Article

Complications of Surgical Abortion

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Abstract

Surgical abortion is one of the most common procedures performed in reproductive-aged women and when performed by a skilled provider in the appropriate setting, it is one of the safest surgeries. Though the risk of complications is low, it increases exponentially with gestational age. Factors increasing risk of morbidity may be demographic, such as increasing patient age; medical, such as prior cesarean delivery; and procedural, such as inadequate dilation. This chapter will provide information on how to recognize factors that increase risk, steps to minimize risk, and to identify and manage complications promptly.

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... Dilatation and evacuation (D and E) is a common 1 and relatively safe gynecological procedure if done by experienced hands. 2,3 Risk of complications increases with gestational age. 2 Common complications after second trimester surgical abortion are incomplete abortion, cervical laceration, hemorrhage, uterine perforation and infection. 1 Uterine rupture is reported with second trimester medical abortion but, it is very rare after surgical abortion. ...
... 2,3 Risk of complications increases with gestational age. 2 Common complications after second trimester surgical abortion are incomplete abortion, cervical laceration, hemorrhage, uterine perforation and infection. 1 Uterine rupture is reported with second trimester medical abortion but, it is very rare after surgical abortion. ...
... 1 Though risk of complication is low, it increases with gestational age. 2 Common complications after second trimester surgical abortion are incomplete abortion (retained products of conception), cervical laceration, hemorrhage, uterine perforation and infection. Uterine rupture is very rare. ...
Article
Dilatation and evacuation (D and E) is the most commonly used method for later abortion. It is one of the safest procedure when performed by experienced personnel. Complication rates are high in second trimester abortion compared to first trimester. Rupture of uterine wall covered with organized blood clots is very rare complication after second trimester surgical abortion. It is a surgical emergency and may have deleterious consequences if diagnosis is delayed. How to cite this article Kaur M, Pandhar DK, Mehra R, Huria A. A Complication of Surgical Abortion: A Rare Presentation. J South Asian Feder Obst Gynae 2014;6(1):33-34.
... The World Health Organization (WHO) defines unsafe abortion as the procedure to terminate an unintended pregnancy performed by unskilled providers or in conditions lacking the minimal medical standards, or both [4]. * In countries where abortion is legal, induced abortion (IA) is a very safe intervention [4,[8][9][10]. In United States (US), the rate of abortion complications requiring hospital admission is less than 0.3% [11]. ...
... Delay in seeking health care attention, which is completely avoidable, is associated with more severe complications and poor outcome [55]. In the same way, more advanced gestations are associated with higher risk of uterine perforation, retained products of conception (RPOC) and mortality [9,73,89]. The triad of lower abdominal pain, fever and vaginal bleeding in any woman of reproductive age should trigger the suspicion of septic abortion [66,71,79,80,89]. ...
... Low-risk perforations are more common in the first trimester, may or may not compromise adjacent organs and usually occur with a sound, dilator or cannula, without suction. High-risk perforations are usually caused by dilation and evacuation, frequently involve other organs and are associated with increased bleeding [9]. ...
Article
Unsafe abortion (UA) is still a main cause of maternal mortality in countries with restrictive abortion laws. Our objective was to review current concepts about septic abortion (SA), its epidemiology, diagnosis, management and prevention. A wide variety of methods for inducing abortion exist. Lastly, misoprostol has replaced more dangerous methods. Septicabortion is a polymicrobial ascending infection. It should be suspected in any young women presenting with lower abdominal pain, fever and vaginal bleeding, as well as with severe sepsis or septic shock.Broad-spectrum antibiotics and source control should be initiated promptly. Removal of retained products of conception should be performed as soon as possible. Indications for laparotomy are failure to respond to uterine evacuation andadequate treatment, uterine perforation with suspected bowel injury, pelvic and adnexal abscesses and clostridial myometritis. Indications for hysterectomy are a uterus of woody appearance or discolored, clostridial necrotizing myometritis, crepitation of the pelvic tissue and radiographic evidence of air within the uterine wall. Aggressive surgical wound debridement and hysterectomy should be performed whenever gas gangrene is present. Effective contraception has been shown to reduce UA but is not enough to cope with high fertility regulation demands. Legalized, safe and accessible abortion services are required.
... En 3 embarazos igual o menores de 12 semanas y en 7 embarazos de 13 a 15 semanas se utilizó inicialmente el misoprostol por vía vaginal y luego de la expulsión del producto se realizó la aspiración manual endouterina (36)(37)(38) . En el 100% de los casos fue exitosa la evacuación uterina. ...
... weeks (36)(37)(38) . Uterine evacuation was successful in all cases. ...
Research
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Objective: To determine causes of medical termination of pregnancy at a national maternal perinatal institute. Design: Descriptive observational study. Setting: Instituto Nacional Materno Perinatal, Lima, Peru. Material: Applications for therapeutic termination of pregnancy. Method: Review of all applications for medical termination of pregnancy performed at the institution between 2009 and 2013. Main outcome measures: Medical reasons for therapeutic termination of pregnancy. Results: During the study period 64 applications for medical termination of pregnancy were submitted to the General Director of the Institute; 61 were approved by the Medical Board: one in 2009, one in 2010, four in 2011, 21 in 2012 and 34 in 2013. The mean age of patients was 30.4 years (19-47 years); most patients had one or two previous deliveries (47%); 69% had no history of previous abortion, and the majority (31 cases, 51%) carried a 19-22 weeks of gestation. The causes for therapeutic termination of pregnancy were risk of life in 8 (13%) pregnant women and risk for physical and mental health in 53 (87%). The most frequent cause the mother considered as risk of life was active systemic lupus erythematosus, and as risk for physical and mental health, fetal congenital malformations incompatible with life including anencephaly and acrania. Misoprostol and uterine curettage were the most often methods (82%, n = 50) used for termination of pregnancy. Conclusions: Cases of therapeutic termination of pregnancy have increased over time at our institution. Most have been due to causes that endangered the mother’s physical and mental health such as fetal congenital malformations incompatible with extrauterine life. Obstetric and perinatology guidelines for therapeutic termination of pregnancy are being formally applied at the Instituto Nacional Materno Perinatal
... En 3 embarazos igual o menores de 12 semanas y en 7 embarazos de 13 a 15 semanas se utilizó inicialmente el misoprostol por vía vaginal y luego de la expulsión del producto se realizó la aspiración manual endouterina (36)(37)(38) . En el 100% de los casos fue exitosa la evacuación uterina. ...
... weeks (36)(37)(38) . Uterine evacuation was successful in all cases. ...
Article
Full-text available
Objetivo: Describir las causas de la interrupción terapéutica del embarazo en el Instituto Nacional Materno Perinatal. Diseño: Estudio observacional descriptivo, tipo revisión de casos. Institución: Instituto Nacional Materno Perinatal, Lima, Perú. Material: Solicitudes para interrupción terapéutica del embarazo. Métodos: Se revisó todos los casos de interrupción terapéutica del embarazo realizados en los diferentes servicios de la institución entre los años 2009 y el 2013. Principales medidas de resultados: Causas de las solicitudes para interrupción terapéutica del embarazo. Resultados: Durante el período de estudio se presentaron a la Dirección General del Instituto 64 solicitudes para interrupción terapéutica del embarazo, de las cuales 61 fueron aprobadas por Junta Médica: una el año 2009, una en el 2010, cuatro en el año 2011, 21 en el 2012 y 34 en el 2013. La edad media de las pacientes fue 30,4 años (19 a 47 años); la mayoría de pacientes tuvo de uno a dos partos previos (47%); el 69% no tenía antecedente de un aborto previo; y la mayoría (31 casos, 51%) llevaba entre 19 y 22 semanas de gestación. Las causas para la interrupción terapéutica del embarazo fueron por riesgo de la vida de la gestante en 8 (13%) casos, y por riesgo en la salud física y mental de la gestante en 53 (87%) casos. La causa más frecuente por riesgo de vida de la gestante fue el lupus eritematoso sistémico activo y las causas por riesgo de la salud física y mental incluyeron las malformaciones congénitas fetales incompatibles con la vida, como anencefalia y acrania. Para la interrupción del embarazo se utilizó con mayor frecuencia el misoprostol más legrado uterino (82%, n = 50). Conclusiones: La proporción de casos de interrupción terapéutica del embarazo está aumentando con el tiempo y la mayoría es por causas que ponen en riesgo la salud física y mental de la madre, como son las malformaciones congénitas del feto incompatibles con la vida extrauterina. Se vienen aplicando los protocolos establecidos en las Guías de Obstetricia y Perinatología del Instituto Nacional Materno Perinatal para la interrupción terapéutica del embarazo.
