Editorial
When Pregnancy Must End in the Second Trimester Alisa B. Goldberg, MD, MPH
See related article on page 1162.
Dr. Goldberg is from the Department of Obstetrics, Gynecology, and Reproductive Biology at the Harvard Medical School, the Division of Family Planning at Brigham and Women’s Hospital, and Clinical Research and Training at the Planned Parenthood League of Massachusetts, Boston, Massachusetts; e-mail: [email protected]. The opinions expressed in this article are those of the author and do not necessarily reflect the views of Planned Parenthood Federation of America, Inc. Financial Disclosure The author did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
VOL. 123, NO. 6, JUNE 2014
T
he well-designed study by Dickinson and colleagues in this month’s issue of Obstetrics & Gynecology (see page 1162) demonstrates that, after oral mifepristone and a loading dose of vaginal misoprostol, repeat doses of vaginal or sublingual misoprostol induce abortion more rapidly and leave fewer women undelivered at 12 and 24 hours than repeat oral misoprostol dosing.1 This is important information to guide the clinical treatment of women undergoing second-trimester labor induction. Mifepristone blocks progesterone receptors, softens the cervix, and sensitizes the uterus to prostaglandins. The use of 200 mg of mifepristone followed 24–48 hours later by misoprostol for second-trimester induction abortion has significantly improved the efficacy (delivery of the fetus within 24 hours) of induction abortion, shortened the induction-todelivery interval, and reduced the amount of prostaglandin required and associated side effects compared with older labor induction techniques. For these reasons, when second-trimester labor induction abortion is performed, mifepristone followed by misoprostol is recommended by the World Health Organization, the Royal College of Obstetricians and Gynaecologists, and the Society of Family Planning.2 So how does labor induction with mifepristone and misoprostol compare with second-trimester abortion by dilation and evacuation (D&E)? Data are sparse. Studies comparing D&E with older instillation labor induction techniques found D&E to be associated with fewer minor and major complications.3 More recent retrospective studies comparing D&E with labor induction with misoprostol alone similarly found fewer complications with D&E. In these newer studies, labor-induction patients were more likely to require an unplanned procedure, usually manual extraction or dilation and curettage for a retained placenta,4,5 or to receive intravenous antibiotics for fever and presumed infection.6 The study by Dickinson et al suggests that retained placenta resulting in heavy bleeding and requiring manual removal or dilation and curettage remains a challenge after second-trimester labor induction with mifepristone and misoprostol.1 Grimes et al conducted a pilot randomized trial to compare D&E with induction abortion with mifepristone and misoprostol and found recruitment difficult because a majority of women preferred D&E and declined participation. Among the 18 women enrolled, there were no serious adverse events, but induction patients reported more pain than did D&E patients.7 Advantages of D&E include that it is usually performed as an outpatient procedure, it is faster than labor induction (depending on the time required for cervical preparation), it is less expensive,8 and it may be less painful depending on anesthesia options available. Also, some women prefer not to have to go through labor and delivery when the outcome is not a viable newborn.
