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Pirhonen J, Erkkola R. Delivery after fetal death in women with earlier cesarean section. A review. Eur J Obstet Gynecol Reprod Biol 2021; 260:150-153. [PMID: 33773261 DOI: 10.1016/j.ejogrb.2021.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/18/2022]
Abstract
The clinical management of intrauterine fetal demise (IUFD) in women with a previous cesarean delivery presents a dilemma for the obstetrician. With the current reluctance of obstetricians to perform vaginal birth after cesarean (VBAC) and the paucity of data to counsel women regarding maternal risks, management options are limited by physician's clinical experience and biases. In the setting of fetal demise, maternal safety becomes the primary concern. Medicolegal pressures may prevent physicians from attempting a trial of labor in this situation. In this review we will a focus on frequency of birth with IUFD after cesarean section (CS), we discuss the options (VBAC vs CS), different complications, methods for induction of vaginal birth as well as risk factors of vaginal birth and cesarean delivery.
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Affiliation(s)
- Jouko Pirhonen
- The Norwegian Continence and Pelvic Floor Center, University Hospital of North Norway, Tromsø, Norway.
| | - Risto Erkkola
- Department of Obstetrics and Gynecology, Turku University Central Hospital, Turku, Finland
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Beshar I, Thomson K, Byrne J. Misoprostol-augmented induction of labour for third trimester fetal demise in a patient with prior hysterotomies. BMJ Case Rep 2021; 14:14/1/e239872. [PMID: 33514616 PMCID: PMC7849869 DOI: 10.1136/bcr-2020-239872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A 31-year-old G3P2002 with history of two prior caesarean sections presented with influenza-like illness, requiring intubation secondary to acute respiratory distress syndrome. Investigations revealed intrauterine fetal demise at 30-week gestation.She soon deteriorated with sepsis and multiple organs impacted. Risks of the gravid uterus impairing cardiopulmonary function appeared greater than risks of delivery, including that of uterine rupture. Vaginal birth after caesarean was achieved with misoprostol and critical care status rapidly improved.Current guidelines for management of fetal demise in patients with prior hysterotomies are mixed: although the American College of Obstetricians and Gynecologists recommends standard obstetric protocols rather than misoprostol administration for labour augmentation, there is limited published data citing severe maternal morbidity associated with misoprostol use. This case report argues misoprostol-augmented induction of labour can be a reasonable option in a medically complex patient with fetal demise and prior hysterotomies.
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Affiliation(s)
- Isabel Beshar
- Stanford University School of Medicine, Stanford, California, USA
| | - Karolina Thomson
- Obstetrics & Gynecology, Santa Clara Valley Medical Center, San Jose, California, USA
| | - James Byrne
- Maternal Fetal Medicine, Obstetrics and Gynecology, Santa Clara Valley Medical Center, San Jose, California, USA,Maternal Fetal Medicine, Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California, USA
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Safety of medical second trimester abortions for women with prior cesarean sections. Arch Gynecol Obstet 2021; 303:1217-1222. [PMID: 33386956 DOI: 10.1007/s00404-020-05904-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Medical second-trimester abortion in women with prior cesarean section (CS) is becoming an increasingly common phenomenon. However, data about the safety of the procedure are limited. This study addresses this issue. METHODS Retrospective cohort single-center study, done in Hadassah Medical Center in Jerusalem, a tertiary-care university hospital. This study included 779 women who needed pregnancy termination between 13 and 26 gestational weeks. 128 women had at least one previous CS (study group), whereas 651 had no CS (reference group). Protocols used were: (1) misoprostol tablets, 800 mcg vaginally followed by 400 mcg orally every 3 h up to four oral doses, (2) Oxytocin drip. Nearly one-fourth of the women received mifepristone as a preliminary treatment for cervical ripening. The outcomes assessed included the following complications: retained placenta, bleeding with or without requiring blood transfusion, infection, cervical lacerations, uterine adhesions and uterine ruptures. RESULTS Previous CS does not appear to increase the incidence of complications, excluding clinical bleeding without requiring blood transfusions (p value 0.05), which has a minimal clinical significance. Oxytocin protocol had 3.44 OR for complications, compared to misoprostol (p value 0.03, CI; 1.12- 10.52). No significant correlation was found between Misoprostol dosage and complications (Mann-Whitney U test, p value 0.057). CONCLUSION Medical second-trimester abortions for women with prior CS should be considered a safe and effective procedure, with a low complication rate. The most serious complication is uterine rupture, which is uncommon; we recorded one case only. Misoprostol protocol should be preferred. CLINICAL TRIAL NUMBER AND DATE IRB 0177-17-HMO, 5/2014.
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Costescu D, Guilbert É. No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:750-783. [PMID: 29861084 DOI: 10.1016/j.jogc.2017.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
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.
