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Practice bulletins > #135 Second Trimester Abortion > Flashcards

#135 Second Trimester Abortion Flashcards

1
Q

what percentage of women have an abortion by age 45?

A

30%

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2
Q

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

A

6.2%

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3
Q

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

A

4%

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4
Q

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

A

1.3%

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5
Q

What is the rate of IUFD?

A

6.22 per 1,000 (20 wks or greater)

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6
Q

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

A

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

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7
Q

What year was Roe v. Wade?

A

1973

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8
Q

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

A

Osmotic dilators or prostaglandin analogues

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9
Q

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

A

Decreased risk of cervical trauma

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10
Q

What is an intact D&E?

A

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

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11
Q

What is a drawback of intact D&E?

A

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

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12
Q

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

A

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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13
Q

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

A

D&E

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14
Q

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

A

D&E

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15
Q

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

A

Misoprostol, either alone or in combination with other agents

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16
Q

What is the preferred 2nd trimester medical abortion regimen?

A

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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17
Q

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

A

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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18
Q

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

A

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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19
Q

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

A

91%

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20
Q

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

A

As of 2010, no.

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21
Q

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

A

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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22
Q

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

A

Childbirth, 14x higher risk

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23
Q

What is the definition of a postabortion hemorrhage?

A

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

24
Q

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

A

0.1-0.6%

25
Q

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

A

0.7%

26
Q

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

A

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

27
Q

What are etiologies of postabortion hemorrhage?

A

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

28
Q

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

A

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

29
Q

How often is D&E complicated by uterine atony?

A

2.6% of cases

30
Q

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

A

3.3%

31
Q

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

A

0.2-0.5%

32
Q

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

A

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

33
Q

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

A

D&E

34
Q

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

A

As low as 65%

35
Q

Is MRI better at diagnosing accreta than ultrasound?

A

Similar, but may be useful to confirm accreta

36
Q

What is the prevalence of postabortion infection in second trimester?

A

0.1-4%

37
Q

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

A

Decrease by 40%

38
Q

What antibiotics are used for surgical prophylaxis for abortions?

A

Tetracyclines and metronidazole

39
Q

What antibiotics are recommended for second-trimester medical abortion?

A

None

40
Q

What is the rate of amniotic fluid embolism?

A

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

41
Q

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

A

80%

42
Q

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

A

10-20/100,000

43
Q

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

A

Retained placenta (21%)

44
Q

What is the complication rate of D&E?

A

4%

45
Q

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

A

29%

46
Q

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

A

Methylergonovine maleate (unless contraindicated)

47
Q

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

A

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

48
Q

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

A

Bimanual massage. Placement of intrauterine foley catheter or balloon

49
Q

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

A

1.4/10,000

50
Q

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

A

Uterine perforation

51
Q

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

A

Uterine artery laceration

52
Q

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

A

Targeted uterine artery embolization or laparotomy

53
Q

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

A

True

54
Q

How quickly after an abortion can ovulation resume?

A

As early as 21 days after the procedure

55
Q

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

A

Hysteroscopic sterilization, diaphragm, cervical cap

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