Termination Of Third Trimester Pregnancy Research Articles

Evolution of third-trimester pregnancy terminations in France

ObjectiveTo study changes in the reasons for third-trimester termination of pregnancy (TOP) for fetal anomalies over a 20-year period in France. Study designWe compared a consecutive series of third-trimester TOPs from a single centre in 2005–2014 to those performed by Dommergues et al. in a similar centre in 1986–1994, using the same criteria. Main outcome measuresThe process leading to late TOP, using the same categories in both studies. ResultsIn the present series, 205 of 1409 TOPs were performed in the third trimester, vs. 305/956 in the historical series. There were 33 (16.1 %) diagnoses missed at the screening before the third trimester, 55 (26.8 %) cases in which the anomaly was impossible to diagnose until the third trimester, 86 (42 %) cases in which fetal prognosis could not be established until the third trimester despite earlier diagnosis, 31 (15.1 %) TOPs postponed to allow more time for the women/couples to contemplate, versus respectively 113 (37 %), 55 (18 %), 122 (40 %), and 15 (5%) in the historical series. ConclusionThere was a significant drop in the rate of anomalies missed earlier. The increase in late TOP due to couples requiring additional time for contemplation might result from changes in counselling processes.

Preinduction cervical ripening with vaginal misoprostol in second and third trimester intrauterine fetal demise

Aim: To study the effectiveness of vaginal misoprostol according to the FIGO 2017 guideline for preinduction cervical ripening in second and third trimester pregnancy with intrauterine fetal demise.
 Methods: During six months period from October 2017 to April 2018 at Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, Nepal, cases admitted for second and third trimester termination of pregnancy for fetal demise were studied using the International Federation of Gynaecology and Obstetrics (FIGO) recommended doses of vaginal misoprostol. For gestational age of 13-26 weeks 200µg, for 27-28 weeks dose of 100µg and for >28 weeks dose of 25µg, every 6 hours was used. Main outcome measured included change in modified Bishop Score, insertion of first dose of vaginal misoprostol to delivery interval and maternal side effects.
 Results: In this study including 54 cases, mean preinduction Bishop score was 2.12. Bishop score remained unchanged in 2 cases, 28 had score between 4 to 6, 10 cases had score between 7 to 8 and 14 cases had Bishop score more than 8. The change in Bishop Score is statistically significant (p=0.007). 50 cases had vaginal delivery and it occurred within 19.83±13.1 hours. It took minimum 3 hours to maximum 52 hours from the first dose of misoprostol to delivery of the fetus. No side effects were noted within 24 hours of the last dose of vaginal misoprostol.
 Conclusions: Vaginal misoprostol according to FIGO guideline 2017 is safe and effective for preinduction cervical ripening in second and third trimester intrauterine fetal demise leading to successful vaginal delivery.

21st World Congress on Ultrasound in Obstetrics and Gynecology, 18-22 September 2011, Los Angeles, USA: presentations and awards

21st World Congress on Ultrasound in Obstetrics and Gynecology, 18-22 September 2011, Los Angeles, USA: presentations and awards

Second- and third-trimester termination of pregnancy in women with uterine scar — a retrospective analysis of 111 gemeprost-induced terminations of pregnancy after previous cesarean delivery

BackgroundThis study was conducted to evaluate and analyze the efficacy and safety of using gemeprost for second- and third-trimester termination of pregnancy (TOP) in women with uterine scar due to previous cesarean section. Study DesignRetrospective analysis of 111 medical TOPs for fetal anomaly or death at 14 to 34 weeks of gestation in women with a history of cesarean section was performed at a German tertiary care center from 2005 to 2009. Abortion was induced via intravaginal application of the prostaglandin analogue gemeprost (1 mg) every 6 h. ResultsOne hundred eleven women with one (89.2%) or two (10.8%) previous cesarean sections underwent medical TOP with gemeprost. The median induction-to-expulsion interval was 18 h 24 min (range, 2 h 20 min–168 h 28 min), and in 34 (30.6%) cases, the induction interval was longer than 24 h. The overall incidence of severe complications was 9/111 (8.1%), including one case of silent uterine rupture (with the need for blood transfusion), four cases of atonic and three secondary hemorrhages and one case of peritonitis due to uterine perforation during curettage. Failure of induction (induction-to-expulsion >48 h) occurred in 11 cases (9.9%). ConclusionGemeprost-induced TOP in the second and third trimester in women with uterine scar due to previous cesarean section is effective and has a low complication rate.

