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 Basaranoglu1
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.
Introduction 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 pregnancy.
(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
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Please answer questions 1-10 with reference to the passage that follows. One and only one response is correct for each question. 1. The title of the article suggests that: a. it is no longer fair to describe certain tropical diseases as ‘neglected’ because huge steps have been taken towards their eradication b. little medical progress has been made, because researchers
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