... Abnormal placentation such as placenta accreta, increta and percreta, characteristically seen in women with a prior uterine scar, has the potential to cause massive hemorrhage during second-trimester surgical abortion [59]. Over the past 30 years, the incidence of placenta accreta has increased fourfold, with approximately 3 per 1,000 deliveries affected, largely due to the increased number of cesarean deliveries. ...
Article
Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Hemorrhage can be caused by atony, coagulopathy and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration and retained tissue. Evidence on which to make recommendations regarding risk factors and treatment for postabortion hemorrhage is extremely limited. Although medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different. Identifying patients who may be at increased risk of hemorrhage can help reduce blood loss with abortion. Specifically, women with a uterine scar and complete placenta previa seeking abortion at gestations greater than 16 weeks should be evaluated for placenta accreta. For women at high risk of hemorrhage, referral to a high-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and exam, (2) massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible re-aspiration or balloon tamponade, and (4) interventions such as embolization and surgery. The Society of Family Planning recommends preoperative identification of women at high risk of hemorrhage as well as development of an organized approach to treatment. Further studies are needed on prophylactic use of uterotonic medication, intraoperative ultrasound and optimal delivery of the placenta after second-trimester medical abortion.
... Approximately 71 % (15/21) of these complications occurred during the first trimester surgical abortion and remaining 27 % (6/22) during the second trimester. The distribution of this complication through the trimesters is contrary to the fact that second trimester abortion has a higher rate of all complications than abortions performed in the first trimester [13,15,31]. This is due to (1) higher incidence of (legal or illegal) surgical abortions during the first trimester and (2) thickening of the uterus as pregnancy advances lowering the possibility of instrumental perforation. ...
Article
Full-text available
Objective: Small bowel obstruction after unrecognized or conservatively treated uterine perforation is extremely rare. It is a surgical emergency and the delay in diagnosis and treatment has deleterious consequences for the mother. The purpose of this study is to critically review the available literature and ascertain the level of evidence for the mechanisms, diagnosis and management of small bowel obstruction after uterine perforation due to surgical abortion. Methods: Systematic literature search was conducted in Pubmed (1946 to 2012) and Pubmedcentral (1900 to 2012) including all available English and French language fulltext articles. Three evaluators reviewed and selected all available case reports and case series. Search terms included small bowel obstruction, bowel obstruction, bowel incarceration, bowel entrapment, vaginal evisceration, uterine perforation, uterine rupture, and abortion. The exclusion criteria were (1) complex injuries where small bowel incarceration was present but with bleeding and/or bowel perforation as the leading symptomatology; (2) articles only numbering the patients without details on the topic. Analyses of incidence, risk factors, mechanisms of the disease, time of clinical presentation, diagnostic modalities, treatment, and maternal outcome were included. Results: Of the 73 articles screened 30 cases of small bowel obstruction were included in the review forming incidence, risk factors, and mechanisms of the disease, diagnosis, therapy, and maternal outcome. Conclusions: A systematic review defined four mechanisms of small bowel obstruction after transvaginal instrumental uterine perforation with significant variations in clinical presentation and time of presentation. Duration of symptoms depend on the mechanism of small bowel obstruction. Vaginal evisceration is surgical emergency and treatment is mandatory without diagnostic workup. Survival rate during last century is 93 %. Multicentric trials and publication of all such cases are needed to determine algorithms for diagnosis and management of small bowel obstruction caused by instrumental uterine perforation.
... As mentioned in the mortality section, the likelihood of harm is dependent on gestational age with risk directly proportional to gestational age. One US study estimates a hazard ratio of 1.38 for TOP complication for each week aer a TOP procedure is performed with the same being true for TOP-related mortality [50]. ...
Article
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During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.
... Other estimates also show that about 97% of all unsafe abortions occur in low-and middle-income countries (LMICs) mostly in sub-Saharan Africa (SSA) (Ganatra et al., 2017). It has been reported that pregnancy termination has dire consequences on the health of women (example: hemorrhage, sepsis, and uterine perforation) and thus intimate partner violence (IPV) contributes to pregnancy termination (Diedrich & Steinauer, 2009). ...
Article
Full-text available
Intimate partner violence is predominant in sub-Saharan Africa and has serious adverse effects on the physical, psychological, and reproductive health of those who experience it. For reproductive health outcomes, experiencing intimate partner violence has been linked with higher odds of unintended pregnancies that can result in abortion. Hence, we examined the association between intimate partner violence and pregnancy termination among women in sub-Saharan Africa. This study used data from the Demographic and Health Surveys of 25 countries in sub-Saharan Africa, which adopted a cross-sectional study design. Bivariate and multivariable binary logistic regression models were used to examine the association between intimate partner violence and pregnancy termination. The results were presented as crude odds ratios (cORs) and adjusted odds ratios (aORs), with 95% confidence intervals (CIs). The prevalence of intimate partner violence and pregnancy termination were 40.8% and 16.5%, respectively. The odds of pregnancy termination were higher among women who had experienced intimate partner violence [cOR = 1.57, 95% CI = 1.52–1.61] compared to those who had never experienced intimate partner violence. This persisted after controlling for potential confounders [aOR = 1.56, 95% CI = 1.51– 1.61]. At the country level, intimate partner violence had a significant association with pregnancy termination in all the countries considered, except Sierra Leone and Namibia. These findings highlight the need for laws and policies to protect women from intimate partner violence in sub-Saharan Africa, especially in the countries that recorded higher odds of intimate partner violence and pregnancy termination.
... 9 Women with previous cesarean sections, placenta previa and those with previous damage to uterine wall with history of surgical abortion are at greater risk for placenta percreta. 10 The spontaneous rupture of uterus before labor is extremely rare. 8,11,12 ...
