Vaginal misoprostol for second-trimester pregnancy termination after one 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.

Uterine rupture following prostaglandins use in second trimester medical abortion: Fact or fiction? A systematic review

BACKGROUND

Prostaglandins (PGs) have emerged as key drugs in second trimester medical abortion (STMA) and are currently a cornerstone in obstetric practice. Nevertheless, the application of PGs, integral to labor and abortion procedures, is not risk-free, and has been associated with several complications, particularly maternal fever and uterine rupture (UR).

OBJECTIVES

The main outcome of the present systematic review was to assess the safety of PGs use in STMA, particularly in scarred uterus (SC).

SEARCH STRATEGY

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a comprehensive systematic review by searching multiple databases, including MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database, and the research registers of Web of Science during the years 1990-2022.

SELECTION CRITERIA

Only articles regarding cases of UR occurred after the use of PGs for STMA were included in the article. We excluded papers regarding UR during first trimester abortion induction of labor or pregnancy or unrelated to PGs use for STMA. Risk of bias was assessed employing a modified version of the "Newcastle-Ottawa Scale" (NOS).

DATA COLLECTION AND ANALYSIS

A total of 178 studies were initially identified as potentially meeting the criteria for inclusion in the review. After full text evaluation, 110 other articles were excluded and 67 studies that suited the inclusion criteria were included. A total of 19 of the included studies were judged to have a high risk of bias. Given the heterogeneous nature of the findings, we opted for a narrative synthesis of the results.

MAIN RESULTS AND CONCLUSIONS

PGs appear to be an effective pharmacologic tool for STMA; however, their use is not entirely risk-free. STMA requires well-equipped obstetric centers with skilled clinicians and surgeons prepared for emergencies. Ultrasonographic scans should be routinely performed during STMA management, since a UR can also be silent during the induction of labor. Intrapartum transabdominal, transperineal, and transvaginal ultrasound may have the diagnostic potential to early recognize this obstetric emergency, to facilitate rapid medical and surgical treatment, improving the outcome.

Comparing the outcomes of termination of second trimester pregnancy with a live fetus using intravaginal misoprostol between women with and without previous cesarean section

OBJECTIVE

To compare the outcomes of termination of pregnancy with live fetuses in the second trimester (14-28 weeks), using misoprostol 400 mcg intravaginal every 6 h, between women with previous cesarean section (PCS) and no previous cesarean section (no PCS).

METHODS

A comparative study was conducted on a prospective database of pregnancy termination in the second trimester, Chiang Mai university hospital. Inclusion criteria included: (1) singleton pregnancy; (2) gestational age between 14 and 28 weeks; and (3) pregnancy with a live fetus and medically indicated for termination. The participants were categorized into two groups; PCS and no PCS group. All were terminated using misoprostol 400 mcg intravaginal every 6 h. The main outcomes were induction to fetal delivery interval and success rate, defined as fetal delivery within 48 h.

RESULTS

A total of 238 women, including 80 PCS and 158 no PCS, were recruited. The success rate of fetal delivery within 48 h between both groups was not significantly different (91.3% vs. 93.0%; p-value 0.622). The induction to fetal delivery interval were not significantly different (1531 vs. 1279 min; p-value > 0.05). Gestational age was an independent factor for the success rate and required dosage of misoprostol. The rates of most adverse effects of misoprostol were similar. One case (1.3%) in the PCS group developed uterine rupture during termination, ending up with safe and successful surgical removal and uterine repair.

CONCLUSION

Intravaginal misoprostol is highly effective for second trimester termination of pregnancy with PCS and those with no PCS, with similar success rate and induction to fetal delivery interval. Gestational age was an independent factor for the success rate and required dosage of misoprostol. Uterine rupture could occur in 1.3% of PCS, implying that high precaution must be taken for early detection and proper management.

SYNOPSIS

Intravaginal misoprostol is highly effective for termination of second trimester pregnancy with a live fetus, with a comparable success rate between women with and without previous cesarean section, with a 1.3% risk of uterine rupture among women with previous cesarean section.