OBSTETRICS & GYNECOLOGY
1153
Advantages of labor induction include delivery of an intact fetus, which some women wish to see and hold and which can facilitate fetal evaluation for anatomic abnormalities when desired.9 The ability to conduct cytogenetic analyses is equivalent after D&E and labor induction,9 and grief resolution is comparable when women self-select their abortion procedure.10 Labor-induction abortion does not require a specialized surgical skill or an adequate caseload to maintain those skills, so, in many settings, it is easier to access. Ideally, women should be able to select whichever method of abortion they prefer. However, servicedelivery issues are complicated, influenced by the politics and stigma associated with abortion, and many institutions and even countries have systems of care in which one method predominates. Approximately 96% of second-trimester abortions are performed by D&E in the United States and 75% in England and Wales, whereas nearly all second-trimester abortions are performed by labor induction in Finland and Sweden.11 Institutions with limited access to D&E should work to increase access to this technique, which many patients prefer and which can be used to terminate a pregnancy quickly in emergent situations, such as active bleeding from placental abruption. A D&E can spare some women from a prolonged induction at best and a hysterotomy at worst. However, safe D&E requires not only a skilled surgeon but also appropriate facilities, a care team that often includes anesthesia providers, nurses, and medical assistants, and adequate cervical preparation. In many situations, there may be overlap of the procedures and medications used to prepare the cervix for D&E and initiate labor induction. Such hybrid procedures using misoprostol have been described for later abortions.12 Among women hospitalized for medical or obstetric complications, cervical preparation can begin as soon as the decision is made to terminate the pregnancy and abortion may be completed by either D&E or delivery, whichever can be accomplished sooner. Among women who do not generally require hospitalization, such as those with fetal anomalies or psychosocial or economic indications for abortion, there should be more flexibility in procedure choice and scheduling. For women undergoing outpatient D&E, a more controlled cervical ripening process that softens and dilates the cervix without causing expulsion before the procedure is optimal. Both D&E and labor induction with mifepristone and misoprostol are safe and effective secondtrimester abortion techniques. In countries where mifepristone is available, institutions should ensure
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access to evidence-based mifepristone and misoprostol labor-induction regimens such as those presented in this issue of the journal.1 Simultaneously, sincere efforts should be made to expand access to D&E and to accommodate patient preferences. However, for many patients, access to any form of second-trimester abortion remains a challenge, and women advance in gestation as they struggle to overcome barriers to care. Regardless of technique, efforts should focus on providing women access to safe second-trimester abortion in a timely fashion.
REFERENCES 1. Dickinson JE, Jennings BG, Doherty DA. Mifepristone and oral, vaginal or sublingual misoprostol for second-trimester abortion: a randomized controlled trial. Obstet Gynecol 2014; 123:1162–8. 2. Borgatta L, Kapp N. Society of Family Planning. Clinical guidelines. Labor induction abortion in the second trimester. Contraception 2011;84:4–18. 3. Grimes DA, Hulka JF, McCutchen ME. Midtrimester abortion by dilatation and evacuation versus intra-amniotic instillation of prostaglandin F2 alpha: a randomized clinical trial. Am J Obstet Gynecol 1980;137:785–90. 4. Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for secondtrimester abortion. Am J Obstet Gynecol 2002;187:393–7. 5. Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011; 117:788–92. 6. Edlow AG, Hou MY, Maurer R, Benson C, Delli-Bovi L, Goldberg AB. Uterine evacuation for second-trimester fetal death and maternal morbidity. Obstet Gynecol 2011;117: 307–16. 7. Grimes DA, Smith MS, Witham AD. Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: a pilot randomised controlled trial. BJOG 2004;111: 148–53. 8. Cowett AA, Golub RM, Grobman WA. Cost-effectiveness of dilation and evacuation versus the induction of labor for second-trimester pregnancy termination. Am J Obstet Gynecol 2006;194:768–73. 9. Lal AK, Kominiarek MA, Sprawka NM. Induction of labor compared to dilation and evacuation for postmortem analysis. Prenat Diagn 2014 [Epub ahead of print February 28]. 10. Burgoine GA, Van Kirk SD, Romm J, Edelman AB, Jacobson SL, Jensen JT. Comparison of perinatal grief after dilation and evacuation or labor induction in second trimester terminations for fetal anomalies. Am J Obstet Gynecol 2005; 192:1928–32. 11. Lohr PA, Hayes JL, Gemzell-Danielsson K. Surgical versus medical methods for second trimester induced abortion. The Cochrane Database of Systematic Revies 2008, Issue 23, Art. No.: CD006714. doi: 10.1002/14651858.CD006714.pub2. 12. Hern WM. Laminaria, induced fetal demise and misoprostol in late abortion. Int J Gynaecol Obstet 2001;75:279–86.
