Diseases information. Disorders. Treatment.

High-Dose Oxytocin
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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.
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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
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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
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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.

Fetal Death In Utero

Fetal death in utero can be managed with D&E, provided that the surgeon is familiar with the procedure. Vaginal
prostaglandin E2 is highly effective for this problem, usually producing fetal abortion in about 10 hours, but often with
significant vomiting, diarrhea, and fever as side effects. Beyond 28 weeks of gestation the full dose of vaginal
prostaglandin E2 should not be used, or overstimulation and uterine rupture may occur. The standard suppository can
be cut into quarters and administered 5 mg at a time for better control of uterine activity. The same low-dose regimen
can be used cautiously in patients with asthma if immediate respiratory support (inhalation) is available. Blood or
amniotic fluid may impair vaginal absorption of the prostaglandin. Coagulation studies should be obtained
preoperatively because disseminated intravascular coagulopathy is a significant risk after either D&E or vaginal
prostaglandin E2 for management of fetal death.

Intrauterine Prostaglandins
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Intraamniotic prostaglandin is an effective abortion regimen, but it has several disadvantages, including incomplete
abortion, the need for a second injection in many cases, the risk of cervical rupture in the primigravida, and the lack
of a direct toxic effect on the fetus. Results with intraamniotic prostaglandin F2ca are much improved if overnight
treatment with laminaria is used before infusion. Mean times to abortion are reduced from 29 hours to 14 hours, and fewer patients require a second dose. Cervical rupture is very rare. Incomplete abortion is common with prostaglandin abortion, and routine curettage is advised. This can be accomplished easily under local anesthesia in a properly equipped treatment room and reduces rates of postabortal hemorrhage and infection to low levels. Failed prostaglandin abortions can be managed by D&E or by intramuscular or vaginal prostaglandin. To avoid uterine rupture, oxytocin should not be used until after fetal expulsion because prostaglandin and oxytocin are synergistic.
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Systemic Prostaglandins

Three different prostaglandins are available for systemic administration: prostaglandin E2 vaginal suppositories;
carboprost tromethamine for intramuscular injection; and misoprostol, an analogue of prostaglandin E1. Prostaglandin
E2 is given as a 20-mg vaginal suppository every 3 hours. The mean time to abortion is 13.4 hours, with 90% of patients
aborting by 24 hours. When 250 mcg of carboprost tromethamine is given intramuscularly every 2 hours, the mean time
to abortion is 15-17 hours, with about 80% of patients aborting by 24 hours. Misoprostol is given vaginally as a single
0.200-mg tablet every 12 hours. Mean time to abortion is comparable to that of the other two prostaglandin regimens.
Vomiting and diarrhea are common with prostaglandin E2 and carboprost, but are rare with misoprostol. About one third
of patients treated with prostaglandin E2 will have a temperature elevation of 1 EC or more. This temperature elevation
is not seen with carboprost or misoprostol. An ultrasound-guided fetal intracardiac injection of either potassium chloride
or digoxin may be given. Alternatively, hypertonic sodium chloride can be given as an intraamniotic injection
Retained placenta is common with all prostaglandin-induced abortions. If spontaneous expulsion has not occurred within 30 minutes or heavy bleeding occurs, instrumental evacuation should be done to prevent further blood loss. Thiscan be accomplished with low-dose intravenous sedation in a treatment room equipped with a uterine aspirator.
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Most abortions are performed before 13 menstrual weeks. Later abortions are generally performed because of fetal
defects, maternal illness, or maternal age. Younger women are much more likely to request abortion after 12 weeks.