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No 360 - Avortement provoqué : avortement chirurgical et méthodes médicales au deuxième trimestre. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:784-821. [DOI: 10.1016/j.jogc.2018.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Andrikopoulou M, Lavery JA, Ananth CV, Vintzileos AM. Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies. Am J Obstet Gynecol 2016; 215:177-94. [PMID: 27018469 DOI: 10.1016/j.ajog.2016.03.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/16/2016] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Maria Andrikopoulou
- Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY.
| | - Jessica A Lavery
- Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Cande V Ananth
- Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY
| | - Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY
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Peng P, Liu XY, Li L, Jin L, Chen WL. Clinical analyses of 66 cases of mid-trimester pregnancy termination in women with prior cesarean. Chin Med J (Engl) 2015; 128:450-4. [PMID: 25673444 PMCID: PMC4836245 DOI: 10.4103/0366-6999.151073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: The rate of cesarean delivery has significantly increased in China in the last decade. Women with prior cesarean history tend to have a higher risk of uterine rupture during termination of the pregnancy in mid-trimester than those without such a history. The aim of our study was to evaluate the influences of the potential risk factors on uterine rupture in women with prior cesarean. Methods: We conducted this retrospective study of women with prior cesarean section, who underwent mid-trimester pregnancy termination between January 2006 and December 2013 in Peking Union Medical College Hospital. The protocol was oral administration of mifepristone and misoprostol for the patients with the gestational ages below 16 weeks or intra-amniotic injection of ethacridine lactate (EL) for those with at least 16 weeks of gestational ages. The thickness of the lower uterine segment (LUS) was measured before the termination of pregnancy. Logistic regression was used to study the risk factors of uterine rupture. Results: The total rate of successful abortion was 93.9% (62/66). Four patients failed in induction, and one of them received curettage, whereas the other three experienced uterine rupture (4.5%). The successful rates of abortion were 85.7% (30/35) for women treated with mifepristone-misoprostol and 86.1% (31/36) for those treated with EL. There was a significant difference in the mean LUS thickness between the uterine rupture group (3.0 ± 2.0 mm) and the nonrupture group (7.0 ± 3.0 mm) (P < 0.05). The LUS thickness of <3 mm was associated with uterine rupture during mid-trimester pregnancy termination in women with prior cesarean (odds ratio, 94.0; 95% confidence interval 4.2–2106.1) after adjusted maternal age, gestational age, interdelivery interval and prior cesarean section. Severe bleeding that required transfusion occurred in one case (1.5%). Conclusions: Both the mifepristone-misoprostol and the EL regimens were effective and safe for the termination of mid-trimester pregnancy in women with prior cesarean. A thinner LUS is associated with a relatively high risk of uterine rupture.
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Affiliation(s)
| | - Xin-Yan Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
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Kanao S, Fukuda A, Fukuda H, Miyamoto M, Marumoto E, Furuya K, Nishiyama R, Ohyagi C, Ogawa H. Spontaneous uterine rupture at 15 weeks' gestation in a patient with a history of cesarean delivery after removal of shirodkar cerclage. AJP Rep 2014; 4:1-4. [PMID: 25032050 PMCID: PMC4078139 DOI: 10.1055/s-0033-1358767] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/16/2013] [Indexed: 12/31/2022] Open
Abstract
A pregnant woman presented with acute upper abdominal pain and nausea at 15 weeks' gestation. She had a history of cesarean delivery for abruption after the removal of a Shirodkar cerclage that was placed because of cervical shortening caused by conization. She became pregnant again 14 months later. Ultrasonography revealed no significant findings, and a single intrauterine pregnancy with positive fetal heart activity was confirmed. An intestinal obstruction was suspected because abdominal radiography showed multiple air-fluid levels in the colon. Over the 3 hours following admission, her symptoms gradually worsened, and plain abdominal computed tomography (CT) showed a large hemorrhage in the abdominal cavity, but the uterine wall appeared intact at this time. Subsequently, dynamic CT revealed discontinuity of the uterine muscle layer. During laparotomy, uterine rupture with complete opening of the uterine wall at the site of the previous transverse scar was identified. A dead fetus was located within the amniotic sac in a blood-filled abdominal cavity. She received a total of 10 units of packed red blood cells and 6 units of fresh frozen plasma for the resuscitation. She was discharged on the eighth postoperative day without any complications.
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Affiliation(s)
- Serika Kanao
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Aya Fukuda
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Hirotsugu Fukuda
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Mayuko Miyamoto
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Eriko Marumoto
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Kiichiro Furuya
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Rie Nishiyama
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Chifumi Ohyagi
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
| | - Haruki Ogawa
- Department of Obstetrics and Gynecology, Osaka Kouseinenkin Hospital, Osaka, Japan
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Clouqueur E, Coulon C, Vaast P, Chauvet A, Deruelle P, Subtil D, Houfflin-Debarge V. [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]. ACTA ACUST UNITED AC 2014; 43:146-61. [PMID: 24461423 DOI: 10.1016/j.jgyn.2013.11.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- E Clouqueur
- Clinique d'obstétrique, pôle « femme-mère-nouveau-né », hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France.
