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Clinician's Guide for Second-Trimester Abortion, Second Edition

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Several procedures can be used to perform abortion in the second trimester. In general, these procedures can be described as surgical or medical; the latter method, which involves the use of medication, is often called induction abortion. Both types of methods are recommended by the World Health Organization (WHO, 2003) and are used in various countries. In the United States, approximately 95 percent of all secondtrimester abortions are performed with dilatation and evacuation (D&E) (Darney et al., 1996), and it is the method most commonly used by non–National Health Service abortion providers in the United Kingdom (Royal College of Obstetricians and Gynaecologists [RCOG], 2005). In parts of Western Europe, such as France and Sweden, induction abortions are more common than D&E procedures are. This guide provides information about both surgical and induction-abortion methods for pregnancies from 13 through 24 weeks of pregnancy, on the basis of the most recent scientific evidence available.
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... It is considered completely outdated and has long been out of use in developed countries. 12 D&E is carried out in Viet Nam at 13-18 weeks of pregnancy. This method requires preparation of the cervix and evacuation of the uterus with suction and special forceps. ...
... 14 The recommended second trimester medical abortion methods are a combination of mife-pristone and misoprostol or misoprostol alone. 12 Although these are being used widely in many other countries, and are both effective and safe, they have not yet been introduced into the regular abortion services in Viet Nam. In the National Guidelines for providing reproductive health services in Viet Nam, medical abortion has just been approved for use in the first trimester. ...
... In 1999, a team from the nongovernment international organization Ipas worked closely with the Vietnamese MOH to introduce D&E to five senior Vietnamese physicians already proficient in MVA for first-trimester abortion. Standardized procedures were written in a training module and then translated into Vietnamese [15]. We used a competency-based training approach with pelvic model practice, role-plays, pre-and post-training written tests, interactive lectures, case studies and a standardized D&E procedure with a checklist. ...
... Fourteen percent were breastfeeding at the time of their abortion. Median pregnancy duration was 14.6 weeks (range, [12][13][14][15][16][17][18] (Tables 2 and 3). Twenty-eight percent of the patients were over 15 weeks. ...
Article
The dilation and evacuation (D&E) procedure was modified for use in a low-resource setting where access to electric vacuum aspiration is limited. In this demonstration project, buccal misoprostol is used for cervical preparation, followed by evacuation using manual vacuum aspiration (MVA) and forceps. Senior physicians at the Hanoi Obstetrics and Gynecology Hospital were trained in D&E and subsequently conducted 439 D&E procedures. The primary outcomes were efficacy and safety. Secondary outcome measures include efficacy of buccal misoprostol for cervical preparation prior to D&E and the feasibility of MVA for use in the D&E procedure. Successful abortion took place in 100% of the cases. Three major complications occurred. This procedure may be appropriate in other low-resource settings lacking safe, effective abortion services in the second trimester.
... The assessments confirmed whether the sites met the selection criteria as well as criteria developed by Ipas. 9 Five of the six hospitals (covering 10% of the population) satisfied the prerequisites for both methods and an adequate recovery area. The sixth hospital did not offer first trimester services or have space for second trimester services, and providers were less willing to introduce them. ...