OP26.02: Second and third trimester termination of pregnancy for fetal anomaly: impact of a previous Caesarean section on maternal morbidity

OP26.02: Second and third trimester termination of pregnancy for fetal anomaly: impact of a previous Caesarean section on maternal morbidity

Low-dose vaginal misoprostol in the management of intrauterine fetal death

Objectives. To assess the effectiveness and side effects of vaginal misoprostol (Vagiprost® tablet) termination of second and third trimester pregnancy complicated with intrauterine fetal death (IUFD).Design. A prospective observational cohort study.Setting. Tanta University Hospital.Patients. The study carried out on 324 women with fetal demise in the second and third trimesters, from January 2008 to December 2009.Intervention. All patients were subjected to history taking, physical examination, and the Bishop Scoring. Application of 25 μg misoprostol in the posterior fornix of the vagina, this was repeated every 4 h over 24 h. We assessed the adverse effects, progress, and outcomes.Results. The success rate was 90% and 45% in women in the third and second trimesters, respectively. The mean induction-termination interval was 8.95 ± 2.63 and 15.3 ± 5.37 h for women in the third and second trimesters, respectively. The induction termination interval correlated negatively with the duration of gestation. Approximately, 90% of second trimester and 55% of third trimester women required oxytocin augmentation. The mean value of total required dose of misoprostol was 166.3 ± 7.5 and 120 ± 28.79 μg for women in the second and third trimesters, respectively.Conclusion. Vagiprost appears to be a safe, effective, practical, and inexpensive method for termination of third trimester pregnancy complicated with of IUFD.

Second- and third-trimester management of medical termination of pregnancy and fetal death in utero after prior caesarean section

ObjectivesTo evaluate the results and risks of a protocol for second- and third-trimester termination of pregnancy after prior caesarean section. Study designThis is a retrospective study, conducted in a level 3 (university hospital) maternity unit between January 2001 and September 2008. 67 women with a history of caesarean section underwent second- and third-trimester termination of pregnancy. The protocol was administration of 600mg mifepristone the first day and application of laminaria tents the second day. One the third day, 48h after mifepristone, two 200μg tablets of misoprostol were given orally every 3h until delivery. Epidural analgesia was performed routinely. Complications analysed were uterine rupture, labour lasting over 12h, and bleeding requiring blood transfusion. ResultsDelivery was vaginal in 64 cases (95.5%), a median 4h 20min (P25: 3h 5min, P75: 7h 7min) after administration of misoprostol (median number of tablets 2; P25: 2, P75: 4). The median number of tablets of misoprostol was significantly higher for termination of pregnancy than for fetal death in utero (4 vs. 2; p=0.002). The rate of uterine rupture was 4.8% [95% CI: 1.2–14.2]. Bleeding during delivery requiring a transfusion occurred in 2 cases (3.0%; 95% CI: 0.5–11.3). ConclusionA high rate of vaginal delivery was achieved at low doses of misoprostol, with a short median induction-to-delivery interval, and a rate of uterine rupture higher than that observed during attempted vaginal delivery at term in a caesarean scar pregnancy. The rate of severe bleeding during delivery was low.

Low Dose Vaginal Misoprostol in the Management of Women with Intrauterine Fetal Death

