#135 Second Trimester Abortion Flashcards by Angela Nolin

what percentage of women have an abortion by age 45?

30%

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What percentage of abortions take place between 13 and 15wks?

6.2%

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What percentage of abortions take place at 16wks or later?

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What percentage of abortions are performed at 21wks or later?

1.3%

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What is the rate of IUFD?

6.22 per 1,000 (20 wks or greater)

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What percentage of second-trimester abortions are performed by D+E?

95%, however terminations by medical abortion may be under reported

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What year was Roe v. Wade?

1973

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What are options for cervical preparation prior to D&E?

Osmotic dilators or prostaglandin analogues

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What is the benefit of cervical preparation prior to D&E?

Decreased risk of cervical trauma

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What is an intact D&E?

Removal of an intact fetus except for possible decompression of the calvaria

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What is a drawback of intact D&E?

Requires more advanced cervical dilation that is usually achieved over several days

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What are benefits of intact D&E over regular D&E?

Preservation of fetal anatomy. Lower risks of uterine perforation and infection by minimizing use of forceps and reduced risk of retained fetal tissue

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Is 2nd trimester D&E or medical abortion more cost effective?

D&E

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Is 2nd trimester D&E or medical abortion associated with lower risks of complications?

D&E

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What is the preferred method for 2nd trimester medical abortion?

Misoprostol, either alone or in combination with other agents

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What is the preferred 2nd trimester medical abortion regimen?

Mifepristone 200mg orally, follwed in 24-48hrs by:

Miso 800mcg vaginally followed by 400mcg vaginal or sublingual miso q3h up to 5 doses, or
Miso 400mcg buccal q3hrs for 5 doses

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What is preferred 2nd trimester medical abortion regimen if mifepristone not available?

400mcg vaginal or sublingual miso q3h, up to 5 doses, or

600-800mcg vaginal miso, followed by 400mcg vaginal or sublingual miso q3h (may be more effective)

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What is regimen for 2nd trimester medical abortion if miso not available?

Oxytocin 20-100u infused IV over 3 hours, followed by 1 hour without oxytocin to allow diuresis. Dosage may be slowly increased to max of 300u over 3hrs

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What is the efficacy of mifepristone followed by misoprostol for 2nd trimester abortion within 24 hr of initiaion of miso?

91%

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Does data support the use of induced fetal demise to improve safety of D&E?

As of 2010, no.

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What is the mortality rate associated with legal, induced abortions?

0.6 per 100,000

[0.1 per 100,000 procedures at 8wks or less, 8.9 per 100,000 procedures at 21 wks or greater]

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Is the risk of death higher with induced abortion or childbirth?

Childbirth, 14x higher risk

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What is the definition of a postabortion hemorrhage?

bleeding that necessitates a clinical response such as transfusion or admission, and/or bleeding in excess of 500mL.

How often does D&E lead to hemorrhage requiring transfusion?

0.1-0.6%

How often does second-trimester medical abortions lead to hemorrhage requiring transfusion?

0.7%

What are risk factors for 2nd trimester hemorrhage by D&E or medical induction?

AMA, insufficient cervical dilation, use of general anesthesia, medical hx of >1 cesarean delivery

What are etiologies of postabortion hemorrhage?

Retained products of conception, uterine atony, cervical laceration, uterine perforation or rupture, abnormal placentation, DIC

What is the rate of incomplete abortion in D&E and medical abortion for 2nd trimester?

<1% in D&E. At least 8% of medical abortion that involves use of mifepristone.

How often is D&E complicated by uterine atony?

2.6% of cases

How often are 2nd trimester D&Es complicated by cervical laceration?

3.3%

What is the frequency of uterine perforation in second-trimester D&E?

0.2-0.5%

What is the risk of uterine rupture for second trimester medical abortion w/ miso in patients with and without prior cesarean section?

0.28% w/ prior cesarean delivery. 0.04% without prior cesarean delivery

With suspicion of abnormal placentation which method of second-trimester abortion is preferred?

D&E

What is the positive predictive value of ultrasound to diagnose placenta accreta?

As low as 65%

Is MRI better at diagnosing accreta than ultrasound?

Similar, but may be useful to confirm accreta

What is the prevalence of postabortion infection in second trimester?

0.1-4%

How much does prophylactic antibiotics decrease the risk of infection after surgical abortion?

Decrease by 40%

What antibiotics are used for surgical prophylaxis for abortions?

Tetracyclines and metronidazole

What antibiotics are recommended for second-trimester medical abortion?

None

What is the rate of amniotic fluid embolism?

1 in 10,000 to 1 in 80,000 pregnancies

What is the mortality rate of amniotic fluid embolism when it occurs after second-trimester abortion?

80%

What is the incidence of fatal and nonfatal PE per 100,000 abortions?

10-20/100,000

What is the most common complication of second-trimester medical abortion? Which occurs how often?

Retained placenta (21%)

What is the complication rate of D&E?

What is the complication rate of second trimester medical abortion (miso only)?

29%

What is first line medical management of 2nd trimester postabortion hemorrhage?

Methylergonovine maleate (unless contraindicated)

Is buccal/sublingual or rectal misoprostol preferred in setting of 2nd trimester postabortion hemorrhage? What dosing?

800-1000mcg buccal/sublingual is preferred based on pharmacokinetic data

What physical (non medication) interventions can help ameliorate 2nd trimester postabortion hemorrhage d/t atony?

Bimanual massage. Placement of intrauterine foley catheter or balloon

What is the rate of hysterectomy following abortions in the US?

1.4/10,000

What is the most common cause of needed hysterectomy after abortion?

Uterine perforation

What should be suspected if bleeding continues after repair of a high cervical tear at time of 2nd trimester abortion?

Uterine artery laceration

How do you manage a suspected uterine artery laceration at the time of 2nd trimester abortion?

Targeted uterine artery embolization or laparotomy

True or false, vasopressin can be used at the time of D&E to decrease risk of bleeding

True

How quickly after an abortion can ovulation resume?

As early as 21 days after the procedure

What contraceptive methods cannot be considered immediately after 2nd trimester abortion?

Hysteroscopic sterilization, diaphragm, cervical cap