PB#135: Second-Trimester Abortion Flashcards
Potential circumstances that could lead to eAB in 2nd tri (4)
Delay in suspecting/testing for pregnancy, delay in obtaining insurance/funding, delay in obtaining referral, difficulty locating/traveling to available provider
Factors associated w/ higher rates of seeking 2nd tri eAB (3)
Poverty, lower education level, multiple disruptive life events
Percentage of pts who choose to terminate pregnancies if major anatomic/genetic anomalies are detected in 2nd tri
47-95%
Possible OB/medical indications for 2nd tri termination/ evacuation (4)
Pre-E, PPROM, pregnancy failure <20wga, IUFD
IUFD rate at >20wga
6.22 deaths per 1,000 live births + fetal deaths
Demographics w/ higher IUFD rates (3)
Teenage, AMA, Black/Hispanic/Native American pts
Two general management options for 2nd tri eAB
Medical, surgical
Most common method of performing 2nd tri eAB
D&E (~95% of cases)
Percentage of abortion providers that offer services at >12wga, percentage of abortion providers that offer services at >20wga
64%, 23%
Percentage of clinics providing 2nd tri eABs that also offer medical termination
33%
Description of “partial-birth abortion”; year that federal ban on “partial-birth abortion” was passed
Vaguely defined, though widely interpreted as ban on intact D&E unless IUFD occurs prior to surgery; 2003
Reason multiple states have banned eABs at >20wga; what medical evidence suggests to refute this
Concerns related to fetal pain; fetal perception of pain may not occur until 3rd tri
Methods for cervical prep (2)
Osmotic dilators, prostaglandin analogs
Most common prostaglandin analog used in cervical prep
Miso
Reason cervical prep is recommended prior to D&E
Reduce risk of cervical trauma
General technique used in D&E
Aspirating amniotic fluid and removing fetus w/ forceps through cervix and vagina, fetal disarticulation/dismemberment commonly occurs, final suction curettage performed to ensure complete evacuation
General technique used in intact D&E
Requires more advanced cervical dilation over several days, followed by removal of intact fetus except for possible decompression of calvarium
When is intact D&E preferable?
When preservation of fetal anatomy is desired
Lower risks associated w/ intact D&E (2)
Uterine perf, infection 2/2 retained fetal tissue
Disadvantages of 2nd tri induction-termination vs D&E (3)
Less cost-effective, associated w/ greater risk of complications (ie incomplete AB), may be prolonged
Conditions in which medical induction-termination may be preferable over D&E (3)
Pregnancies w/ fetal anomalies, genetic disorders, maternal health issues
Meds/Techniques for medical abortion (5)
Prostaglandin analogs (miso), mife, osmotic dilators, Foley catheters, pit
Why is miso (alone or in combo) recommended over other agents alone (3)?
High efficacy, low cost, ease of use
Mife + vaginal miso induction-termination protocol
Mife 200mg PO > miso 800mcg vaginally 24-48h later > miso 400mcg vaginally/sublingually q3h x5 doses max
Next step if eAB has not completed after 5 doses of miso under mife > vaginal miso induction-termination protocol
Pt may be rest x12h then resume cycle again
Mife + buccal miso induction-termination protocol
Mife 200mg PO > miso 400mcg bucally 24-48h later and q3h x5 doses max
Miso only induction-termination protocol w/o miso loading dose (if mife unavailable)
Miso 400mcg vaginally/sublingually q3h x5 doses max
Next step if eAB has not completed after 5 doses of miso under miso only induction-termination protocol
Pt may be rest x12h then resume cycle again
Superior route of miso placement for nullip pts
Vaginal (over sublingual)
Miso only induction-termination protocol w/ miso loading dose (if mife unavailable)
Miso 600-800mcg vaginal loading dose > miso 400mcg vaginally/sublingually q3h
Induction-termination protocol if both mife and miso unavailable
Pit 20-100U IV q3h > 1h w/o pit (to allow for diuresis) > dose slowly increased to max of 300U over 3h
Why is high-dose pit not commonly used in 2nd tri?
Inefficient uterine response to pit 2/2 fewer oxytocin receptors at this gestational period
Do osmotic dilators provide added benefit to induction w/ prostaglandin analogs?