Article
Full-text available
This paper describes experiences and lessons learned about how to establish safe second trimester abortion services in low-resource settings in the public health sector in three countries: Nepal, Viet Nam and South Africa. The key steps involved include securing the necessary approvals, selecting abortion methods, organising facilities, obtaining necessary equipment and supplies, training staff, setting up and managing services, and ensuring quality. It may take a number of months to gain the necessary approvals to introduce or expand second trimester services. Advocacy efforts are often required to raise awareness among key governmental and health system stakeholders. Providers and their teams require thorough training, including values clarification; monitoring and support following training prevents burn-out and ensures quality of care. This paper shows that good quality second trimester abortion services are achievable in even the most low-resource settings. Ultimately, improvements in second trimester abortion services will help to reduce abortion-related morbidity and mortality. Résumé Cet article décrit les expériences et les enseignements obtenus sur la création de services sûrs d'avortement du deuxième trimestre en situation de ressources limitées dans le secteur de la santé publique de trois pays : Népal, Viet Nam et Afrique du Sud. Les étapes clés étaient l'obtention des autorisations, la sélection des méthodes d'avortement, l'organisation des centres, l'acquisition des équipements et fournitures nécessaires, la formation du personnel, la mise en place et la gestion des services et la garantie de qualité. Plusieurs mois sont parfois nécessaires pour obtenir l'autorisation d'introduire ou d'élargir les services d'avortement du deuxième trimestre. Des activités de plaidoyer sont souvent requises pour sensibiliser les acteurs clés de l'administration et du système de santé. Les prestataires et leurs équipes exigent une formation approfondie, notamment une clarification des valeurs ; après la formation, un suivi et un soutien préviennent l'épuisement professionnel et garantissent la qualité des soins. L'article montre que des services de bonne qualité d'avortement au deuxième trimestre sont possibles même dans les environnements aux ressources les plus limitées. En fin de compte, les améliorations dans ces services aideront à réduire la morbidité et la mortalité liées à l'avortement. Resumen En este artículo se describen las experiencias y lecciones aprendidas sobre cómo establecer servicios seguros de aborto en el segundo trimestre, en lugares con escasos recursos, en el sector salud pública de tres países: Nepal, Vietnam y Sudáfrica. Los pasos fundamentales son: obtener la autorización necesaria, seleccionar los métodos de aborto, organizar los establecimientos de salud, obtener el equipo y los suministros necesarios, capacitar al personal, establecer y manejar los servicios y garantizar la calidad. Posiblemente tome varios meses obtener la autorización necesaria para lanzar o ampliar los servicios en el segundo trimestre. Por lo general, se necesitan esfuerzos de promoción y defensa para concientizar a las partes interesadas del gobierno y del sistema de salud. Los prestadores de servicios y su equipo necesitan capacitación completa, que incluya aclaración de valores; el monitoreo y apoyo post-capacitación ayudan a evitar agotamiento y garantizar la calidad de la atención. Es posible lograr servicios de alta calidad de aborto en el segundo trimestre, incluso en los lugares donde existe la mayor escasez de recursos. A la larga, las mejoras en los servicios de aborto en el segundo trimestre ayudarán a disminuir las tasas de morbilidad y mortalidad relacionadas con el aborto.
... These international guidelines recommend that second-trimester sites have at least the same basic facilities as those required for first-trimester procedures, and there are no stipulations for transfusion services or comprehensive emergency obstetric and neonatal care. 25 The Government of Nepal's regulations impose standards for second-trimester abortion services that are not required of other medical procedures of similar acuity and risk imposing burdens that many facilities, including some government district hospitals, cannot bear. Accordingly, these regulations likely do not provide safer services for women but instead may hinder the decentralization of services and further limit access. ...
... The assessments confirmed whether the sites met the selection criteria as well as criteria developed by Ipas. 9 Five of the six hospitals (covering 10% of the population) satisfied the prerequisites for both methods and an adequate recovery area. The sixth hospital did not offer first trimester services or have space for second trimester services, and providers were less willing to introduce them. ...
Article
This paper describes experiences and lessons learned about how to establish safe second trimester abortion services in low-resource settings in the public health sector in three countries: Nepal, Viet Nam and South Africa. The key steps involved include securing the necessary approvals, selecting abortion methods, organising facilities, obtaining necessary equipment and supplies, training staff, setting up and managing services, and ensuring quality. It may take a number of months to gain the necessary approvals to introduce or expand second trimester services. Advocacy efforts are often required to raise awareness among key governmental and health system stakeholders. Providers and their teams require thorough training, including values clarification; monitoring and support following training prevents burn-out and ensures quality of care. This paper shows that good quality second trimester abortion services are achievable in even the most low-resource settings. Ultimately, improvements in second trimester abortion services will help to reduce abortion-related morbidity and mortality.
