Spontaneous abortion: Management

Authors Togas Tulandi, MD, MHCM Haya M Al-Fozan, MD Section Editor Robert L arbieri, MD De!uty Editor Sandy " Fal#, MD Disclosures All to!ics are u!dated as ne$ e%idence beco&es a%ailable and our !eer re%ie$ !rocess is co&!lete' Literature re%ie$ current through( Se! )*+,' - This to!ic last u!dated( abr )., )*+)' /0TR1D2CT/10 3 S!ontaneous abortion, also #no$n as &iscarriage, re4ers to a !regnancy that ends s!ontaneously be4ore the 4etus has reached a %iable gestational age' The &anage&ent o4 di44erent ty!es o4 s!ontaneous abortion $ill be discussed here' 1ther as!ects o4 s!ontaneous abortion, including the clinical &ani4estations and diagnosis o4 the di44erent ty!es o4 abortion, are re%ie$ed se!arately' 5See 6S!ontaneous abortion( Ris# 4actors, etiology, clinical &ani4estations, and diagnostic e%aluation6'7 THREATE0ED A 1RT/10 3 8o&en $ith threatened abortion ha%e traditionally been &anaged e9!ectantly until their sy&!to&s resol%e, a de4initi%e diagnosis o4 non%iable !regnancy can be &ade, or there is !rogression to an ine%itable, inco&!lete, or co&!lete abortion' The use o4 !rogestins to reduce the ris# o4 &iscarriage a&ong $o&en $ith threatened abortion is contro%ersial' A &eta-analysis that included 4our rando&ized trials $ith a total o4 .)+ $o&en 4ound that the rate o4 s!ontaneous abortion $as statistically signi4icantly lo$er $ith !rogestin treat&ent co&!ared $ith !lacebo or no treat&ent 5+. %ersus ): !ercent; relati%e ris# *'<,; =<> C/ *',< to *'?=7 @+A' Brogestins $ere ad&inistered either orally or %aginally, and subgrou! analysis 4ound a signi4icant decrease in the rate o4 abortion only 4or oral !rogestins; the analysis o4 %aginal !rogestins lac#ed su44icient statistical !o$er to detect a di44erence' There $as no signi4icant increase in congenital ano&alies or !regnancy-induced hy!ertension in the !rogestin grou!' Ho$e%er, the &eta-analysis $as li&ited by the s&all nu&ber o4 !artici!ants and e%ents and !oor &ethodological Cuality o4 studies' Many &iscarriages are caused by genetic abnor&alities in the conce!tus' /t is unli#ely that !rogestins could !re%ent a &iscarriage o4 this etiology' The data are insu44icient to &a#e a reco&&endation 4or or against !rogestins 4or $o&en $ith threatened abortion' ed rest is co&&only reco&&ended, but rando&ized trials ha%e not 4ound that bed rest at ho&e or in the hos!ital is bene4icial in !re%enting 4etal loss in $o&en $ith threatened s!ontaneous abortion @)A' Abstinence 4ro& se9ual intercourse is also ty!ically ad%ised, although there are no data to su!!ort this' There are no high Cuality data that su!!ort use o4 hu&an chorionic gonadotro!in, uterine &uscle rela9ants 5eg, tocolytics, beta-agonists7, or %ita&in su!!le&entation 4or !re%enting !regnancy loss in $o&en $ith threatened abortion @,-<A'

SEBT/C A 1RT/10 3 Sus!ected se!tic abortion $ith retained !roducts o4 conce!tion should be &anaged by(

Stabilizing the !atient 1btaining blood and endo&etrial cultures Bro&!tly ad&inistering !arenteral broad s!ectru& antibiotics 5eg, clinda&ycin =** &g e%ery eight hours and genta&icin < &gD#g daily $ith or $ithout a&!icillin ) g e%ery 4our hours; or a&!icillin and genta&icin and &etronidazole <** &g e%ery eight hours; or le%o4lo9acin <** &g daily and &etronidazole; or single agents such as ticarcillin-cla%ulanate ,'+ g e%ery 4our hours, !i!eracillintazobacta& .'< g e%ery si9 hours, or i&i!ene& <** &g e%ery si9 hours7' /ntra%enous antibiotics are ad&inistered until the !atient has i&!ro%ed and been a4ebrile 4or .E hours, then are ty!ically 4ollo$ed by oral antibiotics to co&!lete a +*- to +.-day course' The need to co&!lete a 4ull course $ith oral antibiotics a4ter clinical i&!ro%e&ent has been Cuestioned, based u!on data 4ro& a rando&ized trial that 4ound no di44erence in $o&en $ho recei%ed only a short course o4 intra%enous thera!y @:A' This a!!roach reCuires 4urther e%aluation' Surgically e%acuating the uterine contents

E%acuation o4 the uterus should begin promptly a4ter initiating antibiotics and stabilizing the !atient in cases o4 sus!ected se!tic abortion or retained !roducts o4 conce!tion as delay in e%acuation &ay be 4atal @?,EA' Suction curettage is less trau&atic than shar! curettage' /ndications 4or surgery and !ossible hysterecto&y include 4ailure to res!ond to uterine e%acuation and antibiotics, !el%ic abscess, and clostridial necrotizing &yonecrosis 5gas gangrene7' A discolored, $oody a!!earance o4 the uterus and adne9a, sus!ected clostridial se!sis, cre!itation o4 the !el%ic tissue, and radiogra!hic e%idence o4 air $ithin the uterine $all are indications 4or total hysterecto&y and adne9ecto&y @?A' Surgery, i4 indicated, &ay be !er4or&ed by la!arosco!y' 1n the other hand, &ild endo&etritis 5lo$ grade 4e%er, &ild uterine tenderness, e&!ty uterus on ultrasound e9a&ination7 a4ter a co&!lete s!ontaneous abortion can be &anaged $ith oral broad s!ectru& antibiotics' 5See 6Bost!artu& endo&etritis6'7 C1MBLETE A 1RT/10 3 Tissue that is !assed should be e9a&ined to con4ir& that it is 5or is not7 the !roduct o4 conce!tion' Fetal &e&branes are readily identi4iable and con4ir& !assage o4 at least !art o4 an intrauterine !regnancy' An e&bryo &ay or &ay not be identi4ied' Bassage o4 an intact gestational sac or contraction o4 the uterus $ith scant uterine bleeding and di&inishing uterine cra&!s suggests that a co&!lete abortion has occurred' Blacental %illi can be di44icult to distinguish 4ro& organized clot' 1ne &ethod is to rinse $ith $ater and then 4loat the tissue in a dish o4 $ater, !re4erably $ith a good light source underneath' Filli ha%e a 4rond-li#e a!!earance, $hich has been described as si&ilar to sea$eed 4loating in the ocean 5!icture +A- 7' 2ltrasound e9a&ination &ay be use4ul 4or con4ir&ing the absence o4 signi4icant a&ounts o4 retained intrauterine tissue, but there are no uni%ersally de4ined criteria 4or an e&!ty uterus'

A co&!lete abortion theoretically should not reCuire thera!y, but co&!lete abortions generally cannot be reliably distinguished 4ro& inco&!lete abortions either clinically or ultrasonogra!hically' As a result, so&e !ro%iders !er4or& suction curettage in all o4 these !atients @=A' Due to a !ossible ris# o4 intrauterine adhesions, $e do not ad%ocate this a!!roach' /n addition, treat&ent o4 intrauterine adhesions is not al$ays 4ollo$ed by a !regnancy' 5See GSurgical &anage&entG belo$ and 6/ntrauterine adhesions6'7 The surgical &anage&ent o4 co&!lete abortion is not based u!on data 4ro& co&!arati%e trials' /t see&s clear that surgery is necessary 4or $o&en $ith e9cessi%e bleeding, unstable %ital signs, or ob%ious signs o4 in4ection' 8hether the uterus should be e%acuated in unco&!licated cases needs to be deter&ined by studies that co&!are %arious treat&ent a!!roaches and consider the ty!e o4 &iscarriage 5inco&!lete or co&!lete7, the gestational age, and the clinical status and !re4erences o4 the &other' /n our e9!erience, i4 the ultrasound sho$s an e&!ty uterus and the bleeding is &ini&al, no 4urther action is needed' /0C1MBLETE, /0EF/TA LE, A0D M/SSED A 1RT/10 3 8o&en $ith an inco&!lete, ine%itable, or &issed abortion docu&ented by ultrasound e9a&ination can be &anaged surgically, &edically, or e9!ectantly' Syste&atic re%ie$s o4 rando&ized clinical trials o4 surgical, &edical, and e9!ectant &anage&ent o4 $o&en $ith 4irst tri&ester &issed or inco&!lete abortion generally concluded that all o4 the thera!ies $ere e44ecti%e, but co&!lete e%acuation $ithin .E hours $as &ore li#ely $ith surgical than &edical &anage&ent and &ore li#ely $ith &edical than e9!ectant &anage&ent @+*-+)A' These analyses $ere li&ited by &issing data, di44erent a!!roaches to &edical and e9!ectant &anage&ent, and nonstandardized outco&es' MaHor co&!lications $ere in4reCuent 4or all o4 the &ethods, and !atient satis4action could not be assessed' SubseCuent to these syste&atic re%ie$s, a rando&ized trial 5M/ST7 co&!aring surgical, &edical, and e9!ectant &anage&ent o4 4ailed !regnancy in +)** $o&en re!orted that the incidence o4 in4ection $as ) to , !ercent 4or all three grou!s @+,A; thus, the ris# o4 in4ection is not an i&!ortant %ariable in choosing the thera!eutic a!!roach' Surgical &anage&ent 3 The con%entional treat&ent o4 4irst or early second tri&ester 4ailed !regnancy is dilatation and curettage 5DIC7 or dilatation and e%acuation 5DIE7 to !re%ent !otential he&orrhagic and in4ectious co&!lications 4ro& the retained !roducts o4 conce!tion @+.A' This !rocedure carries anesthesia ris#s and co&!lications such as uterine !er4oration, intrauterine adhesions, cer%ical trau&a, and in4ection, $hich &ight lead to subseCuent in4ertility or ecto!ic !regnancy @+<A' The ris#s, ho$e%er, are s&all and uterine e%acuation can be !er4or&ed sa4ely and e44ecti%ely as an o44ice !rocedure @+:A' Surgical &anage&ent is a!!ro!riate 4or $o&en $ho do not $ant to $ait 4or s!ontaneous or &edically induced e%acuation o4 the uterus 5see belo$7 and those $ith hea%y bleeding or intrauterine se!sis in $ho& delaying thera!y could be har&4ul' Suction curettage is !re4erable to shar! curettage, $hich is associated $ith greater &orbidity @=,+?,+EA' A descri!tion o4 techniCue is discussed se!arately' 5See 6Surgical ter&ination o4 !regnancy( First tri&ester6'7 8e reco&&end do9ycycline 5+** &g orally 4or t$o doses +) hours a!art on the day o4 the surgical !rocedure7 to reduce the ris# o4 !ostabortal se!sis' This reco&&endation is

based on a &eta-analysis that 4ound $o&en gi%en !eriabortal antibiotics had a .) !ercent lo$er ris# o4 in4ection @+=A' These trials in%ol%ed $o&en undergoing induced abortion, but it is li#ely si&ilar bene4its $ould be obser%ed 4or $o&en undergoing surgical e%acuation o4 a 4ailed !regnancy' Ho$e%er, the only rando&ized trial that e%aluated antibiotic !ro!hyla9is be4ore curettage 4or inco&!lete abortion did not obser%e a signi4icant decrease in 4ebrile &orbidity @)*A' Medical treat&ent 3 The a%ailability o4 e44ecti%e &edical thera!ies 4or inducing abortion has created ne$ o!tions 4or $o&en $ho $ant to a%oid surgery and in areas $here surgical inter%ention is not !ractical' Miso!rostol 5a !rostaglandin E+ analog7 is the &ost co&&only used such agent' /ts sa4ety and e44ecti%eness ha%e been established by &ulti!le rando&ized and controlled trials @)+,))A' The ad%antages o4 &iso!rostol o%er other drugs 5including !rostaglandin E)7 are its lo$ cost @),A, lo$ incidence o4 side e44ects $hen gi%en intra%aginally, stability at roo& te&!erature, and ready a%ailability' The ris# o4 a &aHor co&!lication is rare' The e44icacy o4 &iso!rostol 4or &edical &anage&ent o4 !regnancy 4ailure in the 4irst tri&ester $as illustrated in a large, $ell-designed trial in $hich :<) $o&en $ith &issed, inco&!lete, or ine%itable abortion $ere rando&ly assigned ,(+ to recei%e E** &cg &iso!rostol intra%aginally or undergo %acuu& as!iration @).A' Miso!rostol $as re!eated t$o days later 5day ,7 i4 e9!ulsion $as inco&!lete, as diagnosed by sonogra!hic e9a&ination; %acuu& as!iration $as !er4or&ed on day E i4 e9!ulsion $as still inco&!lete' /n &edically &anaged !atients, co&!lete e9!ulsion occurred in ?+ !ercent by day three and E. !ercent by day eight' Bregnancy duration did not a44ect the rate o4 success4ul e9!ulsion, but success4ul e9!ulsion $as lo$er $ith &issed abortion co&!ared $ith inco&!lete or ine%itable abortion 5E+ %ersus =, !ercent7' oth &edical and surgical thera!ies $ere sa4e, e44ecti%e, and acce!table to !atients' The e44icacy o4 &edical treat&ent $ith !rostaglandins de!ends u!on both the dose and route o4 ad&inistration, but there is no consensus on the o!ti&al choice 4or either' A single oral dose o4 .** &cg &iso!rostol resulted in a lo$ rate 5+, !ercent7 o4 e9!ulsion @)<A, $hereas the sa&e dose gi%en &ulti!le ti&es resulted in an e9!ulsion rate o4 <* to ?* !ercent @)<-)EA' The e9!ulsion rate $as e%en higher $ith a dose o4 :** to E** &cg gi%en %aginally 5?* to =* !ercent7 @+<,)+,).,)=-,.A' This &ay be due to the local e44ect o4 &iso!rostol on the uterine cer%i9, the high drug concentration achie%ed in uterine tissue, and the increased bioa%ailability $ith %aginal ad&inistration @,<,,:A' uccal ad&inistration a!!ears to be as e44ecti%e as %aginal ad&inistration, but is associated $ith &ore side e44ects, !robably related to di44erences in !har&aco#inetics 4or the t$o routes o4 ad&inistration @))A A $ell-designed rando&ized trial noted that $o&en treated $ith &iso!rostol e9!erienced signi4icantly longer duration o4 bleeding and greater 4all in he&oglobin than those $ho under$ent curettage @,?A' Although other rando&ized trials ha%e re!orted that &edical and surgical curettage result in a si&ilar a&ount o4 blood loss, &any o4 these trials did not clearly de4ine bleeding outco&e or collect data !ros!ecti%ely'

The o!ti&u& dose and route and 4reCuency o4 ad&inistration ha%e not been established' /n a consensus !a!er by an e9!ert grou! con%ened by the 8orld Health 1rganization in )**?, t$o di44erent regi&ens o4 &iso!rostol $ere !ro!osed @,EA(

For &issed abortion J E** &cg !er %agina& 1R :** &cg sublingually 5each o4 these is a single dose7 For inco&!lete abortion J :** &cg orally 5single dose7

1ur !re4erence is to use &iso!rostol .** &cg !er %agina& e%ery 4our hours 4or 4our doses to ta#e ad%antage o4 the increased e44ecti%eness o4 the %aginal route $hile &ini&izing the ris# o4 side e44ects, $hich are dose and route de!endent' The e9!ulsion rate is ?* to =* !ercent $ithin ). hours; thus, so&e $o&en $ill still reCuire surgical e%acuation' Ho$e%er, the i&&ediate, short-ter&, and &ediu&-ter& &edical co&!lications associated $ith &iso!rostol use are signi4icantly lo$er than $ith surgery @)EA' A co&bination o4 a !rogesterone antagonist 5&i4e!ristone7 and &iso!rostol 5.** &cg orally7 has also been used @,=A' Due to lo$ seru& !rogesterone le%els in $o&en $ith abnor&al !regnancy @.*A, the %alue o4 adding a !rogesterone antagonist is Cuestionable and e9!ensi%e' This hy!othesis $as su!!orted by a !ros!ecti%e cross-o%er trial and a rando&ized controlled trial, both o4 $hich re!orted that &iso!rostol alone or a co&bination o4 &iso!rostol and &i4e!ristone had si&ilar success rates in treat&ent o4 early !regnancy 4ailure @.+,.)A' 5See 6Thera!eutic use and ad%erse e44ects o4 !rogesterone rece!tor antagonists and selecti%e !rogesterone rece!tor &odulators6'7 Batients $ho are treated &edically are instructed to go to the e&ergency de!art&ent i4 they de%elo! e9cessi%e bleeding' Tissues that are !assed %aginally should be !laced in a container and brought to the hos!ital 4or analysis' The long-ter& conce!tion rate and !regnancy outco&e are si&ilar 4or $o&en $ho undergo &edical or surgical e%acuation 4or early !regnancy 4ailure @.,A' Methotre9ate is not used in &anage&ent o4 s!ontaneous abortion' Second tri&ester 3 Second tri&ester abortion is associated $ith higher rates o4 co&!lications than 4irst tri&ester abortion @..A' For e9a&!le, u! to +* !ercent o4 $o&en undergoing induced &edical abortion $ill reCuire hos!italization 4or &edical, social, or geogra!hical reasons @.<A' There has been no clear e%idence o4 su!eriority o4 one &id-tri&ester abortion &ethod o%er another in ter&s o4 sa4ety and acce!tability' /n &ost !ractices, second tri&ester abortion o%er +: $ee#s is co&!leted $ith &iso!rostol in the hos!ital setting and surgical e%acuation is reser%ed 4or retained !roducts o4 conce!tion' Ho$e%er, clinicians !ro4icient in &id-tri&ester surgical !regnancy ter&ination &ay o44er !atients surgical e%acuation' E9!ectant &anage&ent 3 E9!ectant &anage&ent 5EM7 is an alternati%e 4or $o&en $ith early !regnancy 4ailure at less than +, $ee#s o4 gestation $ho ha%e stable %ital signs and no e%idence o4 in4ection @++,.:-<+A' A syste&atic re%ie$ including 4i%e rando&ized trials concluded that co&!ared to surgical e%acuation, EM $as associated $ith a higher ris# o4 inco&!lete &iscarriage, need 4or un!lanned surgical e&!tying o4 the uterus, and bleeding, but $as not an unreasonable a!!roach i4 the $o&an !re4erred

noninter%ention @++A' Rando&ized trials co&!aring &edical &anage&ent to EM ha%e re!orted si&ilar rates o4 success4ul e%acuation @<*,<+A' Discre!ancies in success rates relate to the duration o4 EM, the &edical treat&ent regi&en, the negati%e %alue !laced on %arious &aternal &orbidities, and $hether the subHects had asy&!to&atic early !regnancy 4ailure or inco&!lete &iscarriage' The &aHority o4 e9!ulsions occur in the 4irst t$o $ee#s a4ter diagnosis; ho$e%er, so&e $o&en &ay reCuire !rolonged 4ollo$-u! @<)-<.A' /nco&!lete &iscarriage is &ore li#ely to !roceed to e9!ulsion $ithin t$o $ee#s than a &issed abortion' An inter%al o4 three to 4our $ee#s bet$een diagnosis o4 non%iable !regnancy and e9!ulsion is not unusual' Most $o&en are $illing to $ait $hen a!!ro!riately counseled @<<A and !re!ared 4or $hat to e9!ect @<:A' /4 s!ontaneous e9!ulsion does not occur, &edical or surgical treat&ent can be ad&inistered' Follo$ing s!ontaneous or &edically induced e9!ulsion, so&e !ro%iders !er4or& an ultrasound e9a&ination routinely to e%aluate the uterine ca%ity, others !er4or& this e9a&ination selecti%ely in !atients $hose clinical e9a&ination is suggesti%e o4 retained !roducts o4 conce!tion' There are no uni%ersally de4ined criteria 4or an e&!ty uterus' 1ne o!tion is to !roceed $ith surgical e%acuation i4 retained tissue $ith a dia&eter o4 &ore than +< && is 4ound @.:A' 1thers use a ho&ogeneous intrauterine di&ension less than ++ c&) in co&bined trans%erse and sagittal !lanes to de4ine an e&!ty uterus @<?,<EA' 2sing the latter criteria, < !ercent o4 $o&en had co&!lications and .* !ercent reCuired another inter%ention 5&edical or surgical7' Ho$e%er, there is also e%idence that increased endo&etrial thic#ness is not !redicti%e o4 &orbidity in asy&!to&atic $o&en @<=,:*A' /4 the ultrasound re%eals retained tissue and the !atient is asy&!to&atic or ha%ing only &ini&al bleeding, $e o44er the !atient surgical e%acuation o4 the uterus or e9!ectant &anage&ent 4or another t$o $ee#s' The largest series e%aluating the outco&e o4 EM 4ollo$ed +*=: consecuti%e !atients $ith sus!ected 4irst tri&ester &iscarriage 4or u! to 4our $ee#s @:+A' Each !regnancy $as diagnosed by trans%aginal ultrasound as a co&!lete 5n K .*E7, inco&!lete, &issed, or ane&bryonic &iscarriage' 8o&en $ho did not ha%e a co&!lete &iscarriage 5n K :E:7 $ere o44ered EM or surgical e%acuation' Success4ul s!ontaneous abortion occurred in E+ !ercent o4 all e9!ectantly &anaged !atients, =+ !ercent o4 those $ith inco&!lete &iscarriages, ?: !ercent o4 those $ith &issed abortions, and :: !ercent o4 those $ith ane&bryonic !regnancies' Co&!lications, such as in4ection and e9cessi%e !ain or bleeding, occurred in + !ercent o4 e9!ectantly and ) !ercent o4 surgically &anaged !atients' Thus, EM 4or one &onth a!!ears to be a sa4e and e44ecti%e alternati%e to i&&ediate surgical e%acuation' /n addition, sonogra!hic classi4ication o4 the &iscarriage at !resentation a!!ears !redicti%e o4 success4ul outco&e $ithout surgical inter%ention' Cost analysis 3 /n the M/ST trial, +)** $o&en $ith a diagnosis o4 inco&!lete or &issed &iscarriage at less than +, $ee#s o4 gestation $ere rando&ly assigned to e9!ectant, &edical, or surgical &anage&ent @:)A' The net societal cost !er $o&an $as esti&ated at +*E:, +.+*, and +<E< !ounds, res!ecti%ely' Ho$e%er, cost analyses de!end

on se%eral 4actors, including the sco!e o4 costs considered in the analysis and the co&&unity in $hich the costs are incurred @:,-::A' B1STA 1RT/10 CARE A0D C120SEL/0L 3 8o&en are ad%ised to &aintain !el%ic rest 5ie, nothing !er %agina7 until t$o $ee#s a4ter e%acuation or !assage o4 the !roducts o4 conce!tion, at $hich ti&e coitus and use o4 ta&!ons &ay be resu&ed' /t is custo&ary to ad%ise that !regnancy be de4erred 4or t$o to three &onths, although se%eral studies ha%e sho$n no greater ris# o4 ad%erse outco&e $ith a shorter inter!regnancy inter%al @:?-?*A' Any ty!e o4 contrace!tion, including !lace&ent o4 intrauterine contrace!tion @?+A, &ay be started i&&ediately a4ter the abortion has been co&!leted' 5See 6Bost!artu& and !ostabortion contrace!tion6'7 Light %aginal bleeding can !ersist 4or a cou!le o4 $ee#s a4ter the abortion' Batients should call their !ro%ider i4 hea%y bleeding, 4e%er, or abdo&inal !ain de%elo!s' Menses ty!ically resu&e $ithin si9 $ee#s; i4 nor&al &enses do not resu&e, then the !resence o4 a ne$ !regnancy or, rarely, gestational tro!hoblastic disease should be considered' Although rare, intrauterine adhesions 5also #no$n as Asher&anGs syndro&e7 could occur a4ter surgical e%acuation o4 the uterus' /n the se%ere 4or&, &enses do not resu&e or are scanty' Alloi&&unization !re%ention 3 8o&en $ho are Rh5D7-negati%e and unsensitized should recei%e Rh5D7-i&&une globulin 4ollo$ing surgical e%acuation or u!on diagnosis i4 &edical &anage&ent or EM is !lanned' A dose o4 <* &cg is e44ecti%e through the +)th $ee# o4 gestation due to the s&all %olu&e o4 red cells in the 4eto!lacental circulation 5&ean red cell %olu&e at E and +) $ee#s is *',, &L and +'< &L, res!ecti%ely7, although there is no har& in gi%ing the standard ,** &icrogra& dose, $hich is &ore readily a%ailable' 5See 6Bre%ention o4 Rh5D7 alloi&&unization6'7 Resolution o4 !ositi%e hCL 3 Seru& hCL %alues ty!ically return to nor&al $ithin t$o to 4our $ee#s a4ter a co&!leted abortion 5table +7 @?)-?:A' Follo$-u! hCL testing is unnecessary i4 nor&al &enstrual cycles resu&e' 5See 6Lestational tro!hoblastic disease( E!ide&iology, clinical &ani4estations and diagnosis6'7 Lrie4 counseling 3 Lrie4 counseling is a!!ro!riate @??,?EA' /t is i&!ortant to ac#no$ledge the !atientGs 5and !artnerGs7 grie4 and !ro%ide e&!athy and su!!ort' Ris# 4actors 4or abnor&al grie4 4ollo$ing a &iscarriage include @?=A(

A history o4 or current de!ression, an9iety, or other !sychiatric disorder 0eurotic !ersonality traits Lac# o4 social su!!ort

/4 the etiology o4 the loss is #no$n or sus!ected, the cou!le should be in4or&ed and counseled about recurrence ris#s' /4 re%ersible ris# 4actors 4or s!ontaneous abortion are !resent, these can be addressed, as a!!ro!riate, in a nonHudg&ental $ay' 8hen an etiology cannot be deter&ined, it is i&!ortant to reassure the $o&an that there is no e%idence that so&ething she &ight ha%e done 5eg, se9ual intercourse, hea%y li4ting, bu&!ing her abdo&en, stress7 caused the &iscarriage'

