Original Article
International Journal of Basic and Clinical Studies (IJBCS)
2013;2(2): 35-55 Agacayak E et al.

Risk factors predisposing to surgical evacuation after medical termination of pregnancy
during the second trimester: A retrospective study
Elif Agacayak1, Senem Yaman Tunc1, Ugur Deger2, Eda Demir Kusvuran3, Serdar
1 MD, Department of Gynecology and Obstetrics, Dicle University School of Medicine, Diyarbakir Turkey. 2 MD, Genesis Hospital, Diyarbakir Turkey 3 MD, Ibni Sina Hospital, Osmaniye Turkey Abstract
Purpose: To investigate the possible risk factors which might increase the likelihood of
surgical evacuation after medical termination of pregnancy during the second trimester.
Methods: Data derived from 262 women who had undergone medical termination of
pregnancy during her second trimester in a tertiary care center between January 2009-
February 2013 were retrospectively analyzed. Misoprostol was administered vaginally at
intervals of 4-6 hours at a total dose of 100-4400 mg for medical termination.
Results: Surgical evacuation was performed at a rate of 19.8 percent (52/262). Indications for
surgical evacuation were incomplete abortion in 37, and failure of medical induction of
abortion in six patients. Total dose of misoprostol, time to abortion after induction, duration of
hospitalization, systolic blood pressure at admission and baseline hematocrit levels,
occurrence of side effects of misoprostol seem to increase the likelihood of a surgical
procedure for definite termination of a second- trimester pregnancy.
Conclusion: Both surgical evacuation as well as medical induction of abortion can be utilized
for termination of second- trimester pregnancies. Surgical evacuation should be considered in
case of failure of induction, incomplete abortion or for hemodynamically instable patients.
Correct and timely decision for the selection of an appropriate method is crucial to avoid
hazardous outcomes.
Key words: Second trimester; pregnancy; termination; surgical evacuation.
Correspondence Author:
Elif Agacayak,MD
Department of Obstetrics and Gynecology
Dicle University School of Medicine, Diyarbakir, Turkey
E-mail: drelifagacayak@gmail.com
Tel: 00905059433449 Fax: 0090412 248 85 23
Original Article
International Journal of Basic and Clinical Studies (IJBCS)
2013;2(2): 35-55 Agacayak E et al.

Material and Methods
At least 3% of pregnancies are affected by either a genetic or structural fetal anomaly, were retrospectively analyzed. The local and prenatal screening for anomalies is a trial. The study included patients treated in the obstetrics and gynecology department of a tertiary care center between January proportions ranging from 47% to 90% (2). Most diagnoses of genetic and structural and/or ultrasonography, and, consequently, of gestation were included in the analysis. patients wishing to terminate an anomalous These patients were admitted to our clinic fetus often do so in the second trimester. because of fetal abnormalities, and a dead Both medical and surgical evacuation can fetus. 67 patients were performed cesarean operation previously. Patients aged ≥18 years with a history of live fetuses were surgical evacuation performed during STP included in this study. Exclusion criteria ranges between 5 and 30% (1, 3, 4). There are few studies focusing on the possible severe asthma or coronary artery disease, and the presence of ectopic pregnancy or evacuation for termination of STP (1). In intrauterine contraceptive device in the the literature, older maternal age, higher uterus. Misoprostol (400 mcg; 2×200 mcg, dose of prostaglandin, previous termination Cytotec®, Ali Raif Pharm. Inc., Istanbul, 600 mcg at intervals of 4-6 hours. Total likelihood of surgical evacuation (5,10). To supply secure second trimester abortion, administration was vaginal in all patients. history and careful physical investigation of surgical abortion in the second rimester. complications of abortion and to assess the gestational age of the pregnancy. If there is decrease the amount of blood loss of the a inconsistency between the gestational age menstrual period and the uterine size, an ultrasound examination should be built for delivered, the patients had been monitored accurate dating of the pregnancy ( 10 ). determined for the appropriate observation demographic and clinical factors detected period. The retained placenta was removed in second-trimester pregnancies that seem to be predisposing for surgical evacuation bleeding was accepted as an indication for urgent surgical evacuation. The diagnosis Original Article
International Journal of Basic and Clinical Studies (IJBCS)
2013;2(2): 35-55 Agacayak E et al.

bleeding and ultrasonographic findings
Windows). All differences associated with a chance probability of .05 or less were considered statistically significant. The placental retention, secondary bleeding or variables that are not distributed normally uterine rupture and any necessity for blood Qualitative variables were evaluated via in circumstances where this target could patients respectively. Surgical evacuation was considered to have failed completely. treatment failed to induce abortion after 48 Usually, women without any complications hours. These conditions were considered as after expulsion or dilatation-curettage. Demographic characteristics of the study population are shown in Table 1.
Statistical analysis: Data were analyzed
using the Statistical Package for Social Sciences (SPSS) software (version 15.0 for Table 1. Demographics of our patients that underwent termination of second trimester
(oxytocin, transcervical foley catheter) Uterine rupture Original Article
International Journal of Basic and Clinical Studies (IJBCS)
2013;2(2): 35-55 Agacayak E et al.