Article
Full-text available
Uterine rupture is a life-threatening complication in pregnancy with an incidence of 0.07%, out of which 80% are spontaneous rupture. Placenta percreta is the rarest form of placental implantation abnormalities, with an incidence 1 in 2500 pregnant women.1,2 Spontaneous uterine rupture due to placenta percreta is very rare, with an incidence of 1 in 4,366 pregnant women.3 It often occurs in patients with a history of scar in the uterus.4 Placenta percreta-induced spontaneous uterine rupture at term with previous lower segment cesarean section (LSCS) is difficult to diagnose. A 25-year-old pregnant woman, with history of one incomplete abortion treated by dilatation and curettage followed by a vaginal delivery with stillbirth and one LSCS again with stillbirth at term, was admitted in the emergency ward with history of approx 9 months amenorrhea, breathlessness, pain in abdomen (unable to lie down or even sit), vomiting and loss of fetal movements for last 24 hours. O/E: GC fair, afebrile, Pallor +++, pedal edema +, pulse 100/minutes regular, resp. rate; 40/minutes, thoracic, BP 110/70 mm Hg, lung fields clear with no abnormality detected in heart. On P/A: skin was stretched and a Pfannensteil scar healed by primary intention was present Abdomen tense, tender therefore fundal height could not be assessed. Fetal parts were not palpable and lie/presentation could not be made out. FHS were absent. On P/V; os closed with uneffaced cervix, presenting part could not be made out and was high. No bleeding or leaking per-vaginum was present. Hb 6.7 gm%, TLC 15600, DLC P90, L8, E2, M0. Ultrasound done on 27.5.12 (one month back) outside revealed 32.3 weeks gestation with normal scar thickness, placenta located in upper segment, grade I. No comment was made on the interface between placenta and myometrium in ultrasound report. Patient was subjected to emergency laparotomy, massive hemoperitoneum was found. Examination of uterus revealed an intact previous scar. A full term male stillborn baby was delivered by uterine scar (LSCS) on 21.6.2012, at 10.30 pm The placenta could not be delivered as there was no plain of cleavage between placenta and myometrium. Uterus was exteriorized and to surprise there was a rent of about 3 × 2 cm at left cornua, placental tissue peeping out on removing the clots. Subtotal hysterectomy was performed. Three units blood were transfused. Postoperative period was uneventful and the patient was discharged in satisfactory condition on 9th day. Histopathological examination of the uterine specimen revealed placenta percreta. To conclude uterine rupture should be considered in the differential diagnosis in pregnant women who present with acute abdomen with or without shock. How to cite this article Neerja, Varma M, Thakral RK, Varshney A. Placenta Percreta: An Unusual Etiology for Spontaneous Rupture of Uterus Near Term. J South Asian Feder Obst Gynae 2014;6(3):180-182.
... Abortion may occur spontaneously or intentionally; the latter is also called induced abortion, which may be safe or unsafe. Abortion (incredibly unsafe) may have serious health consequences and cause complications such as hemorrhage, sepsis, and uterine perforation [3,4]. ...
Article
Full-text available
Background Abortion is one of the top five causes of maternal mortality in low and middle-income countries. It is associated with a complication related to pregnancy and childbirth. Despite this, there was limited evidence on the prevalence and associated factors of abortion in East African countries. Therefore, this study aimed to investigate the prevalence and associated factors of abortion among reproductive-aged women in East African countries. Methods The Demographic and Health Surveys (DHS) data of 12 East African countries was used. A total weighted sample of 431,518 reproductive-age women was included in the analysis. Due to the hierarchical nature of the DHS data, a multilevel binary logistic regression model was applied. Both crude and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was calculated for potential associated factors of abortion in East Africa. In the final model, variables with a p value < 0.05 were declared as statistically significant factors of abortion. Results Around 5.96% (95%CI: 4.69, 7.22) of reproductive-aged women in East Africa had a history of abortion. Alcohol use, tobacco or cigarette smoking, being single, poorer wealth index, currently working, traditional family planning methods, and media exposure were associated with a higher risk of abortion. However, higher parity, having optimum birth intervals, and modern contraceptive uses were associated with lower odds of abortion. Conclusions The prevalence of abortion among reproductive-aged women in East Africa was high. Abortion was affected by various socio-economic and obstetrical factors. Therefore, it is better to consider the high-risk groups during the intervention to prevent the burdens associated with abortion.
... As a life-threatening complication of surgical abortion, effective diagnosis of uterine perforation is crucial in expediting appropriate management. Experienced surgeons may detect uterine perforation during surgical abortions if they observe signs of severe pain, suspect that the instrument has passed beyond the expected depth of the uterine cavity without resistance, or extra-uterine structures are visualized in the vagina (4). However, some cases of uterine perforation go undetected during surgical abortions, which tend to prolong morbidity with increased risk of death. ...
Article
Full-text available
Uterine perforation is a rare major complication of surgical abortion which can be detected by ultrasound. In the last four decades, over 70% of case reports on uterine perforation in surgical abortions were from developing countries. Yet ultrasound was rarely used in detecting uterine perforation. This case report presents two cases of uterine perforation in surgical abortions which were detected by ultrasound prior to laparotomy. In the first case, a 34-year old woman was referred to our facility as a case of hypovolaemic shock following termination of pregnancy. An ultrasound examination performed to exclude an intra-abdominal abscess collection revealed a 1.2cm defect in the fundal region of the uterus with extrusion of abdominal contents into the endometrial cavity through the defect. In the second case, a 31-year old woman presented with a history of vomiting, abdominal pain, abdominal distension and absolute constipation after undergoing an evacuation of the uterus for a spontaneous abortion at 7 weeks' gestation. Transabdominal ultrasound showed a defect of 1.4cm wide at the fundus of the uterus, with a structure extending from the abdominal cavity through the defect and into the endometrial cavity. It also showed distension of multiple bowel loops within the abdominal cavity. Sonographic detection of uterine perforation led to appropriate management in both cases. In developing countries, where the incidence of major complications of abortion is still very high, utilizing ultrasound can be helpful in detecting complications such as uterine perforation.
... As a life-threatening complication of surgical abortion, effective diagnosis of uterine perforation is crucial in expediting appropriate management. Experienced surgeons may detect uterine perforation during surgical abortions if they observe signs of severe pain, suspect that the instrument has passed beyond the expected depth of the uterine cavity without resistance, or extra-uterine structures are visualized in the vagina (4). However, some cases of uterine perforation go undetected during surgical abortions, which tend to prolong morbidity with increased risk of death. ...
... Pregnancy termination (especially the unsafe) can have serious health consequences and cause complications such as haemorrhage, sepsis and uterine perforation [7,11]. Unsafe abortion also has undesirable consequences beyond its immediate effects on women's health. ...
Article
Full-text available
Introduction: Pregnancy termination is one of the key issues that require urgent attention in achieving the third Sustainable Development Goal (SDG) of ensuring healthy lives and promoting well-being for all at all ages. The reproductive health decision-making (RHDM) capacity of women plays a key role in their reproductive health outcomes, including pregnancy termination. Based on this premise, we examined RHDM capacity and pregnancy termination among women of reproductive age in sub-Saharan Africa (SSA). Materials and methods: We pooled data from the women's files of the most recent Demographic and Health Surveys (DHS) of 27 countries in SSA, which are part of the DHS programme. The total sample was 240,489 women aged 15 to 49. We calculated the overall prevalence of pregnancy termination in the 27 countries as well as the prevalence in each individual country. We also examined the association between RHDM capacity, socio-demographic characteristics and pregnancy termination. RHDM was generated from two variables: decision-making on sexual intercourse and decision-making on condom use. Binary logistic regression analysis was conducted and presented as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with their corresponding 95% confidence intervals (CI). Statistical significance was declared p<0.05. Results: The prevalence of pregnancy termination ranged from 7.5% in Benin to 39.5% in Gabon with an average of 16.5%. Women who were capable of taking reproductive health decisions had higher odds of terminating a pregnancy than those who were incapable (AOR = 1.20, 95% CI = 1.17-1.24). We also found that women aged 45-49 (AOR = 5.54, 95% CI = 5.11-6.01), women with primary level of education (AOR = 1.14, 95% CI = 1.20-1.17), those cohabiting (AOR = 1.08, 95% CI = 1.04-1.11), those in the richest wealth quintile (AOR = 1.06, 95% CI = 1.02-1.11) and women employed in the services sector (AOR = 1.35, 95% CI = 1.27-1.44) were more likely to terminate pregnancies. Relatedly, women who did not intend to use contraceptive (AOR = 1.47, 95% CI = 1.39-1.56), those who knew only folkloric contraceptive method (AOR = 1.25, 95% CI = 1.18-1.32), women who watched television almost every day (AOR = 1.16, 95% CI = 1.20-1.24) and those who listened to radio almost every day (AOR = 1.11, 95% CI = 1.04-1.18) had higher odds of terminating a pregnancy. However, women with four or more children had the lowest odds (AOR = 0.5, 95% CI = 0.54-0.60) of terminating a pregnancy. Conclusion: We found that women who are capable of taking reproductive health decisions are more likely to terminate pregnancies. Our findings also suggest that age, level of education, contraceptive use and intention, place of residence, and parity are associated with pregnancy termination. Our findings call for the implementation of policies or the strengthening of existing ones to empower women about RHDM capacity. Such empowerment could have a positive impact on their uptake of safe abortions. Achieving this will not only accelerate progress towards the achievement of maternal health-related SDGs but would also immensely reduce the number of women who die as a result of pregnancy termination in SSA.