F2T2RE REBR1D2CT/FE /SS2ES 3 The o%erall ris# o4 &iscarriage in 4uture !regnancy is a!!ro9i&ately )* !ercent a4ter one &iscarriage, )E !ercent a4ter t$o &iscarriages, and ., !ercent a4ter three or &ore &iscarriages @E*A' There also a!!ears to be an increased ris# o4 !reter& deli%ery in subseCuent !regnancies @E+,E)A' The ris# increases $ith increasing nu&ber o4 &iscarriages 51R +'*<-+':: a4ter one &iscarriage, 1R +'=<-)'EE a4ter &ore than one &iscarriage @E)A7' Second tri&ester !regnancy loss is signi4icantly associated $ith recurrent secondtri&ester loss and 4uture s!ontaneous !reter& birth' A4ter a second tri&ester !regnancy loss, one study re!orted ,= !ercent o4 $o&en had a !reter& deli%ery in their ne9t !regnancy, < !ercent had a stillbirth, and : !ercent had a neonatal death @E,A' /n another study o4 ,* $o&en $ith second tri&ester loss, the 4reCuency o4 recurrent second tri&ester loss $as )? !ercent and the 4reCuency o4 subseCuent !reter& birth $as ,, !ercent @E.A' /0F1RMAT/10 F1R BAT/E0TS 3 2!ToDate o44ers t$o ty!es o4 !atient education &aterials, MThe asicsN and M eyond the asics'N The asics !atient education !ieces are $ritten in !lain language, at the <th to :th grade reading le%el, and they ans$er the 4our or 4i%e #ey Cuestions a !atient &ight ha%e about a gi%en condition' These articles are best 4or !atients $ho $ant a general o%er%ie$ and $ho !re4er short, easy-to-read &aterials' eyond the asics !atient education !ieces are longer, &ore so!histicated, and &ore detailed' These articles are $ritten at the +*th to +)th grade reading le%el and are best 4or !atients $ho $ant in-de!th in4or&ation and are co&4ortable $ith so&e &edical Hargon' Here are the !atient education articles that are rele%ant to this to!ic' 8e encourage you to !rint or e-&ail these to!ics to your !atients' 5Oou can also locate !atient education articles on a %ariety o4 subHects by searching on M!atient in4oN and the #ey$ord5s7 o4 interest'7

asics to!ics 5see 6Batient in4or&ation( Miscarriage 5The asics76 and 6Batient in4or&ation( Threatened &iscarriage 5The asics767 eyond the asics to!ics 5see 6Batient in4or&ation( Miscarriage 5 eyond the asics767

S2MMARO A0D REC1MME0DAT/10S

For $o&en $ith threatened s!ontaneous abortion, so&e data su!!ort use o4 !rogestins to !re%ent &iscarriage' The data are insu44icient to &a#e a reco&&endation' 1ther inter%entions, including bed rest, abstaining 4ro& se9ual intercourse, treat&ent $ith hu&an chorionic gonadotro!in, &uscle rela9ants or %ita&in su!!le&entation ha%e not been 4ound to be bene4icial' 5See GThreatened abortionG abo%e'7 8e reco&&end !atients $ith se!tic abortion be stabilized, ad&inistered broad s!ectru& antibiotics, and undergo surgical e%acuation o4 uterine contents 5Lrade + 7' 5See GSe!tic abortionG abo%e'7 High Cuality e%idence 4ro& rando&ized trials has sho$n that surgical, &edical, and e9!ectant &anage&ent o4 inco&!lete, ine%itable, or &issed abortion all result in e%acuation o4 !roducts o4 conce!tion in &ost !atients' Surgical

e%acuation is a &ore success4ul !ri&ary thera!y than &edical or e9!ectant &anage&ent; the e44ecti%eness o4 the latter t$o a!!roaches de!ends u!on the duration o4 ti&e allo$ed be4ore secondary surgical inter%ention and u!on the ty!e o4 non%iable !regnancy' Bostabortal in4ection rates are si&ilar 4or all three a!!roaches, and the 4reCuency o4 other co&!lications is lo$' For these reasons, the choice o4 treat&ent should be based u!on !atient !re4erences' 5See G/nco&!lete, ine%itable, and &issed abortionG abo%e'7 8e reco&&end surgical thera!y 4or $o&en $ho are unstable because o4 bleeding or in4ection and 4or $o&en $ho $ant i&&ediate, de4initi%e treat&ent 5Lrade +A7' 5See GSurgical &anage&entG abo%e'7 8e reco&&end treat&ent $ith &iso!rostol 4or $o&en $ho $ant to a%oid a surgical !rocedure, but do not $ant to $ait 4or s!ontaneous !assage o4 !roducts o4 conce!tion to occur 5Lrade +A7' Se%enty to =* !ercent $ill ha%e a success4ul outco&e $ith &edical &anage&ent alone' 5See GMedical treat&entG abo%e'7 8e reco&&end e9!ectant &anage&ent 4or stable $o&en $ho do not $ant any &edical or surgical inter%ention, and are $illing to $ait days to $ee#s 4or e9!ulsion to occur 5Lrade +A7' leeding and cra&!ing &ay be !rolonged and surgical e%acuation &ay still be reCuired, but as &any as E* !ercent o4 $o&en $ill ha%e a success4ul outco&e $ith e9!ectant &anage&ent alone' 5See GE9!ectant &anage&entG abo%e'7

2se o4 2!ToDate is subHect to the Subscri!tion and License Agree&ent'

REFERENCES
+' 8ahabi HA, Fayed AA, Es&aeil SA, Al Peidan RA' Brogestogen 4or treating threatened &iscarriage' Cochrane Database Syst Re% )*++; (CD**<=.,' )' Ale&an A, Althabe F, elizQn ", ergel E' ed rest during !regnancy 4or !re%enting &iscarriage' Cochrane Database Syst Re% )**<; (CD**,<?:' ,' De%aseelan B, Fogarty BB, Regan L' Hu&an chorionic gonadotro!hin 4or threatened &iscarriage' Cochrane Database Syst Re% )*+*; (CD**?.))' .' Lede R, Duley L' 2terine &uscle rela9ant drugs 4or threatened &iscarriage' Cochrane Database Syst Re% )**<; (CD**)E<?' <' Ru&bold A, Middleton B, Ban 0, Cro$ther CA' Fita&in su!!le&entation 4or !re%enting &iscarriage' Cochrane Database Syst Re% )*++; (CD**.*?,' :' Sa%aris RF, de Moraes LS, Cristo%a& RA, raun RD' Are antibiotics necessary a4ter .E hours o4 i&!ro%e&ent in in4ectedDse!tic abortionsR A rando&ized controlled trial 4ollo$ed by a cohort study' A& " 1bstet Lynecol )*++; )*.(,*+'e+' ?' Stubble4ield BL, Lri&es DA' Se!tic abortion' 0 Engl " Med +==.; ,,+(,+*' E' Fin#iel&an "D, De Feo FD, Heller BL, A4essa ' The clinical course o4 !atients $ith se!tic abortion ad&itted to an intensi%e care unit' /ntensi%e Care Med )**.; ,*(+*=?' =' Forna F, LSl&ezoglu AM' Surgical !rocedures to e%acuate inco&!lete abortion' Cochrane Database Syst Re% )**+; (CD**+==,' +*' Sotiriadis A, Ma#rydi&as L, Ba!atheodorou S, /oannidis "B' E9!ectant, &edical, or surgical &anage&ent o4 4irst-tri&ester &iscarriage( a &eta-analysis' 1bstet Lynecol )**<; +*<(++*.'

++' 0anda T, Beloggia A, Lri&es D, et al' E9!ectant care %ersus surgical treat&ent 4or &iscarriage' Cochrane Database Syst Re% )**:; (CD**,<+E' +)' 0eilson "B, Lyte LM, Hic#ey M, et al' Medical treat&ents 4or inco&!lete &iscarriage 5less than ). $ee#s7' Cochrane Database Syst Re% )*+*; (CD**?)),' +,' Trinder ", roc#lehurst B, Borter R, et al' Manage&ent o4 &iscarriage( e9!ectant, &edical, or surgicalR Results o4 rando&ised controlled trial 5&iscarriage treat&ent 5M/ST7 trial7' M" )**:; ,,)(+),<' +.' He&&in#i E' Treat&ent o4 &iscarriage( current !ractice and rationale' 1bstet Lynecol +==E; =+().?' +<' De&etroulis C, Saridogan E, Tunde D, 0a4talin AA' A !ros!ecti%e rando&ized control trial co&!aring &edical and surgical treat&ent 4or early !regnancy 4ailure' Hu& Re!rod )**+; +:(,:<' +:' Harris LH, Dalton FT, "ohnson TR' Surgical &anage&ent o4 early !regnancy 4ailure( history, !olitics, and sa4e, cost-e44ecti%e care' A& " 1bstet Lynecol )**?; +=:(..<'e+' +?' Lri&es DA' 2nsa4e abortion( the silent scourge' r Med ull )**,; :?(==' +E' TunUal! 1, LSl&ezoglu AM, Souza "B' Surgical !rocedures 4or e%acuating inco&!lete &iscarriage' Cochrane Database Syst Re% )*+*; (CD**+==,' +=' Sa$aya LF, Lrady D, Terli#o$s#e T, Lri&es DA' Antibiotics at the ti&e o4 induced abortion( the case 4or uni%ersal !ro!hyla9is based on a &eta-analysis' 1bstet Lynecol +==:; E?(EE.' )*' Brieto "A, Eri#sen 0L, lanco "D' A rando&ized trial o4 !ro!hylactic do9ycycline 4or curettage in inco&!lete abortion' 1bstet Lynecol +==<; E<(:=)' )+' 0eilson "B, Hic#ey M, FazCuez "' Medical treat&ent 4or early 4etal death 5less than ). $ee#s7' Cochrane Database Syst Re% )**:; (CD**))<,' ))' lu& ", 8ini#o44 , Le&zell-Danielsson T, et al' Treat&ent o4 inco&!lete abortion and &iscarriage $ith &iso!rostol' /nt " Lynaecol 1bstet )**?; == Su!!l )(S+E:' ),' Lraziosi LC, %an der Steeg "8, Reu$er BH, et al' Econo&ic e%aluation o4 &iso!rostol in the treat&ent o4 early !regnancy 4ailure co&!ared to curettage a4ter an e9!ectant &anage&ent' Hu& Re!rod )**<; )*(+*:?' ).' Phang ", Lilles "M, arnhart T, et al' A co&!arison o4 &edical &anage&ent $ith &iso!rostol and surgical &anage&ent 4or early !regnancy 4ailure' 0 Engl " Med )**<; ,<,(?:+' )<' de "onge ET, Ma#in "D, Mane4eldt E, et al' Rando&ised clinical trial o4 &edical e%acuation and surgical curettage 4or inco&!lete &iscarriage' M" +==<; ,++(::)' ):' Chung T, Leung B, Cheung LB, et al' A &edical a!!roach to &anage&ent o4 s!ontaneous abortion using &iso!rostol' E9tending &iso!rostol treat&ent to a &a9i&u& o4 .E hours can 4urther i&!ro%e e%acuation o4 retained !roducts o4 conce!tion in s!ontaneous abortion' Acta 1bstet Lynecol Scand +==?; ?:().E' )?' Chung TT, Cheung LB, Lau 8C, et al' S!ontaneous abortion( a &edical a!!roach to &anage&ent' Aust 0 P " 1bstet Lynaecol +==.; ,.(.,)' )E' Chung TT, Lee DT, Cheung LB, et al' S!ontaneous abortion( a rando&ized, controlled trial co&!aring surgical e%acuation $ith conser%ati%e &anage&ent using &iso!rostol' Fertil Steril +===; ?+(+*<.' )=' Mu44ley BE, Stitely ML, Lher&an R ' Early intrauterine !regnancy 4ailure( a rando&ized trial o4 &edical %ersus surgical treat&ent' A& " 1bstet Lynecol )**); +E?(,)+'

,*' el-Re4aey H, RaHase#ar D, Abdalla M, et al' /nduction o4 abortion $ith &i4e!ristone 5R2 .E:7 and oral or %aginal &iso!rostol' 0 Engl " Med +==<; ,,)(=E,' ,+' Creinin MD, Moyer R, Luido R' Miso!rostol 4or &edical e%acuation o4 early !regnancy 4ailure' 1bstet Lynecol +==?; E=(?:E' ,)' PalQnyi S' Faginal &iso!rostol alone is e44ecti%e in the treat&ent o4 &issed abortion' r " 1bstet Lynaecol +==E; +*<(+*):' ,,' Autry A, "acobson L, Sandhu R, /sbill T' Medical &anage&ent o4 non-%iable early 4irst tri&ester !regnancy' /nt " Lynaecol 1bstet +===; :?(=' ,.' agratee "S, Thullar F, Regan L, et al' A rando&ized controlled trial co&!aring &edical and e9!ectant &anage&ent o4 4irst tri&ester &iscarriage' Hu& Re!rod )**.; +=()::' ,<' Pie&an M, Fong ST, eno$itz 0L, et al' Absor!tion #inetics o4 &iso!rostol $ith oral or %aginal ad&inistration' 1bstet Lynecol +==?; =*(EE' ,:' Than R2, El-Re4aey H, Shar&a S, et al' 1ral, rectal, and %aginal !har&aco#inetics o4 &iso!rostol' 1bstet Lynecol )**.; +*,(E::' ,?' Da%is AR, Hendlish ST, 8estho44 C, et al' leeding !atterns a4ter &iso!rostol %s surgical treat&ent o4 early !regnancy 4ailure( results 4ro& a rando&ized trial' A& " 1bstet Lynecol )**?; +=:(,+'e+' ,E' 8ee#s A, FaVndes A' Miso!rostol in obstetrics and gynecology' /nt " Lynaecol 1bstet )**?; == Su!!l )(S+<:' ,=' Tollitz TM, Meyn LA, Lohr BA, Creinin MD' Mi4e!ristone and &iso!rostol 4or early !regnancy 4ailure( a cohort analysis' A& " 1bstet Lynecol )*++; )*.(,E:'e+' .*' Ledger 8L, S$eeting FM, ChatterHee S' Ra!id diagnosis o4 early ecto!ic !regnancy in an e&ergency gynaecology ser%ice--are &easure&ents o4 !rogesterone, intact and 4ree beta hu&an chorionic gonadotro!hin hel!4ulR Hu& Re!rod +==.; =(+<?' .+' LrWnlund A, LrWnlund L, Cle%in L, et al' Manage&ent o4 &issed abortion( co&!arison o4 &edical treat&ent $ith either &i4e!ristone X &iso!rostol or &iso!rostol alone $ith surgical e%acuation' A &ulti-center trial in Co!enhagen county, Den&ar#' Acta 1bstet Lynecol Scand )**); E+(+*:*' .)' Stoc#hei& D, Machtinger R, 8iser A, et al' A rando&ized !ros!ecti%e study o4 &iso!rostol or &i4e!ristone 4ollo$ed by &iso!rostol $hen needed 4or the treat&ent o4 $o&en $ith early !regnancy 4ailure' Fertil Steril )**:; E:(=<:' .,' Ta& 8H, Tsui MH, Lo# /H, et al' Long-ter& re!roducti%e outco&e subseCuent to &edical %ersus surgical treat&ent 4or &iscarriage' Hu& Re!rod )**<; )*(,,<<' ..' Lross&an D, lanchard T, lu&enthal B' Co&!lications a4ter second tri&ester surgical and &edical abortion' Re!rod Health Matters )**E; +:(+?,' .<' Lalit#u&ar S, ygde&an M, Le&zell-Danielsson T' Mid-tri&ester induced abortion( a re%ie$' Hu& Re!rod 2!date )**?; +,(,?' .:' 0ielsen S, Hahlin M' E9!ectant &anage&ent o4 4irst-tri&ester s!ontaneous abortion' Lancet +==<; ,.<(E.' .?' Chi!chase ", "a&es D' Rando&ised trial o4 e9!ectant %ersus surgical &anage&ent o4 s!ontaneous &iscarriage' r " 1bstet Lynaecol +==?; +*.(E.*' .E' An#u& 8M, 8ieringa-De 8aard M, indels B"' Manage&ent o4 s!ontaneous &iscarriage in the 4irst tri&ester( an e9a&!le o4 !utting in4or&ed shared decision &a#ing into !ractice' M" )**+; ,))(+,.,'

.=' 8ieringa-de 8aard M, Fos ", onsel L", et al' Manage&ent o4 &iscarriage( a rando&ized controlled trial o4 e9!ectant &anage&ent %ersus surgical e%acuation' Hu& Re!rod )**); +?()..<' <*' 0ielsen S, Hahlin M, Blatz-Christensen "' Rando&ised trial co&!aring e9!ectant $ith &edical &anage&ent 4or 4irst tri&ester &iscarriages' r " 1bstet Lynaecol +===; +*:(E*.' <+' Shelley "M, Healy D, Lro%er S' A rando&ised trial o4 surgical, &edical and e9!ectant &anage&ent o4 4irst tri&ester s!ontaneous &iscarriage' Aust 0 P " 1bstet Lynaecol )**<; .<(+))' <)' anerHee S, Asla& 0, 8oel4er , et al' E9!ectant &anage&ent o4 early !regnancies o4 un#no$n location( a !ros!ecti%e e%aluation o4 &ethods to !redict s!ontaneous resolution o4 !regnancy' "1L )**+; +*E(+<E' <,' Cone C, Lreena$ald MH, Scha44er R "r' Manage&ent o4 4irst-tri&ester s!ontaneous abortion' " Fa& Bract +===; .E(,,+' <.' Casi#ar /, ignardi T, Rie&#e ", et al' E9!ectant &anage&ent o4 s!ontaneous 4irst-tri&ester &iscarriage( !ros!ecti%e %alidation o4 the G)-$ee# ruleG' 2ltrasound 1bstet Lynecol )*+*; ,<()),' <<' Creinin MD, Sch$artz "L, Luido RS, By&ar HC' Early !regnancy 4ailure-current &anage&ent conce!ts' 1bstet Lynecol Sur% )**+; <:(+*<' <:' 1gden ", Ma#er C' E9!ectant or surgical &anage&ent o4 &iscarriage( a Cualitati%e study' "1L )**.; +++(.:,' <?' Chung TT, Cheung LB, Sahota DS, et al' E%aluation o4 the accuracy o4 trans%aginal sonogra!hy 4or the assess&ent o4 retained !roducts o4 conce!tion a4ter s!ontaneous abortion' Lynecol 1bstet /n%est +==E; .<(+=*' <E' Leung S8, Bang M8, Chung TT' Retained !roducts o4 gestation in &iscarriage( an e%aluation o4 trans%aginal ultrasound criteria 4or diagnosing an 6e&!ty uterus6' A& " 1bstet Lynecol )**.; +=+(++,,' <=' Creinin MD, Har$ood , Luido RS, et al' Endo&etrial thic#ness a4ter &iso!rostol use 4or early !regnancy 4ailure' /nt " Lynaecol 1bstet )**.; E:())' :*' Fiala C, Sa4ar B, ygde&an M, Le&zell-Danielsson T' Feri4ying the e44ecti%eness o4 &edical abortion; ultrasound %ersus hCL testing' Eur " 1bstet Lynecol Re!rod iol )**,; +*=(+=*' :+' Luise C, "er&y T, May C, et al' 1utco&e o4 e9!ectant &anage&ent o4 s!ontaneous 4irst tri&ester &iscarriage( obser%ational study' M" )**); ,).(E?,' :)' Betrou S, Trinder ", roc#lehurst B, S&ith L' Econo&ic e%aluation o4 alternati%e &anage&ent &ethods o4 4irst-tri&ester &iscarriage based on results 4ro& the M/ST trial' "1L )**:; ++,(E?=' :,' Doyle, 0M, "i&enez-Flores, D", Ra&in, SM' Medical %ersus surgical &anage&ent o4 &issed abortions( An econo&ic analysis' 1bstet Lynecol )**.; +*,(:S' :.' Oou "H, Chung TT' E9!ectant, &edical or surgical treat&ent 4or s!ontaneous abortion in 4irst tri&ester o4 !regnancy( a cost analysis' Hu& Re!rod )**<; )*()E?,' :<' Rocconi RB, Chiang S, Richter HE, Straughn "M "r' Manage&ent strategies 4or abnor&al early !regnancy( a cost-e44ecti%eness analysis' " Re!rod Med )**<; <*(.E:'

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/niciar sesiYn

misoprostol an

0ue%a bVsCueda /n4or&aciYn !ara el !aciente 0o%edades Calculadoras

ac# to Search Results Miso!rostol( Drug in4or&ation Find Brint Miso!rostol( Drug in4or&ation Clic# here to access additional search results in Le9ico&! 1nline' Co!yright +=?E-)*+, Le9ico&!, /nc' All rights reser%ed' 5For additional in4or&ation see 6Miso!rostol( Batient drug in4or&ation6 and see 6Miso!rostol( Bediatric drug in4or&ation67 For abbre%iations and sy&bols that &ay be used in Le9ico&! 5sho$ table7 ALERT( 2'S' o9ed 8arning The FDA-a!!ro%ed labeling includes a bo9ed $arning' See 8arningsDBrecautions section 4or a concise su&&ary o4 this in4or&ation' For %erbati& $ording o4 the bo9ed $arning, consult the !roduct labeling or $$$'4da'go%' rand 0a&es( 2'S' Cytotec rand 0a&es( Canada 0o%o-Miso!rostol; BMS-Miso!rostol Bhar&acologic Category Brostaglandin Dosing( Adult Prevention of NSAID-in u!e gastri! ul!ers: 1ral( )** &cg . ti&es daily $ith 4ood; i4 not tolerated, &ay decrease dose to +** &cg . ti&es daily $ith 4ood; last dose o4 the day should be ta#en at bedti&e

Me i!al termination of pregnan!y: 1ral( Re4er to Mi4e!ristone &onogra!h' "abor in u!tion or !ervi!al ripening #unlabele uses$: /ntra%aginal( )< &cg 5+D. o4 +** &cg tablet7; &ay re!eat at inter%als no &ore 4reCuent than e%ery ,-: hours' Do not use in !atients $ith !re%ious cesarean deli%ery or !rior &aHor uterine surgery 5AC1L, )**=b7' Prevention of postpartum %emorr%age #unlabele use$: 1ral( :** &cg as a single dose ad&inistered i&&ediately a4ter deli%ery; to be used in settings $here o9ytocin is not a%ailable 5F/L1, )*+)7' &reatment of postpartum %emorr%age #unlabele use$: Sublingual( E** &cg as a single dose; to be used in settings $here o9ytocin is not a%ailable' 2se caution i4 a !ro!hylactic dose $as already gi%en, es!ecially i4 ad%erse e%ents $ere obser%ed 5F/L1, )*+)7' &reatment of in!omplete abortion #unlabele use$: 1ral( :** &cg as a single dose 5AC1L, )**=a7 &reatment of misse abortion #unlabele use$: Sublingual( :** &cg; &ay re!eat e%ery , hours 4or ) additional doses i4 needed 5AC1L, )**=a7' /ntra%aginal( E** &cg; &ay re!eat e%ery , hours 4or ) additional doses i4 needed 5AC1L, )**=a7' Dosing( Leriatric Prevention of NSAID-in u!e gastri! ul!ers: Re4er to adult dosing' Dosing( Renal /&!air&ent Dose adHust&ent is not routinely needed; ho$e%er, the dose &ay be reduced i4 the reco&&ended dose is not tolerated' /t is not #no$n i4 &iso!rostol is re&o%ed by dialysis' Dosing( He!atic /&!air&ent 0o dosage adHust&ent !ro%ided in &anu4acturerGs labeling' Dosage For&s( 2'S' E9ci!ient in4or&ation !resented $hen a%ailable 5li&ited, !articularly 4or generics7; consult s!eci4ic !roduct labeling' Tablet, 1ral( Cytotec( +** &cg

Cytotec( )** &cg @scoredA Leneric( +** &cg, )** &cg Leneric ECui%alent A%ailable( 2'S' Oes Ad&inistration /ncidence o4 diarrhea &ay be lessened by ha%ing !atient ta#e dose right a4ter &eals and a%oiding &agnesiu&-containing antacids' 8hen used 4or the !re%ention o4 0SA/Dinduced ulcers, thera!y is usually begun on the second or third day o4 the ne9t nor&al &enstrual !eriod in $o&en o4 childbearing !otential' 2se Bre%ention o4 0SA/D-induced gastric ulcers Medical ter&ination o4 !regnancy o4 Z.= days in conHunction $ith &i4e!ristone 5re4er to Mi4e!ristone &onogra!h 4or details7 2se - 2nlabeled Cer%ical ri!ening and labor induction 5e9ce!t in $o&en $ith !rior cesarean deli%ery or &aHor uterine surgery7; !re%ention o4 !ost!artu& he&orrhage; treat&ent o4 !ost!artu& he&orrhage; treat&ent o4 inco&!lete or &issed abortion in $o&en [+) $ee#s gestation Medication Sa4ety /ssues Sound-ali#eDloo#-ali#e issues( Cytotec\ &ay be con4used $ith Cyto9an Miso!rostol &ay be con4used $ith &eto!rolol, &i4e!ristone Ad%erse Reactions Signi4icant ]+*>( Lastrointestinal( Diarrhea, abdo&inal !ain +> to +*>( Central ner%ous syste&( Headache Lastrointestinal( Consti!ation, dys!e!sia, 4latulence, nausea, %o&iting [+> 5Li&ited to i&!ortant or li4e-threatening7( Abnor&al taste, abnor&al %ision, al#aline !hos!hatase increased, alo!ecia, ana!hyla9is, ane&ia, a&ylase increase, an9iety, arrhyth&ia, arterial thro&bosis, arthralgia, cardiac enzy&es increased, chest !ain, chills, con4usion, CFA, dea4ness, de!ression, dia!horesis, dizziness, dro$siness, dys!hagia, dys!nea, dysuria, ede&a, e!ista9is, ESR increased, 4atigue,

