Trimester Termination Of Pregnancy Research Articles

A cohort study comparing the severity and outcome of intrauterine adhesiolysis for Asherman syndrome after first- or second-trimester termination of pregnancy

ObjectiveTo compare the clinical characteristics of Asherman syndrome and the outcomes of hysteroscopic adhesiolysis in women after first or second-trimester termination of pregnancy (TOP). MethodsThis was a retrospective descriptive analysis of patients with moderate-to-severe intrauterine adhesiolysis (IUAs) after TOP and treated by hysteroscopic adhesiolysis and followed by “second-look” hysteroscopy 3 months later at The Beijing Obstetrics and Gynecology Hospital (China) between January 2013 and March 2016. The American Fertility Society (AFS) scoring system was used to evaluate the intrauterine adhesions. ResultsA total of 236 patients with 180 first-trimester TOP and 56 s-trimester TOP patients were included. The severe adhesion and amenorrhea rates during the second-trimester group (69.6% and 39.3%, respectively) were significantly higher than those in the first-trimester group (36.7% and 7.2%, respectively). AFS score reduction in the second-trimester group (6.2 ± 2.8) was significantly lower than in the first-trimester group (6.5 ± 2.5). The pregnancy rates in the second-trimester group (21.4%) were significantly lower than that in the first-trimester group (43.3%). The pregnancy rate of severe intrauterine adhesions in second-trimester TOP (10.3%) was significantly lower than in first-trimester TOP (40.9%). ConclusionThese findings suggested that second trimester TOP was associated with more severe intrauterine adhesion and a worse prognosis after hysteroscopic adhesiolysis in women with Asherman syndrome when compared to first-trimester TOP.

Does feticide shorten termination duration in second trimester pregnancy terminations?

A retrospective (case-controlled) study was conducted with the aim of identifying the effect of the use of misoprostol on termination time in patients who did and did not undergo feticide procedures in second trimester pregnancy terminations. The sampling of the study consisted of 144 pregnant women who were diagnosed as having major fetal anomalies incompatible with life, and were recommended for termination of pregnancy. The investigation showed that feticide procedures were performed for 99 women, and feticide procedures were not performed for 45 women. Misoprostol protocol was administered for 48 hours in the termination period; whether the feticide procedure directly affected the termination duration in patients who did and did not undergo feticide was evaluated. Abortion/birth was achieved in 103 (71.5%) women during the first 48 hours. There was no significant difference between the termination duration of the misoprostol protocol among the women who did and did not undergo feticide. There was no significant difference between the termination durations and fetal biometric measurements (BPD, HC) except head diameters (p=0.020 and p=0.015). The misoprostol protocol is shown to be effective and safe for the termination of pregnancies during the second trimester. Feticide has no affect on the duration of termination.

Uterine rupture following misoprostol improper use

Introduction: Misoprostol, a synthetic prostaglandin E1 analogue, is considered safe and is being used worldwide for second trimester pregnancy terminations, with successful results. However, complications of uterine rupture and hysterectomy have been reported, and the incidence is higher among women with prior cesarean scar. Maternal morbidity and mortality following induced abortions are directly proportional to the gestational age at termination. We report a case of a 32-year-old multipara, G3P2, with two prior low transverse cesarean sections, who experienced uterine rupture after vaginal misoprostol administration, following an illegal second trimester abortion of an undesired pregnancy of about 20 weeks’ gestation. She presented at emergency room complaining of acute lower abdominal pain and sparse vaginal hemorrhage. Fetal demise and uterine rupture were diagnosed by manual vaginal exam and ultrasound. She underwent emergency exploratory laparotomy that revealed massive hemorrhage arising from a complete and extended uterine rupture from the previous cesarean section scar. A total hysterectomy and intra-operative blood transfusion had to be performed. Her post-operative was uneventful.