No
Most effective regimen for 2nd tri medical eAB; percent efficacy of this method
Mife > miso; up to 91% within 24h of initiation of miso
Rare alternative method of performing 2nd tri eAB (instead of medical eAB or D&E); indications for this method (2)
Hyst/Hysterotomy; if other methods are contraindicated or have failed
Does inducing fetal demise increase safety of 2nd tri medical/surgical eAB?
No, although limited evidence does suggest that induced fetal demise prior to medical eAB may shorten induction time
Techniques used to case fetal demise (3)
Umbilical cord division, intraamniotic/intrafetal digoxin injection, fetal intracardiac KCl injection
Reasons some providers may induce fetal demise prior to 2nd tri eAB
May cause maceration (prior to D&E), may avoid transient fetal survival following expulsion
Mortality rate associated w/ eAB; relative risk of mortality in childbirth compared to mortality rate associated w/ eAB
0.6/100,000 legal induced eABs; 14x higher in childbirth
Does eAB-related mortality increase or decrease w/ each week of gestation?
Increase (rate of 0.1 per 100,000 procedures at <8wga compared to 8.9 per 100,000 procedures at >21wga)
Definition of postabortion hemorrhage
Clinical response to excessive bleeding (ie transfusion, hemorrhage) and/or bleeding >500mL
Percentage of D&Es c/b hemorrhage requiring transfusion; percentage of 2nd tri medical eABs c/b hemorrhage requiring transfusion
0.1-0.6%; 0.7%
Risk factors for eAB-related hemorrhage (4)
AMA, insufficient cervical dilation, general anesthesia, hx of >1 prior C/S
Most common etiologies for refractory hemorrhage (6)
In order: atony (52%), abnormal placentation (17%), cervical lac (12%), uterine perf (7%), LUS bleeding w/o atony (5%), DIC (5%)
Percentage of D&Es c/b retained tissue/incomplete AB; percentage of mife medical eABs c/b retained tissue/incomplete AB
<1%; at least 8%
Percentage of D&Es c/b atony
2.6%
Risk factors for eAB-related atony (3)
Increasing pt age, increasing EGA, prior C/S
Percentage of 2nd tri eABs (both surgical and medical) c/b cervical lac
3.3%
Risk factors for eAB-related cervical lac (4)
Mechanical dilation, nulliparity, advanced gestational age, provider inexperience
Percentage of D&Es c/b uterine perf
0.2-0.5%
Risk factors for eAB-related uterine perf (3); protective measure to decrease risk of uterine perf
Advanced gestational age, multiparity, provider inexperience; cervical prep
Entities that may alert provider of uterine perf (2)
Severe pain, visualization of extrauterine tissue in vagina (brisk bleeding not usually seen unless artery is lacerated)
Complications to always consider if perf is suspected in 2nd tri
Bowel/bladder injury
Percentage of 2nd tri eABs c/b uterine rupture in pts w/ prior C/S; percentage of 2nd tri eABs c/b uterine rupture in pts w/o prior C/S
0.28%; 0.04%
Is miso safe for use in 2nd tri medical eAB w/ hx of C/S; why or why not?
Yes, if one prior C/S; risk of uterine rupture is approximately the same w/ and w/o one prior C/S
US finding + pt hx factor w/ highest suspicion for abnormal placentation
Low-lying placenta/previa + hx of C/S
Preferred method of 2nd tri eAB in pts where abnormal placentation is suspected
D&E (w/ prep made for hemorrhage)
Is preop UAE recommended in 2nd tri eABs where abnormal placentation is suspected; why or why not?
No; PPV of US in diagnosing abnormal placentation is as low as 65%
Method to help confirm abnormal placentation
MRI
Complication that is increased w/ 2nd tri fetal demise
DIC
Management of postabortion hemorrhage w/ c/f coagulopathy
Serial CBCs and coags > if clinical/lab suspicion for coagulopathy, maintain low threshold to give FFP/cryo
Percentage of 2nd tri eABs c/b postabortion infection
0.1-4%
Source/Composition of most postabortion infections; percentage risk decrease of infection 2/2 ppx abx in setting of D&E
Ascending genital tract/polymicrobial (so should be treated w/ broad-spectrum abx); 40%
Recommended ppx abx prior to D&E
Tetracycline or metronidazole
Most effective and inexpensive ppx abx regimen prior to D&E
100mg PO doxy taken 1h prior to D&E, followed by 200mg post-D&E
Are ppx abx recommended for 2nd tri medical eAB?