4e%er, L/ bleeding, L/ in4la&&ation, gingi%itis, glycosuria, gout; gynecological disorders, he&aturia, he!atobiliary 4unction abnor&al, hy!er-Dhy!otension, i&!otence, loss o4 libido, M/, &uscle cra&!s, &yalgia, neuro!athy, neurosis, nitrogen increased, !allor, !hlebitis, !olyuria, !ul&onary e&bolis&, !ur!ura, rash, re4lu9, rigors, sti44ness, synco!e, thirst, thro&bocyto!enia, tinnitus, uterine ru!ture, $ea#ness, $eight changes Contraindications Hy!ersensiti%ity to !rostaglandins; !regnancy 5$hen used to reduce 0SA/D-induced ulcers7 8arningsDBrecautions Concerns related to adverse effects: ^ Aborti4acient( '()S) *o+e ,arning-: Due to t%e abortifa!ient property of t%is me i!ation. patients must be /arne not to give t%is rug to ot%ers) Disease-related concerns: ^ Cardio%ascular disease( 2se $ith caution in !atients $ith cardio%ascular disease' ^ Renal i&!air&ent( 2se $ith caution in !atients $ith renal i&!air&ent' Special populations: ^ Elderly( 2se $ith caution in the elderly' ^ Bregnancy( Ad%erse e%ents ha%e been re!orted $hen used outside o4 current !roduct labeling 5cer%ical ri!ening, induction o4 labor, !ost!artu& he&orrhage7' 2terine tachysystole &ay occur and !rogress to uterine tetany; utero!lacental blood 4lo$ &ay be i&!aired and uterine ru!ture or a&niotic 4luid e&bolis& &ay occur' The ris# o4 uterine ru!ture &ay be increased $ith ad%anced gestational age, grand &ulti!arity, or !rior uterine surgery' 2terine acti%ity and 4etal status should be &onitored in a hos!ital setting' Miso!rostol should not be used in situations $here uterotonic drugs are other$ise contraindicated or ina!!ro!riate' ^ 8o&en o4 childbearing !otential( '()S) *o+e ,arning-: (se of misoprostol uring pregnan!y may !ause abortion. birt% efe!ts. or premature birt%) It is not to be use to re u!e NSAID-in u!e ul!ers in a /oman of !%il bearing potential unless s%e is !apable of !omplying /it% effe!tive !ontra!eptive measures an is at %ig% ris0 of eveloping gastri! ul!ers an 1or t%eir !ompli!ations) /4 needed, the !atient &ust ha%e a negati%e !regnancy test $ithin ) $ee#s o4 starting thera!y, she &ust use e44ecti%e contrace!tion during treat&ent, and thera!y should begin on the second or third day o4 ne9t nor&al &enstrual !eriod' 8o&en o4 childbearing !otential ta#ing this 4or reducing the ris# o4 0SA/D-induced gastric ulcers should be

gi%en oral and $ritten $arnings o4 the !otential ad%erse e%ents i4 !regnancy occurs during treat&ent' Other warnings/precautions: ^ A!!ro!riate use( 2lcers( For use only in !atients at high ris# o4 co&!lications 4ro& gastric ulcers 5eg, the elderly or !atients $ith conco&itant diseases7 or !atients at high ris# 4or de%elo!ing gastric ulcers 5eg, those $ith a history o4 ulcers7 ta#ing 0SA/Ds' Miso!rostol &ust be ta#en during the duration o4 0SA/D thera!y' /t is not e44ecti%e in !re%enting duodenal ulcers in !atients ta#ing 0SA/Ds' Metabolis&DTrans!ort E44ects 0one #no$n' Drug /nteractions 5For additional in4or&ation( Launch Le9i-/nteract_ Drug /nteractions Brogra&7 Antacids( May enhance the ad%erseDto9ic e44ect o4 Miso!rostol' More s!eci4ically, conco&itant use $ith &agnesiu&-containing antacids &ay increase the ris# o4 diarrhea' Manage&ent( A%oid conco&itant use o4 &iso!rostol and &agnesiu&containing antacids' /n !atients reCuiring antacid thera!y, e&!loy &agnesiu&-4ree !re!arations' Monitor 4or increased ad%erse e44ects 5e'g', diarrhea, dehydration7' E+!eptions: Alu&inu& Hydro9ide; Calciu& Carbonate; Sodiu& icarbonate' Risk D: Consider therapy modification Carbetocin( Miso!rostol &ay enhance the thera!eutic e44ect o4 Carbetocin' Risk X: Avoid combination 19ytocin( Miso!rostol &ay enhance the thera!eutic e44ect o4 19ytocin' Manage&ent( The &anu4acturer o4 &iso!rostol reco&&ends a%oiding conco&itant use $ith o9ytocin' Miso!rostol &ay aug&ent e44ects o4 o9ytocin, !articularly $hen gi%en $ithin . hours o4 o9ytocin initiation' Risk D: Consider therapy modification EthanolD0utritionDHerb /nteractions Food( Miso!rostol !ea# seru& concentrations &ay be decreased i4 ta#en $ith 4ood 5not clinically signi4icant7' Bregnancy Ris# Factor ` 5sho$ table7 Bregnancy /&!lications Teratogenic e44ects $ere not obser%ed in ani&al re!roduction studies' Congenital ano&alies 4ollo$ing 4irst tri&ester e9!osure ha%e been re!orted, including s#ull de4ects,

cranial ner%e !alsies, 4alcial &al4or&ations, and li&b de4ects' Miso!rostol &ay !roduce uterine contractions; 4etal death, uterine !er4oration, and abortion &ay occur' '()S) *o+e ,arning-: (se of misoprostol uring pregnan!y may !ause abortion. birt% efe!ts. or premature birt%) It is not to be use to re u!e NSAID-in u!e ul!ers in a /oman of !%il bearing potential unless s%e is !apable of !omplying /it% effe!tive !ontra!eptive measures an is at %ig% ris0 of eveloping gastri! ul!ers an 1or t%eir !ompli!ations) /4 needed, the !atient &ust ha%e a negati%e !regnancy test $ithin ) $ee#s o4 starting thera!y, she &ust use e44ecti%e contrace!tion during treat&ent, and thera!y should begin on the second or third day o4 ne9t nor&al &enstrual !eriod' 8ritten and %erbal $arnings concerning the hazards o4 &iso!rostol should be !ro%ided' Miso!rostol is FDA a!!ro%ed 4or the &edical ter&ination o4 !regnancy o4 Z.= days in conHunction $ith &i4e!ristone' ecause &iso!rostol &ay induce or aug&ent uterine contractions, it has been used o44label as a cer%ical-ri!ening agent 4or induction o4 labor in $o&en $ho ha%e not had a !rior cesarean deli%ery or &aHor uterine surgery' Hy!ersti&ulation o4 the uterus, uterine ru!ture, or ad%erse e%ents in the 4etus or &other &ay occur $ith this use' Lactation Enters breast &il#Duse caution reast-Feeding Considerations Miso!rostol acid 5the acti%e &etabolite o4 &iso!rostol7 has been detected in breast &il#' Concentrations 4ollo$ing a single oral dose $ere ?':-)*'= !gD&L a4ter + hour and decreased to [+ !gD&L by < hours' Ad%erse e%ents ha%e not been re!orted in nursing in4ants 5F/L1, )*+)7' Dietary Considerations Should be ta#en $ith 4ood' Bricing( 2'S' 5Medi-S!an\7 &ablets 5Cytotec 1ral7 +** &cg 5+**7( a))?')E )** &cg 5+**7( a,+<'<< &ablets 5Miso!rostol 1ral7 +** &cg 5:*7( a.='.< )** &cg 5+**7( a++='=<

Dis!laimer: The !ricing data !ro%ided re!resent a &edian A8B andDor AA8B !rice 4or the brand andDor generic !roduct, res!ecti%ely' The !ricing data should be used 4or bench&ar#ing !ur!oses only, and as such should not be used to set or adHudicate any !rices 4or charging or rei&burse&ent 4unctions' Bricing data is u!dated &onthly' Monitoring Bara&eters Bre%ention o4 0SA/D-induced gastric ulcers( Bregnancy test in $o&en o4 re!roducti%e !otential !rior to thera!y; adeCuate diagnostic &easures in all cases o4 undiagnosed abnor&al %aginal bleeding 144-label !regnancy-related uses( 2terine acti%ity and 4etal status' 8hen used 4or inco&!lete or &issed abortion, re-e%aluate +-) $ee#s a4ter dosing /nternational rand 0a&es Alsoben 5TB7; Chro&alu9 5/D7; Cy!rostol 5AT7; Cytil 5C17; Cytolog 5/07; Cytotec 5AE, AR, A2, E, F, L, H, ", R, CH, C/, CL, C1, CR, CO, CP, DE, DT, EC, EE, EL, ES, ET, F/, FR, L , LH, LM, L0, LR, HT, H0, H2, /D, /E, /L, /b, /R, /T, "1, "B, TE, TB, T8, L , LR, L2, LO, MA, ML, MR, MT, M2, M8, M`, MO, 0E, 0L, 0/, 0L, 01, 0P, 1M, BA, BE, BL, BT, bA, R2, SA, SC, SD, SE, SL, ST, SL, S0, SF, SO, TH, T0, TR, T8, TP, 2L, FE, OE, PA, PM, P87; Lastrul 5/D7; Ly&iso 5FR7; /n%itec 5/D7; Misel 5TB7; Misotrol 5C07; 0o!rostol 5/D7; 2-Miso 5T87 Mechanis& o4 Action Miso!rostol is a synthetic !rostaglandin E+ analog that re!laces the !rotecti%e !rostaglandins consu&ed $ith !rostaglandin-inhibiting thera!ies 5eg, 0SA/Ds7; has been sho$n to induce uterine contractions Bhar&acodyna&icsDTinetics Absor!tion( Ra!id and e9tensi%e Metabolis&( He!atic; ra!idly de-esteri4ied to &iso!rostol acid 5acti%e7 Brotein binding( Miso!rostol acid( [=*> Hal4-li4e eli&ination( Miso!rostol acid( )*-.* &inutes

Ti&e to !ea#, seru&( Miso!rostol acid( Fasting( :-)) &inutes E9cretion( 2rine 5E*>7

Misoprostol as a single agent for me i!al termination of pregnan!y

Miso!rostol as a single agent 4or &edical ter&ination o4 !regnancy Authors 8esley Clar#, MD, MBH Caitlin Shannon, MBH e%erly 8ini#o44, MD, MBH Section Editor Mi&i Pie&an, MD De!uty Editor Sandy " Fal#, MD Disclosures All to!ics are u!dated as ne$ e%idence beco&es a%ailable and our !eer re%ie$ !rocess is co&!lete' Literature re%ie$ current through( Se! )*+,' - This to!ic last u!dated( se! )*, )*+)' /0TR1D2CT/10 3 Medical &ethods 4or induced abortion ha%e e&erged o%er the !ast t$o decades as sa4e, e44ecti%e, and 4easible alternati%es to surgery' 0onsurgical alternati%es e9!and a $o&anGs treat&ent o!tions and, in turn, the Cuality o4 care @+A' Moreo%er, in so&e settings, surgical o!tions are not a%ailable to $o&en or are not &edically 4easible' /n 4irst tri&ester abortion, co&bined treat&ent $ith &iso!rostol $ith &i4e!ristone a!!ears to be &ore e44ecti%e than &iso!rostol-alone regi&ens, and thus, are considered the gold standard 4or &edical induction @)-.A' Ho$e%er, &iso!rostolalone regi&ens &ay be the treat&ent o4 choice in settings in $hich &i4e!ristone is not a%ailable or is too costly' Miso!rostol is co&&only used as a single agent 4or second tri&ester induced abortion in the 2nited States and &any other !arts o4 the $orld @<,:A' This to!ic re%ie$ $ill discuss use o4 &iso!rostol in !regnancy ter&ination' 2se o4 &i4e!ristone and other &edical and surgical a!!roaches to !regnancy ter&ination and use o4 &iso!rostol 4or 4etal de&ise or labor induction are re%ie$ed se!arately' 5See 6Mi4e!ristone 4or the &edical ter&ination o4 !regnancy6 and 61%er%ie$ o4 !regnancy ter&ination6 and 6S!ontaneous abortion( Manage&ent6 and 6/ncidence, etiology, and !re%ention o4 stillbirth6 and 6TechniCues 4or ri!ening the un4a%orable cer%i9 !rior to induction6'7 BHARMAC1T/0ET/CS 3 Miso!rostol is a synthetic E+ !rostaglandin 5BLE+7 de%elo!ed and a!!ro%ed originally 4or the !re%ention o4 gastric ulcers' Miso!rostol is not a!!ro%ed by the 2nited States Food and Drug Ad&inistration 4or uterine e%acuation in !regnant $o&en' Miso!rostol ad&inistration in !regnancy induces cer%ical e44ace&ent and uterine contractions at all gestational ages, thereby 4acilitating uterine e%acuation @?A' The

!otency o4 &iso!rostolGs e44ect, ho$e%er, %aries $ith gestational age, as $ell as $ith route o4 ad&inistration, dose, dosing inter%al, and cu&ulati%e dose'

Lestational age 3 The sensiti%ity o4 the uterus to !rostaglandins increases $ith gestational age @?A' For this reason, !ro%iders generally use decreasing a&ounts o4 &iso!rostol $ith increasing gestational age' Route o4 ad&inistration 3 Miso!rostol can be ad&inistered by the 4ollo$ing routes( %aginal, oral, sublingual, buccal, or rectal @E-+,A' Seru& le%el 3 The !har&aco#inetic !ro4ile %aries by route @E,=,+),+,A' 1ral or sublingual ad&inistration leads to a ra!id !ea# in seru& le%el, $hich a!!ears to decrease in one to three hours' Con%ersely, $ith %aginal or buccal dosing, seru& le%els !ea# later and re&ain ele%ated longer @+),+,A' 2terine acti%ity 3 Regular and sustained uterine acti%ity is &ore li#ely 4ollo$ing %aginal, sublingual, or buccal co&!ared $ith oral ad&inistration @+,A' Moist %ersus dry tablets 3 Moistening o4 &iso!rostol tablets does not a!!ear to increase clinical e44ecti%eness @+.-+?A' A rando&ized trial e%aluated 4irst tri&ester abortion using &ethotre9ate 4ollo$ed by $et %ersus dry &iso!rostol; no di44erence $as 4ound bet$een the t$o grou!s @+.A'

C10TRA/0D/CAT/10S Absolute contraindications

Sus!ected or con4ir&ed ecto!ic !regnancy Lestational tro!hoblastic disease High ris# o4 uterine ru!ture 5ie, second or third tri&ester inductions in $o&en $ith &ore than one !rior hysteroto&y, a !rior classical or T-sha!ed uterine incision, or e9tensi%e trans4undal uterine surgery7 /ntrauterine de%ice 5/2D; &ust be re&o%ed be4ore &iso!rostol is ad&inistered7 Allergy to !rostaglandins Contraindications to &edical or surgical uterine e%acuations 5eg, he&odyna&ically unstable, coagulo!athy7 5see 61%er%ie$ o4 !regnancy ter&ination67'

Relati%e contraindications 3 Miso!rostol-alone regi&ens should be used $ith caution in $o&en $ho are at ris# 4or co&!lications o4 !regnancy ter&ination 5eg, coagulo!athy7' Brecautions s!eci4ic to &iso!rostol are considered here' A 4ull discussion o4 abortion co&!lications is !resented se!arately' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GCo&!licationsG'7 Ris# 4actors 4or uterine ru!ture 3 2terine ru!ture is a ris# o4 &iso!rostol use at any ti&e during !regnancy' 8hile the ris# is li#ely higher is $o&en $ith a uterine scar, there are 4e$ re!orts o4 this co&!lication 5table +7 @+EA' /n a syste&atic re%ie$ o4 a%ailable studies, the ris# o4 ru!ture $as *', !ercent a&ong $o&en $ith a !rior cesarean deli%ery $ho $ere undergoing second tri&ester &iso!rostol-induced abortion @+=A' Ad%anced gestational age, high gra%idity 5c, !regnancies7 or uterine ano&alies &ay also increase ris# o4 ru!ture' 2terine ru!ture has only been re!orted once in $o&en undergoing 4irst tri&ester ru!tures @)*A'

/n the second tri&ester, uterine ru!ture is rare, but has been re!orted &ore 4reCuently than in the 4irst tri&ester @)+-)=A' Case re!orts o4 uterine ru!ture in $o&en undergoing second tri&ester abortion $ith &iso!rostol include $o&en $ith scarred @)+-):A and unscarred uteri @):-)=A'

Scarred uterus 3 There are no high Cuality data regarding the ris# o4 uterine ru!ture $ith use o4 &iso!rostol 4or 4irst or second tri&ester !regnancy ter&ination' A&ong 4i%e !ublished case series o4 $o&en $ith a !rior cesarean section $ho $ere undergoing second tri&ester &iso!rostol abortion 5n K E<E7, t$o cases o4 uterine ru!ture $ere re!orted @)+,)),,*-,)A; ho$e%er, they $ere under!o$ered to detect this rare co&!lication' According to obser%ational data regarding obstetric labor induction, &iso!rostol induction is contraindicated in $o&en $ith &ore than one hysteroto&y, a !rior classical or T-sha!ed uterine incision, or e9tensi%e trans4undal uterine surgery' /t has not been established $hether these ris#s a!!ly eCually to !atients undergoing 4irst or second tri&ester induction' 5See 6Choosing the route o4 deli%ery a4ter cesarean birth6, section on G/na!!ro!riate candidatesG'7 8e counsel $o&en that a uterine scar is not a contraindication 4or 4irst tri&ester &iso!rostol induction, but that the ris# &ay increase $ith increasing gestational age, !articularly in the late second tri&ester' 8e counsel $o&en about ris# and &onitor the& 4or signs o4 ru!ture' 2nscarred uterus 3 /n re!orts o4 uterine ru!ture in $o&en $ithout !re%ious uterine surgery, ris# 4actors included grand &ulti!arity @):,)?A, gestational age greater than ), $ee#s @)<A, and use o4 o9ytocin in addition to &iso!rostol @):A' Ho$e%er, o9ytocin can generally be used sa4ely in co&bination $ith &iso!rostol @)?A' For !regnancies at ), or &ore $ee#s, it is contro%ersial $hether it is necessary to decrease the &iso!rostol dose or increase dosing inter%al, though it &ay be !rudent to do so @,,,,.A'

reast4eeding 3 Miso!rostol is e9creted transiently and at lo$ le%els in hu&an breast &il# @,<A' /t a!!ears that the le%els rise and decline $ithin three to 4i%e hours o4 ad&inistration @?,,<A' /t is reasonable to counsel $o&en $ho recei%e &iso!rostol $hile breast4eeding to !u&! and discard all &il# !roduced $ithin 4i%e hours a4ter each dose' BRETREATME0T EFAL2AT/10 A0D BREBARAT/10 3 All $o&en should undergo an initial e%aluation, including a &edical history and a !hysical e9a&ination con4ir&ing gestational age' 2ltrasound is necessary only i4 there is uncertainty about gestational age, !regnancy location or the !resence o4 gestational tro!hoblastic disease' /4 an ultrasound is not !er4or&ed, the !regnancy should be con4ir&ed $ith a urine or seru& hu&an chorionic gonadotro!in 5hCL7' lood ty!e and antibody status are chec#ed and Rh i&&une globulin gi%en i4 indicated' /4 a !atient has an /2D, it &ust be re&o%ed' 1ne o4 the ad%antages o4 &iso!rostol induction is that it can be !er4or&ed sa4ely and e44ecti%ely $ithout &echanical dilation 5eg, rigid or os&otic dilators7' So&e !ro%iders aug&ent the !rocedure $ith !retreat&ent la&inaria 4or inductions a4ter +< $ee#s' Ho$e%er, t$o rando&ized trials in $o&en undergoing second tri&ester ter&ination re!orted that use o4 la&inaria co&!ared $ith no &echanical dilation did not reduce 5+:

and +? hours7 @,:A and &ay !rolong 5++ %ersus +. hours7 @,?A induction ti&e; one trial 4ound an increase in the use o4 &or!hine in !atients treated $ith la&inaria @,?A' A 4ull discussion o4 cer%ical !re!aration 4or !regnancy ter&ination can be 4ound se!arately' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GCer%ical !re!arationG'7 There is no high Cuality e%idence regarding the use o4 antibiotic !ro!hyla9is 4or &edical abortion 5ie, no in%asi%e &ethods 4or cer%ical !re!aration or uterine e%acuation7' Ho$e%er, due to se%eral deaths due to clostridial se!sis in the 2nited States in !atients $ho recei%ed %aginal &iso!rostol in co&bination $ith &i4e!ristone, so&e organizations, such as Blanned Barenthood 5the largest abortion !ro%ider in the 2nited States7, ha%e introduced the use o4 !ro!hylactic antibiotics @,E,,=A' Ho$e%er, deaths due to clostridial in4ection ha%e been re!orted a&ong $o&en ad&inistering &iso!rostol both %aginally and buccally @.*A' 5See 6Mi4e!ristone 4or the &edical ter&ination o4 !regnancy6'7 Bretreat&ent e%aluation 4or !regnancy ter&ination is discussed in detail se!arately' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GBreo!erati%e considerationsG and 6Bre%ention o4 Rh5D7 alloi&&unization6'7 DATA 10 DR2L ADM/0/STRAT/10 3 The o!ti&al &iso!rostol regi&en at any gestational age is deter&ined by achie%ing a balance a&ong e44ecti%eness, ad%erse e44ects, and acce!tability to !atients' As an e9a&!le, higher doses and shorter dosing inter%als increase e44ecti%eness, but also &ay result in higher rates o4 ad%erse e44ects and co&!lications @?A' Route o4 ad&inistration 3 E44ecti%eness 5de4ined as co&!lete abortion $ithout surgical inter%ention7 is higher $ith %aginal co&!ared $ith oral ad&inistration in both 4irst and second tri&esters @.+-..A' Ho$e%er, in a rando&ized trial, $o&en !re4erred oral rather than %aginal dosing @++A' Accu&ulating e%idence regarding sublingual ad&inistration a!!ears !ro&ising regarding e44ecti%eness and !atient acce!tability @.<-.?A' uccal &iso!rostol is also used 4reCuently in co&bination $ith &i4e!ristone' As a single agent, t$o studies ha%e 4ound that buccal &iso!rostol can be e44ecti%e 4or 4irst tri&ester induction and &ay be e44ecti%e in second tri&ester abortion @.E,.=A' /ts use has not been co&!ared to either %aginal ad&inistration or sublingual ad&inistration, $hich are !re4erable @.E,.=A'

1ral %ersus %aginal dosing 3 At E or less $ee#s o4 gestation, a co&!arati%e study e%aluated three oral and 4our %aginal regi&ens in ):* $o&en sho$ed that the rate o4 co&!lete abortion is higher $ith %aginal co&!ared $ith oral ad&inistration 5., to E* %ersus ,= to <* !ercent7 @.+A' For !regnancies bet$een = and +) $ee#s, there are no high Cuality data co&!aring %aginal $ith oral ad&inistration' Ho$e%er, obser%ational studies o4 %aginal &iso!rostol use ha%e re!orted consistently high rates o4 co&!lete abortion 5E< to =* !ercent7 @<*-:*A' At +, or &ore $ee#s, rando&ized trials co&!aring %aginal $ith oral dosing 4ound that the %aginal route $as &ore e44ecti%e 5E: to +** %ersus .< to E= !ercent7 and had a shorter induction-to-deli%ery inter%al 5+* to +< hours %ersus

+) to ,< hours7 @:,.,,..,:+A' Ad%erse e44ects $ere si&ilar bet$een the t$o routes, $ith the !ossible e9ce!tion o4 a higher incidence o4 4e%er $ith %aginal dosing @.,A, and o4 nausea and diarrhea $ith oral dosing @:+A' Findings on ad%erse e44ects are not consistent and thus do not !ro%ide high Cuality e%idence 4or guiding route o4 ad&inistration' Sublingual %ersus %aginal dosing 3 /n !regnancies at +) $ee#s o4 gestation or less, data suggest that the sublingual route &ay be as e44ecti%e as the %aginal route $hen dosed a!!ro!riately @.+,.<,:)A' /n a rando&ized trial that co&!ared t$o %aginal and t$o sublingual regi&ens in )*** $o&en, %aginal &iso!rostol ad&inistered e%ery , or +) hours and sublingual &iso!rostol e%ery three hours $ere si&ilarly e44ecti%e 5E, to E< !ercent7, but sublingual &iso!rostol e%ery +) hours $as less e44ecti%e 5?E !ercent7 @:)A' 8o&en !re4erred sublingual to %aginal ad&inistration' Side e44ects tended to be &ore co&&on a&ong $o&en ta#ing &iso!rostol at ,-hour co&!ared to +)-hour inter%als, %aginal or sublingual; and this 4inding $as signi4icant 4or incidence o4 4e%er' Diarrhea and chills $ere slightly &ore co&&on in $o&en ta#ing &iso!rostol sublingually co&!ared to %aginally, but this di44erence $as not statistically signi4icant and, regardless, &ay not be clinically rele%ant' Si&ilarly, the sublingual route &ay be as e44ecti%e as the %aginal route 4or ter&ination a4ter +) $ee#s @.?,:+,:,-:?A' 1ne &eta-analysis de&onstrated that e44icacy at ). hours $as si&ilar 5!ooled RR +'*., =<> C/ *'=,-+'?7, but that %aginal &iso!rostol &ay be &ore success4ul at .E hours 5!ooled RR *'=:; =<> C/ *'=,-*'==7 and &ay shorten the induction-to-abortion inter%al 58MD -.'<., =<> C/ -E'*, to -+'*<7 @::A' A second &eta-analysis o4 .* rando&ized trials e9a&ining &edical &ethods o4 uterine e%acuation 4or $o&en +) to )E $ee#s !regnant 4ound that $hile &iso!rostol $as &ore 4reCuently %aginally ad&inistered, sublingual ad&inistration $as eCually e44ecti%e @:?A' Rates o4 ad%erse e44ects are si&ilar bet$een the t$o ty!es o4 dosing; ho$e%er, !atients !re4er the sublingual route @.?,:,,:.A' uccal %ersus oral or %aginal dosing 3 uccal ad&inistration o4 &iso!rostol as a single agent 4or &edical ter&ination o4 !regnancy in the 4irst tri&ester a!!ears !ro&ising @:E,:=A' Rando&ized trial data 4or ad&inistration o4 &iso!rostol in co&bination $ith &i4e!ristone 4or !regnancy u! to eight to nine $ee#s o4 gestation ha%e 4ound that the e44icacy o4 buccal dosing is si&ilar to %aginal and better than oral dosing @?*,?+A' uccal ad&inistration $as associated $ith a slight increase in nausea o%er either oral or %aginal dosing' Batient satis4action $as high across all routes' 2sed as a single agent, buccal &iso!rostol $as 4ound to ha%e an e44icacy o4 ?: !ercent a&ong $o&en less than = $ee#s !regnant 5n K +.?7 @.EA' Studies regarding buccal dosing in the second tri&ester ha%e also yielded 4a%orable results, but there are no studies regarding use o4 buccal &iso!rostol as a single agent 4or second tri&ester !regnancy ter&ination @?),?,A' /n one rando&ized trial, the initial &iso!rostol dose $as ad&inistered %aginally, and subseCuent doses $ere gi%en either buccally or %aginally @?.A' The &edian ti&e to abortion in the buccal grou! did not di44er signi4icantly in the buccal co&!ared $ith %aginal dosing grou!s 5+< %ersus +) hours7; no di44erence $as 4ound in !atient !re4erence 4or route o4 ad&inistration'