Manual Vacuum Aspiration (MVA) versus Electric Vacuum Aspiration (EVA) in first trimester medical termination of pregnancy (MTP)

Background: Approximately 47000 pregnancy related deaths occur due to complication of unsafe abortion. To correct this Ministry of Health and Family Welfare had appointed the expert group for MTP Act and amend it to enable increased access to safe abortion services for all women. The WHOs preferred methods to safely and effectively terminate pregnancy during the first trimester of pregnancy are vacuum aspiration and medication abortion. Objectives: To evaluate and compare the efficacy of MVA and EVA in first trimester pregnancy termination. Methods: Study includes cases of pregnancy with less than or equal to 12 weeks of gestation. After receiving consent, cases allocated in two groups Group A followed Manual Vacuum Aspiration while Group B followed Electric Vacuum Aspiration. Each group contains 75 cases. During these procedures, relation of uterine size, blood loss, post-operative pain score, complications were noted and compared between two procedures. Results: The average blood loss was significantly higher in MVA group in more than 10 weeks of gestation. MVA is comparatively less painful than EVA. There is no major difference in complications. Conclusion: MVA is best suited for infra-structure in rural areas and is very useful in poor resource setting hence It is best suited for rural setting, where there is an unmet need for abortion services. Key words: Manual Vacuum Aspiration (MVA), Electric Vacuum Aspiration (EVA), Medicaltermination of pregnancy

OUTCOMES OF SECOND TRIMESTER SURGICAL ABORTION: THE EXPERIENCE OF A TERTIARY HEALTH FACILITY IN ETHIOPIA

ABSTRACTBACkGROUND: Abortion is defined as expulsion or extraction of a fetus before fetal viability. It is a very common occurrence globally (40-50 million per annum. There is increasing evidence to suggest that dilation and evacuation (D&E) leads to fewer complications than medical abortion for second trimester termination of pregnancy. However, there is no recent documentation of the outcome of such a method in Ethiopia. Hence the aim of this study is to document the outcome of second trimester D&E performed at St Paul Hospital and Millennium Medical College (SPHMMC). OBJECTIVE: To describe clinical characteristics and short-term outcomes of second trimester surgical abortion at SPHMMC. METHODS AND SUBJECTS: A retrospective cross-sectional study design was employed to review all cases of dilation and evacuation performed in the six months period from January 1, 2018- July 30, 2018. A structured questionnaire was used to collect selected socio-demographic data, clinical characteristics and acute complications. Data was entered and analyzed using IBM SPSS Statistics, version 20.0 (IBM Corp, Released 2011). RESULT: A total of 43 client records were reviewed and used for this analysis. The median (IQR) age of the study participants was 24 (20,26), with age range of 16 to 34 years old. The average gestational age is 16 weeks + 2 days (ranging from 13 weeks + 1 day to 20 weeks + 6 days). All women received doxycycline prior to performing D&E. No ultrasound was used during all the procedures. Over all complication rate is 2.3%, with 1 case of uterine perforation. The contraceptive uptake rate was 88.4% (38/43). The most common post abortion family planning method was long acting reversible contraceptives (LARC). CONCLUSION: Our review demonstrated that D&E is safe after applying recommended procedures in a tertiary health facility in Ethiopia. Further analysis using a larger sample should be undertaken and comparison should be made with medical induction in order to establish the safety and effectiveness of second trimester surgical abortion. kEY WORDS: second trimester safe abortion, Dilation & Evacuation (Ethiopian Journal of Reproductive Health; 2019; 11;1:1-8)

Randomized Trial comparing Efficacy between a Vaginal Misoprostol Loading and non-Loading Dose regimen for Second Trimester Pregnancy Termination

Randomized Trial comparing Efficacy between a Vaginal Misoprostol Loading and non-Loading Dose regimen for Second Trimester Pregnancy Termination

Low-dose Misoprostol for Second Trimester Pregnancy Termination in Women with a Prior Caesarean Delivery

Low-dose Misoprostol for Second Trimester Pregnancy Termination in Women with a Prior Caesarean Delivery

Study of the Efficacy and Success Rate of Single Dose Oral Mifepristone and Vaginal Misoprostol v/s Vaginal Misoprostol alone for Second Trimester Termination of Pregnancy