| | - C Coulon
- Clinique d'obstétrique, pôle « femme-mère-nouveau-né », hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France
| | - P Vaast
- Clinique d'obstétrique, pôle « femme-mère-nouveau-né », hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France
| | - A Chauvet
- Clinique d'obstétrique, pôle « femme-mère-nouveau-né », hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France
| | - P Deruelle
- Clinique d'obstétrique, pôle « femme-mère-nouveau-né », hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France; Faculté de médecine, université Lille - Nord-de-France, 59045 Lille cedex, France
| | - D Subtil
- Clinique d'obstétrique, pôle « femme-mère-nouveau-né », hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France; Faculté de médecine, université Lille - Nord-de-France, 59045 Lille cedex, France
| | - V Houfflin-Debarge
- Clinique d'obstétrique, pôle « femme-mère-nouveau-né », hôpital Jeanne-de-Flandre, CHRU de Lille, 2, avenue Oscar-Lambret, 59037 Lille cedex, France; Faculté de médecine, université Lille - Nord-de-France, 59045 Lille cedex, France
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Seto MTY, Ngu SF, Cheung VYT, Pun TC. Second trimester medical abortion in a woman with prior classical caesarean section and a uterine leiomyoma--a case report. EUR J CONTRACEP REPR 2013; 18:410-4. [PMID: 23692523 DOI: 10.3109/13625187.2013.797072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Medical abortion in women with the scar of a classical caesarean section (CS) and a large uterine leiomyoma is rarely attempted; it carries the risk of uterine rupture and haemorrhage. CASE A 34-year-old multiparous woman with prior classical CS and a 14 × 10 × 9 cm leiomyoma arising from the uterine isthmus had an induced abortion at 14 weeks' gestation. Mechanical cervical priming with Dilapan(®)-S followed by vaginal misoprostol administration resulted in the uncomplicated expulsion of the uterine contents. CONCLUSIONS An early second trimester medical abortion with misoprostol was successfully performed in a woman with prior classical CS and a large uterine leiomyoma.
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Affiliation(s)
- Mimi T Y Seto
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong , Hong Kong
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Complete cervical avulsion with intravaginal misoprostol for second trimester pregnancy termination. Case Rep Obstet Gynecol 2012; 2012:931497. [PMID: 22919526 PMCID: PMC3419395 DOI: 10.1155/2012/931497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/28/2012] [Indexed: 11/18/2022] Open
Abstract
Intravaginal misoprostol, a synthetic PGE1 analogue, has largely replaced all other techniques for pregnancy termination in II trimester, because of its successful results. Incidence of II trimester pregnancy termination has also increased in the present days, because of prenatal diagnosis of pregnancies with serious fetal abnormalities like cardiovascular and skeletal malformations. But there are serious and life threatening complications reported with the use of intravaginal misoprostol. Here we are reporting a case of complete avulsion of cervix from lower part of the uterus, with the use of intravaginal misoprostol, for II trimester termination of pregnancy. So, clinicians dealing with II trimester termination of pregnancy should be aware of such complications.
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Domröse CM, Geipel A, Berg C, Lorenzen H, Gembruch U, Willruth A. 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. Contraception 2012; 85:589-94. [PMID: 22079607 DOI: 10.1016/j.contraception.2011.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 10/03/2011] [Accepted: 10/05/2011] [Indexed: 10/15/2022]
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Choudhary N, Bagga R, Raveendran A, Saha SC, Dhaliwal LK. Second trimester abortion in women with and without previous uterine scar: Eleven years experience from a developing country. EUR J CONTRACEP REPR 2011; 16:378-86. [DOI: 10.3109/13625187.2011.599453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cayrac M, Faillie JL, Flandrin A, Boulot P. Second- and third-trimester management of medical termination of pregnancy and fetal death in utero after prior caesarean section. Eur J Obstet Gynecol Reprod Biol 2011; 157:145-9. [PMID: 21511389 DOI: 10.1016/j.ejogrb.2011.03.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Revised: 01/31/2011] [Accepted: 03/10/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Mélanie Cayrac
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, University Hospital, Montpellier, France.
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Midtrimester abortion using vaginal misoprostol for women with three or more prior cesarean deliveries. Int J Gynaecol Obstet 2010; 110:50-2. [DOI: 10.1016/j.ijgo.2010.02.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 02/16/2010] [Accepted: 03/08/2010] [Indexed: 11/20/2022]
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Obata-Yasuoka M, Hamada H, Watanabe H, Shimura R, Toyoda M, Yagi H, Takeshima K, Abe K, Nakamura Y, Ogura T, Fujiki Y, Yoshikawa H. Midtrimester termination of pregnancy using gemeprost in combination with laminaria in women who have previously undergone cesarean section. J Obstet Gynaecol Res 2009; 35:901-5. [PMID: 20149039 DOI: 10.1111/j.1447-0756.2009.01044.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM We aimed to assess the efficacy and safety of midtrimester termination of pregnancy using gemeprost in combination with laminaria in women who had previously undergone cesarean section and in women who had not. METHODS Between January 1999 and December 2006, we carried out a retrospective study of termination of pregnancy at 12-21 weeks of gestation at the University of Tsukuba Hospital. Termination of pregnancy was carried out by three-step uterine cervical dilation using laminaria followed by vaginal administration of 1 mg gemeprost every 3 h for up to four doses over 24 h. RESULTS A total of 173 women underwent midtrimester termination of pregnancy. The women were categorized into two groups: those who had previously undergone cesarean section (n = 26) (previous cesarean section group) and those who had not (n = 147) (control group). Seven women had undergone cesarean section at least twice. The gemeprost dose administered was 2.8 +/- 1.4 mg for the previous cesarean section group and 2.4 +/- 1.6 mg for the control group (difference in doses not significant). Although abnormal vaginal bleeding (>500 mL) was more likely to occur in the previous cesarean section group than in the control group (odds ratio, 2.61; 95% confidence interval, 0.63-10.82), none of the woman required blood transfusion. Uterine rupture and failed abortion were not observed. CONCLUSION The efficacy and safety of our laminaria-gemeprost protocol for termination of pregnancy during the midtrimester are similar for women who have previously undergone cesarean section and those who have not.
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Affiliation(s)
- Mana Obata-Yasuoka
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan.