Co&bined-route regi&ens 4or second tri&ester ter&inations 3 Regi&ens that co&bine an initial %aginal &iso!rostol dose 4ollo$ed by oral doses ha%e been co&&only used 4or ter&inations a4ter +) $ee#s and a!!ear to be as e44ecti%e as %aginal-only regi&ens @,?,..,?<-??A' The rationale is to &a9i&ize e44ecti%eness and acce!tability, $hile &ini&izing induction-to-deli%ery inter%al, ad%erse e44ects and co&!lications' /n a rando&ized trial o4 ., $o&en at +, to ), $ee#s o4 gestation, an initial E** &cg %aginal &iso!rostol dose $as 4ollo$ed e%ery eight hours by .** &cg gi%en either orally or %aginally; e44ecti%eness 5E) and E? !ercent7 and induction-to-deli%ery inter%al 5+: and )+ hours7 $ere si&ilar bet$een the oral and %aginal grou!s @??A' A rando&ized trial de&onstrated that )** &cg buccal doses re!eated at si9-hour inter%als, 4ollo$ing an initial .** &cg %aginal dose, result in a si&ilar induction-to-deli%ery inter%al 5+< %ersus +) hours, res!ecti%ely7 @?.A'

Dose and dosing inter%al 3 The o!ti&al regi&en is a dose and dosing inter%al balance $hich generate su44icient and sustained uterine acti%ity $hile &ini&izing ad%erse e44ects @?EA' Longer dosing inter%als ha%e the bene4it o4 e9!osing a $o&an to a decreased ris# o4 ad%erse e44ects' Con%ersely, shorter dosing inter%als 5closer to three hours7 &ay be necessary to generate su44icient uterine acti%ity, in !articular i4 &iso!rostol is gi%en %ia a route $ith a ra!id rise and 4all in seru& le%els 5ie, oral and sublingual7 @=A' 2terine hy!ersti&ulation is rare; ho$e%er, the ris# &ay increase $ith shorter dosing inter%als'

= or less $ee#s 3 Faginal ad&inistration o4 &iso!rostol a!!ears to be &ore e44ecti%e at E** &cg 5generally E* to =* !ercent7 than )** or .** &cg 5), to .: !ercent7, according to obser%ational data @<)A' A %aginal dosing inter%al o4 , to ). hours 5E** &cg BF; total o4 three to 4i%e doses7 is ty!ically used to ter&inate !regnancies u! to nine $ee#s, $ith re!orted success rates o4 E< to =, !ercent in non-co&!arati%e studies @?EA' There are no high Cuality data co&!aring di44erent doses o4 sublingual &iso!rostol 4or ter&inations at Z+) $ee#s' /n studies o4 sublingual-dosing alone and co&!arati%e trials $ith %aginal dosing, .** to E** &cg SL is ty!ically used @.+,.<,:)A' As noted abo%e, ,- rather than +)-hour dosing inter%al $as 4ound to be signi4icantly &ore e44ecti%e in a rando&ized trial 5E. %ersus ?E !ercent7 @:)A' +* to +) $ee#s 3 Lo$er success rates 4or &iso!rostol-alone ha%e been re!orted 4or !regnancies at +* to +) $ee#s o4 gestation 5E. to E? !ercent7 in a 4e$ descri!ti%e studies @<),<E,<=,?=,E*A' The &ost e44ecti%e regi&en a!!ears to be E** &cg BF e%ery +) to ). hours 4or a &a9i&u& o4 three doses @<E,<=A' Data 4ro& a case series o4 <* $o&en suggest that sublingual ad&inistration is also e44ecti%e; the regi&en used $as :** &cg SL e%ery three hours u! to 4i%e doses @.<A' +, to )) $ee#s 3 T$o &iso!rostol regi&ens, .** &cg BF e%ery three hours 1R :** BF &cg e%ery +) hours $ere sa4e, e44ecti%e, and resulted in lo$ induction-to-deli%ery inter%al in rando&ized trials @E+-E,A' Ho$e%er, these t$o regi&ens ha%e not been co&!ared to each other' As noted abo%e, it is unclear $hether sublingual ad&inistration is &ore or less

e44ecti%e than %aginal in this gestational age range' More research is needed to deter&ine $hether sublingual ad&inistration should be used a&ong $o&en $ith gestations +, to )) $ee#s, and the a!!ro!riate regi&en 5see GRoute o4 ad&inistrationG abo%e7' ), to ): $ee#s 3 Many studies ha%e e9a&ined the use o4 &iso!rostol-alone regi&ens beyond ), $ee#s o4 gestation, and data sho$ that the &ethod, e&!loying a %ariety o4 regi&ens, can be sa4ely and e44ecti%ely used in $o&en $ith ad%anced gestations @..,?<,E)-E?A' /n general, ho$e%er, ter&ination a4ter ), $ee#s is not co&&on in the 2nited States, and an o!ti&al regi&en has not been established' As noted abo%e, uterine sensiti%ity to !rostaglandins and ris# o4 uterine ru!ture increase $ith gestational age' There4ore, it &ay be !rudent to use a decreased dose or increased dosing inter%al in this gestational age range @EEA 5see GBhar&aco#ineticsG abo%e7'

0u&ber o4 doses 3 /n !regnancies at +) or less $ee#s, it a!!ears that there is little increase in e44ecti%eness a4ter the second dose o4 &iso!rostol @:*,E=A, although &ost studies ha%e e%aluated regi&ens o4 three to 4i%e doses @?EA' As an e9a&!le, in one study, e44ecti%eness a4ter a second or third dose $ere si&ilar 5E: and EE !ercent7 @E=A' Data on second tri&ester &edical ter&inations $ith &iso!rostol sho$ that &ulti!le doses are highly e44ecti%e co&!ared to single doses' As noted abo%e, reco&&ended doses are lo$er than doses used 4or 4irst tri&ester ter&inations since the uterine is &ore sensiti%e to &iso!rostol and the ris# o4 ru!ture a!!ears greater @::,:?,=*A' As an e9a&!le, )< to <* &cg doses are generally used 4or labor induction in the third tri&ester' The need 4or re!eat doses should be e%aluated !rior to ad&inistration and based on lac# o4 rele%ant clinical signs o4 !rogression 5eg, insu44icient uterine acti%ity or cer%ical dilation7' CL/0/CAL REL/ME0 3 The regi&ens listed belo$ are consistent $ith the regi&ens !ro!osed by a &eeting con%ened by the 8orld Health 1rganization 58H17 as a !relude to 8H1 guidelines 5table )7 @?E,EE,=+A' All gestational ages re4er to $ee#s o4 a&enorrhea' = or less $ee#s 3 Miso!rostol &ay be ad&inistered either in a clinic or at ho&e'

E** &cg SL e%ery three hours 4or u! to three doses @:)A 1R E** &cg BF e%ery , to +) hours 4or u! to three doses @.+,:)A 1R E** &cg buccally e%ery t$o to three hours

+* to +) $ee#s 3 8e suggest ad&inistration in a clinic only due to increased ris# o4 e9cessi%e bleeding and !ossibly o4 uterine ru!ture @?EA'

E** &cg BF e%ery , to +) hours 4or u! to three doses @<E,<=A

+, to )) $ee#s 3 Treat&ent should be ad&inistered only in a clinic setting $ith i&&ediate access to e&ergency surgery and blood trans4usion' /4 deli%ery has not occurred at ). hours, the !rotocol &ay be re!eated @E+,E)A'

.** &cg BF e%ery three to 4our hours 5&a9 4i%e doses7 @E+A 1R :** &cg BF e%ery +) hours @E)A

), or &ore $ee#s 3 Treat&ent should be ad&inistered only in a clinic setting $ith i&&ediate access to e&ergency surgery and blood trans4usion' As noted abo%e, there is no $ell-established regi&en 4or this gestational age range, ho$e%er, it &ay be !rudent to use a decreased dose 5)** to .** &cg7 or increased dosing inter%al 5si9 hours7' 1ne o!tion is to gi%e .** &cg BF e%ery si9 hours @)+,))A 5see GDose and dosing inter%alG abo%e7' M10/T1R/0L D2R/0L TREATME0T 3 8o&en are &onitored during treat&ent $hether it occurs at ho&e or in a clinic setting' The goals o4 &onitoring are to assess treat&ent e44icacy and assess 4or co&!lications' At-ho&e treat&ent 3 A $o&an undergoing &edical ter&ination at ho&e should ha%e easy access to a clinician $ho can ans$er Cuestions and &anage co&!lications &edically or surgically' Batient education should include ho$ to recognize co&!lications 5eg, 4e%er, abdo&inal !ain, or !rolonged or e9cessi%e bleeding7 5table )7' /n addition, a $o&an should also call her !ro%ider i4 it does not see& that the treat&ent has been e44ecti%e' Ty!ically, i4 .E hours ha%e !assed since co&!letion o4 treat&ent and a $o&an has not had bleeding greater than a &enstrual !eriod, it is li#ely that she &ay ha%e an inco&!lete abortion or continuing !regnancy @=)A' /n-clinic treat&ent 3 E9a&ination o4 !resu&ed !roducts o4 conce!tion or !el%ic e9a&ination are !er4or&ed be4ore each additional &iso!rostol dose is ad&inistered in order to deter&ine $hether the 4etus has been e9!elled' The 4reCuency and strength o4 uterine contractions are also &onitored, and additional doses should be de4erred i4 uterine contractions are strong 5strong to !al!ation or by !atient re!ort7 andDor too 4reCuent 5], contractionsD+* &in7 @EEA' /n !regnancies at +, $ee#s or greater, i4 a $o&an does not abort a4ter ). hours, the o!tion o4 a second course o4 &iso!rostol treat&ent or surgical e%acuation can be o44ered @E+,E,A' There are insu44icient data on the sa4ety and e44ecti%eness o4 aug&entation $ith other uterotonics 5eg, !rostaglandins or o9ytocin7 @EEA' As $ith &iso!rostol, i4 additional uterotonics are used, !recautions should be ta#en to a%oid uterine hy!ersti&ulation, as it &ay lead to ru!ture' E9!ulsion o4 the !lacenta should be con4ir&ed' E9!ulsion usually occurs shortly a4ter the 4etus is deli%ered' A4ter e9!ulsion, the !lacenta should be e9a&ined to see $hether it is co&!lete' Ad%ice regarding ti&e inter%al to $ait 4or !lacental e9!ulsion %aries 4ro& ,* &inutes to 4our hours; in a retros!ecti%e study, there $as no &orbidity associated $ith a $aiting !eriod o4 4our hours @=,A' /4 t$o or &ore hours ha%e !assed and the !lacenta has not deli%ered, an in4usion o4 o9ytocin +* units in <** &L o4 nor&al saline ad&inistered intra%enously at a rate o4 )* to ,* dro!s !er &inute &ay be gi%en @EEA' /4 the !lacenta has not deli%ered a4ter in4usion o4 o9ytocin or the $o&an starts bleeding e9cessi%ely, &anual or surgical re&o%al o4 the !lacenta &ay be reCuired'

e4ore discharge 4ro& the clinic, clinicians should obser%e $o&en 4or at least 4our hours to &onitor %ital signs and obser%e 4or se%ere abdo&inal !ain or e9cessi%e %aginal bleeding' /4 .E hours ha%e !assed and abortion is not co&!lete, surgical e%acuation is ty!ically !er4or&ed @EEA' F1LL18-2B 3 A4ter treat&ent, $o&en should be educated about ho$ to recognize co&!lications 5eg, 4e%er, abdo&inal !ain, or !rolonged or e9cessi%e bleeding7 5table )7' A 4ollo$-u! %isit is conducted at one to t$o $ee#s !ost-treat&ent' A thorough clinical history and bi&anual !el%ic e9a&ination is !er4or&ed to e%aluate uterine size, bleeding, and assess 4or in4ection' The &ost i&!ortant Cuestions to as# at the 4ollo$-u! %isit are(

Do you 4eel !regnantR Did you see the e9!ulsion o4 the gestational sac or 4etusR Ho$ &uch bleeding did you ha%eR Are you still bleedingR

These Cuestions and a !el%ic e9a&ination to deter&ine uterine size are su44icient to detect &ost $o&en in need o4 4urther treat&ent 4or inco&!lete abortion 5retained !roducts o4 conce!tion, no or inconsistent uterine gro$th, and lac# o4 cardiac acti%ity on ultrasound7 or ongoing !regnancy 5uterine gro$th consistent $ith the ti&e ela!sed bet$een the 4irst and 4ollo$-u! %isits and cardiac acti%ity on %aginal ultrasound7' /4 there is uncertainty about $hether there is an inco&!lete abortion 5retained !roducts o4 conce!tion, no or inconsistent uterine gro$th, and lac# o4 cardiac acti%ity on ultrasound7 or ongoing !regnancy 5uterine gro$th consistent $ith the ti&e ela!sed bet$een the 4irst and 4ollo$-u! %isits and cardiac acti%ity on %aginal ultrasound7, a %aginal ultrasound e9a&ination &ay be necessary' Lenerally s!ea#ing, a seru& hCL is only used $hen there is concern about non-uterine !regnancy andDor $hen ultrasound is not a%ailable' 8hile hCL concentration &ay re&ain ele%ated 4or $ee#s a4ter co&!lete abortion, a &easure&ent that 4alls to less than )* !ercent o4 its !re-!rocedure %alue generally indicates success4ul !regnancy ter&ination @=.A' Also, there is no consensus regarding the u!!er li&it o4 endo&etrial thic#ness associated $ith a success4ul &edical abortion; there4ore, it is not a good diagnostic tool 4or deter&ining $hether 4urther inter%ention &ay be reCuired @=<-==A' 5See 6Mi4e!ristone 4or the &edical ter&ination o4 !regnancy6'7 Contrace!ti%e &ethod can be started as soon as !ossible' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GContrace!tionG'7 12TC1ME 3 /n early !regnancy, so&e studies suggest that !regnancy ter&ination e44icacy &ay be higher a&ong $o&en at si9 $ee#s and less @+**,+*+A co&!ared $ith those at si9 to eight $ee#s @+**,+*+A' This trend to$ard higher e44ecti%eness $ith decreasing gestational age is si&ilar to the results seen in large trials o4 co&bined &i4e!ristone-&iso!rostol @<:A'

E44ecti%eness 5de4ined as co&!lete abortion7 o4 &iso!rostol alone 4or !regnancy ter&ination is as 4ollo$s'

Z= $ee#s 5$ee#s o4 a&enorrhea7( ?< to E< !ercent @:),?EA +* to +) $ee#s( E* to E< !ercent @?EA c+, $ee#s( E* to =* !ercent @EEA

ADFERSE EFFECTS 3 Miso!rostol is a sa4e and $ell-tolerated &edication @+*)A' Lastrointestinal sy&!to&s 5nausea, diarrhea7 and 4e%er are the &ost co&&on ad%erse e44ects o4 &iso!rostol' These are generally transient and sel4-li&iting' Lastrointestinal sy&!to&s 3 Diarrhea is the &aHor ad%erse reaction that has been re!orted consistently, but it is usually &ild and sel4-li&iting' 0ausea and %o&iting &ay also occur @+*)A' The &aHority o4 cases can be &anaged e9!ectantly or $ith anti-e&etic or anti-Ddiarrheal &edication' These sy&!to&s ha%e been obser%ed $ith all 4our routes o4 ad&inistration; se%erity &ay be dose and inter%al de!endent 5ie, higher doses and shorter dosing inter%als &ay lead to increased sy&!to&s7 @:),?E,+**,+*,A' Fe%er 3 Fe%er, e%en in the absence o4 in4ection is a co&&on e44ect o4 &iso!rostol, re!orted in < to EE !ercent o4 !atients undergoing 4irst tri&ester abortion @?,<),?EA' There is one case re!ort o4 se%ere hy!erther&ia 5.+'= CD+*?'. F7 in a $o&an $ho recei%ed &iso!rostol 4or !ost!artu& he&orrhage !ro!hyla9is @+*.A' Fe%er associated $ith &iso!rostol should subside $ithin ). hours, and anti!yretics &ay be gi%en as needed' /4 4e%er !ersists beyond ). hours, a $o&en should be e%aluated 4or in4ection' Concern has e&erged in 0orth A&erica 4ollo$ing the re!orts o4 si9 cases o4 Clostridiaassociated 4atal to9ic shoc# syndro&e 4ollo$ing use o4 &i4e!ristone and &iso!rostol 4or early !regnancy ter&ination 54i%e cases associated $ith sordellii and one $ith !er4ringens7 @+*<-+*EA' An additional case 5o4 !er4ringens7 $as recently re!orted in a $o&an $ho used la&inaria and &iso!rostol 4or second tri&ester ter&ination' Although se%eral hy!otheses on the &echanis& o4 in4ection ha%e been !ut 4orth, no consensus has been reached @+*=-+++A 5see 6Mi4e!ristone 4or the &edical ter&ination o4 !regnancy6, section on G/n4ectionG7' Bre%ention o4 ad%erse e44ects 3 Bretreat&ent $ith anti!yretic and antidiarrheal &edications &ay slightly reduce the se%erity o4 gastrointestinal ad%erse e44ects @++)A' /n a rando&ized trial o4 $o&en undergoing !regnancy ter&ination at Z? $ee#s, !retreat&ent $ith lo!era&ide . &g o4 lo!era&ide and aceta&ino!hen <** &g !rior to &iso!rostol E** &cg !% co&!ared to no !retreat&ent led to a signi4icant reduction in incidence o4 diarrhea 5), %ersus .. !ercent7, but no di44erence in %o&iting or 4e%erDchills' C1MBL/CAT/10S 3 Co&!lications s!eci4ic to &iso!rostol-only !regnancy ter&ination are discussed belo$' As $ith any uterine e%acuation !rocedure, bleeding or in4ection &ay occur' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GCo&!licationsG'7 /nco&!lete abortion

First tri&ester 3 For $o&en undergoing 4irst tri&ester inductions, &anage&ent o4 ongoing !regnancy 5cardiac acti%ity on ultrasound7 or inco&!lete abortion 5sac or other e%idence o4 !roducts o4 conce!tion, but no gestational gro$th and no cardiac acti%ity on ultrasound7 are generally di44erent' 8e assess $o&en at the 4ollo$-u! %isit 5one to t$o $ee#s7 and ad%ise surgery 4or all ongoing !regnancies' For inco&!lete abortion, $e ad%ise e9!ectant &anage&ent or a second dose o4 &iso!rostol' For $o&en $ho recei%e a second dose, $e schedule a second 4ollo$-u! assess&ent at one to t$o $ee#s' 8e generally donGt gi%e &ore than one additional dose' This is because the cu&ulati%e bene4it o4 additional doses is not established and reCuiring &ulti!le 4ollo$-u! %isits increases the chance o4 loss-to-4ollo$-u!' Second tri&ester 3 For $o&en in second tri&ester, &anage&ent o4 retained !roducts o4 conce!tion 5B1Cs7 de!ends on the !oint in the !rocess at $hich they are sus!ected or diagnosed' A4ter 4etal e9!ulsion and be4ore discharge 4ro& the hos!ital or clinic, clinicians should con4ir& that the 4etus and !lacenta ha%e been co&!letely e9!elled' Many clinicians &anage retained !roducts o4 conce!tion 5B1Cs7 $ith surgical e%acuation' Clinicians can choose either dilatation and curettage or &anual %acuu& as!iration, de!ending on the clinical situation' 5See 6Surgical ter&ination o4 !regnancy( First tri&ester6 and 6Ter&ination o4 !regnancy( Second tri&ester6'7 Ho$e%er, so&e clinicians treat retained B1Cs a4ter a second tri&ester induction $ith an additional dose or t$o o4 &iso!rostol' The e44icacy o4 this !ractice has not been established in the literature, but a%oiding surgical inter%ention is al$ays reco&&ended, and there are no #no$n dangers o4 gi%ing additional &iso!rostol doses a4ter 4etal e9!ulsion' /t is rare 4or retained B1Cs to be detected only a4ter discharge 4ro& the clinic, and there is no standard a!!roach' Manage&ent 5e9!ectant &anage&ent, additional &iso!rostol, or surgery7 should be tailored to the !atientGs !re4erences and the clinical situation' 2terine ru!ture 3 Miso!rostol, and other agents $hich sti&ulate uterine contractions 5eg, o9ytocin, other !rostaglandins7, &ay increase ris# o4 dehiscence or a !rior uterine scar or uterine ru!ture' 5See GRis# 4actors 4or uterine ru!tureG abo%e'7 Bre!rocedure screening o4 !atients 4or ris# 4actors and close obser%ation during treat&ent are crucial to !re%ent or detect early signs o4 uterine ru!ture' /n addition, the &ini&u& cu&ulati%e &iso!rostol dose should be used 5ie, lo$est dose, longest dosing inter%al, lo$est nu&ber or total doses7' Clinical &ani4estations o4 uterine ru!ture 4ollo$ing &edical ter&ination o4 !regnancy are %ariable' /n $o&en $ith #no$n uterine scarring, uterine ru!ture should al$ays be strongly considered i4 se%ere and !ersistent abdo&inal !ain andDor signs o4 intraabdo&inal he&orrhage are !resent' Faginal bleeding is not a cardinal sy&!to&, as it &ay be &odest, des!ite &aHor intraabdo&inal he&orrhage' 1ther clinical &ani4estations include hy!otension ranging 4ro& subtle to se%ere 5hy!o%ole&ic shoc#7, cessation o4 uterine contractions, and uterine tenderness' He&aturia &ay occur i4 the

ru!ture e9tends to the bladder' /n a stable !atient, ultrasound e9a&ination &ay con4ir& the diagnosis @),,++,A' 5See 6Choosing the route o4 deli%ery a4ter cesarean birth6, section on G/na!!ro!riate candidatesG'7 Ru!ture or dehiscence is &anaged $ith e9!loratory la!aroto&y, $ith either uterine re!air or hysterecto&y' Conser%ati%e surgery also reCuires co&!letion o4 the !regnancy ter&ination' Teratogenicity 3 buestions regarding the teratogenicity o4 &iso!rostol &ay arise in cases $here co&!lete abortion is not achie%ed a4ter one or &ore doses and a $o&an does not 4ollo$-u! or chooses to continue a !regnancy' The teratogenic ris# o4 &iso!rostol a!!ears to be lo$ and generally li&ited to 4irst tri&ester e9!osure, according to a re%ie$ o4 case re!orts @++.A' Des!ite the lo$ ris#, $o&en $ho do not abort a4ter induction $ith &iso!rostol should be counseled about the ris# o4 4etal &al4or&ation' The &echanis& 4or &iso!rostol-associated 4etal &al4or&ations a!!ears to be %ascular disru!tion, !ossibly due to alteration o4 4etal blood 4lo$ due to uterine contractions @EE,++.-++?A' M/S1BR1ST1L-AL10E C1MBARED T1 1THER REL/ME0S Miso!rostol %ersus other !rostaglandins 3 Co&!ared $ith other !rostaglandins, &iso!rostol has less ad%erse e44ects, is orally acti%e, te&!erature stable, less e9!ensi%e, and $idely a%ailable, including( BLE) 5dino!rostone7 and BLF)al!ha 5carbo!rost7 @++EA' /n a syste&atic re%ie$ o4 rando&ized trials in $o&en undergoing !regnancy ter&ination in the second or third tri&ester, %aginal &iso!rostol co&!ared $ith ge&e!rost 5another BLE+7 $as associated $ith reduced narcotic analgesia 5RR *':., =<> C/ *'.=J*'E.7 and surgical e%acuation o4 the uterus 5RR *'?+, =<> C/ *'<,J*'=<7 @++=A' Miso!rostol %ersus &i4e!ristoneD&iso!rostol 3 A co&bined regi&en o4 &i4e!ristone and &iso!rostol is &ore e44ecti%e than &iso!rostol-alone in a rando&ized trial @E=A; the &iso!rostol-only regi&en $ould be o4 use in those settings $here &i4e!ristone is not a%ailable' /n addition, co&!ared $ith co&bined thera!y, $o&en $ho ad&inister &iso!rostolalone &ay e9!erience &ore 4e%er and chills 5!robably due to higher and re!eated doses7, $hereas $o&en ad&inistered the co&bined thera!y &ay e9!erience &ore nausea and %o&iting @+*+A' Bretreat&ent $ith &i4e!ristone &ay also reduce the !ain associated $ith the !rocedure' Miso!rostol %ersus &ethotre9ateD&iso!rostol 3 Choice o4 &iso!rostol-alone and co&bined &ethotre9ateD&iso!rostol is contro%ersial @,,.A' Data 4ro& rando&ized trials regarding the co&!arati%e e44icacy o4 the t$o regi&ens are %ariable' Data 4ro& a large retros!ecti%e series re!orted that use o4 &ethotre9ate $ith &iso!rostol $as &ore e44ecti%e than &iso!rostol-alone @)A' Ho$e%er, &ethotre9ate is not $idely a%ailable and

is &ore cu&berso&e to use than &i4e!ristone and &iso!rostol and &iso!rostol alone' Also, it can only be used sa4ely through se%en $ee#s o4 gestation' /0F1RMAT/10 F1R BAT/E0TS 3 2!ToDate o44ers t$o ty!es o4 !atient education &aterials, MThe asicsN and M eyond the asics'N The asics !atient education !ieces are $ritten in !lain language, at the <th to :th grade reading le%el, and they ans$er the 4our or 4i%e #ey Cuestions a !atient &ight ha%e about a gi%en condition' These articles are best 4or !atients $ho $ant a general o%er%ie$ and $ho !re4er short, easy-to-read &aterials' eyond the asics !atient education !ieces are longer, &ore so!histicated, and &ore detailed' These articles are $ritten at the +*th to +)th grade reading le%el and are best 4or !atients $ho $ant in-de!th in4or&ation and are co&4ortable $ith so&e &edical Hargon' Here are the !atient education articles that are rele%ant to this to!ic' 8e encourage you to !rint or e-&ail these to!ics to your !atients' 5Oou can also locate !atient education articles on a %ariety o4 subHects by searching on M!atient in4oN and the #ey$ord5s7 o4 interest'7

eyond the asics to!ics 5see 6Batient in4or&ation( Abortion 5!regnancy ter&ination7 5 eyond the asics767

