Suction curettage as first line treatment in cases with cesarean scar pregnancy: feasibility and effectiveness in early pregnancy.

OBJECTIVE: A cesarean scar pregnancy (CSP) is an extremely rare form of an ectopic pregnancy, which is defined as the localization of a fertilized ovum surrounded by uterine muscular fiber and scar tissue. The objective of this study was to discuss the management options for CSPs in a singleton center. In the current study, we discussed the current management options for CSPs based on our 6 years of experience. MATERIAL AND METHODS: A retrospective evaluation of diagnosed and treated 26 patients with CSPs in Istanbul Kanuni Sultan Suleyman Training and Research Hospital during a 6-year period was discussed. Suction curettage was performed as first-line treatment in patients with a gestation <8 weeks and myometrial thickness >2 mm. RESULTS: Twenty-two (84.6%) patients with CSPs were initially treated surgically (curettage and hysterotomy) and four (15.4%) patients were treated medically with methotrexate injections. Vacuum aspiration was performed in 19 patients as a first-line treatment, six of them needed an additional Foley balloon catheter to be inserted for tamponade because of persistent vaginal bleeding. Suction curettage was successful in 12 patients. The treatment rate for suction curettage with or without Foley balloon catheter tamponade was 16 of 19 (84.2%). CONCLUSION: The early diagnosis of a CSP (7-8 weeks gestation) with a ß-hCG level <17.000 mIU/ml and a myometrial thickness >2 mm can be treated with suction curettage with or without placement of a uterine Foley balloon as curative treatment.

Late termination of pregnancy for lethal fetal anomalies: a national survey of maternal-fetal medicine specialists.

OBJECTIVE: The objective was to ascertain the practices and opinions of US maternal-fetal medicine specialists regarding termination of pregnancy as a management option following late diagnosis of lethal fetal anomalies. STUDY DESIGN: We conducted a cross-sectional mail survey of all US members of the Society of Maternal Fetal Medicine to ascertain how they manage pregnancies diagnosed with lethal fetal anomalies after 24 weeks of gestation. We analyzed the proportion of respondents that discuss termination of pregnancy as a management option, barriers to offering or accessing late termination services, and respondents' opinions about what anomalies are lethal and when pregnancy termination should be permitted. RESULTS: The response rate was 41% (869/2119). Nearly all (93%) respondents discuss delivery near term or when complications arise, while 75% discuss the option of termination of pregnancy soon after the diagnosis of lethal fetal anomalies. Only 52% of the physicians indicated that their patients could obtain termination of pregnancy after 24 weeks at their affiliated medical centers or through providers within 50 miles. Real or perceived legal restrictions represented the most common reason for lack of local services. The proportion of respondents that felt strongly or very strongly that termination of pregnancy should be allowed was 76% for lethal anomalies and 58% for anomalies likely to result in significant long-term impairment. CONCLUSION: Although limited by a modest response rate, our study found that physicians do not consistently discuss immediate termination of pregnancy as an option following late diagnosis of lethal fetal anomalies, and they face numerous barriers to providing these services. IMPLICATIONS: This national survey supports the need for improved services for pregnant women who desire later termination of pregnancy following diagnosis of serious fetal anomalies. Helpful efforts might include educating physicians about the laws and regulations governing late termination of pregnancy, forging more consistent standards of care, and improving collaboration between MFM specialists and family planning providers to enhance access to care.

Successful controlled ovarian stimulation despite elevated hCG levels after first-trimester abortion in the context of fertility preservation.

Fertility preservation prior to gonadotoxic chemotherapy by cryopreservation of the ovarian tissue and controlled ovarian stimulation can be effective immediately after induced abortion in the first trimenon. In a reproductive endocrinology and infertility unit of a tertiary care university-based medical centre (University Hospital of Heidelberg) a 37-year-old women with breast cancer was counseled for fertility preservation. Cryopreservation of ovarian tissue, followed by ovarian stimulation for planned intracytoplasmatic sperm injection (ICSI), transvaginal oocyte aspiration and cryopreservation of fertilized eggs was performed in spite of persistently elevated human chorionic gonadotropin (hCG)-levels after induced abortion. Twenty-four fertilized oocytes with a fertilization rate of 92% were cryopreserved. Ovarian stimulation and oocyte cryopreservation can be successfully performed with good results immediately after miscarriage, despite persistent high hCG-levels.

Risk factors of surgical evacuation following second-trimester medical termination of pregnancy.

