Progesterone after mifepristone: A pilot prospective single arm clinical trial for women who have changed their mind after commencing medical abortion.

AIM: This pilot study aimed to assess the utility of an oral progesterone treatment protocol for women who commenced medical abortion and then changed their mind and wished instead to maintain their pregnancy. METHODS: The Progesterone-After-Mifepristone-pilot for efficacy and reproducibility (PAMper) trial was designed as a prospective single-arm pilot clinical trial, conducted via telehealth. Women aged 18 to 45 years in Australia who reported ingesting mifepristone within the last 72 h to initiate medical abortion and had not taken misoprostol were included. Initial contact was by a web-based form. Following informed consent, participants were prescribed oral progesterone to be taken 400 mg twice per day for 3 days then 400 mg at night until completion of a 19 day course. Pregnancy viability was assessed by ultrasound scan after 14 days of progesterone treatment. RESULTS: Between October 2020 and June 2021, nine women contacted the PAMper trial, of whom six enrolled and commenced progesterone treatment. These women reported ingesting mifepristone at 40-70 days of gestation, with progesterone being commenced within 5.7-72 h of mifepristone ingestion. Five participants had ongoing, live pregnancies at the primary endpoint (ultrasound at >2 weeks). One participant had a miscarriage after 9 days of progesterone treatment. There were no clinically significant adverse events. CONCLUSION: This small study demonstrated a clinically sound protocol for researching the use of progesterone-after-mifepristone for women in this circumstance. Results of this pilot study support the need for further larger scale trials in this field.

Reconsidering post 20-week abortion in Aotearoa New Zealand.

The Abortion Legislation Act 2020 established comprehensive grounds for approving abortions after 20 weeks. These grounds are less restrictive than before law reform. They give qualified health practitioners (QHP) the scope to approve any abortion anyone wants and might reasonably request, if the QHP believes the abortion is clinically justified in the circumstances, having considered all the factors required by law. Because patients hold QHPs accountable under the Health and Disability Commission and legal processes, it is unlikely a QHP will need to justify approving an abortion, although they may well be called upon to justify refusing one.

Telemedicine for First-Trimester Medical Abortion in Canada: Results of a 2019 Survey.

Introduction: Telemedicine has the potential to improve abortion access disparities in Canada. We aimed to explore the provision of telemedicine for first-trimester medical abortion and related barriers in 2019. Methods: We conducted a national, cross-sectional, anonymized, web-based survey of clinicians who provided abortion care in 2019 in Canada. We distributed our survey through professional health organizations to maximize identification of possible eligible respondents and used a modified Dillman technique to foster responses. Questions elicited provider demographics, clinical characteristics, including telemedicine first-trimester medical abortion and perceived related barriers. Descriptive statistics were analyzed using R software. Results: Among 465 respondents, 388 reported providing first-trimester medical abortion across Canada; 44.0% reported experience using telemedicine for some components of care: 49.3% of primary care clinicians and 28.7% of specialists. Telemedicine was used for initial consultation (86.0%), prescription (82.2%), or follow-up (92.2%). The median percentage of telemedicine providers' patients who underwent a dating ultrasound was 90.0. The majority usually followed up with patients through quantitative human chorionic gonadotropin (hCG) (84.2%). Seventy-eight percent perceived barriers to telemedicine; the most common being inability to confirm gestational age with ultrasound (43.0%), and lack of provincial telemedicine abortion fee code to pay practitioners (30.2%), timely access to serum hCG testing (24.6%), and nearby emergency services (23.3%). Discussion: In 2019, fewer than half of respondents reported providing some aspects of first-trimester medical abortion through telemedicine and the majority perceived barriers. Our results can inform knowledge translation activities to reduce barriers and increase telemedicine abortion care in Canada.

Continuation of Contraception Following Termination of Pregnancy in a Canadian Urban Centre.