S2MMARO A0D REC1MME0DAT/10S Bretreat&ent considerations

/n $o&en see#ing !regnancy ter&ination at nine or less $ee#s o4 gestation, $e reco&&end &i4e!ristone $ith &iso!rostol %ersus &iso!rostol alone 5Lrade +A7' Ho$e%er, in settings $here other &edications are not accessible, use o4 &iso!rostol-alone 4or early !regnancy ter&ination is an a!!ro!riate and e44ecti%e choice' 5See GMiso!rostol-alone co&!ared to other regi&ensG abo%e'7 Miso!rostol is co&&only used as a single agent 4or second tri&ester induced abortion in the 2nited States and &any other !arts o4 the $orld' 5See G/ntroductionG abo%e'7 /n $o&en undergoing !regnancy ter&ination at +. or &ore $ee#s, $e reco&&end &iso!rostol o%er ge&e!rost 5Lrade +A7' 5See GMiso!rostol %ersus other !rostaglandinsG abo%e'7 /n $o&en undergoing second tri&ester !regnancy ter&ination $ho are at high ris# o4 uterine ru!ture 5&ore than one hysteroto&y, a !rior classical or T-sha!ed uterine incision, or e9tensi%e trans4undal uterine surgery @eg, &yo&ecto&yA7, $e suggest against using &iso!rostol 5Lrade ) 7' Miso!rostol induction 4or !regnancy ter&ination a!!ears to be sa4e in $o&en $ith one !rior lo$ trans%erse hysteroto&y' Ru!ture is rarely associated $ith &iso!rostol use in 4irst tri&ester' 5See GRis# 4actors 4or uterine ru!tureG abo%e and 6Choosing the route o4 deli%ery a4ter cesarean birth6, section on G/na!!ro!riate candidatesG'7

Clinical !rotocol

/n $o&en undergoing !regnancy ter&ination $ith &iso!rostol-alone, $e suggest sublingual, rather than %aginal or oral, &iso!rostol dosing 5Lrade ) 7' uccal dosing &ay be a reasonable alternati%e to sublingual' Sublingual and

%aginal ad&inistration a!!ear to be co&!arable in e44ecti%eness and sa4ety in rando&ized trials' Faginal ad&inistration is &ore e44ecti%e than oral, ho$e%er, eCui%alent sa4ety has not been con4ir&ed' 5See GRoute o4 ad&inistrationG abo%e'7 For $o&en at nine or less $ee#s, &iso!rostol can be ad&inistered at ho&e or in a clinic setting' At +* or &ore $ee#s, $e conduct &iso!rostol treat&ent and &onitoring in a clinic' 5See GClinical regi&enG abo%e'7 The !otency o4 the e44ect o4 &iso!rostol %aries $ith gestational age, as $ell as $ith route o4 ad&inistration, dose, dosing inter%al, and cu&ulati%e dose' Clinical !rotocols %ary by gestational age' 5See GData on drug ad&inistrationG abo%e and GClinical regi&enG abo%e'7 5table )7' Lastrointestinal sy&!to&s 5nausea, %o&iting, diarrhea7 and 4e%er are the &ost co&&on ad%erse e44ects o4 &iso!rostol' These are generally transient and sel4li&iting' /t is reasonable to gi%e !ro!hylactic anti-diarrheal &edication to decrease the incidence o4 diarrhea; !retreat&ent does not a!!ear to decrease other side e44ects' 5See GAd%erse e44ectsG abo%e'7

Bosttreat&ent issues

8o&en should be educated about ho$ to recognize co&!lications 5eg, 4e%er, abdo&inal !ain, or !rolonged or e9cessi%e bleeding7' 5See GFollo$-u!G abo%e'7 /nco&!lete abortion or continuing !regnancy are the &ost co&&on co&!lications o4 &edical abortion' This can be &anaged e9!ectantly, &edically, or surgically' 5See GCo&!licationsG abo%e'7 2terine ru!ture should be sus!ected in a $o&an $ith se%ere or !ersistent abdo&inal !ain and signs o4 intraabdo&inal bleeding' Bro&!t la!aroto&y is indicated in !atients $ith a !resu&!ti%e diagnosis o4 uterine ru!ture' 5See GCo&!licationsG abo%e'7

2se o4 2!ToDate is subHect to the Subscri!tion and License Agree&ent'

REFERENCES
+' )' ,' .' <' orgatta L, Mullally , Frago%ic 1, et al' Miso!rostol as the !ri&ary agent 4or &edical abortion in a lo$-inco&e urban setting' Contrace!tion )**.; ?*(+)+' Aldrich T, 8ini#o44 ' Does &ethotre9ate con4er a signi4icant ad%antage o%er &iso!rostol alone 4or early &edical abortionR A retros!ecti%e analysis o4 E:?E abortions' "1L )**?; ++.(<<<' 8iebe ER, Trouton T", Li&a R' Miso!rostol alone %s' &ethotre9ate 4ollo$ed by &iso!rostol 4or early abortion' /nt " Lynaecol 1bstet )**:; =<()E:' 1zeren M, ile#li C, Ayde&ir F, oz#aya H' Methotre9ate and &iso!rostol used alone or in co&bination 4or early abortion' Contrace!tion +===; <=(,E=' 2nited 0ations De%elo!&ent Brogra&D2nited 0ations Fund 4or Bo!ulation Acti%itiesD8orld Health 1rganizationD8orld an# S!ecial Brogra& o4 Research De%elo!&ent and Research Training in Hu&an Re!rod' Annual Technical Re!ort, +==?' 8orld Health 1rganization, Lene%a, S$itzerland +==E' Saha S, al R, Lhosh S, Trishna&urthy B' Medical abortion in late second tri&ester--a co&!arati%e study $ith &iso!rostol through %aginal %ersus oral 4ollo$ed by %aginal route' " /ndian Med Assoc )**:; +*.(E+'

:'

?' Tang 1S, Le&zell-Danielsson T, Ho BC' Miso!rostol( !har&aco#inetic !ro4iles, e44ects on the uterus and side-e44ects' /nt " Lynaecol 1bstet )**?; == Su!!l )(S+:*' E' Pie&an M, Fong ST, eno$itz 0L, et al' Absor!tion #inetics o4 &iso!rostol $ith oral or %aginal ad&inistration' 1bstet Lynecol +==?; =*(EE' =' Tang 1S, Sch$eer H, Seyberth H8, et al' Bhar&aco#inetics o4 di44erent routes o4 ad&inistration o4 &iso!rostol' Hu& Re!rod )**); +?(,,)' +*' Danielsson TL, Marions L, Rodriguez A, et al' Co&!arison bet$een oral and %aginal ad&inistration o4 &iso!rostol on uterine contractility' 1bstet Lynecol +===; =,()?<' ++' Ar%idsson C, Hellborg M, Le&zell-Danielsson T' Bre4erence and acce!tability o4 oral %ersus %aginal ad&inistration o4 &iso!rostol in &edical abortion $ith &i4e!ristone' Eur " 1bstet Lynecol Re!rod iol )**<; +),(E?' +)' Scha44 EA, DiCenzo R, Fielding SL' Co&!arison o4 &iso!rostol !las&a concentrations 4ollo$ing buccal and sublingual ad&inistration' Contrace!tion )**<; ?+())' +,' Mec#stroth TR, 8hita#er AT, ertisch S, et al' Miso!rostol ad&inistered by e!ithelial routes( Drug absor!tion and uterine res!onse' 1bstet Lynecol )**:; +*E(<E)' +.' Creinin MD, Carbonell "L, Sch$artz "L, et al' A rando&ized trial o4 the e44ect o4 &oistening &iso!rostol be4ore %aginal ad&inistration $hen used $ith &ethotre9ate 4or abortion' Contrace!tion +===; <=(++' +<' Sanchez-Ra&os L, Danner C", Del#e /, Taunitz AM' The e44ect o4 tablet &oistening on labor induction $ith intra%aginal &iso!rostol( a rando&ized trial' 1bstet Lynecol )**); ==(+*E*' +:' hattacharHee 0, Saha SB, Languly RB, et al' A rando&ized co&!arati%e study on %aginal ad&inistration o4 acetic acid-&oistened %ersus dry &iso!rostol 4or &id-tri&ester !regnancy ter&ination' Arch Lynecol 1bstet )*+); )E<(,++' +?' Bongsatha S, Tongsong T' Rando&ized controlled study co&!aring &iso!rostol &oistened $ith nor&al saline and $ith acetic acid 4or second-tri&ester !regnancy ter&ination' /s it di44erentR " 1bstet Lynaecol Res )*++; ,?(EE)' +E' Loldberg A , Lreenberg M , Darney BD' Miso!rostol and !regnancy' 0 Engl " Med )**+; ,..(,E' +=' Loyal F' 2terine ru!ture in second-tri&ester &iso!rostol-induced abortion a4ter cesarean deli%ery( a syste&atic re%ie$' 1bstet Lynecol )**=; ++,(+++?' )*' Ti& "1, Han "O, Choi "S, et al' 1ral &iso!rostol and uterine ru!ture in the 4irst tri&ester o4 !regnancy( a case re!ort' Re!rod To9icol )**<; )*(<?<' )+' Das#ala#is L", Mesogitis SA, Ba!antoniou 0E, et al' Miso!rostol 4or second tri&ester !regnancy ter&ination in $o&en $ith !rior caesarean section' "1L )**<; ++)(=?' ))' Dic#inson "E' Miso!rostol 4or second-tri&ester !regnancy ter&ination in $o&en $ith a !rior cesarean deli%ery' 1bstet Lynecol )**<; +*<(,<)' ),' El-Matary A, 0a%aratnaraHah R, Econo&ides DL' 2ltrasound diagnosis o4 uterine dehiscence 4ollo$ing &i4e!ristoneD&iso!rostol regi&e in early second tri&ester ter&ination' " 1bstet Lynaecol )**:; ):(<?E' ).' Mazouni C, Bro%ensal M, Borcu L, et al' Ter&ination o4 !regnancy in !atients $ith !re%ious cesarean section' Contrace!tion )**:; ?,()..' )<' 0ay#i 2, Taner CE, Mizra# T, et al' 2terine ru!ture during second tri&ester abortion $ith &iso!rostol' Fetal Diagn Ther )**<; )*(.:='

):' Mazzone ME, 8oole%er "' 2terine ru!ture in a !atient $ith an unscarred uterus( a case study' 8M" )**:; +*<(:.' )?' Al-Hussaini TT' 2terine ru!ture in second tri&ester abortion in a grand &ulti!arous $o&an' A co&!lication o4 &iso!rostol and o9ytocin' Eur " 1bstet Lynecol Re!rod iol )**+; =:()+E' )E' Syed S, 0oreen H, Tahloon LE, Chaudhri R' 2terine ru!ture associated $ith the use o4 intra-%aginal &iso!rostol during second-tri&ester !regnancy ter&ination' " Ba# Med Assoc )*++; :+(,==' )=' Cuellar Torriente M' Silent uterine ru!ture $ith the use o4 &iso!rostol 4or second tri&ester ter&ination o4 !regnancy ( a case re!ort' 1bstet Lynecol /nt )*++; )*++(<E.:<)' ,*' erghella F, Airoldi ", 1G0eill AM, et al' Miso!rostol 4or second tri&ester !regnancy ter&ination in $o&en $ith !rior caesarean( a syste&atic re%ie$' "1L )**=; ++:(++<+' ,+' 0aguib AH, Morsi HM, org TF, et al' Faginal &iso!rostol 4or secondtri&ester !regnancy ter&ination a4ter one !re%ious cesarean deli%ery' /nt " Lynaecol 1bstet )*+*; +*E(.E' ,)' Fa$zy M, Abdel-Hady el-S' Midtri&ester abortion using %aginal &iso!rostol 4or $o&en $ith three or &ore !rior cesarean deli%eries' /nt " Lynaecol 1bstet )*+*; ++*(<*' ,,' Lalit#u&ar S, ygde&an M, Le&zell-Danielsson T' Mid-tri&ester induced abortion( a re%ie$' Hu& Re!rod 2!date )**?; +,(,?' ,.' 0gai S8, Tang 1S, Ho BC' Brostaglandins 4or induction o4 second-tri&ester ter&ination and intrauterine death' est Bract Res Clin 1bstet Lynaecol )**,; +?(?:<' ,<' Fogel D, ur#hardt T, Rentsch T, et al' Miso!rostol %ersus &ethylergo&etrine( !har&aco#inetics in hu&an &il#' A& " 1bstet Lynecol )**.; +=+()+:E' ,:' "ain "T, Mishell DR "r' A co&!arison o4 &iso!rostol $ith and $ithout la&inaria tents 4or induction o4 second-tri&ester abortion' A& " 1bstet Lynecol +==:; +?<(+?,' ,?' orgatta L, Chen AO, Frago%ic 1, et al' A rando&ized clinical trial o4 the addition o4 la&inaria to &iso!rostol and hy!ertonic saline 4or second-tri&ester induction abortion' Contrace!tion )**<; ?)(,<E' ,E' FHerstad M, Trussell ", Lichtenberg ES, et al' Se%erity o4 in4ection 4ollo$ing the introduction o4 ne$ in4ection control &easures 4or &edical abortion' Contrace!tion )*++; E,(,,*' ,=' FHerstad M, Trussell ", Si%in /, et al' Rates o4 serious in4ection a4ter changes in regi&ens 4or &edical abortion' 0 Engl " Med )**=; ,:+(+.<' .*' Meites E, Pane S, Lould C, C' sordellii /n%estigators' Fatal Clostridiu& sordellii in4ections a4ter &edical abortions' 0 Engl " Med )*+*; ,:,(+,E)' .+' lanchard T, Shochet T, CoyaHi T, et al' Miso!rostol alone 4or early abortion( an e%aluation o4 se%en !otential regi&ens' Contrace!tion )**<; ?)(=+' .)' Lilbert A, Reid R' A rando&ised trial o4 oral %ersus %aginal ad&inistration o4 &iso!rostol 4or the !ur!ose o4 &id-tri&ester ter&ination o4 !regnancy' Aust 0 P " 1bstet Lynaecol )**+; .+(.*?' .,' ebbington M8, Tent 0, Li& T, et al' A rando&ized controlled trial co&!aring t$o !rotocols 4or the use o4 &iso!rostol in &idtri&ester !regnancy ter&ination' A& " 1bstet Lynecol )**); +E?(E<,'

..' Dic#inson "E, E%ans SF' A co&!arison o4 oral &iso!rostol $ith %aginal &iso!rostol ad&inistration in second-tri&ester !regnancy ter&ination 4or 4etal abnor&ality' 1bstet Lynecol )**,; +*+(+)=.' .<' Tang 1S, Miao O, Lee S8, Ho BC' Bilot study on the use o4 re!eated doses o4 sublingual &iso!rostol in ter&ination o4 !regnancy u! to +) $ee#s gestation( e44icacy and acce!tability' Hu& Re!rod )**); +?(:<.' .:' Cheung 8, Tang 1S, Lee S8, Ho BC' Bilot study on the use o4 sublingual &iso!rostol in ter&ination o4 !regnancy u! to ? $ee#s gestation' Contrace!tion )**,; :E(=?' .?' hattacharHee 0, Saha SB, Lhoshroy SC, et al' A rando&ised co&!arati%e study on sublingual %ersus %aginal ad&inistration o4 &iso!rostol 4or ter&ination o4 !regnancy bet$een +, to )* $ee#s' Aust 0 P " 1bstet Lynaecol )**E; .E(+:<' .E' 0goc 0T, lu& ", Ragha%an S, et al' Co&!aring t$o early &edical abortion regi&ens( &i4e!ristoneX&iso!rostol %s' &iso!rostol alone' Contrace!tion )*++; E,(.+*' .=' 0goc 0T, Shochet T, Ragha%an S, et al' Mi4e!ristone and &iso!rostol co&!ared $ith &iso!rostol alone 4or second-tri&ester abortion( a rando&ized controlled trial' 1bstet Lynecol )*++; ++E(:*+' <*' Sala#os 0, Tountouris A, otsis D, et al' First-tri&ester !regnancy ter&ination $ith E** &icrog o4 %aginal &iso!rostol e%ery +) h' Eur " Contrace!t Re!rod Health Care )**<; +*().=' <+' Carbonell "L, Rodrdguez ", Felazco A, et al' 1ral and %aginal &iso!rostol E** &icrog e%ery E h 4or early abortion' Contrace!tion )**,; :?(.<?' <)' Carbonell "L, Felazco A, Farela L, et al' Miso!rostol 4or abortion at =-+) $ee#sG gestation in adolescents' Eur " Contrace!t Re!rod Health Care )**+; :(,=' <,' Carbonell "L, Rodriguez ", AragYn S, et al' Faginal &iso!rostol +*** &icrog 4or early abortion' Contrace!tion )**+; :,(+,+' <.' Felazco A, Farela L, Tanda R, et al' Miso!rostol 4or abortion u! to = $ee#sG gestation in adolescents' Eur " Contrace!t Re!rod Health Care )***; <())?' <<' 0gai S8, Tang 1S, Chan OM, Ho BC' Faginal &iso!rostol alone 4or &edical abortion u! to = $ee#s o4 gestation( e44icacy and acce!tability' Hu& Re!rod )***; +<(++<=' <:' Tang 1S, 8ong TS, Tang LC, Ho BC' Bilot study on the use o4 re!eated doses o4 &iso!rostol in ter&ination o4 !regnancy at less than = $ee#s o4 gestation' Ad% Contrace!t +===; +<()++' <?' Este%e "L, Farela L, Felazco A, et al' Early abortion $ith E** &icrogra&s o4 &iso!rostol by the %aginal route' Contrace!tion +===; <=()+=' <E' Carbonell Este%e "L, Farela L, Felazco A, et al' Faginal &iso!rostol 4or late 4irst tri&ester abortion' Contrace!tion +==E; <?(,)=' <=' Carbonell "L, Farela L, Felazco A, et al' Faginal &iso!rostol 4or abortion at +*+, $ee#sG gestation' Eur " Contrace!t Re!rod Health Care +===; .(,<' :*' Carbonell "L, Farela L, Felazco A, FernQndez C' The use o4 &iso!rostol 4or ter&ination o4 early !regnancy' Contrace!tion +==?; <<(+:<' :+' Calis#an E, Dilbaz S, Doger E, et al' Rando&ized co&!arison o4 , &iso!rostol !rotocols 4or abortion induction at +,-)* $ee#s o4 gestation' " Re!rod Med )**<; <*(+?,' :)' %on Hertzen H, Biaggio L, Huong 0T, et al' E44icacy o4 t$o inter%als and t$o routes o4 ad&inistration o4 &iso!rostol 4or ter&ination o4 early !regnancy( a rando&ised controlled eCui%alence trial' Lancet )**?; ,:=(+=,E'

:,' Tang 1S, Lau 80, Chan CC, Ho BC' A !ros!ecti%e rando&ised co&!arison o4 sublingual and %aginal &iso!rostol in second tri&ester ter&ination o4 !regnancy' "1L )**.; +++(+**+' :.' %on Hertzen H, Biaggio L, 8oHdyla D, et al' Co&!arison o4 %aginal and sublingual &iso!rostol 4or second tri&ester abortion( rando&ized controlled eCui%alence trial' Hu& Re!rod )**=; ).(+*:' :<' Languly RB, Saha SB, Mu#ho!adhyay S, et al' A co&!arati%e study on sublingual %ersus oral and %aginal ad&inistration o4 &iso!rostol 4or late 4irst and early second tri&ester abortion' " /ndian Med Assoc )*+*; +*E()E,' ::' Cabrera O, FernQndez-Luisasola ", Lobo B, et al' Co&!arison o4 sublingual %ersus %aginal &iso!rostol 4or second-tri&ester !regnancy ter&ination( a &etaanalysis' Aust 0 P " 1bstet Lynaecol )*++; <+(+<E' :?' 8ildschut H, oth M/, Mede&a S, et al' Medical &ethods 4or &id-tri&ester ter&ination o4 !regnancy' Cochrane Database Syst Re% )*++; (CD**<)+:' :E' lu& ", Ragha%an S, Dabash R, et al' Co&!arison o4 &iso!rostol-only and co&bined &i4e!ristone-&iso!rostol regi&ens 4or ho&e-based early &edical abortion in Tunisia and Fietna&' /nt " Lynaecol 1bstet )*+); ++E(+::' :=' Sayette H, Red$ine D, Si%in /, et al'' uccal use o4 &iso!rostol alone 4or early abortion( The e9!erience in 4our Latin A&erican countries 5abstract7' Contrace!tion )*++; E.(,*)' ?*' 8ini#o44 , Dzuba /L, Creinin MD, et al' T$o distinct oral routes o4 &iso!rostol in &i4e!ristone &edical abortion( a rando&ized controlled trial' 1bstet Lynecol )**E; ++)(+,*,' ?+' Middleton T, Scha44 E, Fielding SL, et al' Rando&ized trial o4 &i4e!ristone and buccal or %aginal &iso!rostol 4or abortion through <: days o4 last &enstrual !eriod' Contrace!tion )**<; ?)(,)E' ?)' Ta!! 0, orgatta L, Stubble4ield B, et al' Mi4e!ristone in second-tri&ester &edical abortion( a rando&ized controlled trial' 1bstet Lynecol )**?; ++*(+,*.' ?,' Batel A, Tal&ont E, Mor4esis ", et al' AdeCuacy and sa4ety o4 buccal &iso!rostol 4or cer%ical !re!aration !rior to ter&ination o4 second-tri&ester !regnancy' Contrace!tion )**:; ?,(.)*' ?.' Ellis SC, Ta!! 0, Frag!%oc 1, orgata L' Rando&ized trial o4 buccal %ersus %aginal &iso!rostol 4or induction o4 second tri&ester abortion' Contrace!tion )*+*; E+(..+' ?<' LiaCuat 0F, "a%ed /, ShuHa S, et al' Thera!eutic ter&ination o4 second tri&ester !regnancies $ith lo$ dose &iso!rostol' " Coll Bhysicians Surg Ba# )**:; +:(.:.' ?:' Ma#hlou4 AM, Al-Hussaini TT, Habib DM, Ma#are& MH' Second-tri&ester !regnancy ter&ination( co&!arison o4 three di44erent &ethods' " 1bstet Lynaecol )**,; ),(.*?' ??' Feld&an DM, orgida AF, Rodis "F, et al' A rando&ized co&!arison o4 t$o regi&ens o4 &iso!rostol 4or second-tri&ester !regnancy ter&ination' A& " 1bstet Lynecol )**,; +E=(?+*' ?E' FaVndes A, Fiala C, Tang 1S, Felasco A' Miso!rostol 4or the ter&ination o4 !regnancy u! to +) co&!leted $ee#s o4 !regnancy' /nt " Lynaecol 1bstet )**?; == Su!!l )(S+?)' ?=' Lui9 C, Balacio M, Figueras F, et al' E44icacy o4 t$o regi&ens o4 &iso!rostol 4or early second-tri&ester !regnancy ter&ination' Fetal Diagn Ther )**<; )*(<..'