Background: Second trimester abortions constitute 10-15% of all induced abortions and are considered to be less safe than first trimester abortions. The combination of mifepristone and misoprostol is now an established and highly effective method for second trimester abortion. Aim: To compare the efficacy and the success rate of single dose oral mifepristone plus vaginal misoprostol versus vaginal misoprostol alone for second trimester termination of pregnancy. Materials and Methods: A comparative study and was conducted in the Department of Obstetrics and Gynecology in a Tertiary Health Care Hospital. The study was carried out by dividing women into two groups (72 each). Group A received 200mg of oral Tablet Mifepristone and 400 of vaginal misoprostol (48 hours later) which was repeated every 4 hourly by 200 of vaginal misoprostol up to a maximum of 4 doses. Group B received 400 of vaginal misoprostol directly and the dose was repeated every 4 hourly by 200 of vaginal misoprostol up to a maximum of 4 doses. Results: The success rate in Group A was 98.6%, whereas in Group B was 84.7%. The mean induction abortion interval in Group A was lesser (6.2 hours) as compared to Group B (10.8 hours) (p value <0.00001). The mean dose of misoprostol in Group A was 613.88mcg compared to the Group B 1591.66mcg (p value <0.00001). Conclusion: Pretreatment with mifepristone significantly reduces the induction abortion interval (I-A-I) and the misoprostol dose.

557: Progesterone decreases human cervical smooth muscle cell contractility

The cervical internal os (IO) contains smooth muscle which may function as a sphincter. Premature cervical failure (funneling at the IO) leading to preterm birth may be due to premature “sphincter” relaxation. Progesterone is used to treat premature cervical failure but the effects of estrogen, progesterone on human cervical smooth muscle cell (HCSMC) function is unclear. We evaluated the effects of estrogen and progesterone on HCSMC contractility and intracellular calcium flux. HCSMC were isolated from cervical biopsies obtained from healthy women undergoing 2nd trimester pregnancy termination and immunostained for: estrogen (ER)/progesterone (PR) receptors, SMC markers (αSMA, SM22, desmin). HCSMC were treated overnight with serum-free media alone or decreasing concentrations (10-5M, 10-7M or 10-9M) of β-estradiol or progesterone and then stimulated with serum-free media/no hormones or 1uM oxytocin for 10min. F:G-actin ratio assays (indirectly measures SMC contractility) were then performed. The same experimental design was followed utilizing 1 dose of β-estradiol or progesterone (10-7M) and calcium flux assays were performed. Experiments were repeated at least twice using HCSMC from 6 women. Statistical analysis included Student’s t-test and ANOVA. Primary HCSMC express ER, PR and mature SMC markers. β-estradiol significantly increases HCSMC contractility and enhances oxytocin-induced contractility (increases F:G actin ratios). Progesterone significantly reduces oxytocin-induced HCSMC contractility (decreases F:G actin ratios, Fig 1). Results were similar regardless of hormone concentration. Intracellular calcium levels were increased by oxytocin and decreased by progesterone. β-estradiol did not increase calcium levels compared to treatment with oxytocin alone (Fig. 2). β-estradiol increases and progesterone decreases HCSMC contractility. Progesterone likely decreases contractility through alterations in intracellular calcium flux. If a smooth muscle sphincter exists at the IO, further studies are needed to comprehend the effect of pregnancy hormones, specifically progesterone, on cervical function in pregnancy. This study highlights the importance of performing studies which mimic the pregnant hormonal environment to accurately understand normal and abnormal cervical function in pregnancy.

Dosing interval between mifepristone and misoprostol in second and third trimester termination.

To compare several strategies for second trimester labor induction for termination of pregnancy (TOP) using misoprostol and mifepristone and to determine which one is more effective in accelerating the time to delivery. This was a retrospective study in which pregnancies that underwent second and third trimester TOP due to fetal anomalies between 2007 and 2017 were classified into a group that received misoprostol alone, a group that received mifepristone followed by misoprostol on the same day, one where misoprostol was given 1day after mifepristone and one where the medications were administered 2days apart. The primary outcome measure was the induction to delivery interval. 481 pregnancies fulfilled the inclusion criteria. In 140 cases, mifepristone was not administered. 341 women received mifepristone prior to induction, which was administered on the day of induction in 85 cases, and 1 or 2days prior to induction in 140 and 19 cases. Median time interval between first induction and delivery was 15.0 (IQR 10.0-24.1) h in case no mifepristone was given and 13.2 (9.7-18.2)h if mifepristone was given on the same day and 9.3 (6.6-14.9) and 10.5 (7.2-22.3) h, if mifepristone was given 1 or 2days prior to induction. After 24h, the proportion of terminated pregnancies in each of the four groups was 75.0, 83.5, 93.2 and 78.9%. A 1day interval between mifepristone and misoprostol is more effective in second and third trimester TOP compared to other strategies in terms of reducing the induction to abortion interval.

