Intervention rates for placental removal following induction abortion with misoprostol.

BACKGROUND: Second-trimester terminations can be performed via surgical or medical methods. It is essential to have the ability to safely and effectively perform induction terminations to offer a full range of services. Many studies of induction abortions report routine operative removal of the placenta after a set time period resulting in high rates of operative procedures. STUDY DESIGN: A retrospective chart review was performed for 233 women who underwent second-trimester induction abortions between November 2003 and November 2006. All women received intraamniotic injection of digoxin for feticide 1 day prior to induction. All inductions were performed using a schedule of 400 mcg of misoprostol initially followed by 200 mcg every 6 h for a maximum of 48 h. There were three methods of administering misoprostol: (1) vaginal administration for all doses, (2) vaginal and buccal used in combination and (3) buccal for all doses. Spontaneous expulsion of the placenta was expected. Operative intervention was performed for excessive bleeding or to expedite hospital discharge after a minimum of 4 h. No manual removal of placenta was done. RESULTS: The rate of operative intervention for retained placentas was 6% (14/233). Most (11/14) of the patients who underwent operative extraction for retained placentas did so to expedite discharge from the hospital. Overall, expectant management to allow spontaneous expulsion of the placenta for at least 4 h was not associated with serious morbidity. CONCLUSIONS: Our regimen of digoxin and misoprostol with a policy of expectant management of placental passage is associated with a very low rate of instrumented removal of the placenta. In the absence of bleeding, patients may be afforded intervals to at least 4 h for spontaneous expulsion of the placenta after fetal expulsion.

Methods for induced abortion.

We describe present methods for induced abortion used in the United States. The most common procedure is first-trimester vacuum curettage. Analgesia is usually provided with a paracervical block and is not completely effective. Pretreatment with nonsteroidal analgesics and conscious sedation augment analgesia but only to a modest extent. Cervical dilation is accomplished with conventional tapered dilators, hygroscopic dilators, or misoprostol. Manual vacuum curettage is as safe and effective as the electric uterine aspirator for procedures through 10 weeks of gestation. Common complications and their management are presented. Early abortion with mifepristone/misoprostol combinations is replacing some surgical abortions. Two mifepristone/misoprostol regimens are used. The rare serious complications of medical abortion are described. Twelve percent of abortions are performed in the second trimester, the majority of these by dilation and evacuation (D&E) after laminaria dilation of the cervix. Uterine evacuation is accomplished with heavy ovum forceps augmented by 14-16 mm vacuum cannula systems. Cervical injection of dilute vasopressin reduces blood loss. Operative ultrasonography is reported to reduce perforation risk of D&E. Dilation and evacuation procedures have evolved to include intact D&E and combination methods for more advanced gestations. Vaginal misoprostol is as effective as dinoprostone for second-trimester labor-induction abortion and appears to be replacing older methods. Mifepristone/misoprostol combinations appear more effective than misoprostol alone. Uterine rupture has been reported in women with uterine scars with misoprostol abortion in the second trimester. Fetal intracardiac injection to reduce multiple pregnancies or selectively abort an anomalous twin is accepted therapy. Outcomes for the remaining pregnancy have improved with experience.