E*' ugalho A, FaVndes A, "a&isse L, et al' E%aluation o4 the e44ecti%eness o4 %aginal &iso!rostol to induce 4irst tri&ester abortion' Contrace!tion +==:; <,()..' E+' 8ong TS, 0gai CS, Oeo EL, et al' A co&!arison o4 t$o regi&ens o4 intra%aginal &iso!rostol 4or ter&ination o4 second tri&ester !regnancy( a rando&ized co&!arati%e trial' Hu& Re!rod )***; +<(?*=' E)' Herabutya O, Chanracha#ul , Bunya%achira B' A rando&ised controlled trial o4 : and +) hourly ad&inistration o4 %aginal &iso!rostol 4or second tri&ester !regnancy ter&ination' "1L )**<; ++)(+)=?' E,' Dic#inson "E, E%ans SF' The o!ti&ization o4 intra%aginal &iso!rostol dosing schedules in second-tri&ester !regnancy ter&ination' A& " 1bstet Lynecol )**); +E:(.?*' E.' Ed$ards RT, Si&s SM' 1utco&es o4 second-tri&ester !regnancy ter&inations $ith &iso!rostol( co&!aring ) regi&ens' A& " 1bstet Lynecol )**<; +=,(<..' E<' Dodd ", 1G rien L, Co44ey "' Miso!rostol 4or second and third tri&ester ter&ination o4 !regnancy( a re%ie$ o4 !ractice at the 8o&enGs and ChildrenGs Hos!ital, Adelaide, Australia' Aust 0 P " 1bstet Lynaecol )**<; .<()<' E:' Langer R, Beter C, Firtion C, et al' Second and third &edical ter&ination o4 !regnancy $ith &iso!rostol $ithout &i4e!ristone' Fetal Diagn Ther )**.; +=()::' E?' Brachasil!chai 0, Russa&eecharoen T, orriboonhirunsarn D' Success rate o4 second-tri&ester ter&ination o4 !regnancy using &iso!rostol' " Med Assoc Thai )**:; E=(+++<' EE' Ho BC, lu&enthal BD, Le&zell-Danielsson T, et al' Miso!rostol 4or the ter&ination o4 !regnancy $ith a li%e 4etus at +, to ): $ee#s' /nt " Lynaecol 1bstet )**?; == Su!!l )(S+?E' E=' "ain "T, Dutton C, Har$ood , et al' A !ros!ecti%e rando&ized, double-blinded, !lacebo-controlled trial co&!aring &i4e!ristone and %aginal &iso!rostol to %aginal &iso!rostol alone 4or electi%e ter&ination o4 early !regnancy' Hu& Re!rod )**); +?(+.??' =*' orgatta L, Ta!! 0, Society o4 Fa&ily Blanning' Clinical guidelines' Labor induction abortion in the second tri&ester' Contrace!tion )*++; E.(.' =+' Sha$ D' Miso!rostol 4or re!roducti%e health( Dosage reco&&endations' /nt " Lynaecol 1bstet )**?; == Su!!l )(S+<<' =)' Sa4e abortion( Technical and !olicy guidelines 4or health syste&s' 8orld Health 1rganization, Lene%a, )**,' =,' Lreen ", orgatta L, Sia M, et al' /nter%ention rates 4or !lacental re&o%al 4ollo$ing induction abortion $ith &iso!rostol' Contrace!tion )**?; ?:(,+*' =.' Fiala C, Sa4ar B, ygde&an M, Le&zell-Danielsson T' Feri4ying the e44ecti%eness o4 &edical abortion; ultrasound %ersus hCL testing' Eur " 1bstet Lynecol Re!rod iol )**,; +*=(+=*' =<' Har$ood , Mec#stroth TR, Mishell DR, "ain "T' Seru& beta-hu&an chorionic gonadotro!in le%els and endo&etrial thic#ness a4ter &edical abortion' Contrace!tion )**+; :,()<<' =:' Luise C, "er&y T, Collons 8B, ourne TH' E9!ectant &anage&ent o4 inco&!lete, s!ontaneous 4irst-tri&ester &iscarriage( outco&e according to initial ultrasound criteria and %alue o4 4ollo$-u! %isits' 2ltrasound 1bstet Lynecol )**); +=(<E*' =?' Creinin MD, Har$ood , Luido RS, et al' Endo&etrial thic#ness a4ter &iso!rostol use 4or early !regnancy 4ailure' /nt " Lynaecol 1bstet )**.; E:())'

=E' Reynolds A, Ayres-de-Ca&!os D, Costa MA, Montenegro 0' Ho$ should success be de4ined $hen atte&!ting &edical resolution o4 4irst-tri&ester &issed abortionR Eur " 1bstet Lynecol Re!rod iol )**<; ++E(?+' ==' Ree%es MF, Fo9 MC, Lohr BA, Creinin MD' Endo&etrial thic#ness 4ollo$ing &edical abortion is not !redicti%e o4 subseCuent surgical inter%ention' 2ltrasound 1bstet Lynecol )**=; ,.(+*.' +**' Hon#anen H, Biaggio L, Hertzen H, et al' 8H1 &ultinational study o4 three &iso!rostol regi&ens a4ter &i4e!ristone 4or early &edical abortion' "1L )**.; +++(?+<' +*+' 0gai S8, Tang 1S, Ho BC' Rando&ized co&!arison o4 %aginal 5)** &icrog e%ery , h7 and oral 5.** &icrog e%ery , h7 &iso!rostol $hen co&bined $ith &i4e!ristone in ter&ination o4 second tri&ester !regnancy' Hu& Re!rod )***; +<())*<' +*)' aird DT' Medical abortion in the 4irst tri&ester' est Bract Res Clin 1bstet Lynaecol )**); +:())+' +*,' "ain "T, Mec#stroth TR, Bar# M, Mishell DR "r' A co&!arison o4 ta&o9i4en and &iso!rostol to &iso!rostol alone 4or early !regnancy ter&ination' Contrace!tion +===; :*(,<,' +*.' Chong OS, Chua S, Arul#u&aran S' Se%ere hy!erther&ia 4ollo$ing oral &iso!rostol in the i&&ediate !ost!artu& !eriod' 1bstet Lynecol +==?; =*(?*,' +*<' Bhili! 0M, 8ini#o44 , Moore T, lu&enthal B' A consensus regi&en 4or early abortion $ith &iso!rostol' /nt " Lynaecol 1bstet )**.; E?()E+' +*:' Shannon C, rothers LB, Bhili! 0M, 8ini#o44 ' /n4ection a4ter &edical abortion( a re%ie$ o4 the literature' Contrace!tion )**.; ?*(+E,' +*?' Fischer M, hatnagar ", Luarner ", et al' Fatal to9ic shoc# syndro&e associated $ith Clostridiu& sordellii a4ter &edical abortion' 0 Engl " Med )**<; ,<,(),<)' +*E' Sina%e C, Le Te&!lier L, louin D, et al' To9ic shoc# syndro&e due to Clostridiu& sordellii( a dra&atic !ost!artu& and !ostabortion disease' Clin /n4ect Dis )**); ,<(+..+' +*=' Couzin "' in4ectious disease' R2-.E:-lin#ed deaths o!en debate about ris#y bacteria' Science )**:; ,+)(=E:' ++*' 8ini#o44 ' Clostridiu& sordellii in4ection in &edical abortion' Clin /n4ect Dis )**:; .,(+..?' +++' Arono44 DM, Hao O, Chung ", et al' Miso!rostol i&!airs 4e&ale re!roducti%e tract innate i&&unity against Clostridiu& sordellii' " /&&unol )**E; +E*(E)))' ++)' "ain "T, Har$ood , Mec#stroth TR, Mishell DR' Early !regnancy ter&ination $ith %aginal &iso!rostol co&bined $ith lo!era&ide and aceta&ino!hen !ro!hyla9is' Contrace!tion )**+; :,()+?' ++,' Das#ala#is L, Ba!antoniou 0, Mesogitis S, et al' Sonogra!hic 4indings and surgical &anage&ent o4 a uterine ru!ture associated $ith the use o4 &iso!rostol during second-tri&ester abortion' " 2ltrasound Med )**<; ).(+<:<' ++.' Miso!rostol and teratology( Re%ie$ing the e%idence, Bhili!, 0, Shannon,

&ermination of pregnan!y: Se!on trimester

Authors Lee B Shul&an, MD Fran# 8 Ling, MD Section Editor Mi&i Pie&an, MD De!uty Editor Sandy " Fal#, MD Disclosures All to!ics are u!dated as ne$ e%idence beco&es a%ailable and our !eer re%ie$ !rocess is co&!lete' Literature re%ie$ current through( Se! )*+,' - This to!ic last u!dated( oct +, )*+)' /0TR1D2CT/10 3 Methods 4or second tri&ester !regnancy ter&ination $ill be discussed here' An o%er%ie$ o4 general issues o4 !regnancy ter&ination 5!reo!erati%e e%aluation, use o4 antibiotics and anesthesia, co&!lications, 4ollo$-u!, etc7 and issues !ertaining to 4irst tri&ester surgical ter&ination o4 !regnancy are re%ie$ed se!arately' 5See 61%er%ie$ o4 !regnancy ter&ination6 and 6Surgical ter&ination o4 !regnancy( First tri&ester6'7 1FERF/E8 3 There are three general &ethods o4 second tri&ester !regnancy ter&ination(

Dilation and e%acuation 5DIE7 Ad&inistration o4 syste&ic aborti4acients /ntrauterine instillation o4 aborti4acients

Hysteroto&y or hysterecto&y are rarely !er4or&ed 4or !regnancy ter&ination' D/LAT/10 A0D E`TRACT/10 Leneral issues 3 Dilation and e9traction 5DIE7 is the &ost co&&on techniCue used 4or second-tri&ester !regnancy ter&ination in the 2nited States @+A' /t has the lo$est &aternal &ortality rate o4 all second tri&ester !regnancy ter&ination !rocedures and co&!arable &orbidity to other second tri&ester techniCues @)A' As an e9a&!le(

/n one study, =<?) e9traction !rocedures $ere co&!ared to )E*< instillation !rocedures using an instillate co&!osed o4 BLF) al!ha and urea @,A' All !rocedures $ere !er4or&ed bet$een +, and ). $ee#s o4 gestation' Serious co&!lications 54e%er o4 ,EeC or &ore, he&orrhage reCuiring blood trans4usion, or !er4or&ance o4 unintended surgery as result o4 an abortion-related incident7 $ere lo$er in $o&en undergoing an e9traction !rocedure 5*'.= %ersus +'*, !ercent7' 1nly uterine !er4oration occurred &ore 4reCuently in the e9traction grou!' These 4indings $ere con4ir&ed in another series o4 $o&en undergoing abortions through the +<th &enstrual $ee# that sho$ed surgical e9traction had a lo$er 4reCuency o4 blood loss reCuiring trans4usion, cer%ical laceration, retained !roducts o4 conce!tion, 4e%er, %o&iting, and diarrhea than labor induction abortion by intra%aginal !rostaglandin 5BL7 su!!ositories @.A' Si&ilar results $ere re!orted in a study co&!aring dilation and e9traction to intraa&niotic saline in4usion @<A' The &aHor co&!lication rate 4or e9traction $as

less than one-hal4 that o4 saline instillation 5*':= and +'?E !ercent, res!ecti%ely7 and there $ere lo$er rates o4 treat&ent co&!lications, such as antibiotic ad&inistration 5) %ersus : !ercent7 and blood trans4usion 5*') %ersus + !ercent7' 1ther studies co&!aring DIE to labor induction 4or cases o4 4etal ano&alies or de&ise in the second tri&ester de&onstrated DIE to be signi4icantly sa4er and &ore e44ecti%e than labor induction in second tri&ester cases underta#en 4or 4etal indications @:A' 1ne study 4ound that DIE $as less &orbid than labor induction 4or uterine e%acuation in cases o4 second tri&ester 4etal de&ise as result o4 an increased ris# o4 !resu&ed in4ection @?A' There are also !sychological bene4its o4 a ra!id !rocedure that does not in%ol%e labor @EA' This $as illustrated in a study that re!orted that $o&en undergoing second tri&ester e9traction e9!erienced less !osto!erati%e !ain, anger, and de!ression than those undergoing labor induction &ethods @=A'

/n a &athe&atical &odel, surgical ter&ination $as less e9!ensi%e than &edical ter&ination using &iso!rostol 5see GMiso!rostolG belo$7 @+*A' /n &any centers, 4eticidal agents are gi%en be4ore any second tri&ester !rocedure !rior to inserting la&inaria so the surgical e9traction $ill be !er4or&ed on a dead 4etus, thus a%oiding uncertainties in abortion la$ 5see G/ntact dilation and e9tractionG belo$7' 1!tions include intracardiac inHection o4 about < &EC !otassiu& chloride or inHection o4 *'< to +'< &g digo9in into the 4etus or a&niotic sac @++A' A large case series re!orted that 4ailure rates 4or intraa&niotic digo9in ad&inistration $ere higher than 4or intra4etal ad&inistration 5E', %ersus ,': !ercent7; there $ere no ad%erse &aternal e%ents @+)A' 2se o4 digo9in is the sa4est a!!roach' Maternal cardiac arrest a4ter atte&!ted 4etal intracardiac inHection o4 !otassiu& chloride has been re!orted @+,A' Cer%ical !re!aration 3 Second-tri&ester e9traction reCuires dilation o4 the cer%i9' Care4ul &anual dilation can achie%e su44icient cer%ical dilation to allo$ uterine e%acuation in &any cases' Ho$e%er, this techniCue carries a signi4icantly increased ris# o4 cer%ical laceration, he&orrhage, and unsuccess4ul uterine e%acuation due to the need 4or e9tensi%e dilation o4 the cer%i9 to allo$ re&o%al o4 the larger %olu&e o4 intrauterine contents @+.A' The !re4erred techniCue o4 cer%ical dilation is to use &ulti!le os&otic dilators 5eg, synthetic or natural sea$eed-based la&inaria7' Brostaglandins are alternati%e agents 4or cer%ical ri!ening' There4ore, !rogressi%e cer%ical dilation, $hich &ay ta#e se%eral days, is !er4or&ed 4or !atient sa4ety' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GCer%ical !re!arationG'7 E%acuation 3 De!ending on the !atient and gestational age, a %ariety o4 anesthetic a!!roaches &ay be used, including conscious sedation, regional bloc#, and general anesthesia' So&eti&es a %asoconstricti%e agent such as %aso!ressin is added to the !aracer%ical bloc# to reduce intra- and !osto!erati%e bleeding' The cer%i9 is !re!!ed $ith antise!tic solution and, a4ter s!ot inHection o4 a local anesthetic 5eg, , &L o4 chloro!rocaine hydrochloride7, the anterior li! is gras!ed $ith a tenaculu&' A !aracer%ical bloc# is then !laced 54igure +7' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GAnesthesiaG'7

A %acuu& cannula o4 +) to +. && is adeCuate 4or e%acuation at +, to +< $ee#s o4 gestation' /nstru&ents s!eci4ically designed to e9tract intrauterine contents are reCuired a4ter +: to +? $ee#s because the !roducts o4 conce!tion are too large to as!irate through e%en +:-&& cannulas' Ho$e%er, large bore cannulas are use4ul in !rocedures a4ter +: $ee#s to as!irate a&niotic 4luid and !lacenta and to !ull the large 4etal !arts do$n to the lo$er uterine seg&ent 4or e9traction $ith 4orce!s' Cannulas should not be inserted dee!ly into the uterus due to the ris# o4 !er4oration' They are rotated ,:* degrees around their long a9is under %acuu& !ressures o4 <* to :* c& Hg' The authors !re4er either the So!her 5!icture +7 or ierer o%u& 4orce!s, although se%eral other o%u& 4orce!s 5Hern, Cle&etson, Beterson, arrett, Sanger, Moore, Forester, Fan Lith, Telly !lacental 4orce!s7 are a%ailable 4or uterine e%acuation in the second tri&ester' The So!her 4orce!s are inserted such that the hinge is at the le%el o4 the cer%ical canal' Although conco&itant ultrasound guidance is not essential 4or a sa4e and success4ul uterine e%acuation, it o4ten 4acilitates the e%acuation !rocedure, !articularly in !roble&atic cases such as se%ere uterine ante4le9ion or 4ibroids @+<,+:A' 2ltrasound guidance has been sho$n to increase sa4ety @+:A' Blacing a hand on the 4undus o4 the uterus during the !rocedure &ay hel! to decrease the ris# o4 !er4oration $hen the uterus is large and assists $ith assess&ent o4 the changing uterine size and !osition' For the sa&e reason, it is !re4erable to e9!lore the uterus $ith a large curette instead o4 narro$er instru&ents, such as 4orce!s or suction cannula' Curettage 3 Suction curettage is !er4or&ed to e9tract any re&aining tissue a4ter the !roducts o4 conce!tion ha%e been e%acuated' The !hysician &ust e9a&ine the s!eci&en to %eri4y that all !roducts o4 conce!tion ha%e been re&o%ed' The 4etal 4oot length should be recorded to corroborate the esti&ated gestational age 5table +7' Co&!lications o4 e9traction !rocedures 3 Co&!lications are si&ilar to those a4ter 4irst tri&ester suction curettage 5eg, he&orrhage, uterine !er4oration, in4ection, retained !roducts o4 conce!tion7 and are addressed in detail se!arately' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GCo&!licationsG'7 Co&!lications are &ore 4reCuent at later gestational ages in &ost @+?A, but not all, studies @<A' This $as de&onstrated in a re!ort sho$ing the rate o4 un!lanned hos!italizations resulting 4ro& e9traction at +, $ee#s $as *': !ercent, but $as +'. !ercent at )* to )+ $ee#s @+?A' The &orbidity associated $ith e9traction !rocedures is lo$er than that $ith labor induction &ethods @+EA' Ho$e%er, other 4actors need to be considered $hen choosing the best techniCue 4or late second-tri&ester uterine e%acuation' As an e9a&!le, the indication 4or uterine e%acuation &ay be an i&!ortant consideration 5ie, is an intact 4etal s!eci&en i&!ortant 4or diagnosis @+=,)*A7 as $ell as the a%ailability o4 !ersonnel s#illed in !er4or&ing D I E !rocedures' /ntact dilation and e9traction 3 /ntact dilation and e9traction 5DI`7 re4ers to a !rocedure in $hich an assisted breech deli%ery o4 the 4etus is acco&!lished, o4ten under ultrasound guidance, and then the cal%ariu& is deco&!ressed so that the 4etus can be deli%ered intact @++A' Multistage la&inaria insertion beginning t$o days be4ore the !rocedure is used to obtain $ide cer%ical dilation'

An obser%ational study co&!aring +)* intact DI`s at a &edian gestational age o4 ), $ee#s to ):, DIEs at a &edian gestational age o4 )+ $ee#s 4ound si&ilar co&!lication rates and outco&es 4or both !rocedures @)+A' The authors tended to choose DI` $hen the cer%i9 $as $ell dilated 5&ean !reo!erati%e dilation < c&, range ) to +* c&7 at &ore ad%anced gestational ages because they belie%ed this a!!roach &ini&ized the need to use 4orce!s 4or disarticulation and e%acuation and thus !otentially reduced the ris# o4 uterine trau&a' The !rocedures $ere !er4or&ed bet$een "une +==: and "une )**,' 8o&en $ho under$ent either !rocedure 4or reasons other than ad%anced cer%ical dilation or BBR1M had a . !ercent ris# o4 s!ontaneous !reter& birth in the subseCuent !regnancy @))A' /n 0o%e&ber )**,, the 2nited States Congress !assed a bill banning !artial birth abortion 5S' ,-E, +*Eth Congress, First Session7' The bill &a#es it illegal to intentionally !er4or& an act that $ill #ill a !artially deli%ered, li%ing 4etus' A !artially deli%ered 4etus is de4ined as one $hose entire head is outside the &otherGs body 5in %erte9 !resentation7 or in $ho& any !art o4 the 4etal trun# !ast the na%el is outside the &otherGs body 5in breech !resentation7' The ban on intact DI` $as not being en4orced because the constitutionality o4 the la$ $as challenged in 4ederal courts in 0e$ Oor#, 0ebras#a, and San Francisco and $as ruled unconstitutional in all three courts' Ho$e%er, in A!ril )**? the Su!re&e Court u!held the la$, $hich does not contain an e9ce!tion to !er&it the !rocedure $hen the &otherGs li4e is threatened; the broader re!ercussions o4 this ruling are currently un#no$n' The ban does not a!!ly to 4etuses that e9!ire be4ore the e%acuation begins, thus so&e !hysicians choose to e44ect 4etal de&ise be4ore the !rocedure to a%oid cri&inal and ci%il liability' /t also does not a!!ly to standard DIEs in $hich the 4etus is re&o%ed in !ieces' 5See GLeneral issuesG abo%e'7 SOSTEM/C A 1RT/FAC/E0TS 3 Syste&ic aborti4acients 5eg, !rostaglandin E), &iso!rostol7 are usually gi%en intra%aginally; occasionally, they are gi%en intra&uscularly 5carbo!rost tro&etha&ine7' Fetacidal agents are reco&&ended in conHunction $ith these !rocedures to a%oid the !ossibility o4 transient 4etal sur%i%al' 1!tions include intraa&niotic instillation o4 saline 5:* &L o4 a ), !ercent solution7, intracardiac inHection o4 about < &EC !otassiu& chloride, or inHection o4 + to +'< &g digo9in into the 4etus or a&niotic sac @++A' Brostaglandin E) 3 BLE) su!!ositories 5)* &g7 can be used 4or second tri&ester !regnancy ter&ination' A su!!ository is !laced in the !osterior 4orni9 at three to 4i%e hour inter%als until abortion occurs @+A' The dose &ay be adHusted do$n$ard to < &g based u!on a &ore ad%anced gestational age 5&ore sensiti%e to !rostaglandins7, a !ronounced uterotonic res!onse, or undesirable side e44ects' Batients are o4ten !re&edicated $ith aceta&ino!hen, co&!azine, and di!heno9ylate to &ini&ize 4e%er, nausea, %o&iting, and diarrhea, $hich in%ariably occur' The &ean ti&e to abortion is +,'. hours and =* !ercent o4 $o&en abort by ). hours @),A' Bosto!erati%e care is the sa&e as that 4or $o&en undergoing other !regnancy ter&ination !rocedures' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GBosto!erati%e careG and 61%er%ie$ o4 !regnancy ter&ination6, section on GFollo$ u!G'7

/nstead o4 %aginal ad&inistration, a lo$er dose o4 BLE) su!!ositories 5+ to , &g7 &ay be inserted bet$een the 4etal &e&branes and endo&etriu& 5e9tra-a&niotic7 by !assing the %iscous gel through a catheter !laced in this location @).A' This a!!roach &ay result in 4e$er syste&ic side e44ects' /ntra%enous o9ytocin &ay be used conco&itantly $ith BLE) to hasten deli%ery, but !oses additional ris#s o4 hy!ersti&ulation and uterine ru!ture' There4ore, $e reco&&end o9ytocin N2& be ad&inistered until at least t$o hours a4ter the last dose o4 BL' A !lacebo controlled rando&ized Euro!ean trial co&!ared outco&es o4 second tri&ester abortion $ith isosorbide &ononitrate 5/M0, .* &g !er %agina7 !lus ge&e!rost 5+ &g u! to three ti&es daily7 %ersus ge&e!rost alone @)<A' The addition o4 /M0 signi4icantly increased the !ro!ortion o4 e9!ulsions $ithin ). hours 5:E %ersus ,E !ercent7; ho$e%er, the &ean induction to abortion inter%al $as not signi4icantly di44erent 4or the t$o grou!s 5),') and )='= hours, res!ecti%ely7' /n addition, /M0 $as associated $ith a high 4reCuency o4 headache 5+E %ersus * !ercent7' Miso!rostol 3 /n the second tri&ester, the BLE+ analog &iso!rostol is sa4e and e44ecti%e 4or !regnancy ter&ination' Higher doses o4 &iso!rostol are associated $ith increased rates o4 side e44ects and co&!lications 5eg, 4e%er, nausea, %o&iting, diarrhea, uterine ru!ture7' A 4ull discussion o4 &iso!rostol-alone regi&ens can be 4ound se!arately' 5See 6Miso!rostol as a single agent 4or &edical ter&ination o4 !regnancy6'7 Miso!rostol $ith &i4e!ristone 3 Co&bining &iso!rostol $ith &i4e!ristone a!!ears to shorten the induction to deli%ery ti&e @):-,+A' The addition o4 &i4e!ristone &ay also decrease !rocedure-related !ain @,+,,)A' These !oints are illustrated by the 4ollo$ing rando&ized trials(

/n one trial, $o&en undergoing abortion at +E to ), $ee#s o4 gestation $ere treated $ith 4eticidal digo9in, and then rando&ized to recei%e )** &g o4 oral &i4e!ristone or !lacebo; all $o&en then under$ent an oral &iso!rostol regi&en the 4ollo$ing day @,*A' Ti&e 4ro& induction to 4etal e9!ulsion $as signi4icantly shorter 4or $o&en $ho had been !re-treated $ith &i4e!ristone co&!ared $ith those $ho $ere not 5+* %ersus +E hours7' A second trial assigned $o&en at +< to )) $ee#s o4 gestation to recei%e )** &g o4 oral &i4e!ristone or la&inaria; all $o&en then under$ent an oral &iso!rostol regi&en the 4ollo$ing day @,+A' Mean induction-to-deli%ery ti&e $as signi4icantly shorter 4or $o&en $ho had recei%ed &i4e!ristone 5+* %ersus +: hours7' Bain $ith cer%ical ri!ening $as also signi4icantly less in the &i4e!ristone grou!' Fetal de&ise !rior to induction, need 4or !ost!artu& curettage, blood loss, !ain during induction, deli%ery, and at the ti&e o4 discharge $ere not signi4icantly di44erent bet$een the t$o grou!s'

Mi4e!ristone can be ad&inistered orally or %aginally @,,A' An e9a&!le o4 an e44ecti%e regi&en is &i4e!ristone 5)** &g7 ad&inistered ,: to .E hours be4ore &iso!rostol 5E** &cg !er %agina 4ollo$ed by .** &cg orally or intra%aginally e%ery three hours u! to 4our doses7 @)?A' Mi4e!ristone $as licensed 4or the ter&ination o4 !regnancy o4 greater than +, $ee#s in France and S$eden in +==), in the 2nited Tingdo& in +==<, and in nine other Euro!ean countries in +=== @,.A'