Sexual well-being after first trimester termination of pregnancy: Secondary analysis of a randomized contraceptive trial.

Although termination of pregnancy is one of the most common procedures conducted worldwide, little is known about sexual well-being after termination of pregnancy. The objective of this study was to assess sexual well-being after termination of pregnancy, and factors affecting it during a 1-year follow up. In total, 748 women requesting first trimester termination of pregnancy and participating in a randomized controlled trial on early provision of intrauterine contraception were provided with questionnaires regarding their sexual life, anxiety, quality of life and contraceptive method used at the time of termination of pregnancy, 3 and 12months after termination of pregnancy. Sexual well-being was measured by the 9-item McCoy Female Sexuality Questionnaire. Anxiety and quality of life were assessed by the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL questionnaire (EQoL). The McCoy index remained unchanged during the follow up. At all three time-points measured, higher (ie, better) McCoy scores were associated with a lower STAI index (mean difference -2.26 [95% CI -3.23 to -1.29], P<0.001; -3.76 [95% CI -4.79 to -2.74], P<0.001; -4.50 [95% CI -5.88 to -3.12], P<0.001) and being in a relationship (1.16 [95% CI 0.08-2.25], P=0.023; 1.67 [95% CI 0.43-2.89], P<0.001; 2.81 [95% CI 1.28-4.34], P<0.001), and correlated positively with a higher EQoL index (r=0.20, r=0.20, r=.27, P<0.001) and higher frequency of intercourse (r=0.50, r=0.46, r=0.42, P<0.001). Women using intrauterine contraception had higher McCoy index measurements at 3months compared with others. There were no significant differences between users of hormonal vs non-hormonal contraceptive methods. Sexual well-being does not change significantly after termination of pregnancy. Instead, it is strongly and positively associated with quality of life, relationship status and frequency of intercourse. Anxiety is negatively associated with sexual well-being.

Efficiency of the Foley catheter versus the double balloon catheter during the induction of second trimester pregnancy terminations: a randomized controlled trial.

To compare induction-to-delivery intervals of Foley catheters and double balloon catheters in second trimester pregnancy terminations. This randomized parallel study was conducted on women who underwent second trimester terminations between December 2016 and December 2017. Pregnant women in the second trimester with a Bishop score < 6 were included in the study. Participants were randomized into two groups, the first being the Foley catheter group and the second being the double balloon catheter group. The time frames from insertion of catheters to the delivery were recorded in each group. A multiple regression analysis was carried out to examine the contribution of factors to the induction-to-delivery interval. A survival analysis was conducted to compare the Foley method and the double balloon method. A total of 91 pregnant women were included in the final analysis. The induction-to-delivery interval was shorter in the Foley catheter group than in the double balloon catheter group (38h 54min ± 21h 6min versus 58h 17min ± 25h 56min). We also found that women with intrauterine fetal death (IUFD) had a shorter time to delivery compared to women with live fetuses (39h 12min ± 18h 46min vs 51h 30min ± 26h 42min, p = 0.04). Women with a history of vaginal delivery also had a shorter induction-to-delivery time compared to women who never delivered vaginally before (38h 12min ± 17h 42min vs 53h 54min ± 27h 18min, p = 0.004). In the multiple regression analysis, the most significant contributor to the induction-to-delivery time was the method used for induction of labor and followed by other factors including the viability of the fetus (live/IUFD), history of vaginal delivery and PPROM. The survival analysis showed that the induction-to-delivery interval was significantly shorter in the Foley catheter group than in the double balloon catheter group (HR 2.51, 95% CI 1.57-4.00, p = 0.001). During the termination of second trimester pregnancies time from induction of labor to delivery is shorter with the Foley catheter compared to double balloon catheter.

