for Failure of Second-Trimester Termination with Misoprostol as a Single Agent.

Background: Understanding the potential risk factors for failure of pregnancy termination is crucial for informed clinical decision making. Such insights can assist clinicians in adjusting the dosage or route of various regimens, as well as in counseling patients and predicting the likelihood of successful outcomes. However, research on these risk factors has been limited, and existing studies have yielded inconsistent results. To address this gap, we conducted a study with a large sample size, focusing on identifying the potential risk factors for failure of second-trimester termination using misoprostol as a single agent, specifically between 14 and 28 weeks of gestation. Methods: A secondary analysis based on a database of second-trimester terminations was conducted. The inclusion criteria were a singleton pregnancy, gestational age between 14 and 28 weeks, an unfavorable cervix, no spontaneous labor pain, intact membranes, and termination with misoprostol alone. Potential risk factors for failure of termination, defined as no abortion within 48 h, were analyzed using univariate and multivariate analyses. Results: A total of 1094 cases were included in the analysis, consisting of 991 successful cases and 103 (9.4%) cases of failure. The significant risk factors for failure of termination included early gestational age, live fetuses, sublingual regimen of 400 mcg every 6 h, and high maternal pre-pregnancy BMI. Previous cesarean sections and lower Bishop scores tended to increase the risk but did not reach a significant level. Conclusions: Second-trimester termination with misoprostol as a single agent was highly effective, with a failure rate of 9.4%. The risk factors for failure included gestational age, fetal viability, misoprostol regimen, and maternal pre-pregnancy BMI, suggesting that these factors should be taken into consideration for second-trimester terminations with misoprostol.

Psychological sequelae following second-trimester termination of pregnancy: A longitudinal study.

The decision to terminate a pregnancy due to fetal anomalies can have a significant emotional impact, especially in second-trimester terminations. Previous studies on the psychological consequences of pregnancy termination have had limitations, and little is known about the outcomes for partners and the impact of fetal donation. Therefore, we aimed to investigate the psychological effects of second-trimester pregnancy termination and identify factors associated with outcomes in both women and men, including donation of fetal remains to science. A longitudinal cohort study was conducted at the Amsterdam UMC in the Netherlands, involving women and partners who underwent termination at or before 23 weeks and 6 days of gestation. Questionnaires were administered at termination, 6 weeks, and 4 months after. We utilized validated questionnaires to assess psychological morbidity (grief, post-traumatic stress and postnatal depression and quality of life [QoL]), and factors that could potentially influence outcomes. Of 241 participants, women displayed more pronounced psychological distress than men, though both groups improved over time. Four months after termination, 27.4% of women and 9.1% of men showed signs of pathological grief. Scores indicative for postnatal depression occurred in 19.8% women and 4.1% of men. A prior psychiatric history was a consistent predictor of poorer outcomes. Fetal donation to the Dutch Fetal Biobank was associated with reduced likelihood of symptoms of complicated grief four months after termination. Second-trimester termination of pregnancy for fetal anomalies can lead to psychological morbidity, particularly in women. However, there is a notable improvement over time for both groups. Individuals with prior psychiatric history appear more vulnerable post-termination. Also, fetal donation to science did not have a negative impact on psychological well-being.

Difference in Time to Delivery Between Dilation and Evacuation (D&E) Versus Induction of Labor for Medical Indications [ID: 1380391