... Abortion may occur spontaneously or intentionally, the later also known as induced abortion, which may be either safe or unsafe. Abortion (especially unsafe) may have serious health consequences and cause complications such as hemorrhage, sepsis and uterine perforation [6,7]. The global rate of abortion has been constant at 28-29/1000 women aged 15-44 years from 2003 to 2008, but the proportion of unsafe abortions has increased from 44.0% in 1995 to 49.0% in 2008 [8]. ...
Article
Full-text available
Background: Abortion is one of the leading causes of maternal death in low- and middle-income countries. In Nepal, abortion is reported to be the third leading cause of maternal death. We aimed to investigate the prevalence and factors associated with abortion and unsafe abortion in Nepal. Methods: This study is based on a nationally representative sample of the Nepal Demographic and Health Survey 2011. Women who had ever had a terminated pregnancy (n = 2395) were studied. The survey elicited information on the most recent abortion. Unsafe abortion was defined according to the providers of abortion services. Binary logistic regression was used to calculate odds ratios (ORs) and 95% Confidence Intervals (CIs) of abortions and unsafe abortions due to demographic, socio-economic and lifestyle-related characteristics. The interaction of the reason for abortion with age and educational status in predicting unsafe abortion was calculated using the predictive margins and their 95% CI. Results: The five-year prevalence of abortion was 21.1% among women of reproductive age who ever had a terminated pregnancy and 16.0% of total abortions were unsafe. Women of Buddhist religion (OR 2.15; 95% CI 1.04, 4.44), those who were literate (secondary level education OR 1.69; 95% CI 1.22, 2.34), those who knew about legal abortion (OR 1.88; 95% CI 1.41, 2.52) and those who were aware of safe places for abortion services (OR 4.96; 95% CI 3.04, 8.09) were more likely to undergo an abortion. Likewise, women in age group 25-34 years (OR 0.43; 95% CI 0.19, 0.97) and those who were in the richest wealth quintile (OR 0.10; 95% CI 0.04, 0.25) were less likely to undergo an unsafe abortion. Educated women of 25-34 years reporting "health risk" as the reason for abortion had a decidedly lower probability (< 10.0%) than the others of going through the unsafe abortion. Conclusions: The prevalence of abortion in Nepal remains high. Education, religion, age, knowledge about legal abortion and safe places to undergo abortion were the major decisive factors associated with abortion. Young, poorest and uneducated women were more likely to undergo unsafe abortions. Therefore, intervention studies among these target groups are warranted.
Chapter
Intestinal obstruction is one of five most common causes of nonobstetric acute abdominal conditions during pregnancy. A wide variety of causes can present during pregnancy as in the nonpregnant population. Some conditions are significantly more common in pregnancy than in the nonpregnant population. These include cecal and sigmoid volvulus and intussusception (when compared to the female population of the same age range) due to the growing uterus which displaces surrounding organs and increased intra-abdominal pressure. The presentation is similar or the same for any underlying cause of intestinal obstruction and depends on the level and severity of obstruction. Clinicians avoid to use plain abdominal X-ray which is commonly diagnostic and adds to earlier diagnosis which influences both maternal and fetal prognosis. Conservative therapy is rarely successful except for small bowel obstruction caused by adhesions but less successful than in general population due to partially fixed small bowel kinking by growing uterus. Other causes necessitate early surgical intervention to save both the mother and the fetus.
Article
Recent evidence suggests that medical schools offer insufficient training to equip students with the knowledge and skills necessary to counsel patients about abortion and to become abortion providers. We conducted a knowledge-assessment survey of medical students before (second-year students) and after (fourth-year students) teaching related to abortion to evaluate the effectiveness of the undergraduate abortion curriculum. Undergraduate medical students answered a knowledge-assessment survey about abortion epidemiology, practice guidelines, abortion methods and procedures, and student readiness to provide abortions. One hundred and twenty six of 266 second-year students (47%) and 67 of 170 fourth-year students (39%) completed the survey. Fourth-year medical students scored higher on average than second-year students (P < 0.001), producing mean scores of 45% and 25%, respectively. Abortion epidemiology was the weakest area of performance for all students. Most medical students would either provide an abortion (37% of fourth-year students, 38% of second-year students) or refer to a provider (36% of fourth-year students and 34% of second-year students). There was no significant relationship between overall scores and student readiness to provide abortions. Medical students in both second and fourth year demonstrated a limited understanding of abortion. Most future physicians participating in this study indicated they would be willing to provide abortions. Curriculum reform to improve abortion training in undergraduate medical programs is essential to provide students with necessary learning opportunities and to ensure safe and effective reproductive health care for women.
Article
To characterize the clinical and laboratory features of coagulopathy following second-trimester surgical abortions. DESIGN. Retrospective study. Gynecologic unit of a university-affiliated medical center. 1249 consecutive women underwent late second-trimester (16-24 weeks) surgical abortions between January 2002 and June 2010. Of those, 20 women (1.6%) were diagnosed with excessive bleeding accompanied by coagulopathy. Women were divided into two groups based on whether the abortion was performed for fetal demise (n=14) or pregnancy termination (n=6). Gestational age, indication for abortion, blood clotting tests, number of blood products and coagulation factors administered. Women who had pregnancy termination began to bleed significantly earlier than those with fetal demise (p<0.05). A significantly higher number of women with fetal demise had a gradual deterioration of the clotting test, compared with women who had pregnancy termination (p<0.05). In women with fetal demise, early bleeding was associated with a more severe clinical presentation. Coagulopathy following surgical abortion manifests differentially in women who have fetal demise and those who have pregnancy termination, implying a different pathophysiology. Women with fetal demise suffering from excessive bleeding following surgical abortion accompanied with mild clotting test abnormalities should be carefully monitored to diagnose and treat an impending disseminated intravascular coagulation.
Article
Disseminated intravascular coagulation (DIC) is a serious and relatively uncommon complication of induced or spontaneous abortion or delivery. Occasionally, it has been reported in the absence of predisposing conditions. Little information in the literature describing idiopathic DIC or the treatment of patients with DIC exists. From 2002 through 2008, 24 cases of presumptive idiopathic DIC occurred following dilation and evacuation (D&E) abortion between 13 5/7 and 23 6/7 weeks' estimated gestational age at a Midwestern ambulatory surgical center. The characteristics of each patient, their pregnancies and surgical experiences were examined and compared with a temporally matched control group of D&E patients. We explored whether the index cases had a predominance of any historical, clinical or reproductive characteristics compared with controls matched for demographic and reproductive landmarks. Overall incidence of presumptive idiopathic DIC was 1.8 per 1000 D&E cases. Compared with matched controls, there was a greater likelihood of DIC with more advanced gestation (p=.009); no case of DIC was under 17 weeks' gestational age. Increased bleeding occurred at a mean time of 153 min after completion of surgery (range, 55-491 min; median, 131 min). Nineteen of 24 cases were successfully treated at the surgical center after receiving 6 to 8 units of fresh-frozen plasma (FFP); 5 cases were transferred to a hospital for further treatment. The abnormal bleeding of presumptive DIC typically begins to appear within 2 h after uncomplicated D&E and is more likely to occur at 17 weeks' estimated gestational age and more. With rapid diagnosis and treatment, most patients were able to be treated in an outpatient setting with up to 6 to 8 units of FFP and rehydration.