Vaginal misoprostol versus combined intracervical foley's catheter and oxytocin infusion for second trimester pregnancy termination in women with previous caesarean sections: a randomised control trial

Second trimester pregnancy termination has been reported to be associated with 3-5 times higher maternal morbidity and mortality risks more than first trimester termination. Medical methods had been thoroughly assessed and it is considered the anchor of the safe abortion care. Howevere, there is no global agreement regarding the ideal method for induction of the second trimester abortion in a scarred uterus. The aim of this study was to achieve vaginal expulsion in an expeditious manner with less maternal complications. A total of 158 women having, a history of previous caesarean section undergoing second trimester pregnancy termination, were randomly allocated into group (1) vaginal misoprostol group (n = 79) or group (2) combined intracervical foley's catheter plus intravenous oxytocin infusion group (n = 79). The primary endpoint was complete fetal expulsion. Meanwhile, secondary outcomes were the rates of maternal complications, in terms of the need for surgical evacuation of retained product of conception (ERPOC), severe haemorrhage, uterine rupture, blood transfusion, cervical laceration, diarrhoea, vomiting and fever. The registration number of this trial https://clinicaltrials.gov/ct2/show/NCT04501809. This study showed that the combined use of intracervical foley's catheter and oxytocin is an effective, and safe alternative to vaginal misoprostol for termination of the second trimester pregnancy in women having a previous caesarean delivery.Impact statementWhy was this study conducted? The purpose of this study is to achieve an expeditious delivery for second trimester pregnancy termination in a scarred uterus by combined mechanical and pharmacological methods without significant morbidity. Physicians should balance the benefit of achieving vaginal exlpusion in an expeditious manner versus the risk of uterine rupture or any other maternal complications.What does this add to what is known? This study showed that a combined mechanical and pharmacolohical approach for second trimester termination of pregnancy has comparable efficacy and safety to vaginal misoprostol which is more affordable to the low resources countries where termination of pregnancy in a scarred uterus still has an increased maternal morbidity.What is the implication of this study on clinical practice? The combined use of intracervical foley's catheter with intravenous oxytocin infusion is a safer option than vaginal misoprostol with less serious maternal complications.

Misoprostol complications in second-trimester termination of pregnancy among women with a history of more than one cesarean section

Objective

This study aims to investigate the complications due to misoprostol administration for second-trimester termination of pregnancy among women with history of 2 or more cesarean scarring.

Methods

The cohort of this retrospective study included 678 subjects who required second-trimester pregnancy termination, from 2013 to 2015 and treated with vaginal misoprostol of 100 to 400 µg. The subjects were divided into 3 groups based on their history of cesarean sections: without a history of cesarean section, with a history of one cesarean section, and with a history of more than one cesarean section and uterine scaring.

Results

The results showed that the success rate of misoprostol administration for pregnancy termination was 95.72%. The rate of bleeding as a complication was significantly higher in subjects with a history of more than one cesarean section than in other participants (risk ratio [RR], 2.24; 95% confidence interval [CI], 1.11-4.0). The incidence of uterine rupture was higher in the group with a history of more than one cesarean section than in other groups. However, no significant difference was observed between the groups (RR, 1.44; 95% CI, 0.27-7.6). There was a significant relationship between the need for other auxiliary treatments in the pregnancy termination and the history of uterine scarring (RR, 3.3; 95% CI, 1.23-9.1).

Conclusion

The present study showed that pregnancy termination using smaller divided dose of misoprostol in patients with previous history of cesarean scarring may be associated with lower incidence of uterine rupture.

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

OBJECTIVE

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.

INTENDED USERS

Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.

TARGET POPULATION

Women with an unintended or abnormal first or second trimester pregnancy.

EVIDENCE

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.

VALUES

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.

BENEFITS, HARMS, AND/OR COSTS

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.

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.

Misoprostol use for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries

OBJECTIVE

To establish the safety and efficacy of misoprostol for second-trimester termination of pregnancy among women with one or more previous cesarean deliveries.

METHODS

In a retrospective study, data were reviewed from women attending a reproductive health clinic in Bloemfontein, South Africa, for second-trimester termination between 2010 and 2013. The study group, comprising women with one or more previous cesareans, was compared with a control group, comprising women with no previous cesarean or uterine scarring. Procedure-specific information was compared, including misoprostol use, termination duration, need for other methods (e.g. oxytocin), placenta delivery, termination outcome, and bleeding.