OBJECTIVE: Minimal evidence exists on the continuation of contraception following termination of pregnancy. Continuation of effective contraception is important because it has been found to reduce unintended pregnancies. This study aims to determine the rate of continuation and choice of contraception following termination of pregnancy. METHODS: A cross-sectional analytic study was undertaken of 400 patients undergoing termination of pregnancy over 2 years. Demographic information and contraception choice prior to, at time of, and 6 months following termination were collected. Data were analyzed to assess relationships between patient characteristics and contraceptive choice. RESULTS: Prior to termination, 58.5% of patients were not using contraception and 22.4% used a less effective method (e.g., barrier or fertility awareness). Following termination, 99.7% of patients chose a method of contraception, and 95.2% chose a more effective method (e.g., long acting reversible contraception, permanent sterilization, combined hormonal contraceptives, progesterone-only contraceptive). Six months following termination, 85.8% of patients were using contraception. A more effective method was continued by 37.8%. There were no significant relationships between choice of contraception and age, previous pregnancies, or social determinants of health. Patients living with their sexual partner were significantly more likely to switch to a less effective method of contraception at 6 months. CONCLUSIONS: Following termination of pregnancy, almost all patients chose a method of contraception and most continued using contraception 6 months following termination.

Mifepristone-Misoprostol Use for Second- and Third-Trimester Medical Termination of Pregnancy in a Canadian Tertiary Care Centre.

OBJECTIVE: This study aims to evaluate the impact of the implementation a mifepristone-misoprostol protocol (MIFE/MISO) on the induction-to-expulsion interval in the context of second- and third-trimester pregnancy termination or intrauterine fetal death (IUFD) compared with misoprostol alone (MISO), and to share the experience of a Canadian tertiary hospital concerning the feasibility and safety of such a protocol. METHODS: This is a single-centre retrospective pre-post cohort study carried out at the Centre Hospitalier Universitaire (CHU) Sainte-Justine between 2017 and 2019. Women in the MIFE/MISO group were instructed to take mifepristone 24-48 hours before induction. Induction in the MIFE/MISO group was performed with misoprostol dosages adjusted to gestational age and the presence of previous uterine scars, while, in the MISO group, all patients received 400 µg of misoprostol vaginally every 4 hours. RESULTS: Ninety-four patients were included in the MIFE/MISO group and 103 patients, in the MISO group. Median time to expulsion was significantly lower in the MIFE/MISO group than the MISO group (13.5 and 19.5 h respectively; P < 0.001). The total dose of misoprostol administered was significantly lower in the MIFE/MISO group than the MISO group, and adverse effects were reported in 60% and 82% of patient records, respectively (P < 0.001). Complication rates were similar between the 2 groups. CONCLUSION: The MIFE/MISO protocol is highly effective for second- and third-trimester induction for pregnancy termination or IUFD, without increasing complication rates and with fewer reported adverse effects. Its implementation is safe and feasible in a tertiary medical centre.

Second- and Third-Trimester Medical Abortion Providers and Services in 2019: Results From the Canadian Abortion Provider Survey.

OBJECTIVES: Mifepristone became available in Canada in 2017. Updated national guidelines recommend its off-label use for second/third-trimester medical abortion (STMA/TTMA) by labour induction. The objective of this study was to explore STMA/TTMA provision in Canada and the role of mifepristone. METHODS: We conducted a national, cross-sectional, web-based, self-administered, anonymized survey, available in English and French. The survey was distributed through health professional organizations and recruited physicians who provided abortion care in 2019. We used a modified Dillman technique to maximize participation. The survey included sections on workforce and clinical care, including mifepristone use. We used R statistical software to produce descriptive statistics. RESULTS: Four hundred sixty-five clinicians responded to the survey, of whom 112 reported providing STMA and 63, TTMA, for a total of 115 respondents providing at least 1 of the 2 services. Two-thirds of respondents were general obstetrician-gynaecologists or family physicians and the remainder were maternal-fetal medicine subspecialists. The majority (64.7%) provided STMA/TTMA in an academic hospital, and 59.4% performed fewer than 5 STMAs (maximum 50) and 76.1%, fewer than 5 TTMA (maximum 15) in 2019. Fifty-nine percent of respondents reported having used mifepristone/misoprostol for STMA. Among mifepristone users, 48.6% used it for TTMA. Most required an indication beyond patient request to provide STMA/TTMA (82.1%/95.5%). CONCLUSIONS: STMA/TTMA care is provided by multiple (sub-) specialties, and mifepristone has not yet been universally implemented. Our results will inform knowledge translation activities aimed at facilitating collaboration between STMA/TTMA providers and health policy and service delivery leaders and will further increase mifepristone use for STMA/TTMA in Canada.