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Vaginal misoprostol for second-trimester pregnancy termination after one previous cesarean delivery. Int J Gynaecol Obstet 2009; 108:48-51. [DOI: 10.1016/j.ijgo.2009.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Revised: 07/30/2009] [Accepted: 08/25/2009] [Indexed: 11/18/2022]
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Ben-Ami I, Schneider D, Svirsky R, Smorgick N, Pansky M, Halperin R. Safety of late second-trimester pregnancy termination by laminaria dilatation and evacuation in patients with previous multiple cesarean sections. Am J Obstet Gynecol 2009; 201:154.e1-5. [PMID: 19539892 DOI: 10.1016/j.ajog.2009.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 03/07/2009] [Accepted: 04/16/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether there is an increased perioperative risk in termination of late second-trimester pregnancy after multiple cesarean sections by laminaria dilatation and evacuation. STUDY DESIGN During the period between January 2002 and June 2008, 636 consecutive patients underwent late second-trimester (17-24 weeks) pregnancy terminations by dilatation and evacuation. Patients were divided into 3 subgroups: those with no previous cesarean section (n = 545), those with 1 previous cesarean section (n = 59), and those with several previous cesarean sections (n = 32). RESULTS There were no significant differences in major perioperative complications, such as anesthetic complications, need for blood transfusion, and cervical lacerations comparing the 3 subgroups. Importantly, there were neither cases of uterine perforation nor retained products of conception in the 3 subgroups. CONCLUSION Late second-trimester pregnancy termination after multiple cesarean sections by laminaria dilatation and evacuation is probably not associated with an increased perioperative risk. Larger studies are needed to empower this study.
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Affiliation(s)
- Ido Ben-Ami
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel
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van der Ploeg JM, Schutte JM, Pelinck MJ, Huisjes AJM, van Roosmalen J, de Vries JIP. Management of fetal death after 20 weeks of gestation complicated by placenta previa. J Matern Fetal Neonatal Med 2009; 20:267-9. [PMID: 17437231 DOI: 10.1080/14767050601134868] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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El-Matary A, Navaratnarajah R, Economides DL. Ultrasound diagnosis of uterine dehiscence following mifepristone/misoprostol regime in early second trimester termination. J OBSTET GYNAECOL 2009; 26:578-80. [PMID: 17000517 DOI: 10.1080/01443610600830912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- A El-Matary
- Fetal Medicine Department, Royal Free Hospital, Hamstead, London, UK.
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Berghella V, Airoldi J, O’Neill AM, Einhorn K, Hoffman M. Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review. BJOG 2009; 116:1151-7. [DOI: 10.1111/j.1471-0528.2009.02190.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Singhal SR, Gupta A, Nanda S. Spontaneous asymptomatic uterine scar dehiscence at 20 weeks of gestation as a result of endomyometritis. Arch Gynecol Obstet 2009; 280:689-90. [PMID: 19221777 DOI: 10.1007/s00404-009-0960-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 01/20/2009] [Indexed: 10/21/2022]
Abstract
Spontaneous uterine rupture during second trimester is a rarity in obstetrics. Rupture of the pregnant uterus is considered spontaneous if the rupture occurs without contractile activity of the myometrium. An unusual case of asymptomatic spontaneous uterine scar dehiscence in second trimester with previous three lower uterine segment caesarean sections following endomyometritis is presented here.
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Bhattacharya R, Raut J, Stanley K. Spontaneous mid-trimester uterine rupture in a twin pregnancy. J OBSTET GYNAECOL 2008; 28:642-3. [PMID: 19003665 DOI: 10.1080/01443610802378124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bhattacharjee N, Ganguly RP, Saha SP. Misoprostol for termination of mid-trimester post-Caesarean pregnancy. Aust N Z J Obstet Gynaecol 2007; 47:23-5. [PMID: 17261095 DOI: 10.1111/j.1479-828x.2006.00673.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of PGE1 analogue, misoprostol, for inducing abortion or labour during mid-trimester in women who have had a prior Caesarean section (one or more). STUDY DESIGN Women who had to undergo termination of pregnancy between 13 and 26 weeks of gestation for various indications and who had at least one previous Caesarean section were studied over a period of two and a half years. The standard regimen for misoprostol in all the cases was 400 microg up to 20 weeks of gestation and 200 microg for pregnancies longer than 20 weeks, either vaginally or sublingually every six hours (up to maximum 24 h). A contemporaneous cohort of women undergoing the same procedure for similar indications but without scarred uteri served as control. RESULTS Eighty women in the study group underwent termination procedures for unwanted pregnancy, missed abortion, fetal anomaly or fetal death. The median induction-abortion interval was 16.4 h (10-21 h) and did not differ much from that in women without previous Caesarean delivery (median: 15.6 h; range 9.6-20 h), P > 0.05. Misoprostol was found to be safe in our cohort of post-Caesarean women and there was no case of scar rupture or dehiscence. No significant differences in rates of incomplete abortions, blood loss or sepsis were detected in the study group compared to the control group. CONCLUSION The use of misoprostol for mid-trimester pregnancy termination is not contraindicated in women with Caesarean scar and is effective and comparable with those in women without scarred uteri.