RESULTS

The study group comprised 268 women: 231 (86.2%) with one and 37 (13.8%) with two previous cesareans. The control group comprised 266 women. Incomplete abortion was recorded in 223 (85.4%) of 261 women in the study group and 213 (80.4%) of 265 in the control group. The number of women with retained placenta was higher in the study than in the control group (158/261 [60.5%] vs 146/265 [55.1%]; P<0.001). Severe bleeding was observed only in the control group (7/266 [2.6%]). No uterine rupture was observed.

CONCLUSION

Misoprostol was safe for second-trimester termination among women with previous cesareans; however, the efficacy of the local regimen was reduced owing to high placental retention.

Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies

OBJECTIVE

The aim of this systematic review and metaanalysis was to determine the efficacy and safety of cervical ripening agents in the second trimester of pregnancy in patients with previous cesarean delivery.

STUDY DESIGN

Data sources were PubMed, EMBASE, CINAHL, LILACS, Google Scholar, and clinicaltrials.gov (1983 through 2015). Eligibility criteria were cohort or cross-sectional studies that reported on efficacy and safety of cervical ripening agents in patients with previous cesarean delivery. Efficacy was determined based on the proportion of patients achieving vaginal delivery and vaginal delivery within 24 hours following administration of a cervical ripening agent. Safety was assessed by the risk of uterine rupture and complications such as retained placental products, blood transfusion requirement, and endometritis, when available, as secondary outcomes. Of the 176 studies identified, 38 met the inclusion criteria. Of these, 17 studies were descriptive and 21 studies compared the efficacy and safety of cervical ripening agents between patients with previous cesarean and those with no previous cesarean. From included studies, we abstracted data on cervical ripening agents and estimated the pooled risk differences and risk ratios with 95% confidence intervals. To account for between-study heterogeneity, we estimated risk ratios based on underlying random effects analyses. Publication bias was assessed via funnel plots and across-study heterogeneity was assessed based on the I(2) measure.

RESULTS

The most commonly used agent was PGE1. In descriptive studies, PGE1 was associated with a vaginal delivery rate of 96.8%, of which 76.3% occurred within 24 hours, uterine rupture in 0.8%, retained placenta in 10.8%, and endometritis in 3.9% in patients with ≥1 cesarean. In comparative studies, the use of PGE1, PGE2, and mechanical methods (laminaria and dilation and curettage) were equally efficacious in achieving vaginal delivery between patients with and without prior cesarean (risk ratio, 0.99, and 95% confidence interval, 0.98-1.00; risk ratio, 1.00, and 95% confidence interval, 0.98-1.02; and risk ratio, 1.00, and 95% confidence interval, 0.98-1.01; respectively). In patients with history of ≥1 cesarean the use of PGE1 was associated with higher risk of uterine rupture (risk ratio, 6.57; 95% confidence interval, 2.21-19.52) and retained placenta (risk ratio, 1.21; 95% confidence interval, 1.03-1.43) compared to women without a prior cesarean. However, the risk of uterine rupture among women with history of only 1 cesarean (0.47%) was not statistically significant (risk ratio, 2.36; 95% confidence interval, 0.39-14.32), whereas among those with history of ≥2 cesareans (2.5%) was increased as compared to those with no previous cesarean (0.08%) (risk ratio, 17.55; 95% confidence interval, 3.00-102.8). Funnel plots did not demonstrate any clear evidence of publication bias. Across-study heterogeneity ranged from 0-81%.

CONCLUSION

This systematic review and metaanalysis provides evidence that PGE1, PGE2, and mechanical methods are efficacious for achieving vaginal delivery in women with previous cesarean delivery. The use of prostaglandin PGE1 in the second trimester was not associated with significantly increased risk for uterine rupture among women with only 1 cesarean; however, this risk was substantially increased among women with ≥2 cesareans although the absolute risk appeared to be relatively small.

Comparison of two misoprostol regimens for mid-trimester pregnancy terminations after FIGO's misoprostol dosage recommendation in 2012

OBJECTIVE

To compare the safety and efficacy of two misoprostol regimens for mid-trimester pregnancy terminations.

METHODS

Retrospective analysis of 263 cases of pregnancy terminations with misoprostol between 12 and 24 weeks was performed. Group 1 (total 129 patients) consisted of patients who were given 200 mcg vaginal misoprostol every 4 h until the abortion, whereas Group 2 patients (total 134 patients) were given misoprostol as in International Federation of Gynecology and Obstetrics's (FIGO) 2012 recommendation. In case of a previous cesarean section doses were halved in both groups. Primary outcomes of the study were the time to abortion and the total drug dose used. Secondary outcome was the rate of complications.