Carbo!rost tro&etha&ine 3 Carbo!rost tro&etha&ine is a !rostaglandin si&ilar to BLF) al!ha e9ce!t 4or the addition o4 a &ethyl grou! at the C-+< !osition' This substitution !roduces a longer duration o4 acti%ity' The dose 4or inducing second tri&ester abortion is )<* &cg intra&uscularly to start, )<* &cg at +'< to ,'< hour inter%als de!ending on uterine res!onse; a <** &cg dose &ay be gi%en i4 uterine res!onse is not adeCuate a4ter se%eral )<* &cg doses; the &a9i&u& total dose ad&inistered should not e9ceed +) &g' The &ean ti&e to abortion is +< to +? hours and E* !ercent o4 $o&en abort $ithin ). hours @,<A' High-dose o9ytocin 3 19ytocin at high doses can also be used as an aborti4acient and is associated $ith less 4e%er and 4e$er gastrointestinal side e44ects than !rostaglandins' The initial dose is <* units in <** &L o4 < !ercent de9troseDnor&al saline o%er three hours @,:A' A4ter an hour o4 rest, the in4usion is re!eated using :* units o4 o9ytocin' This regi&en is continued u! to a &a9i&u& o4 ,** units o9ytocin in <** &L solution 5ie, +::? &2D&in7' Co&!lications 3 Ter&ination o4 !regnancy using syste&ic aborti4acients is associated $ith the sa&e co&!lications as 4or e9traction !rocedures 5see 61%er%ie$ o4 !regnancy ter&ination6, section on GCo&!licationsG7' The ris# o4 co&!lications increases $ith the length o4 the 6third stage6' As an e9a&!le, one series re!orted the co&!lication rate 5he&orrhage or in4ection7 at ,*, :*, and +)* &inutes a4ter 4etal e9!ulsion $as .'), <'), and =', !ercent, res!ecti%ely @,?A' 2se o4 syste&ic aborti4acients &ay also be associated $ith co&!lications such as retained !lacenta and uterine ru!ture' Retained !lacenta 3 A co&&on guideline is that the !lacenta should be e9!elled $ithin ,* to +)* &inutes o4 e9!ulsion o4 the 4etus' A longer !eriod o4 e9!ectant &anage&ent is not necessarily har&4ul, but the &ain bene4it a!!ears to be a%oiding instru&entation' /n a retros!ecti%e study o4 second tri&ester &iso!rostol induction ter&inations, no increased &orbidity $as obser%ed $ith e9!ectant &anage&ent o4 a retained !lacenta u! to 4our hours a4ter 4etal e9!ulsion @,+A' /4 !lacental e9!ulsion is delayed, then the !lacenta can be re&o%ed by suction curettage @,EA' 2terine ru!ture 3 2terine ru!ture 4ro& second tri&ester induction 4or !regnancy ter&ination has been described in case re!orts' 8o&en $ith a scarred uterus 5eg, !re%ious cesarean deli%ery7 are at highest ris# @,=A; other !ur!orted ris# 4actors include grand &ulti!arity and nulli!arity $ith insu44iciently ri!ened cer%i9' Ho$e%er, &ost $o&en $ith a !re%ious hysteroto&y can sa4ely undergo &idtri&ester !regnancy ter&ination @.*A' /0TRA2TER/0E /0ST/LLAT/10 1F A 1RT/FAC/E0T ALE0TS 3 /nstillation o4 aborti4acient agents $as, at one ti&e, a co&&on &ethod 4or second tri&ester !regnancy ter&ination' These techniCues ha%e been largely abandoned due to de%elo!&ent o4 sa4e and e44ecti%e syste&ic agents and o!erati%e techniCues 5discussed abo%e7' Surgical e9traction, !ro%ided the surgeon is e9!erienced $ith second tri&ester abortion techniCues, has a lo$er rate o4 co&!lications be4ore +: to )* $ee#s o4 gestation than intraa&niotic instillation &ethods and ti&e to abortion is &uch 4aster @,,<,+?A' Hy!ertonic agents in4used into the intraa&niotic ca%ity or e9trao%ular s!ace 5ie, bet$een the a&niotic &e&branes and uterine $all7 induce contractions leading to e%acuation o4 uterine contents' The t$o &aHor agents e&!loyed are BLF) al!ha and

hy!ertonic saline' BLF) al!ha has the ad%antage o4 s!eed, but the 4etus &ay be born ali%e and &aternal side e44ects 5eg, %o&iting, diarrhea, inco&!lete abortion7 are co&&on @+A; hy!ertonic saline has the ad%antage o4 causing 4etal death, but the duration o4 the !rocedure can be long and it can cause hy!ernatre&ia, coagulo!athy, and %olu&e o%erload' BLF) al!ha is a%ailable as carbo!rost tro&etha&ine 5He&abate7 @++A' Hy!ertonic urea 5E* to =* g7 is an alternati%e agent, but it has a %ery long in4usion to deli%ery inter%al and there4ore is rarely used' Saline in4usion 3 1s&otic dilators should be !laced at least +) hours !rior to the !rocedure to 4acilitate cer%ical dilation and shorten the in4usion to abortion ti&e' /n addition, use o4 la&inaria or other &aterials to dilate the cer%i9 !rior to instillation o4 aborti4acients 4acilitates e9!ulsion, and &ay !re%ent deli%ery through the lo$er uterine seg&ent in !ri&i!arous 4e&ales' A4ter the $o&an e&!ties her bladder, an +E gauge s!inal needle is inserted into the a&niotic ca%ity @+A' The location is con4ir&ed by $ithdra$ing a s&all a&ount o4 a&niotic 4luid' This is i&!ortant to a%oid intra%ascular or intra&yo&etrial in4usion o4 the hy!ertonic saline, $hich can result in li4e-threatening hy!ernatre&ia, &yo&etrial necrosis, or disse&inated intra%ascular coagulation' T$o hundred &illiliters o4 )* !ercent saline solution 5.* gra&s7 are in4used by gra%ity and the needle re&o%ed' Brostaglandin F) al!ha in4usion 3 The !rocedure is the sa&e as that described abo%e 4or hy!ertonic saline, e9ce!t )'< to < &g BLF) al!ha is in4used as a test dose, 4ollo$ed by +?'< to ,< &g i4 the test dose is tolerated' 1ne-Cuarter o4 $o&en $ill reCuire a second inHection to &aintain labor and co&!lete the !rocedure' Alternati%ely, carbo!rost tro&etha&ine 5) &g7 can be instilled' Co&bined !rostaglandin F) al!ha and hy!ertonic saline in4usion 3 The co&bination o4 these t$o drugs ser%es to hasten the induction to deli%ery inter%al, ensure death o4 the 4etus, and has 4e$ side e44ects' The o!ti&al dose is +'< &g o4 +<-&ethyl-BLF) al!ha and :. to +** &L o4 ),'. !ercent saline' The a%erage ti&e to abortion is eight hours' Barenteral ad&inistration &ust be a%oided because these agents can cause cardiac arrhyth&ias, bronchos!as&, !ul&onary hy!ertension, and hy!o9e&ia' /ntra%enous o9ytocin &ay be used conco&itantly $ith either drug to hasten deli%ery, but !oses additional ris#s, such as hy!ersti&ulation and uterine ru!ture' There4ore, o9ytocin should not be ad&inistered until at least t$o hours a4ter the last dose o4 !rostaglandin' The !lacenta o4ten 4ails to be e9!elled along $ith the second tri&ester 4etus' 19ytocin can be used sa4ely a4ter 4etal deli%ery to hel! $ith !lacental e9!ulsion, but re&o%al $ith 4orce!s and suction curettage is reco&&ended as $ell @.+A' Lentle e9!loration o4 the uterus $ith a large curette is also reco&&ended to &a#e sure !lacental 4rag&ents ha%e not been retained' Contraindications 3 Brostaglandin F) al!ha should not be used in $o&en $ith asth&a, e!ile!sy, glauco&a, !ul&onary hy!ertension, or hy!ertension @.+A' Hy!ertonic saline should be a%oided in $o&en $ho cannot tolerate a saline load and those $ith an intrauterine 4etal de&ise, because o4 the increased !otential 4or coagulo!athy' Bosto!erati%e issues 3 Bosto!erati%e care and &onitoring is the sa&e as that 4or $o&en undergoing other !regnancy ter&ination !rocedures' The ris# o4 !er4oration is

less $ith instillation !rocedures, although o%erall co&!lication rates 4ro& 4e%er, endo&etritis, retained !roducts o4 conce!tion, he&orrhage, and cer%ical inHury reCuiring re!air are the sa&e or higher than those 4or e9traction !rocedures @.)A' 5See 61%er%ie$ o4 !regnancy ter&ination6, section on GCo&!licationsG and 61%er%ie$ o4 !regnancy ter&ination6, section on GBosto!erati%e careG and 61%er%ie$ o4 !regnancy ter&ination6, section on GFollo$ u!G'7 CH1/CE 1F TECH0/b2E 3 The !ri&ary 4actors in choosing a !articular techniCue 4or !regnancy ter&ination are the %olu&e and content o4 intrauterine tissue, the e9!erience o4 the surgeon, and !atient !re4erence' So&e studies suggest bene4it 4or DIE co&!ared to induction techniCues $hen !regnancy ter&ination or uterine e%acuation is !er4or&ed 4or 4etal indications or 4etal death @:,?A' Ho$e%er, both studies $ere underta#en in centers $ith surgeons e9!erienced in !er4or&ing second tri&ester DIE' Li#e$ise, an earlier study 4ound DIE to be sa4er than, and !re4erable to, labor induction techniCues' A rando&ized trial o4 +)) $o&en undergoing ter&ination at +, to )* $ee#s o4 gestation co&!ared &edical 5&i4e!ristone and &iso!rostol7 and surgical e%acuation !rocedures @.,A' 8o&en $ho under$ent surgical ter&ination had signi4icantly less bleeding 5. %ersus ,? !ercent had bleeding greater than &enses7' Fe$er $o&en in the surgical grou! had &oderate or se%ere !ain 5), %ersus ., !ercent had &oderate or se%ere !ain7, but this did not reach statistical signi4icance due to insu44icient statistical !o$er' 8o&en in the surgical grou! 4ound the !rocedure &ore acce!table; &ore re!orted that they $ould choose the sa&e !rocedure again 5+** %ersus <, !ercent7 and 4e$er 4ound the e9!erience to be $orse than e9!ected 5* %ersus <, !ercent7' Further co&!arati%e data are needed' Surgical 3 Dilation and e%acuation 5DIE7 !rocedures reCuire the least a&ount o4 ti&e and can be !er4or&ed in a uterus o4 al&ost any size 4or re&o%al o4 &ost ty!es o4 intrauterine contents 5eg, !lacenta, &olar tissue, 4etal tissue7' The !atient does not e9!erience labor, $hich &ost $o&en consider a bene4it o4 DIE, and the 4etus $ill not be born ali%e, $hich is i&!ortant &edicolegally' There are 4e$er drug-related side-e44ects $ith DIE than $ith nonsurgical abortion; ho$e%er, there is a s&all ris# o4 o!erati%e co&!lications, such as uterine !er4oration, and the 4etus is not deli%ered intact, $hich can be i&!ortant i4 the ter&ination $as done because o4 a 4etal abnor&ality' /n t$o s&all rando&ized trials, dilation and e%acuation resulted in signi4icantly 4e$er co&!lications than either syste&ic use o4 &i4e!ristone $ith %aginal &iso!rostol or intrauterine usage o4 !rostaglandin F) al!ha @..A' For these reasons, DIE is the !re4erred &ethod o4 second tri&ester ter&ination $hen highly e9!erienced !ersonnel are a%ailable and auto!sy o4 an intact 4etus is not i&!ortant 4or counseling @+EA' 0onsurgical 3 0onsurgical techniCues 4or uterine e%acuation in%ol%e labor induction using syste&ic 5eg, intra%aginal or oral !rostaglandins7 or intraa&niotic 5eg, saline, !rostaglandin F) al!ha, urea7 aborti4acients' Although use o4 aborti4acients does not reCuire a s#illed o!erator, !hysicians $ho use nonsurgical &ethods &ust be !re!ared to e&!loy surgical techniCues o4 uterine e%acuation $hen there are retained !roducts o4 conce!tion, a co&&on occurrence 4ollo$ing labor induction &ethods'

There are no data 4ro& large rando&ized trials co&!aring a %ariety o4 &edical a!!roaches on $hich to &a#e a reco&&endation 4or one regi&en o%er another' The 4e$ rando&ized studies $hich are a%ailable are di44icult to co&!are because o4 di44erences in the drug regi&ens e&!loyed' ased u!on the !receding discussion, %aginal &iso!rostol 5.** &cg e%ery 4our hours u! to si9 doses7 a!!ears to be the !re4erred a!!roach because(

Miso!rostol is signi4icantly less e9!ensi%e than %aginal !rostaglandins and is as or &ore e44ecti%e than these agents' 5See 6Miso!rostol as a single agent 4or &edical ter&ination o4 !regnancy6, section on GMiso!rostol %ersus other !rostaglandinsG'7 Miso!rostol is &ore acce!table to $o&en and is as or &ore e44ecti%e than intrauterine instillation o4 !rostaglandin F) al!ha @.<-.EA' /n so&e trials, &iso!rostol had a shorter induction to deli%ery inter%al and 4e$er side e44ects than !rostaglandin F) al!ha' Ho$e%er, &iso!rostol results in &ore li%e births 5)* %ersus < !ercent7 @.<A'

Saline in4usion and urea in4usion act &uch &ore slo$ly than other techniCues @.=,<*A; these &odalities are no longer used alone' HOSTER1T1MO A0D HOSTERECT1MO 3 Hysteroto&y and hysterecto&y ha%e essentially been abandoned as techniCues 4or uterine e%acuation because o4 high rates o4 associated &aternal &orbidity and &ortality and the ready a%ailability o4 less in%asi%e techniCues @<+A' Hysteroto&y is no$ Husti4ied only in rare cases in $hich syste&ic aborti4acients ha%e 4ailed to ter&inate the !regnancy and no !hysician s#illed in !er4or&ing second-tri&ester e9traction !rocedures is a%ailable' Hysterecto&y &ay be Husti4ied in %ery rare instances $hen the need 4or ter&ination is acco&!anied by cer%ical, uterine, or o%arian !athology 5eg, cancer7 reCuiring uterine e9cision' SBEC/AL CASES Fetal de&ise 3 The uterine e%acuation !rocedure and !osto!erati%e care !ro%ided to $o&en carrying a non%iable e&bryo or 4etus is si&ilar to that 4or $o&en undergoing 4irst or second tri&ester !regnancy ter&ination' The ty!e o4 !rocedure is deter&ined by the esti&ated gestational size as deter&ined by &enstrual history, bi&anual !el%ic e9a&ination, and ultrasonogra!hic &easure&ents' The !atientGs 4ibrinogen concentration should be deter&ined to detect a !otential coagulo!athic state de%elo!ing 4ro& retention o4 a non%iable 4etus, $hich is &ost co&&on a4ter )* $ee#s o4 gestation and at &ore than si9 $ee#s 4ro& the actual 4etal death' 5See 6Bathogenesis and etiology o4 disse&inated intra%ascular coagulation6, section on G1bstetrical co&!licationsG'7 Manage&ent o4 late 4etal de&ise 5o%er ). to )E $ee#s7 is re%ie$ed se!arately' 5See 6/ncidence, etiology, and !re%ention o4 stillbirth6'7 Fetal abnor&alities 3 Ter&ination o4 !regnancies a4ter detection o4 congenital abnor&alities has the added concern o4 con4ir&ing the !renatal diagnoses and obtaining any additional in4or&ation about 4etal &alde%elo!&ent' Success4ul and consistent con4ir&ation o4 !renatal diagnostic results by e%aluation o4 !roducts o4 conce!tion obtained by second-tri&ester dilation and e%acuation is !ossible @<)-<.A, although reco%ery o4 an intact 4etus &ay occasionally be reCuired to con4ir& a s!eci4ic !renatal

diagnosis' /n one study, the additional in4or&ation !ro%ided by auto!sy changed the esti&ated ris# o4 recurrence in )? !ercent o4 cases characterized by structural ano&alies and !ossible syndro&es @<<A' Maternal grie4Dde!ression &easured by standard instru&ents a!!ears to be the sa&e regardless o4 the &ethod o4 !regnancy ter&ination 5induction %ersus e9traction7 @<:A, although &ost $o&en undergoing these !rocedures do so in a situation o4 a desired, or e%en highly sought a4ter, !regnancy, in $hich the detection o4 a 4etal abnor&ality resulted in the decision to not continue the !regnancy' Hydatidi4or& &ole 3 2terine e%acuation 4ollo$ing detection o4 hydatidi4or& &ole 5ie, gestational tro!hoblastic disease7 should be !er4or&ed $ithin a hos!ital' /ntra%enous o9ytocin should be started be4ore induction o4 anesthesia to !re%ent e9cessi%e he&orrhage during and i&&ediately 4ollo$ing the !rocedure' leeding &ay be hea%y as the cer%i9 is &anually dilated, but usually subsides $ithin a 4e$ &inutes o4 suction curettage' These !atients are also at ris# 4or hy!erthyroidis&, thyroid stor&, and tro!hoblastic e&bolization, $hich can lead to 4ull blo$n acute res!iratory distress syndro&e' They are best &anaged by !hysicians 4a&iliar $ith the &ulti!le unco&&on, but signi4icant, !roble&s that can arise' Bost-e%acuation 4ollo$-u! o4 beta-hCL titers is critical in these !atients' 5See 6Lestational tro!hoblastic neo!lasia( Staging and treat&ent6'7 Blacenta !re%ia and !re%ious cesarean deli%ery 3 Blacenta !re%ia is not a contraindication to !regnancy ter&ination through the cer%i9, although data are scanty' Bre%ious cesarean deli%ery is also not associated $ith increased ris# 4ro& use o4 la&inaria or DIE @<?A' Ho$e%er, in $o&en $ith ad%anced gestational age, &ulti!le !rior cesareans and anterior !lacentation, the diagnosis o4 accreta should be considered and s!ecial !recautions ta#en in case o4 he&orrhage' There are 4e$ data regarding the sa4ety o4 &iso!rostol 5or other !rostaglandins7 4or second tri&ester !regnancy ter&ination in $o&en $ith !re%ious cesarean deli%eries' 5See 6Miso!rostol as a single agent 4or &edical ter&ination o4 !regnancy6, section on GRis# 4actors 4or uterine ru!tureG'7 /0F1RMAT/10 F1R BAT/E0TS 3 2!ToDate o44ers t$o ty!es o4 !atient education &aterials, MThe asicsN and M eyond the asics'N The asics !atient education !ieces are $ritten in !lain language, at the <th to :th grade reading le%el, and they ans$er the 4our or 4i%e #ey Cuestions a !atient &ight ha%e about a gi%en condition' These articles are best 4or !atients $ho $ant a general o%er%ie$ and $ho !re4er short, easy-to-read &aterials' eyond the asics !atient education !ieces are longer, &ore so!histicated, and &ore detailed' These articles are $ritten at the +*th to +)th grade reading le%el and are best 4or !atients $ho $ant in-de!th in4or&ation and are co&4ortable $ith so&e &edical Hargon' Here are the !atient education articles that are rele%ant to this to!ic' 8e encourage you to !rint or e-&ail these to!ics to your !atients' 5Oou can also locate !atient education articles on a %ariety o4 subHects by searching on M!atient in4oN and the #ey$ord5s7 o4 interest'7

eyond the asics to!ics 5see 6Batient in4or&ation( Abortion 5!regnancy ter&ination7 5 eyond the asics767

S2MMARO A0D REC1MME0DAT/10S E9traction

E9traction is the &ost co&&on techniCue used 4or second-tri&ester !regnancy ter&ination in the 2nited States' 5See GDilation and e9tractionG abo%e'7 E9traction !rocedures reCuire the least a&ount o4 ti&e and can be !er4or&ed in a uterus o4 al&ost any size 4or re&o%al o4 &ost ty!es o4 intrauterine contents 5eg, !lacenta, &olar tissue, 4etal tissue7' The !atient does not e9!erience labor, $hich &ost $o&en consider a bene4it o4 DIE, and the 4etus $ill not be born ali%e, $hich is i&!ortant &edicolegally' There are 4e$er drug-related sidee44ects $ith DIE than $ith nonsurgical abortion; ho$e%er, there is a s&all ris# o4 o!erati%e co&!lications, such as uterine !er4oration, and the 4etus is not deli%ered intact, $hich can be i&!ortant i4 the ter&ination $as done because o4 a 4etal abnor&ality' For these reasons, DIE is the !re4erred &ethod o4 second tri&ester ter&ination $hen highly e9!erienced !ersonnel are a%ailable and auto!sy o4 an intact 4etus is not i&!ortant 4or counseling' 5See GChoice o4 techniCueG abo%e'7 Cer%ical dilation $ith &ulti!le os&otic dilators is reco&&ended !rior to second tri&ester !regnancy ter&ination to !re%ent cer%ical laceration' 5See GCer%ical !re!arationG abo%e'7 A %acuu& cannula o4 +) to +. && is adeCuate 4or e%acuation at +, to +< $ee#s o4 gestation' /nstru&ents s!eci4ically designed to e9tract intrauterine contents are reCuired a4ter +: to +? $ee#s because the !roducts o4 conce!tion are too large to as!irate through e%en +:-&& cannulas' 5See GE%acuationG abo%e'7

Syste&ic aborti4acients

Although use o4 aborti4acients does not reCuire a s#illed o!erator, !hysicians $ho use nonsurgical &ethods &ust be !re!ared to e&!loy surgical techniCues o4 uterine e%acuation $hen there are retained !roducts o4 conce!tion, a co&&on occurrence 4ollo$ing labor induction &ethods' 5See GSyste&ic aborti4acientsG abo%e'7 /ntraa&niotic instillation o4 saline 5:* &L o4 a ), !ercent solution7, 4etal intracardiac inHection o4 about < &EC !otassiu& chloride, or inHection o4 + to +'< &g digo9in into the 4etus or a&niotic sac is suggested to insure 4eticide' 5See GSyste&ic aborti4acientsG abo%e'7 /n $o&en undergoing !regnancy ter&ination, $e reco&&end &iso!rostol o%er ge&e!rost 5Lrade +A7' 5See 6Miso!rostol as a single agent 4or &edical ter&ination o4 !regnancy6 and GMiso!rostolG abo%e'76 and 5see GChoice o4 techniCueG abo%e7' Brostaglandin E) su!!ositories 5)* &g !er %agina& e%ery three to 4i%e hours7 are an alternati%e' The dose should be adHusted do$n to < &g based u!on a &ore ad%anced gestational age 5&ore sensiti%e to !rostaglandins7, a !ronounced uterotonic res!onse, or undesirable side e44ects' 5See GBrostaglandin E)G abo%e'7 Carbo!rost tro&etha&ine and high dose o9ytocin are also acce!table syste&ic aborti4acients 4or second tri&ester !rocedures' 5See GCarbo!rost tro&etha&ineG abo%e and GHigh-dose o9ytocinG abo%e'7

/ntrauterine instillation 3 /nstillation o4 aborti4acient agents has largely been abandoned due to de%elo!&ent o4 sa4e and e44ecti%e syste&ic agents and o!erati%e techniCues' 5See G/ntrauterine instillation o4 aborti4acient agentsG abo%e'7 2se o4 2!ToDate is subHect to the Subscri!tion and License Agree&ent'

REFERENCES
+' A&erican College o4 1bstetricians and Lynecologists' Methods o4 &idtri&ester abortion' AC1L technical bulletin f+*=' A&erican College o4 1bstetricians and Lynecologists, 8ashington, DC +=E?' )' Stubble4ield, BL' Bregnancy ter&ination' !' +,*,' /n( 1bstetrics( 0or&al and Broble& Bregnancies, )nd ed, Labbe, SL, 0iebyl, "R, Si&!son, "L 5eds7, Churchill Li%ingstone, 0e$ Oor# +==+' ,' Ta4rissen ME, Schulz TF, Lri&es DA, Cates 8 "r' Midtri&ester abortion' /ntraa&niotic instillation o4 hy!eros&olar urea and !rostaglandin F) al!ha % dilatation and e%acuation' "AMA +=E.; )<+(=+:' .' Robins ", Surrago E"' Early &idtri&ester !regnancy ter&ination' A co&!arison o4 dilatation and e%acuation and intra%aginal !rostaglandin E)' " Re!rod Med +=E); )?(.+<' <' Lri&es DA, Schulz TF, Cates 8 "r, Tyler C8 "r' Mid-tri&ester abortion by dilatation and e%acuation( a sa4e and !ractical alternati%e' 0 Engl " Med +=??; )=:(++.+' :' ryant AL, Lri&es DA, Larrett "M, Stuart LS' Second-tri&ester abortion 4or 4etal ano&alies or 4etal death( labor induction co&!ared $ith dilation and e%acuation' 1bstet Lynecol )*++; ++?(?EE' ?' Edlo$ AL, Hou MO, Maurer R, et al' 2terine e%acuation 4or second-tri&ester 4etal death and &aternal &orbidity' 1bstet Lynecol )*++; ++?(,*?' E' Lri&es DA, Hul#a "F, McCutchen ME' Midtri&ester abortion by dilatation and e%acuation %ersus intra-a&niotic instillation o4 !rostaglandin F) al!ha( a rando&ized clinical trial' A& " 1bstet Lynecol +=E*; +,?(?E<' =' Taltreider 0 , Lolds&ith S, Margolis A"' The i&!act o4 &idtri&ester abortion techniCues on !atients and sta44' A& " 1bstet Lynecol +=?=; +,<(),<' +*' Co$ett AA, Lolub RM, Lrob&an 8A' Cost-e44ecti%eness o4 dilation and e%acuation %ersus the induction o4 labor 4or second-tri&ester !regnancy ter&ination' A& " 1bstet Lynecol )**:; +=.(?:E' ++' Stubble4ield BL, Carr-Ellis S, orgatta L' Methods 4or induced abortion' 1bstet Lynecol )**.; +*.(+?.' +)' Molaei M, "ones HE, 8eiselberg T, et al' E44ecti%eness and sa4ety o4 digo9in to induce 4etal de&ise !rior to second-tri&ester abortion' Contrace!tion )**E; ??()),' +,' Co#e LA, aschat AA, Mighty HE, Malino$ AM' Maternal cardiac arrest associated $ith atte&!ted 4etal inHection o4 !otassiu& chloride' /nt " 1bstet Anesth )**.; +,()E?' +.' Schulz TF, Lri&es DA, Cates 8 "r' Measures to !re%ent cer%ical inHury during suction curettage abortion' Lancet +=E,; +(++E)' +<' Hornstein MD, 1sathanondh R, irnholz "C, et al' 2ltrasound guidance 4or selected dilatation and e%acuation !rocedures' " Re!rod Med +=E:; ,+(=.?'