INTRODUCTION: Pregnancy termination may be the safest management option among pregnancies with medical conditions that arise during the second trimester and are associated with elevated risk of maternal morbidity and mortality. Termination can be done by dilation and evacuation (D&E) or induction. Each method carries different risk and benefit profiles; however, variations in time to delivery have not been established. We assess the difference in time from diagnosis to delivery between D&E and induction for medically indicated second-trimester terminations. METHODS: Electronic medical records of 85 adult patients who underwent a D&E and 19 who underwent an induction between July 1, 2020, and December 31, 2020, within Kaiser Permanente Northern California were retrospectively surveyed for patient demographics and clinical characteristics, including indication for and method of termination, time of diagnosis and delivery, cervical preparation method, and perioperative complications. RESULTS: Patient demographic and clinical characteristics were similar across groups. The median time from diagnosis to delivery was 74 hours (interquartile range [IQR]: 18–141 hours) in the D&E cohort and 9 hours (IQR: 4–45 hours) in the induction cohort (P<.01). In the induction cohort, there were 21.1% (n=4) complications versus 4.7% (n=4) in the D&E cohort (P=.04). In the induction group, 10.5% (n=2) of patients required an additional procedure to complete the termination. CONCLUSION: The median time from diagnosis to delivery was 65 hours shorter in the induction group compared to D&E. This difference may be deemed clinically significant for patients who weigh time to delivery in their decision-making.

The effect of induction duration on postabortal hemorrhage in second-trimester pregnancy termination with misoprostol

Objective: The aim was to investigate how the duration of induction affects postabortion hemorrhage in second-trimester pregnancy terminations using misoprostol. Methods: This single-center retrospective cohort study was conducted between April 2020 and April 2021 at a university hospital. Singleton pregnant women having gestational age of 13–26 weeks and being hospitalized for termination were included in the study. The misoprostol was administered 200 µg every 4 hours intravaginally to patients already diagnosed with miscarriage, and 400 µg every 3 hours to all remaining patients. Estimated blood loss volume (EBLV) was calculated using a formula previously defined by Stafford et al. A total of 117 singleton pregnant women having gestational age of 13–26 weeks and being hospitalized for pregnancy termination were included in the study. Of these, 78 patients aborted within 0–24 hours (Group 2). The remaining 39 patients aborted in more than 24 hours (Group 1). Results: The EBLV was higher in the study group (p=0.003). In addition, the rate of patients with ≥500 cc and ≥1000 cc blood loss was also significantly higher in the study group (p values 0.049 and 0.016, respectively). After adjusting for potential confounder factors, the probability of blood loss of ≥500 cc and ≥1000 cc was found to be higher in the study group (adjusted OR: 2.720, 95% CI: 1.12–6.58 and adjusted OR: 6.987, 95% CI: 1.25–38.98, respectively). Conclusion: Postabortion hemorrhage risk was found to be higher in patients whose induction period lasted longer than 24 hours in second-trimester terminations with misoprostol. However, there was no deterioration in the patient’s clinical status and no increase in transfusion rates. Care should be taken with regard to vaginal bleeding in misoprostol applications lasting longer than 24 hours.

Interpregnancy Interval After Termination of Pregnancy and the Risks of Adverse Outcomes in Subsequent Birth

Interpregnancy Interval After Termination of Pregnancy and the Risks of Adverse Outcomes in Subsequent Birth

Estimating the proportion of all observed birth defects occurring in pregnancies terminated by a second-trimester abortion.

Prenatal termination of pregnancy may underestimate risks or cause bias in epidemiological studies of birth defects if such studies measure only defects diagnosed postnatally. We aimed to estimate the proportion of all fetuses with birth defects terminated in the second trimester of pregnancy-overall and for specific defects. The study comprised all pregnancies ending in a singleton birth, miscarriage, or termination of pregnancy for which health care services were sought, as recorded in Danish medical registries between 1 January 2007 and 31 December 2011. Of the 420,090 pregnancies, 307,637 fetuses survived until gestational week 12 or beyond; of these, 296,373 (96%) ended in a live birth or stillbirth and 11,264 (4%) ended in a second-trimester termination. The prevalence of birth defects among live births and stillbirths was 3% (9,790/296,373); the corresponding prevalence among second-trimester-terminated pregnancies was 14% (1,563/11,264). Although only 4% of all pregnancies ended in a second-trimester termination, 14% (1,563/11,353) of pregnancies with birth defects were ended by a second-trimester termination. The groups of birth defects with the highest proportion of second-trimester terminations were defects of the nervous system (347/740; 48%) and abdominal wall (58/149; 39%). For many types of birth defects, however, that proportion was less than 10%. The proportion of terminated pregnancies carrying birth defects is considerably greater than the corresponding proportion for pregnancies that end as live births or stillbirths. The proportion of birth defects unobserved at birth due to second-trimester terminations depends on type of defect and lethality.