Median IQR (interquartile range) gestation
alternative seldom used outside the United at TOP (termination of pregnancy) was 15 States. There is a gradual increase in the the women was 29.5±4.95 (range 14 to 51) to serious fetal abnormalities (11-14). In encountered in five patients in the medical fetus could yield valuable information after medical abortion not only to confirm the congenital anomalies but also to further evaluate the subsequent recurrence risk and Total dose of misoprostol (p=0.039), time provide information to help in counseling Although comparisons of medical abortion with surgical evacuation for pregnancies (p=0.031) and occurrence of side effects of demonstrated that both methods are highly acceptable, medical abortion seems to be increase the risk of surgical evacuation. advancing gestation (2-5). Development of menarche (p=0.89), number of pregnancies regimens including the use of misoprostol has increased the efficacy and reduced the side effects of medical abortion. Medical necessity for blood transfusion (p=0.691), abortion is accepted to be as effective as surgical evacuation in the late-first and (p=0.139), use of additional measures (e.g. oxytocin, transcervical Foley catheter etc.) reported to be significantly safer and more (p=0.742) were found not to be associated second-trimester abortion because of fetal Leukocyte count (p=0.301), levels of blood Our results indicate that the total dose of creatinine (p=0.257), bilirubin (p=0.281), misoprostol and occurrence of side effects (p=0.163) and coagulopathy (p=0.586) did Discussion
termination. Therefore, surgical evacuation appears to be a safe and effective option in these circumstances. Since a time interval Provided that fetal anomalies or fetal death evacuation, duration of hospital stay and induction are significantly higher in the prostaglandins for induction of abortion surgical evacuation group. Low levels of hematocrit and high systolic blood pressure Original Article
International Journal of Basic and Clinical Studies (IJBCS)
2013;2(2): 35-55 Agacayak E et al.

are important hemodynamic parameters,
abortion bleeding and uterine curettage ( 3, which favor surgical evacuation. In such a induction with a longer observation period hospital stay. For achievement of this goal, subsequently circulatory and hemodynamic the use of staff experienced in assessing status of the patient would be deteriorated. Mortality rate is increased significantly in the second trimester abortions compared to We think that induction of abortion with those the first trimester. Although absolute misoprostol can be initially considered in higher than the risk associated with a TOP induction, delayed or incomplete abortion after application of misoprostol are signs mortalities have been attributed mostly to infection and to a lesser degree to indirect Conclusion
related complications (5, 21). In our series, Both medical and surgical termination of any case of mortality was not encountered. This may be due to the increased quality of healthcare services and effective prenatal respect to clinical findings including the Surgical evacuation of the contents of the uterus is not routinely required following responsiveness to prostaglandins. In this mid-trimester medical abortion. It should be performed if there is clinical evidence that the abortion is incomplete or medical rather than being alternative modalities. TOP fails (3,5,6). In the literature 2.5-11% Acknowledgement
medical abortion (3,5,7). A relatively low incidence of surgical evacuation have been editors, both native speakers of English. also indicated in previous reports (2,5,9). In our series, the increased rate of surgical References
evacuation (19.8%) may stem from the fact 1. ACOG practice bulletin #77 . Screening that our institution is a referral centre, where mostly complicated pregnancies are with increasing frequency ( >80% ) during screening policies in Europe for structural anomalies, and their impact on detection Original Article
International Journal of Basic and Clinical Studies (IJBCS)
2013;2(2): 35-55 Agacayak E et al.

defects and Down's syndrome. BJOG
single-dose misoprostol plus oxytocin for termination of second-trimester pregnancy. .Medical versus surgical abortion efficacy, 13. P.C. Ho, P.D. Blumenthal, K. Gemzell- Danielsson, R. Gómez Ponce de León , S. termination of pregnancy with a live fetus at 13 to 26 weeks International Journal of measures from a trial in China, Cuba and India. Int J Gynaecol Obstet 1998, 63 (1): pregnancy and fetal death in utero after in Women With a Prior Cesarean Delivery. The American College of Obstetricians and duration of late first and second-trimester 7. Kruse B, Poppema S, Creinin M, et.al. 8. Westhoff C, Dasmahapatra R, Schaff E. misoprostol for women with three or more misoprostol as part of a medical abortion prior cesarean deliveries. Int J Gynaecol 17. Sumant R. Shah, Jagruti B. Tripathi, efficacy, acceptability and cost of medical Hiren D. Suthar, Kaushal J. Modi, Jalpa K. Obstetrics and Gynecology of India ; 2012, vaginal misoprostol regimens, 400μg and prostaglandin analogue for termination of Stuart GS. Second-trimester abortion for early pregnancy: a review. Fertil Steril. pregnancy termination after one previous Original Article
International Journal of Basic and Clinical Studies (IJBCS)
2013;2(2): 35-55 Agacayak E et al.

cesarean delivery. Int J Gynaecol Obstet
second-trimester abortion in the setting of second trimester pregnancy termination in 22. Naz S, Sultana N. Role of misoprostol women with prior caesarean: a systematic for therapeutic termination of pregnancy from 10-28 weeks of gestation. J Pak Med

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