A Retrospective Cost-Effectiveness Analysis of Mifepristone-Misoprostol Medical Abortions in the First Year at the Regina General Hospital.

OBJECTIVE: In July 2017, mifepristone-misoprostol (mife/miso) became available for medical abortion at the Regina General Hospital's Women's Health Centre (RGH WHC). We investigated whether the proportion of abortions performed medically changed as a result of the introduction of mife/miso, whether using mife/miso instead of the surgical alternative would result in cost savings to the health care system, and whether abortion type differed between patients residing in and outside of Regina. METHODS: We conducted a retrospective chart review of all 306 medical abortions from the RGH WHC between July 1, 2017 and June 30, 2018. We obtained medical and surgical abortion information from that year and the preceding one from an administrative database. Statistical methods were used to calculate the costs of mife/miso, methotrexate-misoprostol (MTX/miso) and surgical abortion, as well as cost-effectiveness ratios. RESULTS: The proportion of medical abortions increased from 15.4% in 2016/2017 to 28.7% in 2017/2018 (χ21 = 54.629; P < 0.001). Calculated costs for mife/miso, with and without complications were CAD $1173.70 and CAD $1708.90, respectively, versus CAD $871.10 and CAD $1204.10, respectively, for MTX/miso, and CAD $1445.95 and CAD $2261.95, respectively, for hospital-based vacuum aspiration. At a willingness-to-pay threshold of CAD $318 (the cost of mife/miso), statistical modelling showed a 61.3% chance that mife/miso was more cost-effective than surgical abortion and a 90.8% chance that it was more cost-effective than MTX/miso. Patients from Regina were significantly more likely (χ21 = 29.406; P < 0.001) to receive a medical abortion (34.9% of abortions) than those living outside of Regina (19.6% of abortions). CONCLUSION: The proportion of abortions completed medically increased significantly over the period studied. Patients from Regina were more likely to receive medical abortion during both time periods. Mife/miso had a >50% probability of cost-effectiveness over both surgical and MTX/miso options.

Contraception Use and Attitudes Among Women Seeking Pregnancy Termination: Descriptive Cross-Sectional Survey.

OBJECTIVE: Unintended pregnancy has been linked to poor health and social outcomes for both mother and child. Efforts to reduce unintended pregnancies have been challenged by many financial, social, religious, and cultural factors. This study aimed to investigate how contraception use and misuse in a cohort of females seeking termination of pregnancy contribute to unintended pregnancies. METHODS: We conducted a cross-sectional study with women presenting to a women's health clinic for pregnancy termination from April to December 2017. Consenting participants completed a self-administered, confidential questionnaire that included questions on demographic, ethnic, and social characteristics, as well as behaviours and attitudes related to contraception. Data analysis used descriptive statistics. RESULTS: Data were collected from 334 women; about half (45%) had used contraception at the time of conception, representing a variety of different methods. Contraceptive use was associated with higher education, stable relationship status, and ethnic majority status but not with previous pregnancies or immigration status. Among contraceptive users, imperfect and inconsistent use of contraception (50% and 31%, respectively), and method failure (48%), including condom breakage, were cited as reasons for the current pregnancy. Non-users reported perceived low risk of pregnancy (55%), concerns about contraception (47%), and problems accessing contraception (27%). While the majority of participants were aware of emergency contraception, only 52% reported ever using it. Most participants (89%) planned to use contraception in the future. CONCLUSION: Our study highlights contraceptive behaviours and patterns of individuals seeking abortion. Patient-centered contraceptive counselling in order to facilitate contraceptive choice and access can include information about the most effective contraceptives and the need for back-up contraception methods.