Article
Background: Uterine perforation is a rare but recognized complication of abortion. Perforations may not be recognized at the time of the procedure, and patients may present days or weeks later with sequelae of the complication. Objectives: To raise awareness of this rare complication that can present days to weeks after the precipitating event. Case report: A 21-year-old woman presented 3 weeks after an elective abortion with symptoms of bowel obstruction. Exploratory laparotomy revealed small bowel herniation into a perforated uterus, causing the obstruction. In retrospect, a pre-operative ultrasound and computed tomography (CT) scan suggested this finding, but it went unrecognized at that time. A small bowel resection was performed and the patient made an uneventful recovery. Conclusion: Intrauterine bowel after abortion has been described only a handful of times in the literature. Uterine perforation during abortion is usually asymptomatic and generally can be managed conservatively, but herniation of bowel through the uterine defect can result in obstruction and strangulation. Intrauterine bowel requires prompt laparotomy and possible resection of non-viable bowel. Although ultrasound and CT scans may aid in diagnosis of this rare complication, a clinical suspicion for uterine perforation should be maintained by health care providers when treating patients who have had an abortion.
Article
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In this Journal in 1972 100 leaders in obstetrics and gynecology published a compelling statement recognizing the legalization of abortion in several states and anticipating the 1973 Supreme Court decision in Roe v. Wade. They projected the numbers of legal abortions likely to be required by American women and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women's health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists. Forth year later we undersigned 100 professors examine our predecessors statement in light of medical advances and legal changes since and suggest a further course of action for obstetrician gynecologists.
Article
Aim: The aim of this paper was to evaluate the effectiveness of sublingual use of misoprostol in women undergoing first trimester surgical abortion. Special consideration was given in a sub-group analysis according to parity. Methods: A retrospective study was conducted, enrolling patients during 2006-2009. Pregnancies less than 12 weeks of gestation were exclusively included. Our sample was divided in: group 1, in which we included women who had received 400 mcg of misoprostol sublingually two hours before surgical abortion and group 2, with no use of misoprostol. Cervical dilatation and estimated blood loss (EBL) were compared between the two groups. Moreover, a sub-group analysis of the former parameters was made separately in nulliparous and multiparous women. Results: Out of 79 patients included, 48 (60.75%) received misoprostol, while 31 (39.25%) did not. Cervical dilatation was significantly higher in group 1 (6.4±2.1 mm vs. 4.7±1.7 mm in group 2, P=0.001), while EBL was significantly lower in the same group (105.0±22.1 mL vs. 120.3±24.2 mL for group 2, P=0.005). Concerning the sub-analysis, cervical dilatation was significantly increased and EBL was significantly lower in multiparous receiving misoprostol comparing with those who did not (P=0.001 and P=0.002, respectively). However, the same parameters did not differ significantly between the two sub-groups of nulliparous women. Conclusion: Sublingual administration of 400mcg misoprostol is effective concerning cervical ripening and EBL in women undergoing first trimester surgical abortion. According to the results of the present clinical trial prostaglandin E1 is more effective in multiparous group of women.
Article
Objetive We performed an open, prospective, exploratory and longitudinal study to evaluate the use of intracervical anesthetic infiltration with instrumental uterine curettage in 20 women undergoing pregnancy termination. Patients and methods The patients’ age ranged from 17 to 49 years (mean and SD: 26.95 ± 9.2058). The length of gestation ranged from 5 to 14 weeks (mean and SD: 8.75 ± 2.4622). The SPSS program was used for the statistical analysis. Results For intracervical anesthesia, 10 ml lidocaine at 1% was used; 5 ml was applied at infiltration points iii and ix clockwise. Anesthesia lasted 30 to 70 minutes (mean and SD: 48.25 ± 13.8992). Conclusions Operating time (infiltration and curettage) ranged from 7 to 14 minutes (mean and SD: 10.9 ± 2.1886). Blood loss ranged from 50 to 150 ml (mean and SD: 100 ± 44.7213). All studies were longitudinal.
Article
Objective To describe the effectiveness of buccal misoprostol as an adjunct to laminaria for cervical ripening before later second-trimester abortion by dilation and evacuation (D&E). Methods A randomized, double-blinded, placebo-controlled trial of 196 women undergoing D&E between 21–23 weeks’ gestation. Subjects had overnight laminaria and 400mcg buccal misoprostol or placebo 3–4 hours before the abortion. We used logarithmic transformation of the primary outcome—D&E procedure duration—to achieve a normal distribution. Results Mean D&E duration was 1.7 minutes shorter with misoprostol (p = 0.02). The median duration was 9.7 versus 10.4 minutes in the misoprostol and placebo groups, respectively (p = .09). Cervical dilation was slightly greater with misoprostol (median 75 mm vs. 73 mm, p = 0.04); however, physicians did not find the misoprostol D&Es easier to complete. Half of subjects reported severe pain after misoprostol vs. 11% with placebo (p < 0.001). Conclusion Adjuvant buccal misoprostol results in slightly shorter D&Es at the cost of more side effects.
Article
Background Delayed pregnancy testing has been associated with presentation for abortion in the second trimester. Little is known about acceptability of potential interventions to hasten pregnancy recognition. Study design 592 women presenting for abortion at six clinics in the United States completed surveys on contraceptive use, risk behavior, timing of first pregnancy test and interest in interventions to speed pregnancy recognition and testing. Results 48% of women presenting for second-trimester abortion delayed testing until at least 8 weeks. In multivariate analysis, women who often spotted between periods had higher odds of delaying pregnancy testing (odds ratio, OR, 2.7, 95% confidence interval, CI, 1.04-6.94). Women who often missed periods had higher odds of second trimester abortion (OR 2.1, 95% CI 1.34-3.13). The majority (64%) of women were not aware of a fertile time in the menstrual cycle; these women had higher odds of second trimester abortion (OR 2.0, 95% CI 1.21-3.37). 94% of women expressed interest in at least one potential intervention to help recognize pregnancy earlier. Conclusions While there was near universal interest in earlier pregnancy recognition, no single proposed intervention or scenario was endorsed by the majority. Improving sexual health awareness is an important consideration in future efforts to expedite pregnancy testing. Implications We found near universal interest in earlier pregnancy recognition, though no single proposed intervention or scenario garnered majority support. Based on our findings, the concept of improving sexual health awareness through education should be incorporated in the development of future strategies to hasten recognition of unintended pregnancy.
Article
Aim: The aim of this study was to explore the knowledge, attitudes and practices on medical abortion of abortion service providers in rural areas of China. Material and Methods: A cross-sectional study via self-administered questionnaire was conducted among 362 abortion service providers from family planning service centers (FPSC) and hospitals in rural areas of Henan Province, China, between November 2009 and May 2010. Results: Most of the providers were female (99.4%) and obstetricians/gynecologists (63.3%). The knowledge score achieved ranged from 9.4 to 78.1 points, with both the median and the mode of 56.3 points. Of the 52.2% (189/362) of providers having a preference on abortion method, 30.2% (57/189) preferred medical abortion, while 69.8% (132/189) preferred surgical abortion. In total, 50.7% (174/343) of the providers indicated the provision of medical abortion should be expanded, with the three biggest challenges in its further expansion being increased complications/failures, poor client knowledge/awareness, and problems with drug/equipment supplies. Of all the providers, 81.7% and 92.2% reported they had experience in providing medical abortion and surgical abortion, respectively. Medical abortion providers were mainly experienced in misoprostol with oral (81.8%)/vaginal (79.6%) prostaglandin (misoprostol/gemeprost). Conclusion: Knowledge on medical abortion of providers working in rural China was at a moderate level. Providers preferred surgical abortion to medical abortion. Providers have more experience in providing surgical abortion than medical abortion. Efforts should be made to overcome the perceived challenges in future expansion of medical abortion.