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Scioscia M, Vimercati A, Pontrelli G, Nappi L, Selvaggi L. Patients’ obstetric history in mid-trimester termination of pregnancy with gemeprost: Does it really matter? Eur J Obstet Gynecol Reprod Biol 2007; 130:42-5. [PMID: 16309822 DOI: 10.1016/j.ejogrb.2005.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2004] [Revised: 05/17/2005] [Accepted: 08/08/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective was to investigate the importance of previous obstetric history for termination of pregnancy in the second-trimester with gemeprost alone. STUDY DESIGN A consecutive series of 423 mid-trimester inductions of abortion at our teaching hospital was reviewed. Termination of pregnancy was carried out with 1mg of vaginal gemeprost every 3h up to three doses over a 24-h period, repeated the following day if necessary. Failed induction was defined as women undelivered by 96 h. The study population was then stratified by gestational age, parity, gravidity and previous uterine scars. Main outcome parameters were failed induction and complication rates. Statistical analysis was performed using the chi(2) test or Fisher's exact test for categorical data, and the t-test and linear regression for continuous variables. RESULTS No significant differences were found in the primary outcome parameters with regard to the obstetric parameters considered. The failed induction rate was 1.2% with an overall incidence of complications of 7.4%. Parity was the main factor that affected clinical response (time to abortion interval and number of pessaries). CONCLUSION Patients' obstetric history does affect the clinical response to gemeprost, but its safety and effectiveness are preserved. These data provide clinicians with important information for correct counselling.
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Affiliation(s)
- Marco Scioscia
- Department of Obstetrics and Gynaecology, University of Bari, Policlinico di Bari, Piazza Giulio Cesare 11, 70125 Bari, Italy.
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Reichman O, Cohen M, Beller U. Prostaglandin E2 mid-trimester evacuation of the uterus for women with a previous cesarean section. Int J Gynaecol Obstet 2006; 96:32-3. [PMID: 17189634 DOI: 10.1016/j.ijgo.2006.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2006] [Revised: 09/18/2006] [Accepted: 09/19/2006] [Indexed: 11/21/2022]
Affiliation(s)
- O Reichman
- Department of Obstetric and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
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Lalitkumar S, Bygdeman M, Gemzell-Danielsson K. Mid-trimester induced abortion: a review. Hum Reprod Update 2006; 13:37-52. [PMID: 17050523 DOI: 10.1093/humupd/dml049] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mid-trimester abortion constitutes 10-15% of all induced abortion. The aim of this article is to provide a review of the current literature of mid-trimester methods of abortion with respect to efficacy, side effects and acceptability. There have been continuing efforts to improve the abortion technology in terms of effectiveness, technical ease of performance, acceptability and reduction of side effects and complications. During the last decade, medical methods for mid-trimester induced abortion have shown a considerable development and have become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of pregnancy (TOP). Advantages and disadvantages of medical versus surgical methods are discussed. Randomized studies are lacking, and more studies on pain treatment and the safety of any method used in patients with a previous uterine scar are debated, and data are scarce. Pain management in abortion requires special attention. This review highlights the need for randomized studies to set guidelines for mid-trimester abortion methods in terms of safety and acceptability as well as for better analgesic regimens.
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Affiliation(s)
- S Lalitkumar
- Department of Woman and Child Health, Division for Obstetrics and Gynaecology, Karolinska University Hospital/Karolinska Institute, Stockholm, Sweden
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Mazouni C, Provensal M, Porcu G, Guidicelli B, Heckenroth H, Gamerre M, Bretelle F. Termination of pregnancy in patients with previous cesarean section. Contraception 2005; 73:244-8. [PMID: 16472563 DOI: 10.1016/j.contraception.2005.09.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Revised: 09/12/2005] [Accepted: 09/13/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of termination of pregnancy using mifepristone and misosprostol at more than 15 weeks' gestation in patients with uterine scar due to previous cesarean section. MATERIALS AND METHODS This retrospective study was conducted in a tertiary maternity ward between January 2000 and October 2004. A total of 252 women at more than 15 weeks' gestation underwent termination of pregnancy including 50 women with uterine scar due to previous cesarean section (Group 1) and 202 control patients (Group 2) without known uterine scar. Abortion was induced with mifepristone and a prostaglandin analogue. Women between 15 and 34 weeks' gestation received misoprostol intravaginally every 3 h at doses of 200 microg (Group 1) or 400 microg (Group 2). Women at more than 34 weeks' gestation received Prostin E2 vaginal gel. Main end points were hemorrhage, fever, retained placenta, occurrence of complications including uterine rupture and dehiscence, and final outcome. RESULTS A total of 13 (26%) patients in Group 1 and 79 (39.1%) in Group 2 were at more than 24 weeks' gestation. The abortion failure rate was 2% (1/50) in Group 1 and 0.5% (1/202) in Group 2 (p = .28). The median induction-to-delivery interval was 8.5 h (range, 3.0-114.2 h) for Group 1 and 9.0 h (range, 1.3-124.3 h) in Group 2 (p = .26). One case of uterine rupture and one case of dehiscence were observed, both in women in Group 1. The incidence of hemorrhage was not significantly different between Group 1 and Group 2 (2% vs. 0.9%, respectively, p = .56). The incidence of retained placenta was higher in the Group 1 (70% vs. 52.5%, respectively, p = .025). CONCLUSION In this retrospective series of women who underwent abortion at 15-35 weeks' gestation using mifepristone and a prostaglandin analogue for labor induction abortion, history of cesarean section was not associated with higher morbidity except risk of uterine rupture. However, dose and interval of misoprostol should be determined. A larger study is needed before drawing definitive conclusions about the safety of these regimens.