A national survey of dilation and evacuation training in maternal–fetal medicine fellowships

Maternal���fetal medicine (MFM) specialists often care for women seeking second-trimester terminations for fetal or obstetrical complications. It is unknown how training in dilation and evacuation (D&E) is offered during MFM fellowships. Our study aims to describe D&E training and provision among MFM fellows.

Uterine artery embolization to treat hemorrhage following second-trimester abortion by dilatation and surgical evacuation

Background This study was conducted to review cases of second-trimester postabortal hemorrhage (PAH) occurring at a private women's health facility that were treated with uterine artery embolization (UAE). Methods A retrospective review was conducted on all second-trimester terminations performed at a private women's health facility between 1999 and 2006. Cases of PAH treated with UAE were reviewed in detail, reviewing progress, operative and discharge notes along with anesthesia records. Results Fifteen cases of PAH were identified among 3936 second-trimester terminations that were performed. Seven cases were identified in which UAE was used to treat PAH. Etiologies leading to hemorrhage varied in the seven cases as did the presence of coexisting factors such as infection and anatomic lesions. All cases were successfully treated by UAE, requiring no additional surgical intervention. Conclusion Given the success of embolization, we offer this as an alternative to exploratory surgery and hysterectomy and as a first-line approach in cases of PAH after conservative management strategies have failed.

Intervention rates for placental removal following induction abortion with misoprostol

Background Second-trimester terminations can be performed via surgical or medical methods. It is essential to have the ability to safely and effectively perform induction terminations to offer a full range of services. Many studies of induction abortions report routine operative removal of the placenta after a set time period resulting in high rates of operative procedures. Study Design A retrospective chart review was performed for 233 women who underwent second-trimester induction abortions between November 2003 and November 2006. All women received intraamniotic injection of digoxin for feticide 1 day prior to induction. All inductions were performed using a schedule of 400 mcg of misoprostol initially followed by 200 mcg every 6 h for a maximum of 48 h. There were three methods of administering misoprostol: (1) vaginal administration for all doses, (2) vaginal and buccal used in combination and (3) buccal for all doses. Spontaneous expulsion of the placenta was expected. Operative intervention was performed for excessive bleeding or to expedite hospital discharge after a minimum of 4 h. No manual removal of placenta was done. Results The rate of operative intervention for retained placentas was 6% (14/233). Most (11/14) of the patients who underwent operative extraction for retained placentas did so to expedite discharge from the hospital. Overall, expectant management to allow spontaneous expulsion of the placenta for at least 4 h was not associated with serious morbidity. Conclusions Our regimen of digoxin and misoprostol with a policy of expectant management of placental passage is associated with a very low rate of instrumented removal of the placenta. In the absence of bleeding, patients may be afforded intervals to at least 4 h for spontaneous expulsion of the placenta after fetal expulsion.

Effect of placenta previa on blood loss in second-trimester abortion by labor induction using gemeprost

Objectives The study was conducted to determine whether placenta previa increases bleeding during gemeprost-induced termination of second-trimester pregnancy. Methods We carried out a retrospective study of 158 second-trimester terminations between 12 and 21 weeks' gestation. We compared the intraoperative blood loss among three groups: women without placenta previa undergoing gemeprost termination, women with placenta previa undergoing gemeprost termination and women with placenta previa undergoing dilatation and evacuation (D&E). Results Eleven of 158 women (7.0%) had placenta previa; four underwent D&E and seven had gemeprost termination. There was no statistical difference in mean intraoperative blood loss among the three groups, although one of the seven women with placenta previa who underwent gemeprost termination developed serious bleeding requiring blood transfusion. Conclusion The use of gemeprost for second-trimester pregnancy termination in women with placenta previa seems to be relatively safe and does not increase intraoperative blood loss in the majority of cases.