Objectives The study was conducted to assess the effectiveness and side effects of vaginal misoprostol (Vagiprost® tablet) in termination of second and third trimester pregnancy complicated with intrauterine fetal death. Design A prospective observational cohort study. Setting Tanta University Hospital. Patients The study was carried out on 324 women with fetal demise in the second and third trimesters. Cases were collected during the period from January 2008 to December 2009. Intervention All patients were subjected to history taking, physical examination, Bishop Scoring. Application of 25 μg misoprostol in the posterior fornix of the vagina, this will be repeated every 4 hours over 24 hours. The adverse effects, progress, and outcomes were assessed. Results the success rate was 90% and 45% in women with third and second trimesters respectively. The mean induction-termination interval was 8.95 ± 2.63 and 15.3 ± 5.37 hours for women with third and second trimesters respectively. The induction termination interval correlated negatively with the duration of gestation. Approximately, 90% of second trimester and 55% of third trimester women required oxytocin augmentation. The mean value of total required dose of misoprostol was 166.3 ± 7.5 and 120 ± 28.79 μg for women with second and third trimesters respectively. Conclusion Vagiprost appears to be a safe, effective, practical, and inexpensive method for termination of third trimester pregnancy complicated with of intrauterine fetal death (IUFD), its effects increase with parity and duration of gestation.

Induced termination of second and third trimester pregnancy in women with scarred uterus

To investigate the suitable mode of induced termination of pregnancy at second and third trimester for women with scarred uterus. A retrospective study was performed in 90 cases of second and third trimester pregnant women with scarred uterus, who requested termination of pregnancy due to medical indications in Beijing Obstetrics and Gynecology Hospital from September 2002 to June 2009. The indications of termination of pregnancy were fetal anomaly, serious pregnant complication and intrauterine fetal deaths. 72 second trimester pregnant women and 18 third trimester pregnant women were included in this study. The interval time of previous operation to this pregnancy were recorded. And it was < 2 years in 20 cases and ≥ 2 years in 70 cases. The patients with normal Hepatic function began to take mifepristone and had an allergic test of Ethacridine Lactate. The method of mifepristone combined with Ethacridine Lactate were adopted when the allergic test was negative (group A, 54 cases). The method of mifepristone combined with carboprost methylate suppositories were used in the patients who had a positive reaction to the allergic test of Ethacridine Lactate, or who failed to amniotomy to inject Ethacridine Lactate because of oligohydramnios or small gestational age (group B, 36 cases). Record the detail information of every patient. (1) Age, gestational weeks, gravidity and parity. (2) The mode of previous operation (inducing the scar of uterus), previous operation time and indication. (3) The mode of induced labor in this pregnancy, the interval time from administration to uterine contraction, delivery or not and the interval time from induction to delivery. (4) Postpartum hemorrhage, the successful rate of induce labor, placental retention ratio and rupture of uterus or not. (1) It had no significant difference between group A and group B in age, gravidity, parity and the interval time of previous operation to this pregnancy (P > 0.05). But there was significant difference between two groups in gestational weeks of induction (16 weeks vs. 25 weeks, P < 0.01). (2) It had no significant difference between two groups in successful rate of induction and postpartum hemorrhage (P > 0.05), but the time from induction to regular uterine contraction and delivery in group B was significant shorter than that of group A (P < 0.01). The rate of delivery with 24 hours in group B was 94%. It was significant higher than that of group A (13%, P < 0.01). (3) The rate of retained placenta in group B (31%, 11/35) was significant higher than group A (10%, 5/52), but the ratio of residual of placenta and membranes in group A was significant higher than that of group B (54% vs. 34%). It was no significant difference in total rate of postpartum complication between two groups. Further analysis was done in relationship of complication and the time of previous operation. It was no significant difference between the over 2 years group and the less 2 years group in the incidence rate of complications including placental retention, residual of placenta and membranes, rupture of uterus, placental abruption and postpartum hemorrhage. (4) There was 1 case of uterine rupture in group B and 1 case of placental abruption in group A. Both of methods of mifepristone combined with carboprost methylate suppositories and the mifepristone combined with Ethacridine Lactate are feasible to induced second trimester and late trimester termination of pregnancy for women with scarred uterus. But sufficient preoperation preparation and the course of induction and labor careful monitoring must be done to prevent the uterine rupture.

Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow up study

The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact.