Dilation and Evacuation
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Transcervical instrumental evacuation of the uterus (D&E) is the method most commonly used in the United States for
mid-trimester abortions before 21 menstrual weeks. Two D&E techniques are used and differ primarily in the preparatory
steps that precede the evacuation. In the one-stage technique, forcible dilation is performed slowly and carefully to
sufficient diameter to allow insertion of large, strong ovum forceps for evacuation. The better approach is a two-stage
procedure in which multiple laminaria are used to achieve gradual dilatation over several hours before extraction.
Overnight placement of one set of laminaria is sufficient preparation for the early mid-trimester, but beyond 18-20
weeks, two sets of laminaria and 2 days of preparation are often used. Oral tetracycline or doxycycline should be started
after laminaria insertion and continued for 2 days after uterine evacuation. Uterine evacuation is accomplished with
long, heavy forceps, using the vacuum cannula to rupture the fetal membranes, drain amniotic fluid, and ensure
complete evacuation. A large-bore, 16-mm vacuum system facilitates the procedure.
The procedure causes discomfort despite a paracervical block, and most patients will benefit from conscious seda-tion.
If general anesthesia is elected, potent inhalation agents should be avoided or used only in low concentrations to
avoid uterine atony and increased blood loss. Standard care of the anesthetized patient must be provided, with
continuous monitoring of tissue oxygenation and end-expiratory carbon dioxide and frequent monitoring of vital signs.
The patient must be closely supervised until she is fully recovered from anesthesia.
Preoperative ultrasonography is necessary for all cases 14 weeks and beyond. Intraoperative real-time
ultrasonography helps to locate fetal parts within the uterus. Paracervically administered vasopressin has been demon-strated
to significantly reduce bleeding, but vasopressin must be used with caution. A maximum of 4 units should be
used, and it is usually diluted with saline or Xylocaine. Vasopressin should not be used in women with heart disease
or hypertension. Intravenous oxytocin is begun early in the procedure, just after rupture of the membranes.
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Coagulopathy can be seen after D&E, apparently because tissue thromboplastins have been released into the
maternal venous sinusoids. The use of oxytocin and intracervical vasopressin may reduce this risk. To avoid negative
pressure in the uterine vasculature, the Trendelenburg position should not be used.
After the procedure, the operator must examine the fetal parts carefully to be sure that evacuation is complete. If the
fetal calvarium has been retained in the uterus and gentle attempts at extraction fail, the procedure should be completed
under ultrasound guidance. If this is not available, it is best to stop, administer an oxytocin infusion for 2 hours, and
try again. By then, the remaining fetal parts usually will have been pushed down to the internal cervical os and they can
be extracted easily.

Dilation and evacuation becomes progressively more difficult as gestational age advances, and in the United States
instillation techniques are often used after 21 weeks. Dilation and evacuation can be offered in the late mid-trimester,
but the technique should be modified. The use of two sets of laminaria tents for a total of 36-48 hours is favored. A
further modification is the Hern combination method. After multistage laminaria treatment, urea is injected into the
amniotic sac. Extraction is then accomplished after labor begins and after fetal maceration has occurred.
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Mifepristone (RU 486) is an analogue of norethindrone with high affinity for progesterone receptors. It acts as a false
transmitter and blocks natural progesterone. It can effectively induce an abortion in an early gestation after a single oral
dose. The effectiveness is increased to approximately 95% by the addition of a low-dose prostaglandin analogue.
In France, where the drug has been used extensively, women with amenorrhea of less than 50 days and pregnancy
confirmed by serum b-hCG or ultrasonography receive an oral dose of mifepristone on day 1. On day 3, the patient
returns for prostaglandin (sulprostone or gemeprost) and D immune globulin if she is D negative. Patients remain in
the clinic for 4 hours, during which time expulsion of the pregnancy usually occurs. The patient then returns 8-15 days
later for measurement of b-hCG or ultrasonography. In more than 17,000 cases treated in France, complete abortion
was achieved in 95% of cases.

Failed abortion or excessive bleeding requires vacuum curettage. No serious complications or side effects have
occurred with mifepristone in this dosage. However, sulprostone, the prostaglandin E2 analogue used in Europe, has
been associated with myocardial infarction in three cases, resulting in one death. All three women were cigarette
smokers and were older than age 35. Misoprostol, the prostaglandin E1 analogue used with mifepristone in the United
States, has not been related to myocardial ischemia.
Another effective medical regimen for early abortion is the combination of the antifolate agent methotrexate with
misoprostol. Methotrexate is given as a single intramuscular dose followed 5-7 days later with vaginal misoprostol.
Efficacy appears to be slightly less than that observed with the mifepristone and misoprostol combination, and bleeding
may last longer. In the higher doses used to treat malignancy, methotrexate can have significant side effects, but these
are extremely rare with the low-dose regimen described above.