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Affiliation(s)
- Chafika Mazouni
- Department of Obstetrics and Gynecology, Conception Hospital, 13385 Marseille, France.
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Daskalakis G, Papantoniou N, Mesogitis S, Papageorgiou J, Antsaklis A. Sonographic findings and surgical management of a uterine rupture associated with the use of misoprostol during second-trimester abortion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:1565-8. [PMID: 16239663 DOI: 10.7863/jum.2005.24.11.1565] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- George Daskalakis
- First Department of Obstetrics and Gynecology, Fetal Medicine Unit, Alexandra Hospital, University of Athens, Athens, Greece.
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Scioscia M, Pontrelli G, Vimercati A, Santamato S, Selvaggi L. A short-scheme protocol of gemeprost for midtrimester termination of pregnancy with uterine scar. Contraception 2005; 71:193-6. [PMID: 15722069 DOI: 10.1016/j.contraception.2004.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 10/25/2004] [Accepted: 10/27/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study is to investigate the safety and effectiveness of a short-scheme protocol of gemeprost for second trimester induction of abortion in women with previous uterine surgery. STUDY DESIGN Retrospective review of women who underwent second trimester medical termination of pregnancy (TOP) at our hospital in a 5-year period. A short regimen of gemeprost was used: over a 24-h period, 1 mg vaginal gemeprost was given every 3 h up to three doses after which, if abortion did not occur, another course at the same dosage schedule was administered up to 4 days. Induction failure was defined as women undelivered by 96 h. A homogeneous population was identified. Statistical analysis was performed with the chi(2) test or Fisher's Exact Test for categorical data and t test for continuous variables. RESULTS Four hundred seventeen women underwent medical midtrimester TOP in the 5-year study period. Two hundred five patients were selected for this review, comparing 63 patients with scarred uterus to 142 women without uterine scars. There were no differences between the two groups in induction-to-abortion interval and number of pessaries given. The overall failure of induction rate was 1.5% and need for blood transfusion was 0.5%. No uterine rupture was reported. CONCLUSION The regimen of gemeprost proposed seems to be as safe and effective in patients with uterine scars as in women with unscarred uteri with a very low incidence of complications.
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Affiliation(s)
- Marco Scioscia
- Department of Obstetrics and Gynaecology, University of Bari, 70125 Bari, Italy.
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Dickinson JE. Misoprostol for Second-Trimester Pregnancy Termination in Women With a Prior Cesarean Delivery. Obstet Gynecol 2005; 105:352-6. [PMID: 15684164 DOI: 10.1097/01.aog.0000151996.16422.88] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the use of misoprostol in second-trimester abortion in women with prior cesarean deliveries. METHODS A review of women with prior cesarean deliveries undergoing abortion at 14-28 weeks of gestation for a fetal anomaly over a 7.5-year period. Outcome data were compared with a contemporaneous cohort of women with unscarred uteri undergoing the same procedure. Misoprostol was used to induce abortion in all cases, and a variety of dosage regimens were used, the most frequent being 400 mug vaginally every 6 hours (71.3%). RESULTS During the study period, 720 consecutive women underwent a second-trimester abortion for a fetal anomaly using misoprostol. One hundred one women (14%) had at least 1 prior cesarean delivery: 78 women had 1, 19 women had 2, and 4 women had 3 prior cesarean deliveries. Women with a prior cesarean birth were significantly older (30 years [interquartile range 26-35] versus 33 years [29-37], no cesarean delivery versus cesarean delivery, P = < .001) and of increased parity. The median gestational age at delivery was 19.4 weeks (interquartile range 18-20.7) versus 19.3 weeks (17.7-21), no cesarean delivery versus cesarean delivery, P = .48. The presence of a prior uterine scar did not impact upon abortion duration (16.6 hours [12.1-23.8] versus 14.5 hours [11.4-21.4], no cesarean delivery versus cesarean delivery, P = .07). No differences in blood loss, major hemorrhage, or blood transfusion occurred. There was no case of uterine rupture or hysterectomy. CONCLUSION In second-trimester abortion, the use of misoprostol in women with prior cesarean delivery was not associated with an excess of complications compared with women with unscarred uteri. LEVEL OF EVIDENCE II-2.
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Affiliation(s)
- Jan E Dickinson
- School of Women's and Infants' Health, The University of Western Australia, King Edward Memorial Hospital for Women, 374 Bagot Road, Subiaco, Perth, Western Australia 6008, Australia.
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Lichtenberg ES, Frederiksen MC. Cesarean scar dehiscence as a cause of hemorrhage after second-trimester abortion by dilation and evacuation. Contraception 2004; 70:61-4. [PMID: 15208054 DOI: 10.1016/j.contraception.2004.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2003] [Revised: 02/17/2004] [Accepted: 02/17/2004] [Indexed: 12/01/2022]
Abstract
Women who have had a cesarean section have a risk of uterine rupture when undergoing a second-trimester pregnancy termination. Beyond the first trimester, uterine rupture has been associated with the use of labor-induction agents and, less often, a placenta accreta. Scar dehiscence, a less disruptive form of scar separation, has not been reported with dilation and evacuation abortion. We present two cases of uterine scar dehiscence causing serious bleeding after otherwise uncomplicated dilatation and evacuation procedures. Neither case was associated with uterine contractions, an iatrogenic perforation or placenta accreta. Uterine scar dehiscence, a surreptitious process, can be the cause of hemorrhage after uncomplicated dilatation and evacuation.