RESULTS

Total dose and time to abortion did not differ between the groups. As for complications, one patient (%0.8) in group 1 developed HELLP syndrome and had hysterotomy. One patient (%0.8) in group 2 had uterine rupture and had total hysterectomy. Two patients in both groups considered failure of induction and terminated with surgery (hysterotomy). Groups did not show difference in induction failure rates.

CONCLUSIONS

We respect the presence of dose recommendation stated by the FIGO and found similar results with our recent protocol. Other misoprostol regimens used worldwide should also be compared with this guideline in order to improve its efficacy.

[Use of misoprostol for induction of labor in case of fetal death or termination of pregnancy during second or third trimester of pregnancy: Efficiency, dosage, route of administration, side effects, use in case of uterine scar]

OBJECTIVE

Study, based on the literature, of the use of misoprostol for induction of labor in cases of second or third trimester fetal death or termination of pregnancy and define the different mode of administration.

MATERIALS AND METHODS

Bibliographic review using the Medline and Pubmed databases and the guidelines of the international professional societies. Selection of papers in French and English. Keywords used: misoprostol, termination of pregnancy, mid and third trimester, scarred uterus, previous cesarean section, uterine rupture.

RESULTS

Misoprostol is effective for induction of labor in case of second or third fetal death or termination of pregnancy. Comparing to oral route, vaginal route reduces the induction-expulsion time and the rate of patients remaining undelivered in the first 24 hours without increasing side effects. Oral route is a possible alternative if preferred by the patient. Sublingual route seems interesting but data are limited. The use of moderate doses (800-2400 μg/day) every 3 to 6 hours seems to be the best compromise between efficiency and tolerance. It is not possible to recommend a specific dosing schedule. The risk of uterine rupture in case of previous cesarean section justifies the use of minimum effective dose for these patients. In this case, it is recommended not to exceed a dose of 100 μg for each dose. The induction-birth period and doses of misoprostol required to induce labor are reduced when combined with mifepristone administered 36 to 48 hours before.

CONCLUSION

Misoprostol is effective and safe for induction of labor in case of second or third trimester fetal death or termination of pregnancy.

Misoprostol versus High Dose Oxytocin and Laminaria in Termination of Pregnancy in Second Trimester Pregnancies

BACKGROUND

In 2 recent decades, found drug regimen to induce abortion that are more effective than surgery. Prostaglandins especially misoprostol, oxytocin and osmotic dilators such as laminaria use for termination but the best method is unknown. Therefore we aimed to assess the comparison between the Misoprostol regimen and the highly concentrated oxytocin with laminaria regimen in second trimester of pregnancy termination.

METHODS

In this randomized clinical trial, 100 women with gestational age 14 to 24 week coming to hospital due to termination of pregnancy in the absence of uterine contractions and items of exclusion criteria enrolled to study and randomly assign to 2 groups and received misoprostol (group 1) or oxytocin (group 2). Data collected with use of observation, examination and demographic checklist. In group 1, in admission time and then every 6 hour patients received 200 µgr misoprostol until start the pain or vaginal bleeding or abortion in 48 hr. in group 2, patients first received laminaria in cervix with duration of 6 hr and then oxytocin 50 unit in 500 cc normal saline in 3 hr. after 1 hr rest, oxytocin dosage elevated as multiple into 2 and continue until termination or maximum dose of 300 u in 500 cc normal saline. Data entered to SPSS software version 16 and analyzed with use of descriptive methods and also Chi-square and T-test.

RESULTS

In each group enrolled 50 women that approximately no different in baseline characteristic. Number of abortion in misoprostol group was more than oxytocin group (P<0.001) and duration of abortion also was shorter than oxytocin in misoprostol group (P<0.001). Side effects in 23 (46%) women in misoprostol group were seen but no side effect seen in oxytocin group. Complementally interventions was seen in 31 women (60%) in misoprostol group versus 32 women (62%) in oxytocin group but this difference was not significant (P>0.05).

CONCLUSION

This study demonstrated that misoprostol is effective than oxytocin in termination of pregnancy but with attention to limitation of this study include of limited abortion causes due to legal laws, additional studies on different doses of misoprostol and oxytocin due to achieve to suitable regimen with lower side effects recommended.