Misoprostol for second and third trimester termination of pregnancy: A review of practice at the Women's and Children's Hospital, Adelaide, Australia

To assess clinical outcomes for women undergoing induction of labour either for fetal anomaly or following intrauterine fetal death using intravaginal misoprostol. Between January 1999 and December 2002, clinical outcomes for women who were admitted to the delivery suite of the Women's and Children's Hospital, South Australia, were prospectively collected and entered onto a database by the attending midwife. The effect of cumulative dose of misoprostol, indication for induction of labour, parity and gestational age were assessed. One hundred and ninety nine women were admitted during the study period. Women who required in excess of 800 microg of misoprostol were more likely to have side-effects (57/78 women dose > 800 microg misoprostol versus 71/121 women dose < or = 800 microg, RR 0.80 95% CI 0.66-0.98), in particular diarrhoea (12/78 women dose > 800 microg misoprostol versus 5/121 women dose < or = 800 microg, RR 0.27 95% CI 0.10-0.73) and elevated temperature (46/78 women dose > 800 microg misoprostol versus 36/121 women dose < or = 800 microg, RR 0.50 95% CI 0.36-0.70). Women with an intrauterine fetal death (IUFD) were less likely to require in excess of 800 microg of misoprostol to effect the termination (10/56 women IUFD versus 70/143 women fetal anomaly, RR 0.36 95% CI 0.20-0.66), had a shorter induction to birth interval (mean 13.2 h +/- 7.5 h, women IUFD versus 21.2 +/- 17.5 h, women fetal anomaly, WMD -8.02 95% CI -11.49 to -4.55) and were more likely to give birth within 24 h of the induction process commencing (48/56 women IUFD versus 106/143 women fetal anomaly, RR 1.16 95% CI 1.00-1.34). Side-effects increase with increasing dose of misoprostol. Induction following intrauterine fetal death is associated with a need for lower doses of misoprostol and a shorter induction to birth interval.

Second- and Third-Trimester Therapeutic Terminations of Pregnancy in Cases with Complete Placenta previa – Does Feticide Decrease Postdelivery Maternal Hemorrhage?

Objective: To study the feasibility of second- and third-trimester termination of pregnancy (TOP) with complete placenta previa, and the impact of performing feticide before labor induction on maternal hemorrhagic morbidity. Patients and Methods: From 1987 to 2002, the databases of two referral hospitals were reviewed. We identified 15 cases of second- or third-trimester TOP in women with complete placenta previa. Feticide was performed 2–14 days before induction in 6/15 cases. Cervical ripening was achieved in 8 cases by mifepristone alone (n = 2) or by mifepristone and dilapan (n = 6). Labor was induced by vaginal gemeprost (n = 2), intramuscular (n = 5) or intravenous (n = 4) sulprostone, vaginal misoprostol (n = 1) or a combination of misoprostol and sulprostone (n = 3). Hemorrhage was defined by the need for transfusion. The difference between the preoperative and the lowest per- or postoperative maternal hemoglobin level was also analyzed. Results: Of the 9 women who underwent labor induction without previous feticide, 4 required blood transfusions, 1 of whom had a hemostat hysterectomy. The mean hemoglobin difference was 2.5 g/dl (range: 0.5–5.3). None of the 6 patients with preinduction feticide required transfusion. The hemoglobin difference was significantly smaller in this group than in terminations without previous feticide (mean: 1.0 g/dl ; range: 0.1–2.2; p = 0.03). Conclusion: In cases with complete placenta previa, second- or third-trimester TOP is feasible. It carries a substantial risk of hemorrhage that might be decreased by preinduction feticide.

Feticide during Second- and Third-Trimester Termination of Pregnancy: Opinions of Health Care Professionals

Objective: To study the opinions of professionals on feticide being performed as the first step of late termination of pregnancy (TOP). Setting: Tertiary care obstetrical unit with policy of routine feticide in late TOP. Method: Questionnaire survey. Results: 101/109 professionals responded (23 midwives, 22 doctors, 24 nurses, 21 auxiliaries, 9 others). 90 had heard of feticide, 83 knew about how and 38 about when the procedure was done. When asked about what the goals of feticide were, 94 respondents quoted, ‘preventing parents from facing neonatal agony’, 73 ‘avoiding fetal pain’, 85 ‘preventing labor ward staff from facing neonatal agony’, and 60 ‘complying with legal rules’. 54 respondents thought feticide was beneficial to their patients or improved their own professional practice, and 71 declared the procedure was emotionally positive, yet stressful. 48 respondents declared lacking information on feticide. Respondents who had attended to feticide at least once (n = 59) knew more on feticide, and were more positive on the impact feticide had on their practice than those who had never attended a feticide (n = 42). Conclusions: In a highly specialized center, professionals had positive opinions on feticide, expecting it would avoid fetal or neonatal agony and pain.