Article
The development of dilatation and evacuation (D&E) as a method of second trimester surgical abortion occurred soon after abortion law reform took place in the 1960s and 1970s in Europe and the United States. Today, D&E is the predominant method of second trimester abortion in many parts of the world. Debate still exists as to whether surgical or medical methods are optimal for second trimester pregnancy termination. A continuing challenge to provision of D&E is the availability of a large enough pool of skilled providers. This article reviews the current surgical methods used in second trimester abortion, as well as their safety, advantages and disadvantages, acceptability and associated complications. Methods used to ensure safe and efficient surgical termination of second trimester pregnancies such as cervical preparation and ultrasound guidance are also reviewed.
Article
In Viet Nam, abortion has been legal up to 22 weeks of pregnancy since the 1960s. There are about one million induced abortions every year. First trimester abortion is provided at central, provincial, district and commune level, while second trimester abortion is provided only at central and provincial level. For second trimester abortion, dilatation and evacuation (D&E) has been introduced at some central and provincial hospitals, and medical abortion protocols have been included in the draft National Standards and Guidelines currently being updated. However, Kovac's, an unsafe method, is still often used at many provincial hospitals. While access to first trimester abortion services is not difficult, there are still many barriers to second trimester abortion, especially for young, unmarried women. In order to prevent unwanted pregnancies, increase access to safe abortion and improve quality of care, the Vietnamese Ministry of Health is working with others to establish national policies and developing effective models for women-friendly comprehensive abortion care, including post-abortion family planning. This paper, based on published information, interviews and observations by the second author of service delivery in 2006–2008, provides an overview of second trimester abortion services in Viet Nam and ongoing plans for improving them. Résumé Au Viet Nam, depuis les années 60, l'avortement est légal jusqu'à 22 semaines de grossesse. Près d'un million d'avortements y sont pratiqués chaque année. L'avortement du premier trimestre est assuré aux niveaux central, provincial, du district et de la commune. Pour l'avortement du deuxième trimestre, certains hôpitaux centraux et provinciaux ont introduit la méthode par dilatation et évacuation, et le projet de normes et directives nationales qui est actuellement mis à jour inclut des protocoles d'avortement médicamenteux. Néanmoins, même si elle n'est pas sûre, la méthode Kovac est encore souvent utilisée dans beaucoup d'hôpitaux provinciaux. Alors que l'accès à l'avortement du premier trimestre est aisé, de nombreux obstacles demeurent à l'avortement du deuxième trimestre, en particulier pour les jeunes femmes célibataires. Afin d'éviter les grossesses non désirées, élargir l'accès à l'avortement médicalisé et relever la qualité des soins, le Ministère vietnamien de la santé collabore avec d'autres institutions pour définir des politiques nationales et établir des modèles efficaces de services d'avortement centrés autour des femmes, notamment de planification familiale post-avortement. Cet article, fondé sur des informations publiées, des entretiens et l'observation de la prestation de services par les auteurs en 2006-2008, décrit les services d'avortement du deuxième trimestre au Viet Nam et les projets en cours pour les améliorer. Resumen En Viet Nam, el aborto es legal hasta las 22 semanas de embarazo desde la década de los sesenta. Cada año se inducen aproximadamente un millón de abortos. A nivel central, provincial, distrital y comunal, se proporcionan servicios de aborto en el primer trimestre, mientras que los de segundo trimestre son proporcionados sólo a nivel central y provincial. Para este último, la dilatación y evacuación (D&E) ha sido introducida en algunos hospitales centrales y provinciales, y los protocolos de aborto con medicamentos se han incluido en la versión preliminar de las Normas y Directrices Nacionales, en proceso de actualización. Sin embargo, Kovac, un método inseguro, aún se utiliza con frecuencia en muchos hospitales provinciales. Aunque no es difícil acceder a los servicios de aborto en el primer trimestre, todavía existen muchas barreras al aborto en el segundo trimestre, especialmente para las mujeres jóvenes y solteras. A fin de evitar embarazos no deseados, ampliar el acceso al aborto seguro y mejorar la calidad de la atención, el Ministerio de Salud de Viet Nam está trabajando con otros para establecer políticas nacionales y crear modelos eficaces para la atención integral del aborto centrada en la mujer, que incluyan la planificación familiar postaborto. En este artículo, basado en información publicada, entrevistas y observaciones de los autores de la prestación de servicios en 2006–2008, se proporciona una visión general de los servicios de aborto en el segundo trimestre en Viet Nam y de los planes en curso para mejorarlos.