Osmotic Dilator Intra-Abdominal Perforation: A Case Report.

BACKGROUND: This report describes an unusual case of a retained hygroscopic osmotic dilator following second trimester dilation and evacuation. CASE: A 24-year-old woman presented for elective pregnancy termination at 16 weeks gestational age. A cervical osmotic dilator could not be retrieved and fractured on attempted removal. Magnetic resonance imaging showed perforation through the cervix, possibly traversing the peritoneum. Hysteroscopy and laparoscopy were performed to remove the retained dilator. Significant inflammation and mesenteric adhesions surrounded the osmotic dilator, which was successfully removed. CONCLUSION: This is the first reported case of an intra-abdominal osmotic dilator. Although this device is inert, close follow-up and timely retrieval, possibly with hysteroscopy or laparoscopy, are recommended to minimize the resulting inflammatory response.

Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries.

OBJECTIVE: Abortion-related complications remain one of the leading causes of maternal morbidity and mortality worldwide. Nearly half of all abortions are unsafe, and the vast majority of these occur in low- and middle-income countries. The use of mifepristone with misoprostol for medical abortion has been proposed and implemented to improve abortion safety. DATA SOURCES: A systematic review of the literature was conducted in PubMed, Embase, Cochrane, and CINAHL. STUDY SELECTION: Criteria for study inclusion were first-trimester abortion, use of mifepristone with misoprostol, and low- or middle-income country status as designated by the World Health Organization. DATA EXTRACTION: Results for effectiveness, safety, acceptability, and qualitative information were assessed. DATA SYNTHESIS: The literature search resulted in 181 eligible articles, 52 of which met our criteria for inclusion. A total of 34 publications reported effectiveness data on 25 385 medical abortions. The average effectiveness rate with mifepristone 200 mg and misoprostol 800 µg was 95% up to 63 days gestation. A sensitivity analysis was performed to assume that all women lost to follow-up failed treatment, and the recalculated effectiveness rate remained high at 93%. The average continuing pregnancy rate was 0.6%. A total of 22 publications reported safety and acceptability data on 17 381 medical abortions. Only 0.8% abortions required presentation to hospital, and 87% of patients found the side effects of treatment acceptable. Overall, 95% of women were satisfied with their medical abortion, 94% would choose the method again, and 94% would recommend this method to a friend. A total of 16 publications reported qualitative results and the majority supported positive patient experiences with medical abortion. CONCLUSIONS: Mifepristone and misoprostol is highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.

Midwives' integration of post abortion manual vacuum aspiration in the Democratic Republic of Congo: a mixed methods case study & positive deviance assessment.