No
Incidence of fatal/nonfatal PE in setting of 2nd tri eAB
10-20/100,000
Incidence of AFE in all pregnancies; mortality rate of AFE associated w/ 2nd tri eAB
1/10,000-1/80,000; 80%
Advantages of D&E (5)
Scheduled timing, typically faster/more cost-effective, fewer complications (~4% compared to up to 29% w/ miso medical eAB), less pt-reported pain, pts more likely to say they would opt for same procedure again
Most common complication of medical eAB, and percent of cases in which this complication occurs
Retained placenta (21%)
Advantages of intact D&E (2)
Ability to perform autopsy, preferable when uterine instrumentation should be minimized (ie chorio, fetal anomalies such as severe hydrocephalus)
Advantage of medical eAB
Ability to perform autopsy
Initial assessment/management of post-abortion hemorrhage
Immediate visual and digital cervical exam to assess for cervical lacs, bimanual exam to assess tone, US to identify reaccumulation of blood/retained tissue
Initial management of post-abortion hemorrhage if atony is suspected (2)
Prompt uterine massage, administration of uterotonics
First-line agent for atony in 2nd tri; second-line agent for atony in 2nd tri
Methergine, unless contraindicated (ie pts w/ HTN); miso 800-1000mcg
Management of refractory/excessive post-AB bleeding
Obtain additional IV access, begin fluid resuscitation, consider serial CBCs/coags, obtain T&S for poss transfusion (of both blood and coag factors, as DIC is possible in setting of post-AB hemorrhage)
Lab to obtain in anticipation of possible UAE
Cr (BMP)
Mechanical methods of controlling post-AB hemorrhage (2)
Foley catheter (inflated to 30-60mL saline), intrauterine balloon (infalted to 120-250mL saline)
Management of persistent refractory post-AB bleeding (2)
UAE, laparoscopy/laparotomy/hyst
In cases where hemorrhage was 2/2 atony/cervical lac/DIC/LUS bleeding, percentage of cases in which UAE successfully avoids need for hyst; in cases where hemorrhage was 2/2 abnormal placentation, percentage of cases in which UAE successfully avoids need for hyst
100%; 43%
Rate of hyst among 2nd tri eABs; most common cause of post-AB hemorrhage leading to hyst
1.4/10,000 ABs; uterine perf
Management of minor abrasions during eAB (2)
Basic ferric subsulfate solution, silver nitrate
Entity to consider if bleeding continues s/p repair of high cervical tear; management option in such a case
Uterine artery lac; targeted UAE (or laparotomy, if UAE not possible)
Preop methods to reduce risk of excessive blood loss/hemorrhage and cervical lacs associated w/ D&E (2)
Vasopressin in paracervical block; routine cervical prep
Is intraop US necessary for 2nd tri eAB?
While helpful, not required
Is grief resolution better for pts who choose D&E or medical eAB in cases of fetal demise/termination for fetal anomalies?
Similar between D&E and medical eAB
Demographics more likely to report delays in accessing AB care (3)
Poor pts, Black pts, teen pts
What percentage of pts seeking AB have had prior ABs?
~50%
Earliest that ovulation can resume s/p eAB procedure
21 days (so contraception should be started immediately after)
Options that cannot be considered for 2nd tri eAB and initiated on day of procedure (2)
Diaphragm, cervical cap
Advantages of immediate IUD insertion over interval insertion s/p 2nd tri D&E (3)
Higher adherence, lower pregnancy rates, high pt satisfaction
Post-AB IUD expulsion rate in immediate post-AB group vs interval-insertion group
6.8% vs 5.0%
Are PID and IUD perf rates higher w/ immediate post-AB IUD insertion vs interval-insertion?
No