Abortion Training in United States Obstetrics and Gynecology Residency Programs

To identify characteristics of programs which provide training in abortion, to calculate the number of procedures done during training, and to compare the availability of abortion training in 2004 with that of prior national surveys. An investigator-designed questionnaire about abortion training in obstetrics and gynecology residency programs was mailed to all U.S. residency directors. Collected data included program information, abortion training, and numbers of residents trained. Data were analyzed to estimate differences in abortion training by region, program size, and type of training offered. Of the 252 questionnaires mailed, 185 (73%) were returned. Of the 185, 94 (51%) program directors reported routine instruction in elective abortion, 72 (39%) optional training, and 19 (10%) no training. Large programs and programs located in the Northeast and West Coast were significantly more likely to offer routine training in terminations (P < .01). In the programs offering routine training, more than 50% of residents received instruction in termination practices. Of those practices, the most common were first-trimester surgical abortion (85% of programs), followed by medical abortion (59%), second-trimester induction (51% of programs), and dilation and extraction (36%). As compared with those in programs with optional training, residents in programs with routine training were significantly more likely to receive instruction in all modalities of abortion provision and performed proportionally more first- and second-trimester terminations (P < .01). Routine training in elective abortion resulted in greater exposure to abortion practices and greater experience in more complicated abortion techniques during residency.

Characteristics of clients seeking first- and second-trimester terminations of pregnancy in public health facilities in Cape Town.

Characteristics of clients seeking first- and second-trimester terminations of pregnancy in public health facilities in Cape Town.

D&E alternative to induction for second-trimester terminations

D&E alternative to induction for second-trimester terminations

Psychological outcome in women undergoing termination of pregnancy for ultrasound‐detected fetal anomaly in the first and second trimesters: a pilot study

To ascertain and compare psychological morbidity following first- and second-trimester termination for fetal anomaly. This was a cohort study of 30 women aged 20-40 years in a north London teaching hospital, 14 of whom had had a first-trimester termination and 16 a second-trimester termination for fetal anomaly. The main outcome measures were questionnaire data (General Health Questionnaire-28, Beck Depression Inventory, Perinatal Grief Scale, Impact of Event Scale (IES)) at 6 weeks, 6 months and 12 months after termination. There were high levels of psychological distress in both groups at each time point, and for the combined group the mean total scores on the IES remained above the cut-off for the entire study period. Those having second-trimester terminations had a significantly higher level of post-traumatic stress symptomatology 6 weeks after termination (14/16 vs. 6/14; odds ratio = 9.3; 95% CI, 1.5-57.7). Psychological morbidity following termination of pregnancy for fetal anomaly is prevalent and persistent. Our data suggest that in the short term (as assessed at a 6-week follow-up), second-trimester termination may be more stressful compared with first-trimester termination.

Congenital abnormalities in twins

Selective termination for an anomalous twin in discordant twin pregnancy has been a management option for nearly two decades. Using current conventional prenatal diagnostic techniques, the diagnosis of a twin gestation discordant for a congenital anomaly is commonly confirmed in the second trimester. Selective termination is thus usually a second-trimester procedure. The risks of second-trimester terminations as well as protocol choices, including indications and timing, have evolved over the years. Ethical issues regarding selective termination have developed significantly and continue to be debated.

Second-Trimester Abortion: Perspectives After a Decade of Experience

This book is the most extensive volume currently available concerning the controversial subject of second-trimester abortion. The carefully referenced proceedings are a result of a national conference on second-trimester abortion held in 1979, when 37 internationally known experts gathered in Chapel Hill, NC, to discuss the medical and social aspects of the second-trimester abortion procedure. While general agreement exists regarding the best method of terminating first-trimester pregnancies, there has been considerable controversy as to the safety and proper technique in second-trimester terminations, of which more than 100,000 are performed annually in the United States. The past decade of experience with second-trimester abortion is presented to the reader with authoritative accounts of the available techniques, including indications, contraindications, and complications. While instillation procedures were used more frequently ten years ago, now D and E emerges as the method of choice, at least up to the 18th menstrual week. No consensus is