When Pregnancy Must End in the Second Trimester
OBSTETRICS & GYNECOLOGY
When Pregnancy Must End in the Second Trimester Alisa B. Goldberg, MD, MPH
See related article on page 1162.
Dr. Goldberg is from the Department of Obstetrics, Gynecology, and Reproductive Biology at the Harvard Medical School, the Division of Family Planning at Brigham and Women’s Hospital, and Clinical Research and Training at the Planned Parenthood League of Massachusetts, Boston, Massachusetts; e-mail: [email protected]. The opinions expressed in this article are those of the author and do not necessarily reflect the views of Planned Parenthood Federation of America, Inc. Financial Disclosure The author did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
VOL. 123, NO. 6, JUNE 2014
T
he well-designed study by Dickinson and colleagues in this month’s issue of Obstetrics & Gynecology (see page 1162) demonstrates that, after oral mifepristone and a loading dose of vaginal misoprostol, repeat doses of vaginal or sublingual misoprostol induce abortion more rapidly and leave fewer women undelivered at 12 and 24 hours than repeat oral misoprostol dosing.1 This is important information to guide the clinical treatment of women undergoing second-trimester labor induction. Mifepristone blocks progesterone receptors, softens the cervix, and sensitizes the uterus to prostaglandins. The use of 200 mg of mifepristone followed 24–48 hours later by misoprostol for second-trimester induction abortion has significantly improved the efficacy (delivery of the fetus within 24 hours) of induction abortion, shortened the induction-todelivery interval, and reduced the amount of prostaglandin required and associated side effects compared with older labor induction techniques. For these reasons, when second-trimester labor induction abortion is performed, mifepristone followed by misoprostol is recommended by the World Health Organization, the Royal College of Obstetricians and Gynaecologists, and the Society of Family Planning.2 So how does labor induction with mifepristone and misoprostol compare with second-trimester abortion by dilation and evacuation (D&E)? Data are sparse. Studies comparing D&E with older instillation labor induction techniques found D&E to be associated with fewer minor and major complications.3 More recent retrospective studies comparing D&E with labor induction with misoprostol alone similarly found fewer complications with D&E. In these newer studies, labor-induction patients were more likely to require an unplanned procedure, usually manual extraction or dilation and curettage for a retained placenta,4,5 or to receive intravenous antibiotics for fever and presumed infection.6 The study by Dickinson et al suggests that retained placenta resulting in heavy bleeding and requiring manual removal or dilation and curettage remains a challenge after second-trimester labor induction with mifepristone and misoprostol.1 Grimes et al conducted a pilot randomized trial to compare D&E with induction abortion with mifepristone and misoprostol and found recruitment difficult because a majority of women preferred D&E and declined participation. Among the 18 women enrolled, there were no serious adverse events, but induction patients reported more pain than did D&E patients.7 Advantages of D&E include that it is usually performed as an outpatient procedure, it is faster than labor induction (depending on the time required for cervical preparation), it is less expensive,8 and it may be less painful depending on anesthesia options available. Also, some women prefer not to have to go through labor and delivery when the outcome is not a viable newborn.