Book
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The primary purpose of this reference manual is to provide guidance to healthcare personnel on improving the quality of care available to women seeking abortion services. This manual introduces the Ipas MVA Plus® and Ipas EasyGrip® cannulae, and explains the manual vacuum aspiration (MVA) abortion procedure in detail. It also explains medication-abortion methods that use the medications misoprostol and mifepristone. All the methods described here offer women safe, effective options for first-trimester uterine evacuation.
Article
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National statistics are beginning to suggest that dilatation and evacuation (D & E) may have important advantages for the patient experiencing a second-trimester abortion. However, significant emotional reactions of medical and counseling staff tend to accompany this procedure. The present study used a self-administered questionnaire followed by an interview. The respondents were 15 present and former staff members of a small outpatient abortion clinic. All the respondents were asked to describe the various reactions to the D & E procedures, which are performed up to the 23rd menstrual week of gestation. A follow-up study was conducted one year later. There was clear agreement that D & E is qualitatively a different procedure, medically and emotionally, than early abortion. Many of the respondents reported serious emotional reactions that produced physiological symptoms, sleep disturbances, effects on interpersonal relationships, and moral anguish. This study attempts to evaluate these reactions in the context of the reports of the medical advantages of D & E.
Article
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Fetal measurements, especialty fetal foot length, were corre-lated with fetal age-as measured by last menstrual dates-for 1800 tissue specimens obtained after dilatation and evacuation abortion. These observations were compared l'{ith Streeter's results from 1920. Fetal ages ranged from ten through 26 completed menstrual weeks. Fetal measurements including weight, knee-to-heel length, biparietal diameter, placental weight, and amniotic fluid volume were correlated with foot length. Sonographic biparietal diameter obtained by real-time imaging was correlated with tissue measure-ment of biparietal diameter for various fetal ages. The difficulties of establishing valid correlations are discussed, and a table of recommended vaiues for fetal measurements by week of fetal age is provided. (Obstet Gynecol 63:26, 1984) In reading Streeter's 1 1920 description of fetal measure-ments, one senses the frustration he experienced in studying this stage of human development. Most of his specimens were obtained from obstetric depart-ments throughout the country where women had experienced spontaneous abortions. Little was known of the pregnancy histories, and the menstrual dates were frequently absent or questionable. Because the specimens were preserved in formalin, Streeter ad-vises us that an artifactual element may have been introduced. No similarly complete data concerning human fetal measurements have appeared in the medical literature since Streeter published his results. The present report reviews fetal measurements from the tenth through the 26th completed menstrual week of fetal age in fresh specimens obtained through dilatation and evacuation abortion in a private outpatient abortion facility. Re-sults are compared with those obtained by Streeter.
Article
Objective To assess the effectiveness of a regimen comprising mifepristone followed by a combination of the vaginal and oral administration of misoprostol for mid-trimester medical termination of pregnancy. Design Retrospective analysis of prospectively collected data in women undergoing mid-trimester medical termination of pregnancy. Setting Aberdeen Royal Infirmary, Scotland. Sample A consecutive series of 500 women with pregnancies of 13–21 weeks of amenorrhea undergoing legally induced abortion in one Scottish NHS hospital. Methods Each woman received a single oral dose of mifepristone 200 mg and 36–48 h later vaginal misoprosto1800 pg. Three hours following the first dose of misoprostol, 400 yg doses were administered orally at three hourly intervals, to a maximum of four doses. Success was defined as abortion occurring with five doses of prostaglandin, or within 15 h of administration of the first dose of prostaglandin. Results Ninety-seven percent aborted successfully. The median dose of misoprostol required was 1200 yg and the median induction-toabortion interval after first prostaglandin administration was 6.5 h. The median number of doses of misoprostol required to induce abortion, and the induction-toabortion interval, was statistically significantly higher among women at gestations 17–21 weeks than among those at 13–16 weeks (P= 0–0001). A total of 9.4% required surgical evacuation of the uterus under general anaesthesia and 66.4% of the women were managed as day cases. Conclusions The combination of oral mifepristone 200 mg followed by vaginally and orally administered misoprostol provides a noninvasive and effective regimen for second trimester termination of pregnancy.