Detection of major anomalies during the first and early second trimester: Single-center results of six years

Objective:Fetal structural malformations affect approximately 2-3% of all pregnancies. Only focusing on trisomy screening in first trimester and deferring the anatomic screening to second trimester may result with late detection of major anomalies that can be diagnosed earlier with careful examination.Material and Methods:This was a descriptive study of retrospective data that were obtained from all terminated single pregnancies due to ultrasonographic findings of major anomalies from 2011 to 2016 in our department. The study was based on a chart review and only abnormalities that were diagnosed before the 16th week were included.Results:Two hundred forty-four first trimester pregnancy terminations were performed. In total, 273 anomalies were detected in the 244 patients. Cranial NTD comprised 32% of all anomalies (n=89). Fifteen percent of anomalies (n=41) needed detailed anatomic scanning for early diagnosis.Conclusion:In this study, we presented the number and percentage of our early diagnosed anomalies by years, as well showed our diagnostic performance for specific anomalies such as atrioventricular septal defect during a 5-year period. The study provides valuable information for future studies in Turkey and shows the need for an anatomic scan protocol while performing aneuploidy screening during early gestation.

Study of Mifepristone and Misoprostol Vs Misoprostol alone in mid trimester termination of pregnancy in tertiary care hospital

Study of Mifepristone and Misoprostol Vs Misoprostol alone in mid trimester termination of pregnancy in tertiary care hospital

Incidence and contributing factors for uterine rupture in patients undergoing second trimester termination of pregnancy in a large tertiary hospital - a 10-year case series

IntroductionUterine rupture is a rare complication in second trimester termination of pregnancy (TOP) with an overall incidence of up to 1.1%. There are concerns that patients with previous caesarean section(s) were at an increased risk of uterine rupture. However, there is no published data in our local population to date. This study aims to identify the incidence and contributing factors for uterine rupture in women undergoing TOP in Singapore. Study DesignThis is a retrospective review of all women who had TOP between 14+0 weeks to 23+6 weeks gestation from January 2005 to December 2014 in a large tertiary hospital. Patients’ characteristics and details of TOP were retrieved from pre-existing hospital databases. The gestation age and dose of gemeprost used were retrieved from an internal hospital audit conducted from December 2012 to July 2016. ResultsA total of 3385 patients underwent TOP from 2005 to 2014. An estimated 339 patients had a scarred uterus. Seven cases of uterine rupture were identified, with an overall incidence of 0.21% (7/3385). The incidence of uterine rupture in patients with scarred uterus was 2.1% (7/339). Contributing factors identified included higher mean dose of abortifacient, usage of multiple abortifacients and methods, advanced gestation age and short interval between last caesarean section and current TOP. ConclusionSecond trimester TOP on scarred uterus warrants careful usage of abortifacient with minimal cumulative dosage and should be carried out in early second trimester gestation whenever feasible. Prostaglandin analogues appeared to be safe for TOP in unscarred uteruses.

Low-dose vaginal misoprostol with or without Foley catheter for late second-trimester pregnancy termination in women with previous multiple cesarean sections

Purpose: To compare between low dose vaginal misoprostol with and without Foley catheter for late second trimester pregnancy termination in women with previous multiple cesarean sections.Materials and methods: A prospective randomized controlled clinical trial, patients were randomly allocated to either low dose vaginal misoprostol group (n = 40) or combined low dose vaginal misoprostol plus Foley catheter group (n = 38). The primary outcome was complete abortion. Secondary outcomes were induction-to-abortion interval, the number of misoprostol doses and occurrence of complications.Results: Incomplete abortion rate was significantly lower in combined group than misoprostol only group (2.6%versus 15% respectively, p = .03). Induction-to-expulsion interval with the combined vaginal misoprostol plus Foley catheter was significantly shorter (p = .01) and the number of misoprostol doses in the combined group was significantly lower (p = .04). No statistically significant difference in the frequency of complications between both groups.Conclusions: The combination of low dose vaginal misoprostol and Foley catheter is an effective and safe method for termination of second trimester pregnancy in women with previous multiple cesarean sections.

