High-Dose Oxytocin. Hypertonic Saline. Hysterotomy and Hysterectomy

High-Dose Oxytocin

Oxytocin in sufficient doses can be effective as a primary abortifacient in the mid-trimester. Fifty units is given in 500
mL of 5% dextrose and normal saline over a 3-hour period. After 1 hour of rest, the oxytocin infusion is repeated, using
100 units of oxytocin in the next 500-mL infusion, which is also given over 3 hours. If abortion does not occur, each
subsequent 3-hour infusion should have an additional 50 units of oxytocin added until the patient aborts or a final
solution of 300 U of oxytocin in 500 mL is reached (1,667 mU/min). Water intoxication may occur with this regimen and
requires close monitoring.

Cancer information

Hypertonic Saline

Historically, hypertonic saline is important because it was the first effective labor-induction method for mid-trimester abortion. Maternal hazards unique to hypertonic saline include cardiovascular collapse, pulmonary and cerebral edema, and renal failure if the solution is accidentally injected intravenously. All patients are at risk for serious disseminated intravascular coagulopathy. Attention to proper technique for saline amnioinfusion by gravity flow through connecting tubing from a single-dose bottle makes such complications rare. More common problems with hyper~ tonic saline are similar to problems associated with all of the labor induction methods: failed abortion, incomplete abortion, retained tissue, hemorrhage, infection, and embolism.

When hypertonic saline is administered by itself, the mean time between instillation and abortion is 33-35 hours.

Augmentation with oxytocin reduces this time to 25-26 hours and improves efficacy, but there is an increased occurrence of disseminated intravascular coagulopathy, water intoxication, and cervical or uterine rupture.

OTHER APPROACHES

Hysterotomy and Hysterectomy

Hysterotomy is essentially a cesarean delivery. There is little indication for this procedure as the primary method for abortion because the risk of major complications and death is greater with hysterotomy and hysterectomy than for any other abortion technique. In most cases, failed abortion is now managed with parenteral prostaglandins, and the only time hysterotomy should be used for a failed abortion is when a uterine anomaly is present.

The coexistence of pregnancy and a separate indication for hysterectomy (eg, cervical cancer) has been taken as an indication for gravid hysterectomy. Most patients are best served by a simpler means of pregnancy termination and a more complete evaluation of their other gynecologic problems before definitive therapy. In these rare cases, referral of the patient is preferable to the addition of a major surgical procedure to her other medical problems.

Selective Reduction

In cases of multifetal pregnancies, selective reduction by means of ultrasound-guided intracardiac injection of potassium chloride has been practiced as a means of avoiding the risks of extreme prematurity for the surviving pregnancies.

Coagulation surveillance is advised after second-trimester procedures. Selective reduction should not be attempted with twin-twin transfusion syndrome because of the possibility of embolism and infarction in the surviving twin.

Subsequent Reproduction

Legal abortion as currently practiced in the United States has no measurable adverse effect on later reproduction. This probably reflects the safety of current abortion technology. Most abortions are performed by vacuum curettage under local anesthesia in the first trimester. The impact of mid-trimester methods on subsequent pregnancy is less well established and may vary with the method used. For example, forced dilation of the cervix to a large diameter for D&E in the late second trimester may increase the risk of prematurity later. To avoid this complication, laminaria, their synthetic alternative, or low-dose prostaglandins should be used to prepare the cervix for late abortion.

LEGAL ISSUES

Some states have laws requiring that certain mandatory information be given to patients or that a certain period must elapse after obtaining consent before abortion can be performed. In some jurisdictions, minors must notify their parent(s), obtain parental consent, or obtain judicial consent before obtaining an abortion.

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