BACKGROUND: Second-trimester medical termination of pregnancy (TOP) is associated with a higher risk of surgical evacuation than earlier medical TOP. Little is known about risk factors of surgical evacuation. Therefore, we assessed these risk factors among women undergoing second-trimester medical TOP. STUDY DESIGN: Data on 227 women were derived from a prospective randomized trial comparing 1- and 2-day mifepristone-misoprostol intervals in second-trimester medical TOP between 2008 and 2010. RESULTS: The rate of surgical evacuation was 30.8%. The risk of surgical evacuation was increased by a history of curettage [odds ratio (OR) 4.4; 95% confidence interval (CI) 1.7-11.7], fetal indications for TOP (OR 6.1; 95% CI 1.1-34.4), age above 24 years (OR 2.4; 95% CI 1.1-5.3) and a 2-day interval (OR 2.2; 95% CI 1.1-4.1). CONCLUSIONS: History of curettage, fetal indication, increasing age and 2-day interval between mifepristone and misoprostol increase the risk of surgical evacuation in cases of second-trimester medical TOP. These findings are important when optimizing clinical service in second-trimester TOP.

Evaluation of pregabalin as an adjuvant to patient-controlled epidural analgesia during late termination of pregnancy.

INTRODUCTION: Late termination of pregnancy combines psychological distress with severe physical pain. The present study evaluated the benefit of adding oral pregabalin to epidural analgesia during this procedure. METHODS: Healthy women were randomly allocated to receive either oral pregabalin 150 mg/12 h or prazepam 10 mg/12 h at the induction of the late termination of pregnancy procedure. When they felt abdominal pain (numerical rating scale ranging from 0 [no pain] to 100 [worst pain possible]), patient-controlled epidural analgesia was activated and set to deliver ropivacaine 0.1% with sufentanil 0.25 µg/ml, 5 ml/h with a bolus dose of 5 ml/30 min. Rescue analgesia was available as needed by administration of 10 ml ropivacaine 0.1% (pain score less than 60/100) or 0.2% (at least 60/100). The primary outcome was the consumption of epidural analgesics. RESULTS: Forty-eight patients participated in the study. Demographic and obstetric data were similar. Pregabalin reduced total ropivacaine consumption 11.3 ± 3.2 mg/h (mean ± SD) versus 15.1 ± 4.9 mg/h in the prazepam group (P = 0.005), an effect related to a decrease in the need for rescue analgesia. In the pregabalin group, fewer women asked for rescue dose (75 vs. 96%; P = 0.048), and the number of rescue doses per patient was reduced (1 [0-2] vs. 2 [1-3]); median [interquartile range], P = 0.005), particularly the need for ropivacaine 0.2%. DISCUSSION: This is the first study considering the use of pregabalin for labor pain associated with late termination of pregnancy, showing that pregabalin 150 mg/12 h is a helpful adjuvant to epidural analgesia. Modulation of both visceral sensitization and affective component of pain may contribute to the benefits observed.

Prenatal diagnosis and abortion for congenital abnormalities: is it ethical to provide one without the other?

This target article considers the ethical implications of providing prenatal diagnosis (PND) and antenatal screening services to detect fetal abnormalities in jurisdictions that prohibit abortion for these conditions. This unusual health policy context is common in the Latin American region. Congenital conditions are often untreated or under-treated in developing countries due to limited health resources, leading many women/couples to prefer termination of affected pregnancies. Three potential harms derive from the provision of PND in the absence of legal and safe abortion for these conditions: psychological distress, unjust distribution of burdens between socio-economic classes, and financial burdens for families and society. We present Iran as a comparative case study where recognition of these ethical issues has led to the liberalization of abortion laws for fetuses with thalassemia. We argue that physicians, geneticists and policymakers have an ethical and professional duty of care to advocate for change in order to ameliorate these harms.

Medical and ethical considerations in twin pregnancies discordant for serious cardiac disease.

OBJECTIVE: Prenatal ultrasound has led to the early diagnosis of major anomalies. However, the ready availability of this technology has led to increasing challenges for physicians counseling affected parents, which is all the more difficult in a twin pregnancy with only one affected fetus. This paper reviews the medical and ethical considerations in twin pregnancies discordant for a serious cardiac condition. STUDY DESIGN: Six recent twin pregnancies discordant for a serious cardiac condition and their outcomes are presented. Options considered in the management of the pregnancy were to continue or terminate the pregnancy, selectively terminate the affected twin or to decide whether to treat the affected twin once delivered. An approach to decision making in such situations has been formulated after critical analysis of the factors involved. RESULTS: Four of the six pregnancies were monochorionic twins. Two sets of parents decided to terminate the pregnancy. In the four that continued, two opted for the affected twin to be appropriately managed once delivered. A further two considered selective termination but opted to continue the pregnancy because of the risk of premature labor and/or cerebral hypoxia following such intervention. They sought a commitment, however, that they be given the option whether to treat the affected twin following delivery. Eventually both elected to have their babies treated, one of whom died in the postoperative period. DISCUSSION: Medical considerations included the risks of continuation of the pregnancy for the mother and her twins, the safety of termination (total or selective), and the risks to the unaffected fetus. Ethical issues revolved around concepts of autonomy, beneficence and justice from the standpoint of the family and the twins. The gestation and the viability of the twins played an important role in decision making and approaches, taking into account the local legal and other considerations. CONCLUSION: Attention is drawn to the complexities of the issues involved in twin pregnancies complicated by a serious cardiac condition in one of the twins. Optimal counseling requires sound clinical knowledge about the medical risks to the mother and her twins, and a clear understanding of the key ethical considerations. Such an approach will assist parents in their very difficult decision making.

