Medication abortion failure in women with and without previous cesarean delivery

Induced Abortion After Previous Caesarean Section: A Scoping Review

BACKGROUND

Previous caesarean section (CS) is increasingly common among women undergoing induced abortion.

AIMS

To map and analyse existing literature on abortion safety, outcomes and management in those with previous CS.

MATERIALS AND METHODS

Four databases were systematically searched from inception to July 2024. Primary human studies in English reporting on outcomes, safety or management of first- or second-trimester medical (MToP) or surgical (SToP) abortion in women with previous CS were included. Uterine rupture incidence was analysed cumulatively in the first and secondtrimesters by the number of CS and the type of prostaglandin used. Data on the efficacy and safety of MToP and SToP, including studies reporting on the management of abortion in the setting of abnormal placentation, were collected and analysed by theme.

RESULTS

In total, 164 articles met inclusion criteria. Incidence of uterine rupture in first-trimester MToP was 0 of 2194 cases, in second-trimester misoprostol MToP in those with 1 previous CS was 0.5% (10/1910) and 2.2% (18/835) in women with ≥ 2 CS (p < 0.001). Mifepristone priming did not increase the rupture rate in second-trimester MToP (p = 0.77). Previous CS was a modest risk factor for retained products after MToP across both trimesters (OR 1.48, CI 1.29-1.70).

CONCLUSION

Medical and surgical abortion in the first and second trimester appears safe in women with prior CS; however, risks include uterine rupture, need for surgical intervention and haemorrhage from undiagnosed placenta accreta. Further research and guidance are needed on managing abortion after previous classical CS, ≥ 3 previous CS and those with abnormally invasive placenta.

Medication Abortion: A Comprehensive Review

This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.

Risk factors for surgical intervention of early medical abortion

BACKGROUND

By being noninvasive, medical termination of pregnancy has increased worldwide access to abortion and improved safety of unsafe abortion. However, secondary surgical intervention is the most frequent complication to medical abortion.

OBJECTIVE

We aimed to identify and quantify risk factors for surgical intervention in women undergoing medically induced termination of pregnancy before 9 completed weeks of gestation.

STUDY DESIGN

We conducted a nationwide cohort study, including all pregnancies terminated before 63 gestational days in women aged 15-49 years during the period 2005-2015. Induction regimen was 200 mg mifepristone followed 24-48 hours later by 0.8 mg vaginal misoprostol. All included pregnancies were followed up for 8 weeks from mifepristone administration. Data were retrieved from national health registers. Multiple logistic regression provided adjusted odds ratios of surgical intervention with 95% confidence intervals. The discriminative ability of the risk factors in identifying surgical intervention was assessed by cross-validated area under the receiver operating characteristic curve.

RESULTS

Of 86,437 early medical abortions, 5320 (6.2%) underwent a surgical intervention within 8 weeks after induction. The proportion of surgical interventions increased from 3.5% in the 5th to 6th gestational week to 10.3% in week 9, odds ratio, 3.2 (95% confidence interval, 2.9-3.6). Compared with women aged 15-19 years, the risk of surgical intervention increased with increasing maternal age until the age of 30-34 years, odds ratio, 1.7 (95% confidence interval, 1.5-1.9), where after the risk decreased to an odds ratio for age group 40-49 of 1.2 (95% confidence interval, 1.0-1.4). Compared with nulliparous women, a history of only vaginal deliveries with spontaneous delivery of placenta implied an odds ratio of 1.1 (95% confidence interval, 1.0-1.2), women with a history of at least 1 cesarean delivery, an odds ratio of 1.5 (95% confidence interval, 1.3-1.6), and women having experienced a manual removal of placenta after a vaginal birth, an odds ratio of 2.0 (95% confidence interval, 1.7-2.4). Previous medically induced abortion decreased the risk of surgical intervention, odds ratio 0.84 (95% confidence interval, 0.78-0.91), whereas previous early (before 56 days of gestation) surgically induced abortion implied a 53% (95% confidence interval, 1.4-1.7) increased risk of surgical intervention. Previous surgical abortion after 55 days of gestation increased the risk by 17% (95% confidence interval, 1.1-1.3). The area under the receiver operating characteristic curve of the model including all quantified risk factors was 63% (95% confidence interval, 62-64%).

CONCLUSION

Gestational age, maternal age, previous deliveries, and history of medically and surgically induced abortions all had a significant influence on the risk of surgical intervention of early medical abortion. However, inclusion of all quantified risk factors still left most interventions unpredictable.

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

OBJECTIVES

To compare uterine rupture rates in women having a medical abortion receiving gemeprost alone to those receiving mifepristone plus gemeprost.

STUDY DESIGN

We 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.

RESULTS

One 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.

CONCLUSIONS

We rep orted no difference in the incidence of uterine rupture between the gemeprost-alone and gemeprost and mifepristone groups.

IMPLICATIONS

Uterine rupture is a rare complication of second-trimester medical abortion with gemeprost. Use of mifepristone prior to gemeprost does not affect this risk.