Article
Objective To compare the use of 600 and 200 mg mifepristone prior to second trimester termination of pregnancy with the prostaglandin misoprostol. Design A randomised study. Setting A Scottish teaching hospital. Participants Seventy women undergoing legal induced abortion between 13 and 20 weeks of gestation. Intervention Administration of either 600 or 200 mg mifepristone 36 to 48 hours prior to prostaglandin. Main outcome measure Induction-abortion interval. Results The geometric mean induction abortion interval was 6.9 (95 % CI 5.8–8.4) h and 6.9 (95 % CI 5.8–8.2) h in the 600 and 200 mg groups, respectively (no significant difference). The median dose of misoprostol was 1600 pg (three doses) in each group. Analgesic requirements and prostaglandin-related side effects were similar between groups. Overall, 11-4% of women required surgical evacuation of the uterus as a result of retained placenta. Conclusions The dose of mifepristone used in second trimester abortion can be reduced from 600 to 200 mg.
Article
RU 486 activity for therapeutic pregnancy termination through prostaglandin was studied in a controlled survey including 50 patients, in the second and third trimester of pregnancy (in conformity with the French law). Patients were randomly divided into two groups. The first one was administered orally 200 mg of RU 486, 48 hours before the first Sulprostone injection. The control group did not receive any RU 486. The mean duration between prostaglandin administration and miscarriage was significantly shorter in the RU 486 group (13.16 hours), than in the control group (23.16 hours). Women with RU 486 treatment needed less prostaglandin doses and, above all, had less prostaglandin secondary effects than the patients in the control group.
Article
Second trimester elective abortion is safest when accomplished with cervical dilation and instrumental uterine evacuation (D and E), but this procedure carries with it a risk of uterine perforation and possible intra-abdominal trauma. In order to determine if the routine use of intraoperative ultrasonography reduces the risk of this feared and serious complication, 353 elective abortions at 16 to 24 weeks gestation performed without sonography were compared to 457 in which sonography was routinely employed. All 810 operations were carried out in one clinic using the same operative technique. The routine intraoperative use of ultrasonographic imaging to guide intrauterine forceps during uterine evacuation for second trimester elective abortion resulted in a significant reduction in uterine perforation, the rate declining from 1.4% to .2%. These findings support the routine use of intraoperative ultrasonography for second trimester elective abortion to reduce the incidence of uterine perforation and make the procedure a safer one.
Article
Pain during first-trimester abortion by suction-curettage under local anesthesia alone was measured with the McGill Pain Questionnaire (MPQ), and verbal and visual analogue scales in 109 women. The average intensity of abortion pain ranked among moderately intense pain recorded with the MPQ. However, the pain scores had a wide range and appeared influenced by several demographic, psychosocial and medical variables. A correlation/stratified multiple regression design was used to examine the sources of individual variability in pain reports. The results indicated that over a third of the variance in pain reports could be predicted by a set of variables which included the patient's age, self-reports of pre-operative depression, anxiety, fear, low pain tolerance, social and moral concerns, and gynecological characteristics such as uterus retroversion, menstrual pain and gestational age. Pain scores were significantly higher for women who reported moderate to severe levels of pre-abortion depression and for younger patients (13-17 years); other psychosocial and gynecological features made small additional contributions to the prediction of pain scores. The implications of the results are discussed in relation to pain management strategies and underscore the special needs of each woman facing an abortion.