Andrea Henkel, MD

Abstract

OBJECTIVES: To assess shorter mifepristone-misoprostol intervals compared to current guidelines for second trimester medical abortion on total abortion time (mifepristone to fetal expulsion) and induction time (first misoprostol to fetal expulsion).METHODS: This retrospective cohort study included women who elected for a second trimester medical abortion with mifepristone and misoprostol at an academic tertiary medical center in the United States from January 2008 to June 2018. We abstracted times of mifepristone administration, first dose of misoprostol, and fetal expulsion from the medical record. We assessed outcomes based on the shorter intervals <12 hours and 12 to 24 hours compared to the guideline mifepristone-misoprostol interval (24-48 hours).RESULTS: The study population included eighty-nine women, 47, 28, and 14 women in the <12 hour, 12-24 hour, guideline (24-48 hour) groups, respectively. The cohort had a median gestational age of 220/7 weeks (range: 150/7-270/7) and parity of 1 (range: 0-5) with no differences observed between groups. Total abortion times were 20.7 hours (range: 3.7-46.9), 30.6 hours (16.7-48.0), and 42.8 hours (32.7-62.6), respectively (p<0.001). Induction times were 12.9 hours (range: 1.2-36.6), 11.7 hours (2.0-35.2), and 9.3 hours (5.3-16.5), respectively. Fetal expulsion within 12 hours of first misoprostol dose occurred in 22 (47%), 14 (50%), and 9 (64%), respectively (p=0.52).CONCLUSIONS: Shorter mifepristone-misoprostol intervals (less than 24 hours) significantly decrease the total abortion time while maintaining a clinically similar induction time.IMPLICATIONS: Shortening the mifepristone-misoprostol interval in second trimester medical abortion significantly decreases the total abortion time which may be preferable to some women or health systems. (Words: 25).

View details for DOI 10.1016/j.contraception.2020.06.009

View details for PubMedID 32592800

Abstract

This case of an intra-abdominal levonorgestrel 52mg intrauterine system found three weeks after manual postplacental placement demonstrates the importance of proper insertion technique and ascertainment of fundal placement. Ultrasound guidance can be considered if fundal placement is uncertain. Short interval follow up should be recommended to confirm proper placement.

View details for DOI 10.1016/j.contraception.2020.01.015

View details for PubMedID 32081642

View details for DOI 10.1016/j.ajogmf.2020.100146

View details for PubMedID 32838258

View details for PubMedCentralID PMC7237374

View details for Web of Science ID 000473810000080

Abstract

Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Cahill EP, Henkel AG, Shaw JG, Shaw KA OBJECTIVE: To understand effect of adjunct misoprostol with overnight osmotic dilators for dilation and evacuation for cervical preparation after 16 weeks gestation on procedure time and dilation, complication rate, and side effects.We searched PubMed, ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, dilators and reviewed reference lists of published reports. Randomized controlled trials of cervical preparation for second trimester D&E using overnight osmotic dilators comparing adjunct misoprostol to placebo were included. Weighted mean and standard deviation (SD) and pooled binary outcomes were compared with two sample t-test or chi-square respectively.Among 84 articles identified, three met inclusion criteria of randomized controlled trials comparing adjunct misoprostol to placebo with overnight osmotic dilators prior to second trimester abortion with 457 total subjects at 16-24 weeks gestation (misoprostol n=228; placebo n=229). In the meta-analysis, misoprostol as compared to placebo did not significantly decrease mean procedure times (8.5 + 4.6 vs 9.6 + 5.8 minutes, p=0.78) or need for manual dilation (18% vs 28%, p=0.23). There was no difference in total complications (p=0.61), major complications (hemorrhage, uterine perforation, hospitalization, p=0.44), or cervical lacerations (p=0.87).Current limited evidence suggests that use of adjunctive misoprostol with osmotic dilators after 16 weeks does not affect procedure time or need for manual dilation. Further research is needed to determine if adjunctive misoprostol affects major complications and blood loss.Adjunctive misoprostol does not affect procedure time or need for manual dilation in mid to late second trimester abortion. Further research is needed to determine the effect of adjunctive misoprostol on major complications and blood loss.

View details for DOI 10.1016/j.contraception.2019.09.005

View details for PubMedID 31811840

View details for DOI 10.1097/AOG.0000000000003151

View details for PubMedID 30741819

View details for DOI 10.1097/GCO.0000000000000501

View details for Web of Science ID 000455903200013

Abstract

PURPOSE OF REVIEW: To describe recent advances in management of early pregnancy loss.RECENT FINDINGS: Addition of mifepristone to current protocols for medical management of miscarriage increases effectiveness of a single dose of misoprostol and significantly reduces subsequent aspiration procedures. Women with an incomplete evacuation after medical management may be treated expectantly with similar rates of complete expulsion compared with surgical management at 6 weeks. As cytogenetic analysis improves, analysis of products of conception can be performed whether collected after surgical or medical management and is an efficient strategy in starting a recurrent pregnancy loss work-up. For those seeking pregnancy after miscarriage, conception immediately following an early pregnancy loss is not associated with increased risk of subsequent miscarriage. However, recent studies suggest that the original intendedness of the pregnancy resulting in miscarriage does not predict future reproductive goals of the woman, so family planning should be discussed at the time of miscarriage.SUMMARY: Miscarriage is a common experience among reproductive-aged women and advances in medical management and modern-day aspiration techniques make the use of the sharp curette obsolete.

View details for PubMedID 30299321