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Affiliation(s)
- E Steve Lichtenberg
- Department of Obstetrics and Gynecology, Northwestern University Feinberg Medical School, Chicago, IL, USA.
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Tutschek B, Hecher K, Somville T, Bender HG. Twin-to-twin transfusion syndrome complicated by spontaneous mid-trimester uterine rupture. J Perinat Med 2004; 32:95-7. [PMID: 15008396 DOI: 10.1515/jpm.2004.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Twin-to-twin-transfusion syndrome (TTS) is a serious complication in about 15% of monochorionic twin pregnancies. In severe TTS, the anemic pump twin (donor) develops anhydramnios and the hypervolemic recipient tense polyhydramnios, which often first calls attention to the condition. The most common problems of TTS are fetal complications such as single or double intrauterine demise, spontaneous abortion, prematurity due to uterine distension leading to contractions, preterm rupture of membranes and ultimately neurological impairment. We report a pregnancy with TTS in which rapid development of polyhydramnios led to rupture of a scarred uterus at 19 weeks' gestation. To the best of our knowledge, this is the first report of a potentially lethal maternal complication of TTS.
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Affiliation(s)
- Boris Tutschek
- Department of Gynecology and Obstetrics, University Hospital, Düsseldorf, Germany.
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Ngai SW, Tang OS, Ho PC. Prostaglandins for induction of second-trimester termination and intrauterine death. Best Pract Res Clin Obstet Gynaecol 2003; 17:765-75. [PMID: 12972013 DOI: 10.1016/s1521-6934(03)00068-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The introduction of synthetic prostaglandin has revolutionized the treatment protocol for induction of second-trimester abortion and intrauterine death. Gemeprost is the only licensed synthetic prostaglandin analogue for second-trimester abortion in the United Kingdom. However, it is expensive and needs to be stored in a refrigerator. Misoprostol is marketed for use in the prevention and treatment of peptic ulcer. It is inexpensive and can be stored at room temperature. It has been widely used for induction of second-trimester abortion and intrauterine death. Misoprostol, 400 microg given vaginally every 3hours, is probably the optimal regimen for second-trimester abortion. The combination of misoprostol and mifepristone significantly reduced the induction-to-abortion interval when compared with the misoprostol-only regimen. In addition, misoprostol can also be used as a cervical priming agent prior to dilatation and evacuation in second-trimester abortion.
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Affiliation(s)
- Suk Wai Ngai
- Department of Obstetrics and Gynaecology, The University of Hong Kong 6/F., Queen Mary Hospital, Hong Kong SAR, People's Republic of China.
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Debby A, Sagiv R, Girtler O, Sadan O, Glezerman M, Golan A. Extra-amniotic prostaglandin E2 for midtrimester termination of pregnancy in live fetuses vs. fetal demise. Arch Gynecol Obstet 2003; 268:301-3. [PMID: 14504874 DOI: 10.1007/s00404-002-0369-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2002] [Accepted: 07/09/2002] [Indexed: 10/26/2022]
Abstract
This study compared the course of midtrimester termination of pregnancies with fetal demise and those with a viable fetuses by extra-amniotic prostaglandin (PG) E(2). A total of 275 women who underwent second trimester abortion with extra-amniotic PGE2(2) were divided into two groups: 95 patients (35%) with fetal demise and 180 women (65%) with a live fetuses. Extra-amniotic PGE2(2) was administered in doses of 200 micro g every 2 h up to 20 doses. Bumm curettage was performed in the majority of the patients. We compared the duration and complication rate between the groups. The median induction to abortion interval was significantly shorter in the fetal demise group (13 vs. 21 h) than in the live fetus group. Mean gestational ages and complication rates were similar. Midtrimester termination of pregnancy with extra-amniotic PGE2(2) is a safe method with a low complication rate. In cases of pregnancy with fetal demise extra-amniotic PGE2(2) is associated with a significantly shorter induction to abortion interval than with a live fetus.
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Affiliation(s)
- A Debby
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Sacker Faculty of Medicine, Tel Aviv University, Holon 58100, Tel Aviv, Israel
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Dommergues M. Termination of pregnancy for fetal neurological abnormalities. Childs Nerv Syst 2003; 19:600-4. [PMID: 12920539 DOI: 10.1007/s00381-003-0780-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2003] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Prenatal screening for fetal abnormalities may identify conditions likely to result in perinatal death or in survival with a risk of handicap, for which termination of pregnancy is legal in many countries. DISCUSSION When considering termination of pregnancy, it is crucial that prenatal diagnosis be as accurate as possible and that the prognosis of the condition diagnosed in utero is thoroughly understood by the parents. Our ability to predict postnatal outcome in borderline cases should not be overestimated. Parents should not precipitate their decision, and in some European countries, the absence of a gestational age limit at which a termination may be performed is viewed as a guarantee against hasty terminations. Maternal morbidity potentially associated with termination should be kept as low as possible. This includes maternal analgesia, and avoiding uterine trauma to preserve fertility and to prevent obstetrical complications in subsequent pregnancies. Bereavement should also be taken into account. Tests that could contribute to confirming the diagnosis or to establishing the aetiology of the abnormality, such as fetal karyotype or platelet count, should be implemented when appropriate, since post-termination genetic counselling relies on such data. Post-mortem examination is often crucial for genetic counselling and should include X-rays and gross examination of the fetus as well as brain and spine examination by a neuropathologist with expertise in the field of fetal medicine. Specific post-mortem procedures sometimes need to be planned before termination, for instance, in fetal akinesia sequence. First trimester surgical techniques and second or third trimester medical techniques of termination of pregnancy are reviewed.