Management of the third stage of labor in pregnancies terminated by prostaglandin E2.

In the management of second-trimester medical terminations of pregnancy, it is a commonly accepted practice to allow 2 hours for the third stage of labor. This practice is based on data from terminations with saline solution as the abortifacient. Herein we report our experience with the use of prostaglandin E2 vaginal suppositories for midtrimester terminations, with particular regard to placental delivery rates and associated complications. Ninety-six patients underwent prostaglandin E2 vaginal suppository terminations. Fifty-eight percent of patients had spontaneous placental delivery within 2 hours of the passage of the fetus; approximately two thirds of these were expelled within 30 minutes. Previous work involving elective saline solution-induced terminations suggested the 2-hour time limit for the third stage of labor. This was based on an unacceptable complication rate of greater than 4% beyond 2 hours. The present study of the use of prostaglandin E2 suppositories for a variety of indications demonstrated a similar complication rate of 4% at 30 minutes. These findings suggest expectant management beyond this time limit may produce unacceptably high complication rates.

PIP: On the basis of experience with 2nd-trimester abortions induced by saline solution, a consensus has been reached that a retained placenta should be surgically removed if complete spontaneous passage does not occur within 2 hours of fetal delivery. The purpose of this study was to analyze the management and complications of the 3rd stage of labor when abortion is induced by prostaglandin (PG) E2 vaginal suppositories--at present the most widely used abortifacient. 96 women who underwent PGE2 pregnancy termination in 1984-87, for indications such as anatomic abnormalities, chromosomal abnormalities, and fetal death, were included in the study. The mean induction length (time from placement of the 1st PGE2 suppository to fetal delivery) was 15 hours, 33 minutes. 58 patients (60%) delivered the placenta spontaneously within the 2-hour time limit. An additional 10 patients delivered the placenta spontaneously while awaiting surgical intervention. Retained placenta was more likely to occur in patients with fetuses of an earlier gestational age (15-16 weeks). Previous uterine surgery, previous induced abortion, and gravidity did not have an effect on placental delivery. Hemorrhage, the major complication of 2nd-trimester pregnancy termination, occurred with significantly greater frequency when the 3rd stage of labor was of increasing duration. At 2 hours, there was a 3-fold increase in the complication rate compared with placental delivery at 15 minutes. Analysis of the likelihood of spontaneous placental delivery suggests that more than 50% of placentas that are destined to pass spontaneously do so within 15 minutes and 64% pass within 30 minutes. Given both the likelihood of spontaneous placental delivery by 30 minutes and the increasing complication rate with further expectant management, it is recommended that 30 minutes be accepted as the appropriate time limit for expectant management of the 3rd stage of labor when pregnancies are terminated by PGE2.

Psychological sequelae of elective abortion.

A mild, short, depressive and guilt ridden period following abortion is quite common, but a severe psychological reaction is rare. The indication for the abortion and the preabortal psychological state of the patient are the two most important factors. Almost all reported instances of postabortion psychoses have occurred in patients who had severe preabortal psychiatric problems. Women undergoing abortion for socioeconomic or psychosocial indications appear to be at minimal risk for long-term negative psychological sequelae. In contrast, women in whom abortion is carried out because of exposure to rubella and the risk of fetal malformation, maternal organic disease or the prenatal diagnosis of a genetically defective fetus are at greater risk and may need supportive psychotherapy.

The psychological sequelae of abortion performed for a genetic indication.

Psychometric testing and psychiatric interviews were conducted on 13 families in which the women had undergone amniocentesis for the prenatal detection of a genetic defect in the fetus and, upon receiving positive results, elected to have a therapeutic abortion. The indication for amniocentesis was maternal age in two families, a previous child with Down's syndrome in one family, a previous child with a recessively inherited inborn error of metabolism in four families, and the mother being a carrier for an X-linked disease in six families. The incidence of depression following selective abortion may be as high as 92 per cent among the women and as high as 82 per cent among the men studied, and was greater than that usually associated with elective abortion for psychosocial indications or with delivery of a stillborn. Four families experienced separations during the pregnancy-abortion period. Despite the emotional trauma of the procedure, most of the families studied would repeat their course of action and consider selective abortion preferable to the alternative birth of a defective child. Several modifications in the amniocentesis and selective abortion procedure which might diminish the concomitant emotional trauma are suggested.