Early detection of ectopic pregnancy, incomplete abortion, or failed abortion is possible if the physician performing the
operation carefully examines the specimen immediately after the abortion. The patient may have an ectopic pregnancy
if no chorionic villi are found. To detect an incomplete abortion that might result in continued pregnancy, the actual
gestational sac must be identified. The history and physical examination should be reviewed. Determination of the b-hCG
level and frozen section of the aspirated tissue and vaginal probe ultrasonography may be useful. If the b-hCG
level is greater than 1,500-2,000 mIU, chorionic villi are not identified on frozen section, or retained tissue is identified
by ultrasonography, immediate laparoscopy should be considered. Other patients may be followed closely with serial
b-hCG assays until the problem is resolved. With later (>13 weeks) gestations, all of the fetal parts must be identified
by the surgeon to prevent incomplete abortion. It is not sufficient to send the tissue to the pathologist.
Heavy bleeding or fever after abortion suggests retained tissue. If the postabortal uterus is larger than 12-week size,
it is wise to perform preoperative ultrasonography to determine the amount of remaining tissue. When fever is present,
high-dose intravenous antibiotic therapy should be initiated, and curettage should be performed shortly thereafter.
Because of the need to cover a broad spectrum of possible pathogens, a combination of two or three agents is
suggested. If there is hemolysis or failure of the patient to improve within 12-24 hours after uterine evacuation,
hysterectomy may be indicated and can be lifesaving.
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Complications and Fragmented Care

Patients who have recently had an abortion and are experiencing complications often seek care at a local hospital
emergency department. A physician managing such a patient should make every effort to communicate with the
abortion provider to learn the details of the procedure, any suspected complications, results of screening tests, results
of the fresh examination of the aborted tissue, and whether D immune globulin was given if the patient is D negative.
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Perforation
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The risk of perforation is less than 1 in every 1,000 first-trimester abortions. It increases with gestational age and is
greater for parous women than for nulliparous women. The use of laminaria reduces the risk. Perforation is best
evaluated by laparoscopy to determine the extent of the injury. Often, the abortion can be completed during the
laparoscopic procedure if the puncture is in the uterine fundus and there is no active bleeding.
The clinical picture produced by uterine perforation depends on the anatomic location of the injury. Perforations at
the junction of the cervix and lower uterine segment can lacerate the ascending branch of the uterine artery within the
broad ligament, giving rise to severe pain, a broad ligament hematoma, and intraabdominal bleeding. Management
requires laparotomy, ligation of the severed vessels, and repair of the uterine injury. Hysterectomy should not be
required to manage such an injury.
Low cervical perforations may injure the descending branch of the uterine artery within the dense collagenous
substance of the cardinal ligaments. In this case, there is no intraabdominal bleeding. The bleeding is external, through
the cervical canal, and may subside temporarily as the artery goes into spasm. Deaths have occurred as a result of this
bleeding several hours or even days after an unrecognized low cervical perforation. Usually, this complication can be
managed with hysterectomy, but consideration should be given to arteriography and selective embolization of the
hypogastric arteries if recurring postabortal hemorrhage suggests this diagnosis.

Hemorrhage
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Excessive bleeding may indicate uterine atony, a low-lying implantation, a pregnancy of more advanced gestational age
than the first trimester, or perforation. Management requires rapid reassessment of gestational age by examination of
the fetal parts already extracted and gentle exploration of the uterine cavity with a curette and forceps. Intravenous
oxytocin should be administered, and the abortion should be completed. The uterus then should be massaged to ensure
contraction. When these measures fail, the patient should be transferred immediately to a hospital and should receive
intravenous fluids and have her blood crossmatched. Persistent postabortal bleeding strongly suggests retained tissue
or clot (hematometra) or trauma, and prompt surgical intervention with laparoscopy and repeat vacuum curettage is
indicated.

Hematometra
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Lower abdominal pain of increasing intensity in the first 30 minutes after the procedure suggests either hematometra
or postabortal syndrome. If there is no fever or bleeding is brisk, and on examination the uterus is large, globular, and
tense, hematometra is the possible diagnosis. This condition could be mistaken for a broad ligament hematoma, except
that the mass is midline and arises from the cervix. The treatment is immediate reevacuation. Pretreatment with ergot
or the use of oxytocin reduces the incidence of this phenomenon.