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Affiliation(s)
- Marc Dommergues
- Maternité, Hôpital Necker Enfants Malades, AP-HP, 149 rue de Sèvres, 75743 Paris Cedex 15, France.
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Abstract
OBJECTIVES To analyze and determine the safety and effectiveness of induced fetal demise as an adjunctive method in outpatient abortion for patients with advanced pregnancies and to evaluate the independent effect of intrauterine misoprostol administered after amniotomy in late abortion. METHODS During a 9-year period, 1677 abortions were performed for patients whose pregnancies ranged from 18 through 34 menstrual weeks in an outpatient facility. Of these, 832 were performed by one physician. Techniques for performing all the abortions included induction of fetal demise by intrauterine fetal injection of digoxin and/or hyperosmolar urea, serial multiple laminaria treatment of the cervix, amniotomy, oxytocin induction of labor, and assisted delivery or surgical evacuation of the fetus and placenta. In the last 411 of the 832 patients whose abortions were performed by one physician, misoprostol was placed in the lower uterine segment following amniotomy in order to enhance labor induction, cervical ripening, and fetal expulsion. RESULTS Of the entire group of 1677 cases, the median gestational age was 22 menstrual weeks. The median procedure time for all cases was 10 min. Measured median blood loss was 125 ml. Blood loss and procedure time increased with length of gestation, but these were not affected by misoprostol. There were three major complications (0.2%) in the overall series. Among patients seen by one physician (N=832), amniotomy-to-procedure time was shorter by 26 min for patients receiving misoprostol, and there was 27% more variability in amniotomy-to-procedure time among patients not receiving misoprostol. Complication rates for patients receiving misoprostol were the same as for those not receiving misoprostol. There were no major complications in the 832 patients seen by one physician, no uterine rupture or perforations, and no cervical lacerations. CONCLUSIONS Outpatient abortion may be performed safely from 18 through 34 menstrual weeks using combined surgical and medical procedures. Use of intrauterine post-amniotomy misoprostol was associated with reduced amniotomy-to-procedure time and reduced variability in the amniotomy-to-procedure time.
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Affiliation(s)
- W M Hern
- Boulder Abortion Clinic, 1130 Alpine Boulder, CO 80304, USA.
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Thakur A, Heer MS, Thakur V, Heer GK, Narone JN, Narone RK. Subtotal hysterectomy for uterine rupture. Int J Gynaecol Obstet 2001; 74:29-33. [PMID: 11430938 DOI: 10.1016/s0020-7292(01)00389-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this paper was to stratify patients with uterine rupture in extremis (with hypotension, change in vital organ function, and altered mental status) and evaluate outcome for patients undergoing subtotal hysterectomy (STH) vs. uterine repair (UR). METHODS Of 39667 hospital deliveries between 1993 and 1998 at a university hospital, 367 presented with uterine rupture. Of these, 96 presented in extremis and had an irregularly torn uterus found at operation. Charts were retrospectively reviewed to stratify patient population with uterine rupture and their outcome. Results were analyzed using Fisher's exact test. RESULTS Patients with uterine rupture were 31-35 years old, para> or =3, had received no antenatal care, and presented with rupture in the lower uterine segment. Sixty-one patients underwent STH while 35 underwent UR. The groups were similar with respect to patient age, parity, cause of rupture, and clinical condition at the time of evaluation (P=0.2). The operative time for STH was significantly less than UR, 35 min vs. 75 min (P<0.01). Maternal mortality was significantly higher in patients undergoing UR vs. STH, 46% vs. 20% (P=0.01). Maternal morbidity occurred in 30% of patients undergoing STH vs. 50% in patients undergoing UR (P=0.01). The time to discharge was significantly less in patients undergoing STH compared to UR, 14.5 days vs. 27 days (P<0.01). CONCLUSIONS Patients with uterine rupture in extremis tend to be young, multiparous, receive no antenatal care, and have uterine rupture of the lower segment. STH significantly lowered operative time, morbidity, time to discharge, and mortality than UR in patients in extremis with uterine rupture.
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Affiliation(s)
- A Thakur
- Department of Surgery, UCLA School of Medicine, Los Angeles, CA, USA
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Edwards RK, Ripley DL, Davis JD, Bennett BB, Simms-Cendan JS, Cendan JC, Stone IK. Surgery in the pregnant patient. Curr Probl Surg 2001; 38:213-90. [PMID: 11296493 DOI: 10.1067/msg.2001.112768] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- R K Edwards
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, Florida, USA
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Affiliation(s)
- P S Ramsey
- University of Alabama at Birmingham 35249-7333, USA
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Abstract
Uterine atony, inversion, and rupture are potentially fatal events that may occur in pregnancy. They are obstetric emergencies that require immediate attention. Although all women may experience these complications, identification or known risk factors allow the obstetric team to prepare for rapid diagnosis and intervention. This article includes management options to help prepare for these uncommon events.
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Affiliation(s)
- D L Ripley
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, USA
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