BACKGROUND: Despite a recognized need for midwives to provide post abortion care, there exist barriers preventing them from integrating lifesaving skills such as manual vacuum aspiration (MVA) into practice. This collaborative research with the Professional Association of Congolese Midwives (SCOSAF), sought to understand how certain midwives in the Democratic Republic of Congo (DRC) have overcome barriers to successfully integrate MVA for post abortion care. Specifically, in order to provide locally-driven solutions to the problem of inadequate post abortion care in the DRC, this study aimed to identify examples of positive deviance, or midwives who had successfully integrated MVA in complex working environments following an in-service training facilitated by their midwifery association, SCOSAF. METHODS: Creswell's mixed method comparative case study design was used to identify positive deviant midwives who had practiced MVA one or more times post training and to explore their strategies and enabling factors. Other midwives who had not practiced MVA post training permitted for a comparison gro cup and further interpretations. Sources of data included a sequential survey and semi-structured interviews. RESULTS: All 102 midwives invited to be surveyed were recruited and 34% reported practicing MVA post training (positive deviant midwives). No statistical significance was found between the two groups' demographics and practice facility type. Overall, both groups had positive attitudes regarding midwifery-led MVA and legalization of abortion. Positive deviant midwives demonstrated and described more confidence and competence to practice and teach MVA. They were more likely to identify as teachers and overcome interprofessional barriers by teaching MVA to physicians, medical students and other midwives and position themselves as experts during post abortion emergencies. CONCLUSION: Results provided important insight to midwives' integration of post abortion care in Kinshasa. Strategies used by positive deviant midwives in emergencies allowed them to navigate challenging contexts in order to practice MVA, while simultaneously increasing the credibility of their profession and the dissemination of evidenced-based MVA practice. Programs designed to work with and promote positive deviant midwives as knowledge brokers could be tested for their overall impact on the diffusion of midwifery-led MVA to improve access to safe, respectful reproductive care.

Induced abortion according to immigrants' birthplace: a population-based cohort study.

BACKGROUND: Most abortions occur due to unintended pregnancy. Unintended pregnancies are linked to poor health outcomes. Canada receives immigrants from countries with disparate sexual and reproductive health contexts which may influence abortion rates post-migration. We examined the association between abortion and region of birth and birth order among Canadian immigrants. METHODS: We conducted a population-based person-years (PY) cohort study in Ontario, Canada using administrative immigration (1991-2012) and health care data (1991-2013). Associations between induced abortion and an immigrant's region of birth were estimated using poisson regression. Rate ratios were adjusted for age, landing year, education, neighborhood income quintile and refugee status and stratified by birth order within regions. RESULTS: Immigrants born in almost all world regions (N = 846,444) were 2-5 times more likely to have an induced abortion vs. those born in the US/Northern & Western Europe/Australia & New Zealand (0.92 per 100 PY, 95% CI 0.89-0.95). Caribbean (Adjusted Rate Ratio [ARR] = 4.71, 95% CI 4.55-4.87), West/Middle/East African (ARR = 3.38, 95% CI 3.26-3.50) and South American (ARR = 3.20, 95% CI 3.09-3.32) immigrants were most likely to have an abortion. Most immigrants were less likely to have an abortion after vs. prior to their 1st birth, except South Asian immigrants (RR = 1.60, 95% CI 1.54-1.66; RR = 2.23, 95% CI 2.12-2.36 for 2nd and 3rd vs 1st birth, respectively). Secondary analyses included further stratifying regional models by year, age, education, income quintile and refugee status. CONCLUSIONS: Induced abortion varies considerably by both region of birth and birth order among immigrants in Ontario.

Impact of legislative change on waiting time for women accessing surgical abortion services in a rural hospital in the Northern Territory.

BACKGROUND: Women face challenges when accessing abortion, including varied legislation and reduced access to services in rural and remote settings. There are limited clinical guidelines in Australia and little information regarding the patient journey, particularly the timeframe between referral to abortion procedure. Legislation reform in the Northern Territory (NT) legalised early medical abortion (EMA) in primary health care, providing an opportunity to review service provision of elective surgical abortion prior to and after these changes. AIMS: To review the waiting time to access abortion, percentage eligible for EMA based on ultrasound gestation alone, percentage of Indigenous women accessing abortion in the NT and the effects of the legislation change. MATERIALS AND METHODS: Retrospective audit-analysed surgical abortion data from 354 patient files who underwent suction curettage of uterus between 2012-2017 in one NT public hospital. RESULTS: Mean wait-time ranged from 20 to 22 days in 2012-2016 and dropped to 15 days in 2017 following the law reform. Sixty-two percent of women waited longer than that in the recommended clinical guidelines. Indigenous women represented approximately 25% of patients accessing surgical abortion services. Average gestation at surgical abortion procedure increased following reform. Prior to reform up to 95% of patients accessing surgical abortion would have been eligible for EMA at time of referral. CONCLUSIONS: Results demonstrate potential for changes in service provision of abortion in the NT with increased choice, patient-centred care and reduced waiting times. This audit demonstrated the possibility to move the majority of abortion services into primary health care leading to cost savings.