Termination of third-trimester pregnancy before term with gemeprost vaginal pessaries

Determination of the efficacy and side-effects of the synthetic prostaglandin analog gemeprost for termination of pregnancy in the third trimester. Retrospective record study of 40 women who had undergone third trimester termination of pregnancy before term by serial administration of gemeprost because of intrauterine fetal death or hopeless fetal prognosis. Patients with multiple pregnancy, a Bishop score > 5, contractions or contraindications to prostaglandins were excluded. Gemeprost vaginal pessaries (1-mg) were given at 6-hourly intervals until labor intervened. The main parameter studied was the induction-delivery interval, the length of time between administration of the first dose and delivery. Statistical analysis was performed with the chi-square and the Mann-Whitney U-test. The median induction-delivery interval was 14.4 h (range 3-48 h). Delivery occurred within 12 h in 17 women (42.5%), within 24 h in 27 women (67.5%) and within 36 h in 37 women (92.5%). An average of 2.6 doses were given per patient. Multigravidae had a significantly shorter induction-delivery interval than primigravidae (p < 0.01). A total of 87.5% women required analgesia. Side-effects were infrequent. The administration of gemeprost vaginal pessaries represents an efficient method with few side-effects for the induction of labor in the third trimester, provided patients are chosen carefully and monitored closely.

Termination of third-trimester pregnancy before term with gemeprost vaginal pessaries

Objective. Determination of the efficacy and side-effects of the synthetic prostaglandin analog gemeprost for termination of pregnancy in the third trimester. Patients. Retrospective record study of 40 women who had undergone third trimester termination of pregnancy before term by serial administration of gemeprost because of intrauterine fetal death or hopeless fetal prognosis. Patients with multiple pregnancy, a Bishop score > 5, contractions or contraindications to prostaglandins were excluded. Methods. Gemeprost vaginal pessaries (1-mg) were given at 6-hourly intervals until labor intervened. The main parameter studied was the induction-delivery interval, the length of time between administration of the first dose and delivery. Statistical analysis was performed with the chi-square and the Mann–Whitney U-test. Results. The median induction-delivery interval was 14.4 h (range 3–48 h). Delivery occurred within 12 h in 17 women (42.5%), within 24 h in 27 women (67.5%) and within 36 h in 37 women (92.5%). An average of 2.6 doses were given per patient. Multigravidae had a significantly shorter induction-delivery interval than primigravidae (p < 0.01). A total of 87.5% women required analgesia. Side-effects were infrequent. Conclusions. The administration of gemeprost vaginal pessaries represents an efficient method with few side-effects for the induction of labor in the third trimester, provided patients are chosen carefully and monitored closely.

Ethics in fetal medicine

In this chapter we provide an overview of current ethical issues in fetal medicine. We begin with an introduction to the language and concepts of ethics. We then show how ethical principles can be applied to fetal medicine. In this part of the chapter we introduce the concept of the fetus as a patient and explain its implications for directive versus non-directive counselling. We then take up two current clinical controversies, routine obstetric ultrasound and termination of third trimester pregnancy.

Monitoring perinatal mortality by birth weight specific mortality rates

The perinatal mortality at University Central Hospital of Turku, Finland decreased significantly from 15.7/1000 in years 1970–1975 to 8.9/1000 in years 1976–1978. The main decrease has occurred in weight groups of 1000 g and more. In years 1976–1978 the perinatal mortality of non-malformed babies in the weight group 1500–1999 g was 93 1000 , in the group 2000–2499 g 21 1000 and in the group of 2500 g and over 1.7/1000. The early neonatal mortality of non-malformed infants has decreased significantly only in the weight group of 1500–1999 g. The 1-week survival rate has been 48% in the weight group 500–999 g, but 77% in the weight group 1000–1499 g. The birth weight specific mortality rates are greatly required when the quality of obstetrical care is assessed. Birth weight specific neonatal mortality rates are essential when guidelines for elective termination of third trimester pregnancy are designed.