Article
Evaluating and "cleaning" of the uterine cavity is probably the most performed operation in women. It is done for several reasons: abortion, evaluation of irregular bleeding in premenopausal period, and postmenopausal bleeding. Abortion is undoubtedly the number one procedure with more than 44 million pregnancies terminated every year. This procedure should not be underestimated and a careful preoperative evaluation is needed. Ideally a sensitive pregnancy test should be done together with an ultrasound in order to confirm a uterine pregnancy, excluding extra-uterine pregnancy, and to detect genital and/or uterine malformations. Three out of four abortions are performed by surgical methods. Surgical methods include a sharp, blunt, and suction curettage. Suction curettage or vacuum aspiration is the preferred method. Despite the fact that it is a relative safe procedure with major complications in less than one percent of cases, it is still responsible for 13% of all maternal deaths. All the figures have not declined in the last decade. Trauma, perforation, and bleeding are a danger triage. When there is a perforation, a laparoscopy should be performed immediately, in order to detect intra-abdominal lacerations and bleeding. The bleeding should be stopped as soon as possible in order to not destabilize the patient. When there is a perforation in the uterus, this "entrance" can be used to perform the curettage. This is particularly useful if there is trauma of the isthmus and uterine wall, and it is difficult to identify the uterine canal. A curettage is a frequent performed procedure, which should not be underestimated. If there is a perforation in the uterus, then this opening can safely be used for vacuum aspiration.
Article
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Purpose of the study: To evaluate postoperative pain after mini-invasive surgical treatment for dysfunctional uterine bleeding (DUB) with transcervical endometrial resection or thermal ablation balloon. Materials and methods: A longitudinal observational study, analyzing 47 women affected by DUB who underwent endometrial ablation was conducted. The authors collected evaluation of pelvic pain at one and four hours after intervention and the individual necessity of analgesics. After 30 days, all patients underwent a gynecological visit to evaluate postoperative outcome. Results: Pelvic pain was higher one and four hours after procedure in thermal balloon ablation group, and patients in the same group required more analgesic rescue dose. There were no complications such as uterine perforation, heavy blood loss or thermal injuries with both the procedures. Conclusion: Thermal balloon ablation appears a more painful procedure than endometrial resection, both in the immediate postsurgical time and 30 days after surgery. Ad hoc anaesthesiologic and analgesic protocol should be adopted to ensure quick recovery and good acceptance of the procedure.
Chapter
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Changed attitudes to pregnancy have resulted in women involving themselves increasingly in social, commercial, and professional activities virtually throughout their pregnancies, thus exposing themselves to a risk of accidental injury similar to that in the nonpregnant population. Pelvic ligamentous laxity and the protuberant abdomen of pregnancy contribute to instability of gait, predisposing the pregnant woman to falls especially with progression of pregnancy. The prominent abdomen, especially toward term, becomes vulnerable to any form of trauma, and it has been suggested that minor accidental injury is more common during pregnancy than at any other time in adult life. A study from 2008 estimated that injuries resulting in an emergency department visit occurred in 3.7 % of pregnancies [1]. A reported 0.3 % of pregnant women require hospital admission because of trauma [2, 3] or less than 1 % of all trauma admissions in Australia [4]. Unintentional injuries are the leading cause of death among 18–34-year-old women in the United States and account for more than 8.6 million emergency department visits each year among adult women [5].
Article
Uterine perforation is an infrequent but serious complication of dilation and evacuation (O&E). The purpose of this case report is to describe management strategies once a uterine perforation is identified. A 15-year-old female at 15 weeks' gestation presented to a freestanding clinic for elective abortion. After serial cervical dilation, omentum was seen in the suction curette. The patient was transferred to a nearby hospital, she underwent an exploratory laparotomy. A 1.5-cm anterior uterine perforation was found. The uterus was evacuated under direct visualization prior to repair of the defect. Uterine perforation during D&E often requires laparotomy to repair the defect and to evaluate for injury to adjacent organs. Evacuation can be completed transcervically under direct visualization or through the perforation site.
Article
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In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women's health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists. Forty years later, 100 professors examine the statement of their predecessors in light of medical advances and legal changes and suggest a further course of action for obstetrician gynecologists.
Article
Background: Postabortion hemorrhage occurs in up to 2% of second-trimester pregnancy terminations. Postabortion hemorrhage is the leading cause of postabortion maternal mortality. We report the successful use of an obstetric balloon for second-trimester postabortion hemorrhage complicated by disseminated intravascular coagulation. Case: A 38-year-old multigravid woman presented with hypovolemic shock from disseminated intravascular coagulation after second-trimester termination of an anomalous fetus. An intrauterine Foley catheter filled with 60 mL of fluid failed to tamponade bleeding. An obstetric balloon filled with 330 mL of fluid temporized bleeding until the patient's coagulopathy was corrected. Conclusion: An obstetric balloon should be considered in the management of second-trimester postabortion hemorrhage complicated by disseminated intravascular coagulation while coagulopathy is corrected.
Article
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In spite of legalising abortion and making safe abortion available at affordable price at accessible distance to almost everyone, unsafe abortion especially second trimester abortion is still a big health problem in Nepal. The objective of the study is to fi nd the demographic profile, reasons for seeking abortion and to see the effectiveness of Misoprostol in preparing the cervix. A prospective study was done in the two second trimester abortion trainings conducted in Maternity hospital, Kathmandu. Total 57 clients had second trimester abortion performed. Information was collected from structured questionnaire and then data was analysed. Commonest reason for seeking abortion was, multiparity (61.4%). Common reasons for second trimester abortion were, completed family size with unwanted pregnancy (61.4%), unwanted pregnancy in married (10.52%) unwanted pregnancy in unmarried (5.26%). Second trimester abortion is one of the most common procedures performed in reproductive-aged women and when performed by a skilled provider in the appropriate setting, it is one of the safest surgeries, if it is well supported by change in policy of the country and acceptability of the people.
Article
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The safety and approach late second-trimester outpatient dilatation and evacuation abortion is controversial. In this series, 1000 dilataton and evacuation abortions were performed on patients from 17 through 25 menstrual weeks' gestation in a private office outpatient facility. Each patient experienced serial multiple laminaria treatment over two days before abortion. Patients at 20 weeks' gestation or more also received adjunctive urea amnioinfusion on the day of the procedure. Three patients (0.3%) experienced major complications. Although a wide variety of clinical problems was encountered, procedure times were short, blood loss was generally low, and other complication rates were low. Recommendations for staffing and the prevention of complications are discussed.
Article
The incidence of abortion has declined nearly every year between 1990 and 2005, but this trend may be ending, or at least leveling off. Access to abortion services is a critical issue, particularly since the number of abortion providers has been falling for the last three decades. In 2009 and 2010, all facilities known or expected to have provided abortion services in 2007 and 2008 were contacted, including hospitals, clinics and physicians' offices. Data on the number of abortions performed were collected and combined with population data to estimate national and state-level abortion rates. Abortion incidence, provision of early medication abortion, gestational limits, charges and antiabortion harassment were assessed by provider type and abortion caseload. In 2008, an estimated 1.21 million abortions were performed in the United States. The abortion rate increased 1% between 2005 and 2008, from 19.4 to 19.6 abortions per 1,000 women aged 15-44; the total number of abortion providers was virtually unchanged. Small changes in national abortion incidence and number of providers masked substantial changes in some states. Accessibility of services changed little: In both years, 35% of women of reproductive age lived in the 87% of counties that lacked a provider. Fifty-seven percent of nonhospital providers experienced antiabortion harassment in 2008; levels of harassment were particularly high in the Midwest (85%) and the South (75%). The long-term decline in abortion incidence has stalled. Higher levels of harassment in some regions suggest the need to enact and enforce laws that prohibit the more intrusive forms of harassment.