Mifepristone and Misoprostol Vs Misoprostol Alone in Second Trimester Termination of Pregnancy

During the last decade, medical methods for second trimester abortion have considerably improved and become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for second trimester abortion. But where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective. The objective of this study is to compare the efficacy of mifepristone with misoprostol and misoprostol alone for second trimester termination of pregnancy. It is a comparative study conducted on 60 patients from 13 to 18 weeks of gestation admitted for second trimester termination on legal indications. Mean induction abortion interval was comparable in both the groups. Of the 30 cases in each group, nine cases in each Group A and six cases in Group B had incomplete/failed expulsion. Among these 15 cases, only nine required check curettage for complete evacuation while others received oxytocics only for completion. The distribution of these cases was also comparable in both the groups. Only one patient in Group B had complete failure of expulsion and underwent surgical evacuation. However, the difference in dosage of misoprostol required for complete expulsion and incidence of side effects were significantly higher in the group B. Mifepristone and misoprostol combined together is now an established, highly effective and safe method for medical method of second trimester termination. However, when mifepristone is not available or affordable, misoprostol alone can also be used effectively, although a higher total dose is needed and side effects are higher than with the combined regimen.

Second Trimester Pregnancy Termination in Previous Cesarean Section Patients With Unfavorable Cervix: A Randomized Controlled Clinical Trial Comparing 3 Different Methods

Second Trimester Pregnancy Termination in Previous Cesarean Section Patients With Unfavorable Cervix: A Randomized Controlled Clinical Trial Comparing 3 Different Methods

Maternal outcomes in first and second trimester termination of pregnancy: which are the risk factors?

To evaluate maternal complications of first trimester and second trimester termination of pregnancy (TOP) performed after first or second trimester positive prenatal diagnosis (PD). We performed a retrospective study from January 2007 to December 2011, on 844 patients, who underwent a TOP after positive amniocentesis or chorionic villus sampling (CVS) for foetal aneuploidies, performed for maternal age ≥35 years of age, positive prenatal screening (PS) or for genetic reasons. Exclusions criteria were gestational age >22+0 weeks, twin pregnancy and co-existing maternal pathologies. We compared maternal complications of first trimester and second trimester TOP and we established which risk factors were correlated to higher maternal complications (haemorrhages, transfusion, repeated uterine curettage and infections). Maternal complications were significantly higher in second trimester TOP. Previous uterine surgery is a significant risk factor for maternal complications in second trimester TOP, but not in first trimester TOP. Six uterine ruptures and three hysterectomies occurred, all in multiparous women with second trimester TOP. All uterine ruptures occurred in women with previous caesarean sections. First trimester TOP in women with risks factors for maternal complications guarantees better maternal outcomes and less health costs. Thus, in these women we should prefer a first trimester PS and PD.

P22.05: Outcome of pregnancy after the prenatal diagnosis of isolated major congenital heart diseases

To analyse cases with a diagnosis of isolated major congenital heart diseases (MCHDs) in terms of gestational age (GA) at the suspicion, GA at the diagnosis, the management and the outcome of the pregnancy. This is a multicentre retrospective analysis of cases with isolated MCHDs in four tertiary centres from 2010 to 2016. In the study period, in over 36 hundred pregnancies, 105 cases of isolated MCHDs were diagnosed in these centres. The time of positive diagnosis was 16+6 weeks of amenorrhea (range: 12+6 – 36+1weeks of gestation). 60 couples (57.14%) chose first and second trimester termination of pregnancy. The median time interval between the diagnosis and the termination procedure was 3.5 days (range: 1-7 days). In 36 cases (60%), termination of pregnancy took place in or after the 18th week of gestation. In this study group we had: cases of tricuspid atresia with ventricular septal defect (TrAVSD), cases tetralogy of Fallot (TOF), cases of critical aortic stenosis (AoSt), cases of atrioventricular septal defect - AVSD (partial and complete), and cases of cardiac tumours. We may hypothesise that the diagnosis could have been made earlier in few of them. Most couples (54/60 - 90%) requested for repeated multidisciplinary counselling before termination and only one couple expressed the intention of engaging in a medical litigation for a delayed diagnosis. In our country many parents experience difficulties in coping with the severe prenatal diagnosis of MCHD. Implementation of a uniform prenatal care including first-trimester cardiac screening could lead to an earlier accurate diagnosis in a reduced number of cases. There is need for cost-analysis studies and ethics debates before changing health policies. The additional minor risk due to medical second trimester termination and litigation must be balanced against incomplete counselling after FT suspicion and against the disadvantages of FT surgical terminations request.