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care in British Columbia: Phase I.

BACKGROUND: Over 30% of women in Canada undergo an abortion. Despite the prevalence of the procedure, stigma surrounding abortion in Canada leads to barriers for women to access this service. The vast majority of care is concentrated in urban settings. There is evidence to support utilization of innovative mobile and other technology solutions to empower women to safely and effectively self-manage aspects of the abortion process. This study is part 1 of a 3-phase study that utilizes user-centered design methodology to develop a digital health solution to specifically support follow-up after an induced surgical abortion. OBJECTIVE: This study aimed to (1) understand how women at 3 surgical abortion clinics in an urban center of British Columbia utilize their mobile phones to access health care information and (2) understand women's preferences of content and design of an intervention that will support follow-up care after an induced abortion, including contraceptive use. METHODS: The study design was based on development-evaluation-implementation process from Medical Research Council Framework for Complex Medical Interventions. This was a mixed-methods formative study. Women (aged 14-45 years) were recruited from 3 urban abortion facilities in British Columbia who underwent an induced abortion. Adaptation of validated surveys and using the technology acceptance model and theory of reasoned action, a cross-sectional survey was designed. Interview topics included demographic information; type of wireless device used; cell phone usage; acceptable information to include in a mobile intervention to support women's abortion care; willingness to use a mobile phone to obtain reproductive health information; optimal strategies to use a mobile intervention to support women; understand preferences for health information resources; and design qualities in a mobile intervention important for ease of use, privacy, and security. Responses to questions in the survey were summarized using descriptive statistics. Qualitative analysis was conducted with NVivo using a thematic analysis approach. This study was approved by the local ethics board. RESULTS: A waiting-room survey was completed by 50 participants, and semistructured interviews were completed with 8 participants. The average age of participants was 26 years. Furthermore, 94% (47/50) owned a smartphone, 85% (41/48) used their personal phones to go online, and 85% would use their cell phone to assist in clinical care. Qualitative analysis demonstrated that women prefer a comprehensive website that included secure email or text notifications to provide tools and resources for emotional well-being, contraceptive decision making, general sexual health, and postprocedure care. CONCLUSIONS: A community-based mixed-methods approach allowed us to understand how women use their cell phones and what women desire in a mobile intervention to support their postabortion care. The findings from this formative phase will assist in the development and testing of a mobile intervention to support follow-up care after an induced surgical abortion.

Unplanned pregnancies in New Zealand.

BACKGROUND: Unplanned pregnancies can bring risk. It is important to have an accurate count of unplanned pregnancies, but to date there is no precise number for New Zealand or Australia. AIMS: This analysis estimates the number and proportion of pregnancies in New Zealand that are unplanned. MATERIALS AND METHODS: Estimates were generated using information about unplanned births from the Growing Up in New Zealand study, combined with data on the number of births and abortions from Statistics New Zealand and estimates of miscarriages. These were further refined by age and ethnic group. RESULTS: Of an estimated 95 335 pregnancies in New Zealand in 2008, over half (53%) were unplanned. Unplanned pregnancies resulted in 24 131 births. As a percentage of all pregnancies, 25% were births from unplanned pregnancies, 19% were abortions and 8% were unplanned pregnancies that ended in miscarriage. There were a high number of unplanned pregnancies among younger women as well as among Maori and Pacific women, and a low number among women in their 30s and European women. CONCLUSIONS: Programs, policy and practice should be designed to accommodate women with unplanned pregnancies. Ensuring accessible pregnancy care such as antenatal care and abortion and making preconception care programs widely available, particularly for women with chronic health conditions, will reduce the health risk posed by unplanned pregnancies. Reducing the number of unplanned pregnancies through comprehensive sexuality education and contraception is important for those in their teens and early 20s, and continues to be important throughout the reproductive lifespan.