Article
A case of severe postpartum hemorrhage is reported. Three separate surgical procedures failed to reveal the source of bleeding, and standard surgical techniques, including bilateral ligation of the hypogastric arteries, were unsuccessful in producing hemostasis. However, angiography successfully identified the specific bleeding vessel, and transcatheter embolization with Gelfoam fragments quickly and effectively stopped the hemorrhage. The authors consider angiographic embolization to be an effective alternative approach to the control of pelvic hemorrhage and recommend that the technique be considered prior to surgical intervention.
Article
The comparative safety of methods used to perform second-trimester abortion is an important public health concern. Morbidity and mortality studies indicate that dilatation and evacuation (D & E) is safer than instillation abortion, which is safer than hysterotomy or hysterectomy. In the third phase of the Joint Program for the Study of Abortion, the adjusted relative risk of serious complications associated with intra-amniotic instillation of urea and prostaglandin F2 alpha (the safest abortifacient regimen) was 1.9 times that associated with D & E (95% confidence interval 1.2-3.1). Surveillance of abortion mortality in the United States from 1972 to 1981 revealed a death-to-case rate of 4.9 per 100 000 abortions associated with D & E, 9.6 with instillation methods, and over 60 with hysterotomy or hysterectomy. Little information exists on potential late sequelae of second-trimester abortion. D & E appears to be the safest method of second-trimester abortion available in the United States.
Article
The Center for Reproductive and Sexual Health is an ambulatory abortion clinic performing first trimester procedures under paracervical block. Sixty thousand (60,000) procedures have been performed from July 1, 1970, to August 1, 1972. A syndrome of syncope, abdominal pain, and tenderness several hours postprocedure, closely resembling the picture of uterine perforation, has been identified and is called, for want of a better understanding of the pathophysiology involved, the postabortal pain or "redo" syndrome. It is promptly relieved by resuctioning ("redoing") the patient. Because of the masses of firm clot found in the uterus at the time of resuctioning, it is suggested that a significant coagulopathy resembling that previously described in second trimester abortion may be operative here. © 1973 The American College of Obstetricians and Gynecologists.
Article
The frequency of hysterectomy as treatment for abortion complications may reflect the incidence of serious abortion morbidity. To examine this use of hysterectomy, the authors analyzed reports of approximately 237,000 legal abortions performed in the United States from 1970 to 1978. Overall, the rate of hysterectomy associated with curettage abortion decreased from 4.6 per 10,000 abortions in 1970 to 1971 to 1.4 per 10,000 in 1975 to 1978; the rate of hysterectomy associated with instillation abortion fell from 6.8 to 4.3 per 10,000 for the same years. A history of older age, previous births, use of instillation abortion, and preexisting gynecologic disorders increased the likelihood of hysterectomy. In cases of curettage abortion, hysterectomy rates increased significantly with advancing gestational age. Changes in abortion technology, improvements in physician skill, and more conservative management of complications have likely contributed to the decreasing frequency of hysterectomy necessitated by abortion complications.
Article
The dilatation and evacuation procedure was explored in 1971 as an alternative method of second-trimester abortion. The results in 11,747 cases from 1972 through 1981 are presented. Although complications do occur--most notably hemorrhage, cervical laceration, fever, and perforation--the overall complication rate was lower than that reported for saline or prostaglandin in other large series. Further study and refinement of technique may help bring this shorter, safer, and more convenient procedure within the reach of larger numbers of women seeking second-trimester abortion.
Article
Hemorrhage is one of the most frequent complications after dilation and evacuation. A small fraction of patients with hemorrhage will not respond to standard therapies. We discuss a case where both reaspiration and standard pharmacologic therapy failed to control hemorrhage and where hemorrhage was ultimately controlled by tamponade with two Foley catheters. We propose this method as an additional alternative for controlling hemorrhage after dilation and evacuation before resorting to angiographic embolization or surgery.
Article
In pregnancy and puerperium disseminated intravascular coagulopathy may accompany abruptio placenta, intrauterine fetal demise with retained dead fetus, amniotic fluid embolism, endotoxin sepsis, preecalampsia with HELLP and massive transfusion. Clinical signs and symptoms of DIC can include oozing from venipuncture sites and/or mucous membranes, red cell lysis from activation of the complement system, hemorrhage from coagulopathy and possible uterine atony, hypotension from hemorrhage and/or bradykinin release, and oliguria from end-organ insult and hypovolemia/hypotension. Treatment of DIC consists of replacement of volume, blood products, and coagulation components and cardiovascular and respiratory support with elimination of underlying triggering mechanism.
Article
The purpose of this study was to compare complication rates of patients who undergo dilation and evacuation or medical abortion between 14 and 24 weeks of gestation. We present a retrospective cohort study of 297 women who underwent either dilation and evacuation or medical abortion. Statistical methods included the Student t test, the chi(2) test, the Fisher exact test (where appropriate), and logistic regression. The overall complication rate was significantly lower in patients who underwent dilation and evacuation than in patients who underwent medical abortion (4% vs 29%; P <.001). Medical abortions with misoprostol resulted in a lower complication rate than abortions with other medications (odds ratio, 0.2; 95% CI, 0.1-0.4). More Laminaria was associated with a decreased risk of complications with surgical abortions (odds ratio, 0.9; 95% CI, 0.7-1.0). Dilation evacuation is the safest method of second-trimester abortion. Misoprostol is safer than other methods for medical abortion. Maximal use of Laminaria will decrease complication rates in surgical abortion.
Article
To assess risk factors for legal induced abortion-related deaths. This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor-specific mortality rates. During 1988-1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13-15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16-20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation. Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths. II-2
Article
To investigate the value of transvaginal sonographic findings of intraplacental lacunae for predicting adherent placenta and clinical outcome in patients with placenta previa totalis and a history of Cesarean section. Fifty-one patients with placenta previa totalis diagnosed by transvaginal sonography and with a history of Cesarean section who delivered at our hospital were included in the study. The sonographic findings of intraplacental lacunae were classified into one of four grades. Pathological analysis of the placenta was performed for all patients who delivered, and in cases of hysterectomy, examination of the uterus was also performed. The placental findings and obstetric complications, including massive transfusion, intensive care unit admission and Cesarean hysterectomy, were compared with the grade of lacuna. Lacunae were classified as Grade 1+ in 10 cases, Grade 2+ in 11 cases, Grade 3+ in five cases and as Grade 0 (i.e. lacunae were absent) in the remaining 25 cases. When lacunae of > or = Grade 1+ were considered, the sensitivity, specificity, positive predictive value and negative predictive value of diagnosing adherent placenta were 86.9%, 78.6%, 76.9% and 88.0%, respectively. When lacunae of > or = Grade 2+ were considered, the sensitivity, specificity, positive predictive value and negative predictive value of diagnosing placenta increta or percreta were 100%, 97.2%, 93.8% and 100%, respectively. Hysterectomy was performed in 18 cases, among whom two cases showed Grade 1+ lacunae, 11 cases showed Grade 2+ lacunae, and five cases showed Grade 3+ lacunae. No hysterectomy was performed in any case in which lacunae were absent. Compared to those without lacunae, the number of massive transfusions and intensive care unit admissions and cases of disseminated intravascular coagulopathy and Cesarean hysterectomy were significantly greater in those with lacunae (P < 0.0001). Transvaginal sonographic findings of intraplacental lacunae in patients with placenta previa totalis and a history of Cesarean section are useful in the prediction of adherent placenta and may have a role in the prediction of clinical outcome.