OBSTETRICS & GYNECOLOGY
1153
Advantages of labor induction include delivery of an intact fetus, which some women wish to see and hold and which can facilitate fetal evaluation for anatomic abnormalities when desired.9 The ability to conduct cytogenetic analyses is equivalent after D&E and labor induction,9 and grief resolution is comparable when women self-select their abortion procedure.10 Labor-induction abortion does not require a specialized surgical skill or an adequate caseload to maintain those skills, so, in many settings, it is easier to access. Ideally, women should be able to select whichever method of abortion they prefer. However, servicedelivery issues are complicated, influenced by the politics and stigma associated with abortion, and many institutions and even countries have systems of care in which one method predominates. Approximately 96% of second-trimester abortions are performed by D&E in the United States and 75% in England and Wales, whereas nearly all second-trimester abortions are performed by labor induction in Finland and Sweden.11 Institutions with limited access to D&E should work to increase access to this technique, which many patients prefer and which can be used to terminate a pregnancy quickly in emergent situations, such as active bleeding from placental abruption. A D&E can spare some women from a prolonged induction at best and a hysterotomy at worst. However, safe D&E requires not only a skilled surgeon but also appropriate facilities, a care team that often includes anesthesia providers, nurses, and medical assistants, and adequate cervical preparation. In many situations, there may be overlap of the procedures and medications used to prepare the cervix for D&E and initiate labor induction. Such hybrid procedures using misoprostol have been described for later abortions.12 Among women hospitalized for medical or obstetric complications, cervical preparation can begin as soon as the decision is made to terminate the pregnancy and abortion may be completed by either D&E or delivery, whichever can be accomplished sooner. Among women who do not generally require hospitalization, such as those with fetal anomalies or psychosocial or economic indications for abortion, there should be more flexibility in procedure choice and scheduling. For women undergoing outpatient D&E, a more controlled cervical ripening process that softens and dilates the cervix without causing expulsion before the procedure is optimal. Both D&E and labor induction with mifepristone and misoprostol are safe and effective secondtrimester abortion techniques. In countries where mifepristone is available, institutions should ensure
1154
Goldberg
access to evidence-based mifepristone and misoprostol labor-induction regimens such as those presented in this issue of the journal.1 Simultaneously, sincere efforts should be made to expand access to D&E and to accommodate patient preferences. However, for many patients, access to any form of second-trimester abortion remains a challenge, and women advance in gestation as they struggle to overcome barriers to care. Regardless of technique, efforts should focus on providing women access to safe second-trimester abortion in a timely fashion.
REFERENCES 1. Dickinson JE, Jennings BG, Doherty DA. Mifepristone and oral, vaginal or sublingual misoprostol for second-trimester abortion: a randomized controlled trial. Obstet Gynecol 2014; 123:1162–8. 2. Borgatta L, Kapp N. Society of Family Planning. Clinical guidelines. Labor induction abortion in the second trimester. Contraception 2011;84:4–18. 3. Grimes DA, Hulka JF, McCutchen ME. Midtrimester abortion by dilatation and evacuation versus intra-amniotic instillation of prostaglandin F2 alpha: a randomized clinical trial. Am J Obstet Gynecol 1980;137:785–90. 4. Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for secondtrimester abortion. Am J Obstet Gynecol 2002;187:393–7. 5. Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011; 117:788–92. 6. Edlow AG, Hou MY, Maurer R, Benson C, Delli-Bovi L, Goldberg AB. Uterine evacuation for second-trimester fetal death and maternal morbidity. Obstet Gynecol 2011;117: 307–16. 7. Grimes DA, Smith MS, Witham AD. Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: a pilot randomised controlled trial. BJOG 2004;111: 148–53. 8. Cowett AA, Golub RM, Grobman WA. Cost-effectiveness of dilation and evacuation versus the induction of labor for second-trimester pregnancy termination. Am J Obstet Gynecol 2006;194:768–73. 9. Lal AK, Kominiarek MA, Sprawka NM. Induction of labor compared to dilation and evacuation for postmortem analysis. Prenat Diagn 2014 [Epub ahead of print February 28]. 10. Burgoine GA, Van Kirk SD, Romm J, Edelman AB, Jacobson SL, Jensen JT. Comparison of perinatal grief after dilation and evacuation or labor induction in second trimester terminations for fetal anomalies. Am J Obstet Gynecol 2005; 192:1928–32. 11. Lohr PA, Hayes JL, Gemzell-Danielsson K. Surgical versus medical methods for second trimester induced abortion. The Cochrane Database of Systematic Revies 2008, Issue 23, Art. No.: CD006714. doi: 10.1002/14651858.CD006714.pub2. 12. Hern WM. Laminaria, induced fetal demise and misoprostol in late abortion. Int J Gynaecol Obstet 2001;75:279–86.
When Pregnancy Must End in the Second Trimester
OBSTETRICS & GYNECOLOGY