Turkish nursing students' attitudes towards voluntary induced abortion.

OBJECTIVE: To evaluate Turkish nursing students' attitudes towards voluntary induced abortion.. METHODS: This cross-sectional study was conducted between January and June 2015, comprising students of Ege University Nursing Faculty and Celal Bayar University School of Health, located in two different cities of Turkey. Data was collected with a three-part questionnaire, focussing on students' characteristics, the knowledge of abortion law in Turkey and attitudes towards voluntary induced abortion. SPSS 15 was used for data analysis.. RESULTS: The mean score of students' attitude towards voluntary induced abortion was 39.8±7.9 which shows that nursing students moderately support abortion. Female students, students coming from upper class in society, and students who had higher family income and sexual experiences had more supportiveness attitudes towards voluntary induced abortion (p<0.05). Those who lived in a village before university life, who had extended family, and students of parents with low educational level, had lower score in this regard (p<0.05). CONCLUSIONS: Nursing students should be encouraged to behave non-judgmentally to women who want to have abortion.

[Method selection and perioperative management of termination of pregnancy during the first and second trimester of pregnancy with severe cardiovascular disease].

Objective: To summarize and analyze the methods of termination of pregnancy in the first and second trimester of pregnancy with severe cardiovascular disease. Methods: A retrospective analysis of 27 cases of termination of pregnancy in the first and second trimester of pregnancy in Beijing Anzhen Hospital from January 1, 2016 to December 30, 2017. All of these pregnant women were pregnancy complicated with severe cardiovascular disease in grade Ⅴ pregnancy risk. Results: (1) The age of 27 pregnant women was 22-40 years, gestational age was 6-27 weeks; cardiac function grade before induced labor was: 5 cases of grade Ⅱ, 15 cases of grade Ⅲ, 7 cases of grade Ⅳ. The cardiovascular diseases included ventricular septal defect in 9 cases, simple atrial septal defect in 3 cases, patent ductus arteriosus in 2 cases, tetralogy of Fallot in 2 cases, rheumatic valvular disease in 1 case,arrhythmia-paroxysmal atrial velocity in 2 cases, cardiomyopathy in 2 cases, hypertensive cardiopathy in 2 cases, primary pulmonary hypertension in 1 case, tissue disease complicated with pulmonary hypertension 1 case, hyperthyroid heart disease in 1 case, coronary heart disease in 1 case. Among them, 21 cases were complicated with pulmonary hypertension, and 5 cases with Eisenmenger syndrome. (2) Methods of termination of pregnancy: in 27 cases, eight cases of vacuum curettage, and 2 cases of forceps curettage under general anesthesia without intubation; rivanol intraamniotic induction of labor in 1 case; and hysterotomy delivery in 16 cases (11 cases were treated with continuous epidural anesthesia, 1 case was treated with combined spinal and epidural anesthesia, 4 cases were treated with spinal anesthesia) . (3) After termination of pregnancy, one patient with severe primary pulmonary hypertension at 19 weeks of gestation died on the 1st day postoperative. No significant changes in cardiac function were observed in other patients before and after termination of pregnancy, and all of them survived. Conclusions: In patients with severe cardiovascular disease, termination of pregnancy after pregnancy may result in maternal death even at the second trimester of pregnancy.It is strongly recommended that such patients undergo pre-pregnancy assessment and fertility counseling.If visiting doctor after pregnancy, we should organize a multidisciplinary consultation as soon as possible to assess the risk of continuing pregnancy and give medical advice. If the risk of pregnancy is high, we should terminate the pregnancy as early as possible, after making a suitable treatment plan. During termination of pregnancy, temporary or permanent contraception may be taken if the condition permits.