Article
The incidence of placenta accreta has increased dramatically over the last three decades, in concert with the increase in the cesarean delivery rate. Optimal management requires accurate prenatal diagnosis. The purpose of this study was to determine the precision and reliability of ultrasonography and magnetic resonance imaging (MRI) in diagnosing placenta accreta. A historical cohort study was performed with information gathered from our obstetric, radiologic, and pathology databases. Records from January 2000 to June 2005 were reviewed to identify patients with a diagnosis of placenta previa, low-lying placenta with a prior cesarean delivery, or history of a myomectomy to determine the accuracy of pelvic ultrasonography in the diagnosis of placenta accreta. The records of those considered to be suspicious for placenta accreta and subsequently referred for additional confirmation by MRI were also analyzed. The sonographic and MRI diagnoses were compared with the final pathologic or operative findings or with both. Of the 453 women with placenta previa, previous cesarean delivery and low-lying anterior placenta, or previous myomectomy, 39 had placenta accreta confirmed by pathological examination. Ultrasonography accurately predicted placenta accreta in 30 of 39 of women and correctly ruled out placenta accreta in 398 of 414 without placenta accreta (sensitivity 0.77, specificity 0.96). Forty-two women underwent MRI evaluation because of findings suspicious or inconclusive of placenta accreta by ultrasonography. Magnetic resonance imaging accurately predicted placenta accreta in 23 of 26 cases with placenta accreta and correctly ruled out placenta accreta in 14 of 14 (sensitivity 0.88, specificity 1.0). A two-stage protocol for evaluating women at high risk for placenta accreta, which uses ultrasonography first, and then MRI for cases with inconclusive ultrasound features, will optimize diagnostic accuracy.
Article
To estimate the association between the number of prior cesarean deliveries and pregnancy outcomes among women with placenta previa. Women with a placenta previa and a singleton gestation were identified in a concurrently collected database of cesarean deliveries performed at 19 academic centers during a 4-year period. Maternal and perinatal outcomes were analyzed after stratifying by the number of cesarean deliveries before the index pregnancy. Of the 868 women in the analysis, 488 had no prior cesarean delivery, 252 had one prior cesarean delivery, 76 had two prior cesarean deliveries, and 52 had at least three prior cesarean deliveries. Multiple measures of maternal morbidity (eg, coagulopathy, hysterectomy, pulmonary edema) increased in frequency as the number of prior cesarean deliveries rose. Even one prior cesarean delivery was sufficient to increase the risk of an adverse maternal outcome (a composite of transfusion, hysterectomy, operative injury, coagulopathy, venous thromboembolism, pulmonary edema, or death) from 15% to 23%, which corresponded, in multivariable analysis, to an adjusted odds ratio of 1.9 (95% confidence interval 1.2-2.9). Conversely, gestational age at delivery and adverse perinatal outcome (a composite measure of respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3 or 4, seizures, or death) were unrelated to the number of prior cesarean deliveries. Among women with a placenta previa, an increasing number of prior cesarean deliveries is associated with increasing maternal, but not perinatal, morbidity. II.
Article
We did computer searches to find studies that compared any operation to any medicine used for abortion at this stage of pregnancy. We wrote to researchers and looked through book chapters and other articles to find more studies. We found two studies. The first compared dilation and evacuation (D&E) to injecting a drug into the pregnant womb. The second compared D&E to drugs taken by mouth and by vagina. The D&E operation was better than injecting medicines into the womb. Medicines taken by mouth and vagina worked as well and were as acceptable as a D&E, but caused more pain and side effects. More studies with modern medicines used for abortion after 3 months of pregnancy are needed.
Article
Accurate information about abortion incidence and services is necessary to monitor levels of unwanted pregnancy and women's ability to access abortion services. All known abortion providers in the United States were contacted for information about abortion services in 2004 and 2005. This information, along with data from the U.S. Census Bureau, was used to examine national and state trends in numbers of abortions and abortion rates, proportions of counties and metropolitan areas without an abortion provider, and accessibility of abortion services. An estimated 1.2 million abortions were performed in the United States in 2005, 8% fewer than in 2000. The abortion rate in 2005 was 19.4 per 1,000 women aged 15-44; this rate represents a 9% decline from 2000. There were 1,787 abortion providers in 2005, only 2% fewer than in 2000. Some 87% of U.S. counties, containing 35% of women aged 15-44, did not have an abortion provider in 2005. Early medication abortion, offered by an estimated 57% of known providers, accounted for 13% of abortions (and for 22% of abortions before nine weeks' gestation). The average amount paid for an abortion at 10 weeks was $413-after adjustment for inflation, $11 less than in 2001. The numbers of abortions and the abortion rate continued their long-term decline through 2005. Reasons for this trend are unknown but may include improved access to and use of contraceptives or decreased access to abortion services.
Article
Although less than 2% of abortions in the United States occur after 20 weeks, procedures performed at more advanced gestations are associated with increased morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20 or more weeks' gestation reduces procedural risk. However, few clinical trials have included sufficient information on best practices for cervical preparation in this gestational age range. For procedures at 20 or more weeks' gestation, at least 1 day of cervical preparation is recommended. Evidence is less clear that the procedure is faster or safer with the use of either serial dilation over more than 1 day or adjuvant misoprostol. Osmotic dilators are preferable to misoprostol, but there are insufficient data to support either laminaria or Dilapan as the preferred dilator. Fewer Dilapan are needed to gain the same amount of dilation as laminaria. The Society of Family Planning recommends preoperative cervical preparation before D&E between 20 and 24 weeks. Further studies are needed to clarify the best means to prepare the cervix to minimize abortion complications and improve outcome in this gestational age range.
Article
Approximately 1 out of 10 abortions in the United States occurs in the second trimester of pregnancy. This study uses survival analysis to identify the factors which delay each step of the process of obtaining an abortion. This is a secondary data analysis of a cross-sectional study investigating a sample of 398 women who presented for elective abortion at an urban hospital. Respondents completed a survey using an audio-assisted self-interviewing program and provided a timeline for their process of obtaining an abortion. In our analysis, we divided the abortion process into three steps ending in three distinct events (first pregnancy test, calling a clinic, getting an abortion). Factors associated with delay during the first step include obesity [hazard ratio (HR) 0.8, 95% CI 0.6-1.0], abuse of drugs or alcohol (HR 0.7, 95% CI 0.6-1.0), prior second-trimester abortion (HR 0.6, 95% CI 0.4-0.8) and being unsure of last menstrual period (HR 0.6, 95% CI 0.4-0.7) and emotional factors such as being in denial (HR 0.8, 95% CI 0.6-1.0) and fear of abortion (HR 0.7, 95% CI 0.5-1.0). This study identified key factors associated with delay in obtaining abortion care. Interventions which seek to address these factors, especially those factors associated with later pregnancy suspicion and testing, may reduce abortion delay and facilitate women obtaining their abortions when medical risk and overall cost are lower.
Article
To summarize the efficacy of postabortion uterine artery embolization in cases of refractory hemorrhage. Forty-two women were identified who had postabortion uterine artery embolization at San Francisco General Hospital between January 2000 and August 2007. Seven underwent embolization for hemorrhage caused by abnormal placentation. Embolization was successful in 90% (38 of 42) of cases. All failures (n=4) were in patients who had confirmed abnormal placentation. However, three of seven women (43%) with probable accreta diagnosed by ultrasonography were treated successfully with uterine artery embolization. Two patients experienced complications of uterine artery embolization. These complications-one contrast reaction and one femoral artery embolus-were treated without further sequelae. Uterine artery embolization is an alternative to hysterectomy in patients with postabortion hemorrhage refractory to conservative measures, especially when hemorrhage is caused by uterine atony or cervical laceration.
Thecomparative safetyof second-trimester abortionmeth-ods
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  • Schulzkf
GrimesDA,SchulzKF.Thecomparative safetyof second-trimester abortionmeth-ods. Ciba Found Symp. 1985;115:83–101
Prevention and management of postpartum hemorrhage- SOGC Clinical Practice Guidelines (No. 88)
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