+:' Darney BD, S$eet RL' Routine intrao!erati%e ultrasonogra!hy 4or second tri&ester abortion reduces incidence o4 uterine !er4oration' " 2ltrasound Med +=E=; E(?+' +?' Beterson 8F, erry F0, Lrace MR, Lulbranson CL' Second-tri&ester abortion by dilatation and e%acuation( an analysis o4 ++,?.? cases' 1bstet Lynecol +=E,; :)(+E<' +E' Autry AM, Hayes EC, "acobson LF, Tirby RS' A co&!arison o4 &edical induction and dilation and e%acuation 4or second-tri&ester abortion' A& " 1bstet Lynecol )**); +E?(,=,' +=' Rayburn 8F, La4erla ""' Mid-gestational abortion 4or &edical or genetic indications' Clin 1bstet Lynaecol +=E:; +,(?+' )*' "ac#son LL, Pachary "M, Fo$ler SE, et al' A rando&ized co&!arison o4 transcer%ical and transabdo&inal chorionic-%illus sa&!ling' The 2'S' 0ational /nstitute o4 Child Health and Hu&an De%elo!&ent Chorionic-Fillus Sa&!ling and A&niocentesis Study Lrou!' 0 Engl " Med +==); ,)?(<=.' )+' Chasen ST, Talish R , Lu!ta M, et al' Dilation and e%acuation at ]orK)* $ee#s( co&!arison o4 o!erati%e techniCues' A& " 1bstet Lynecol )**.; +=*(++E*' ))' Chasen ST, Talish R , Lu!ta M, et al' 1bstetric outco&es a4ter surgical abortion at ] or K )* $ee#sG gestation' A& " 1bstet Lynecol )**<; +=,(++:+' ),' Surrago E", Robins "' Midtri&ester !regnancy ter&ination by intra%aginal ad&inistration o4 !rostaglandin E)' Contrace!tion +=E); ):()E<' ).' Mac#enzie /P, E&brey MB' Single e9tra-a&niotic inHection o4 !rostaglandins in %iscous gel to induce abortion' r " 1bstet Lynaecol +=?:; E,(<*<' )<' E!!el 8, Facchinetti F, Schleussner E, et al' Second tri&ester abortion using isosorbide &ononitrate in addition to ge&e!rost co&!ared $ith ge&e!rost alone( a double-blind rando&ized, !lacebo-controlled &ulticenter trial' A& " 1bstet Lynecol )**<; +=)(E<:' ):' Loldberg A , Lreenberg M , Darney BD' Miso!rostol and !regnancy' 0 Engl " Med )**+; ,..(,E' )?' Tang 1S, Thong T", aird DT' Second tri&ester &edical abortion $ith &i4e!ristone and ge&e!rost( a re%ie$ o4 =<: cases' Contrace!tion )**+; :.()=' )E' Asho# B8, Te&!leton A, 8agaarachchi BT, Flett LM' Midtri&ester &edical ter&ination o4 !regnancy( a re%ie$ o4 +**) consecuti%e cases' Contrace!tion )**.; :=(<+' )=' artley ", aird DT' A rando&ised study o4 &iso!rostol and ge&e!rost in co&bination $ith &i4e!ristone 4or induction o4 abortion in the second tri&ester o4 !regnancy' "1L )**); +*=(+)=*' ,*' Ta!! 0, orgatta L, Stubble4ield B, et al' Mi4e!ristone in second-tri&ester &edical abortion( a rando&ized controlled trial' 1bstet Lynecol )**?; ++*(+,*.' ,+' Lreen ", orgatta L, Sia M, et al' /nter%ention rates 4or !lacental re&o%al 4ollo$ing induction abortion $ith &iso!rostol' Contrace!tion )**?; ?:(,+*' ,)' S!itz /M, ardin C8' Clinical !har&acology o4 R2 .E:--an anti!rogestin and antiglucocorticoid' Contrace!tion +==,; .E(.*,' ,,' 0gai S8, Tang 1S, Ho BC' Rando&ized co&!arison o4 %aginal 5)** &icrog e%ery , h7 and oral 5.** &icrog e%ery , h7 &iso!rostol $hen co&bined $ith &i4e!ristone in ter&ination o4 second tri&ester !regnancy' Hu& Re!rod )***; +<())*<' ,.' Sitru#-8are, R, !ersonal co&&unication'

,<' Robins ", Mann L/' Midtri&ester !regnancy ter&ination by intra&uscular inHection o4 a +<-&ethyl analogue o4 !rostaglandin F) al!ha' A& " 1bstet Lynecol +=?<; +),(:)<' ,:' 8in#ler CL, Lray SE, Hauth "C, et al' Mid-second-tri&ester labor induction( concentrated o9ytocin co&!ared $ith !rostaglandin E) %aginal su!!ositories' 1bstet Lynecol +==+; ??()=?' ,?' Castadot RL' Bregnancy ter&ination( techniCues, ris#s, and co&!lications and their &anage&ent' Fertil Steril +=E:; .<(<' ,E' Tirz DS, Haag MT' Manage&ent o4 the third stage o4 labor in !regnancies ter&inated by !rostaglandin E)' A& " 1bstet Lynecol +=E=; +:*(.+)' ,=' Cha!&an S", Cris!ens M, 1$en ", Sa%age T' Co&!lications o4 &idtri&ester !regnancy ter&ination( the e44ect o4 !rior cesarean deli%ery' A& " 1bstet Lynecol +==:; +?<(EE=' .*' Dic#inson "E' Miso!rostol 4or second-tri&ester !regnancy ter&ination in $o&en $ith a !rior cesarean deli%ery' 1bstet Lynecol )**<; +*<(,<)' .+' Hern, 8M' Abortion !ractice' " Li!!incott, Bhiladel!hia, BA +=E.' .)' Centers 4or Disease Control' Abortion sur%eillance +=E+' Atlanta, LA +=E<' .,' Telly T, Suddes ", Ho$el D, et al' Co&!aring &edical %ersus surgical ter&ination o4 !regnancy at +,-)* $ee#s o4 gestation( a rando&ised controlled trial' "1L )*+*; ++?(+<+)' ..' Lohr BA, Hayes "L, Le&zell-Danielsson T' Surgical %ersus &edical &ethods 4or second tri&ester induced abortion' Cochrane Database Syst Re% )**E; (CD**:?+.' .<' A#oury HA, Hannah ME, Chitayat D, et al' Rando&ized controlled trial o4 &iso!rostol 4or second-tri&ester !regnancy ter&ination associated $ith 4etal &al4or&ation' A& " 1bstet Lynecol )**.; +=*(?<<' .:' Baz , 1hel L, Tal T, et al' Second tri&ester abortion by la&inaria 4ollo$ed by %aginal &iso!rostol or intrauterine !rostaglandin F)al!ha( a rando&ized trial' Contrace!tion )**); :<(.++' .?' Munthali ", Moodley "' The use o4 &iso!rostol 4or &id-tri&ester thera!eutic ter&ination o4 !regnancy' Tro! Doct )**+; ,+(+<?' .E' Su LL, is$as A, Choolani M, et al' A !ros!ecti%e, rando&ized co&!arison o4 %aginal &iso!rostol %ersus intra-a&niotic !rostaglandins 4or &idtri&ester ter&ination o4 !regnancy' A& " 1bstet Lynecol )**<; +=,(+.+*' .=' Co&!arison o4 intra-a&niotic !rostaglandin F) al!ha and hy!ertonic saline 4or induction o4 second-tri&ester abortion' r Med " +=?:; +(+,?,' <*' Ragab M/, Edel&an DA' Midtri&ester abortion( a co&!arison o4 intraa&niotic !rostaglandin F)al!ha and hy!ertonic saline' /nt " Lynaecol 1bstet +=?:; +.(,=,' <+' DeCherney AH, Sch$arz RH, Drobney H' /n4ection as a co&!lication o4 thera!eutic abortion' Ba Med +=?); ?<(.=' <)' Shul&an LB, Ling F8, Meyers CM, et al' Dilatation and e%acuation is a !re4erable &ethod 4or &id-tri&ester genetic ter&ination o4 !regnancy' Brenat Diagn +=E=; =(?.+' <,' Shul&an LB, Ling F8, Meyers CM, et al' Dilation and e%acuation 4or secondtri&ester genetic !regnancy ter&ination' 1bstet Lynecol +==*; ?<(+*,?' <.' Shul&an, LB, Ling, F8, Meyers, CM, et al' Dilation and e%acuation 4or secondtri&ester genetic !regnancy ter&ination( u!date on a reliable and !re4erable &ethod' A& " Lyn Health +==+; <(,*'

<<' oyd BA, Tondi F, Hic#s 0R, Cha&berlain BF' Auto!sy a4ter ter&ination o4 !regnancy 4or 4etal ano&aly( retros!ecti%e cohort study' M" )**.; ,)E(+,?' <:' urgoine LA, Fan Tir# SD, Ro&& ", et al' Co&!arison o4 !erinatal grie4 a4ter dilation and e%acuation or labor induction in second tri&ester ter&inations 4or 4etal ano&alies' A& " 1bstet Lynecol )**<; +=)(+=)E' <?' Schneider D, u#o%s#y /, Cas!i E' Sa4ety o4 &idtri&ester !regnancy ter&ination by la&inaria and e%acuation in !atients $ith !re%ious cesarean section' A& " 1bstet Lynecol +==.; +?+(<<.'

2vervie/ of pregnan!y termination

Literature re%ie$ current through( Se! )*+,' - This to!ic last u!dated( se! ++, )*+,' /0TR1D2CT/10 3 2terine e%acuation is an integral !art o4 obstetric and gynecologic care, not only 4or electi%e !regnancy ter&ination, but also in the &anage&ent o4 s!ontaneous abortion, intrauterine 4etal de&ise, retained !roducts o4 conce!tion, and gestational tro!hoblastic neo!lasia' The choice o4 techniCue 4or uterine e%acuation de!ends &ore u!on uterine %olu&e and o!erator e9!erience than the underlying indication 4or the !rocedure' /ssues co&&on to both 4irst and second tri&ester !regnancy ter&ination $ill be re%ie$ed here' TechniCues 4or 4irst and second tri&ester !rocedures are discussed se!arately' 5See 6Surgical ter&ination o4 !regnancy( First tri&ester6 and 6Ter&ination o4 !regnancy( Second tri&ester6'7 /0C/DE0CE A0D EB/DEM/1L1LO 3 According to the Centers 4or Disease Control 5CDC7, the rate o4 !regnancy ter&ination in the 2nited States 52S7 in )**E $as +: !er +*** $o&en aged +< to .. years, or ),. !er +*** li%e births; there $as a . !ercent decrease in the rate o4 abortions 4ro& +=== @+A' The CDC 4igures are based u!on data %oluntarily re!orted to state health agencies and are inco&!lete' The Alan Lutt&acher /nstitute, $hich sur%eys all #no$n abortion !ro%iders, re!orted a rate o4 += abortions !er +*** $o&en in )**E @)A' The esti&ated $orld$ide rate 4or abortion in )**E $as )E !er +*** $o&en ages +< to .. @,A; the highest rate $as in Eastern Euro!e 5., !er +***7 and the lo$est rate $as in 8estern Euro!e 5+) !er +***7' Forty-nine !ercent o4 abortions $ere classi4ied as 6unsa4e6 5generally re4erring to illegal !rocedures7, co&!ared $ith .< !ercent in +==<' 2nsa4e abortions occurred &ostly in de%elo!ing countries; the rate o4 unsa4e abortion in A4rica $as =? !ercent and in south central Asia $as :< !ercent' /n the 2nited States in )**E, there $ere :'. &illion !regnancies a&ong :) &illion $o&en' Fi4ty !ercent o4 !regnancies $ere unintended and += !ercent o4 !regnancies resulted in !regnancy ter&ination @)A' /n the England in )*+*, there $ere ))<,:** unintended !regnancies and +<<,<** induced abortions @.A' Abortion rates $ere highest in $o&en ages )* to ). 5,* !er +*** $o&en7 and )< to )= 5)) !er +***7 @+A' The rate o4 abortion in adolescents $as +*'? !er +*** $o&en, $ith the highest rates 4or those ages +E to += 5)+ to ): !er +***7 co&!ared $ith +? or younger 5+ to +, !er +***7'

Most ter&inations $ere !er4or&ed in $o&en $ho $ere un&arried 5E. !ercent7 and had one or &ore children 5<= !ercent7 @+A' The abortion rate a&ong $o&en li%ing belo$ the 4ederal !o%erty le%el 5a=<?* 4or a single $o&an $ith no children in )**)7 is &ore than 4our ti&es that o4 $o&en abo%e ,** !ercent o4 the !o%erty le%el 5.. %ersus +* abortions !er +*** $o&en7 @<,:A' Most abortions in the 2S in )**E $ere !er4or&ed in non-His!anic $hite 5,? !ercent7 or non-His!anic blac# 5,: !ercent7 $o&en' Abortion rates !er +*** $o&en in a s!eci4ic racial grou! are higher in non-His!anic blac# 5,,'< !er +***7 and His!anic $o&en 5)*': !er +***7 than in non-His!anic $hite $o&en 5E'?7' The %ast &aHority o4 !regnancy ter&inations $ere !er4or&ed in the 4irst tri&ester( :, !ercent at ZE $ee#s and =+ !ercent at Z+, $ee#s o4 gestation @+A' For later gestational ages, ? !ercent o4 abortions $ere !er4or&ed at +. to )* $ee#s o4 gestation and + !ercent at c)+ $ee#s' Adolescents and non-His!anic blac# $o&en $ere &ore li#ely than other $o&en to undergo abortion at c+. $ee#s' Botential barriers to early abortion include( e9!ense, delay in recognition and con4ir&ation o4 !regnancy, !arental in%ol%e&ent la$s, and lac# o4 access to an abortion !ro%ider' Eighty-se%en !ercent o4 all 2S counties lac#ed an abortion !ro%ider in )***; ,. !ercent o4 all 2S $o&en li%e in those counties @?A' Re!eat !regnancy ter&inations accounted 4or a!!ro9i&ately .) !ercent o4 all induced abortions in the 2S @+A' For gestational ages Z+, $ee#s, ?: !ercent o4 ter&inations $ere !er4or&ed %ia curettage and +< !ercent $ere &edication abortions 5use o4 &edication abortions greatly increased 4ro& , !ercent in )**+7 @+A' For gestational ages o4 c+. $ee#s, = !ercent $ere !er4or&ed %ia curettage and *'+ !ercent %ia intrauterine instillation' The &ost co&&on reasons gi%en 4or choosing abortion are that ha%ing a baby $ould inter4ere $ith $or#, school, or other res!onsibilities; inability to a44ord a child; not $anting to be a single !arent; and ha%ing !roble&s $ith a husband or !artner @EA' BRE1BERAT/FE C10S/DERAT/10S Site 3 Bregnancy ter&inations can be !er4or&ed sa4ely in 4reestanding clinics @=A and in an o44ice setting $ith !ro!er eCui!&ent 4or !er4or&ing in-o44ice surgical !rocedures' Hos!italization &ay be reCuired 4or $o&en $ith &edical conditions that !lace the& at higher ris# o4 &edical or surgical co&!lications 5eg, cardiac disease, coagulo!athy7' Leneral issues 3 Bhysicians !er4or&ing any uterine e%acuation !rocedure should obtain a co&!rehensi%e !atient history, including any co&!lications during !re%ious si&ilar !rocedures' Breo!erati%e counseling includes a thorough discussion o4 the %arious ty!es o4 !regnancy ter&ination !rocedures; the ris#s, bene4its, and e9!ected outco&e o4 each !rocedure' A nondirecti%e discussion o4 alternati%es 5eg, continuing !regnancy, ado!tion7 is e9tre&ely i&!ortant @+*A' A signed in4or&ed consent should be obtained 4ro& all !atients'

So&e states ha%e &andatory $aiting ti&es bet$een $hen the !atient is counseled and the actual !rocedure, so&e states reCuire !arental noti4ication or consent 4or abortions in &inors 5&inors ha%e the right to see# a court order authorizing the !rocedure7 @++A, $hile others &andate that s!eci4ic to!ics be co%ered in the counseling session' Abortion !ro%iders ha%e an obligation to be in4or&ed about local and 4ederal la$s co%ering their !ractice' Deter&ining gestational age 3 Deter&ining the correct gestational age is a critical !art o4 !re-abortion care' /n this to!ic, the gestational age re4ers to the date 4ro& the 4irst day o4 the last &enstrual !eriod' The gestational age guides choices regarding the ty!e o4 !rocedure, including(

Medication %ersus surgical abortion J The e44icacy o4 &edication abortion using &i4e!ristone and &iso!rostol is $ell established u! to .= days o4 gestation' /n selected cases, &i4e!ristoneD&iso!rostol abortion is !er4or&ed at u! to =+ days o4 gestation' 5See 6Mi4e!ristone 4or the &edical ter&ination o4 !regnancy6, section on GClinical e44icacyG'7 2se o4 surgical e9traction %ersus suction curettage J Suction curettage can ty!ically e%acuate !regnancies u! to +. $ee#s o4 gestation' More ad%anced gestations usually reCuire initial use o4 suction curettage 4ollo$ed by use o4 e9traction 4orce!s' Legality o4 abortions !er4or&ed at the cus! o4 restricted age li&its

Bel%ic ultrasound e9a&ination is the &ost e44ecti%e &ethod o4 deter&ining gestational age, and this is the &ethod used by &ost abortion !ro%iders in the 2nited States' Ho$e%er, use o4 &enstrual dating 5i4 the !atient is certain o4 the date o4 her last !eriod and has regular &enses7 con4ir&ed by !el%ic e9a&ination is acce!table in the 4irst tri&ester' The clinical !olicy guidelines o4 the 0ational Abortion Federation 50AF7, a !ro4essional organization o4 abortion !ro%iders in the 2nited States, do not &andate ultrasound !receding abortion in the 4irst tri&ester since doing so is not al$ays necessary or e%en hel!4ul and &ight i&!ede access to abortion in underser%ed regions $here ultrasound is una%ailable @+)A' Bro%iders should obtain ultrasound, ho$e%er, !rior to second tri&ester surgical abortion' 8hen &enstrual dating is used, the date is esti&ated based u!on the inter%al 4ro& the last &enstrual !eriod and a bi&anual !el%ic e9a&ination is !er4or&ed to assess the uterine size' 2ltrasound e9a&ination should be !er4or&ed i4 the !atient is uncertain o4 her dates, has irregular !eriods, uterine size is inconsistent $ith &enstrual dating, or uterine size cannot be adeCuately assessed 5eg, due to obesity7' 2n4ortunately, !hysical e9a&ination is &isleading in &any cases' As an e9a&!le, one study co&!ared dating by !el%ic e9a&ination $ith ultrasound and 4ound that, e%en in the 4irst tri&ester, !el%ic e9a&ination dating di44ered by &ore than t$o $ee#s in +* !ercent o4 cases 4or senior gynecologists and nearly )< !ercent 4or Hunior clinicians @+,A' Measure&ent o4 4etal !arts 4ollo$ing abortion can !otentially 4urther corroborate gestational age assign&ent' Se%eral 4or&ulae e9ist to hel! !ro%iders e9tra!olate gestational age 4ro& 4etal 4oot length @+.A' 8hile !ost hoc docu&entation o4 gestational age 4ro& 4etal &easure&ents &ight ser%e &edicolegal !ur!oses i4 gestational age is subseCuently called into Cuestion, it o44ers no clinical or surgical %alue'

Assess&ent o4 gestational age is discussed in detail se!arately' 5See 6Brenatal assess&ent o4 gestational age6'7 Laboratory tests 3 The !atientGs he&atocrit 5or he&oglobin7 and Rh5D7 status should be deter&ined; other tests &ay be $arranted de!ending u!on her &edical or surgical history or indication 4or the !rocedure 5eg, 4ibrinogen concentration i4 there has been an intrauterine 4etal death7' Many !ro%iders screen 4or se9ually trans&itted !athogens and treat !atients $ith !ositi%e results !rior to the !regnancy ter&ination' 1thers gi%e !erio!erati%e antibiotic !ro!hyla9is and o&it screening in lo$ ris# $o&en or screen at the ti&e o4 the !rocedure and subseCuently treat !ositi%e results as a!!ro!riate' Screening guidelines 4or selecting indi%iduals at increased ris# o4 ha%ing se9ually trans&itted in4ections can be 4ound se!arately' 5See 6Screening 4or se9ually trans&itted in4ections6'7 /&aging 3 Breo!erati%e ultrasonogra!hy should be considered i4 there is a discre!ancy bet$een uterine size and gestational age, uncertain 4etal %iability, or the diagnosis is in doubt 5!ossible ecto!ic !regnancy or hydatidi4or& &ole7' /t is also i&!ortant, at ad%anced gestational ages, to insure that the !rocedure is in accordance $ith state and 4ederal la$' /ndeed, recent la$s and court rulings ha%e led so&e !ro%iders to !er4or& 4etoto9ic !rocedures !rior to uterine e%acuations so as to ensure that the !rocedures do not %iolate any la$s concerning later-in-gestation !regnancy ter&inations' Concurrent intrao!erati%e ultrasonogra!hy should be arranged in cases o4 abnor&al cer%icouterine architecture 5eg, uterine ano&aly or 4ibroids, cer%ical constriction7 or abnor&al intrauterine contents 5eg, hydatidi4or& &ole7' Antibiotic !ro!hyla9is 3 Antibiotic !ro!hyla9is is reco&&ended 4or surgical abortion @+<A as !ostabortal endo&etritis occurs in < to )* !ercent o4 $o&en not gi%en antibiotics 5table +7 @+:A' A &eta-analysis 4ound !ro!hylactic antibiotics reduced u! to one-hal4 o4 !eriabortal endo&etritis in all subgrou!s o4 $o&en undergoing thera!eutic abortion, e%en $o&en at lo$ ris# 5ie, no history o4 !el%ic in4la&&atory disease and a negati%e !reo!erati%e chla&ydia culture7 @+:A' SeCuelae o4 !ostabortal in4ection include in4ertility, ecto!ic !regnancy, and chronic !el%ic !ain' The o!ti&al duration o4 !ost !rocedure thera!y has not been deter&ined' /n rando&ized trials, three days a!!eared to be as e44ecti%e as se%en @+?A and one day $as &ore e44ecti%e than !lacebo @+E,+=A' There is no e%idence regarding the use o4 antibiotic !ro!hyla9is 4or &edical abortion 5ie, no in%asi%e &ethods 4or cer%ical !re!aration or uterine e%acuation7' 5See 6Mi4e!ristone 4or the &edical ter&ination o4 !regnancy6'7 Cer%ical !re!aration 3 Dilation o4 the cer%i9 to allo$ insertion o4 instru&ents and re&o%al o4 the !roducts o4 conce!tion is usually necessary !rior to surgical !rocedures 4or !regnancy ter&ination' This can be acco&!lished &echanically using os&otic dilators 5eg, la&inaria7 or rigid dilators, or by using !har&acological agents 5eg, &iso!rostol @)*A7' A co&bination o4 &ethods &ay be needed, although any cer%ical !re!aration $ill li#ely 4acilitate the uterine e%acuation !rocedure and reduce the &orbidity and &ortality associated $ith the !rocedure'

AdeCuate cer%ical !re!aration can hel! &ini&ize the occurrence o4 !rocedure-related co&!lications, such as cer%ical laceration and uterine !er4oration' Ris# 4actors 4or co&!lications during dilation include( cer%ical stenosis, uterine ano&alies, se%ere uterine 4le9ion, adolescence @)+A, ad%anced gestational age, !ro%ider ine9!erience @)),),A, and, !ossibly, !arity @)+,),-)<A' Rigid dilators 3 Rigid dilation is !er4or&ed using instru&ent sets $ith !rogressi%ely increasing dia&eters' Ta!ered Bratt or Denniston 5a !lastic eCui%alent o4 Bratt7 dilators are !re4erred o%er blunt Hern or Hegar dilators, $hich reCuire a greater use o4 4orce 54igure +A- 7 @):A' Mechanical dilation is belie%ed to be &ore trau&atic to the cer%i9 than other &ethods @)<A' 5See 6Dilation and curettage6, section on GCer%ical dilationG'7 1s&otic dilators 3 1s&otic dilators 5natural( sea$eed La&inaria Ha!onica; synthetic( Dila!an-S, La&icel7 absorb cer%ical &oisture, gradually enlarging the endocer%ical canal and so4tening the cer%i9' 1s&otic dilator-induced cer%ical change also results 4ro& the release o4 endogenous !rostaglandins, $hich 4urther so4ten the cer%i9 and 4acilitate the dilation !rocess @)?A' 2se o4 os&otic dilators hel!s !re%ent cer%ical inHury and &ay also decrease the ris# o4 uterine !er4oration @)+,)),)EA' A large cohort study o4 +<,*** 4irst tri&ester abortions obser%ed that use o4 la&inaria signi4icantly reduced ris# o4 cer%ical inHury co&!ared to rigid dilators 5RR *'+=, =<> C/ *'*?-*'<)7 @)<A' /n a subseCuent larger cohort study 5:?,+?< 4irst tri&ester abortions7, the sa&e authors noted use o4 la&inaria also reduced the ris# o4 uterine !er4oration, but the result $as not statistically signi4icant 5RR *'+?, =<> C/ *'*)-+')7 @)=A' 2se o4 os&otic dilators is not associated $ith an increased ris# o4 !ostabortal in4ection' Rando&ized trials that co&!ared use o4 la&inaria to rigid dilation or to Dila!an did not 4ind signi4icant di44erence is !ostabortal in4ection rates @,*A' 0e%ertheless, bacterial conta&ination is !ossible because la&inaria are !roduced 4ro& sea$eed, and sterilization techniCues &ay not be +** !ercent e44ecti%e @,+-,,A' /n rare cases, a !atient &ay ha%e a hy!ersensiti%ity or ana!hylactic reaction to la&inaria @,.A' This is li#ely /gE-&ediated due to !re%ious e9!osure to la&inaria during an abortion or other gynecologic !rocedures' 2nli#e &anual dilation, $hich is !er4or&ed i&&ediately be4ore e%acuation, os&otic dilators &ust be !laced se%eral hours !rior to the !rocedure to gi%e the& ti&e to e44ect cer%ical change' The synthetic dilators are &ore e9!ensi%e than la&inaria, but $or# &ore Cuic#ly and there4ore &ay be &ore use4ul 4or sa&e-day !rocedures 5table )7'

Ho$ to use la&inaria 3 Bro!er use o4 la&inaria tents reCuires that they be inserted and le4t in !lace 4or +) to +E hours to achie%e o!ti&al cer%ical dilation 5$o&en can be sent ho&e 4ollo$ing insertion o4 the la&inaria tents7, although they can be re&o%ed earlier, a4ter si9 hours, o4ten $ith su44icient dilation'

/nsertion o4 a large nu&ber o4 s&all dia&eter la&inaria 5) or , &&7 is !re4erable to using a 4e$ large ones 5: &&7 because !lace&ent is easier and there is better cer%ical dilation' So&e !ost-insertion cra&!ing is co&&on; a !aracer%ical bloc# or other analgesic a!!roach &ay be reCuired 54igure )7'

The la&inaria are #e!t in !lace $ith t$o . by . gauze s!onges tuc#ed into the 4ornices and the nu&ber o4 la&inaria inserted recorded in the $o&anGs chart' She should a%oid intercourse and return to the o44ice $hen instructed or i4 she de%elo!s bleeding, ru!ture o4 &e&branes, or 4e%er' Failure to re&o%e the la&inaria $ithin .E hours o4 !lace&ent can result in se%ere in4ection' Brostaglandin E+ analogs 3 Miso!rostol can also be used 4or !reo!erati%e cer%ical ri!ening @,<-.+A' Brostaglandin analogues are eCui%alent to os&otic dilators in reducing the a&ount o4 4orce needed 4or cer%ical dilation @.)A; co&!arati%e studies are need to e%aluate $hether they decrease the incidence o4 &aHor i&&ediate co&!lications, such as uterine !er4oration and cer%ical laceration @.,A' A dose o4 .** &cg !er %agina t$o to three hours !rior to the !rocedure $as reco&&ended in a study atte&!ting to deter&ine o!ti&al dosing @,.A, ad&inistration only one hour be4ore ter&ination $as not e44ecti%e @,?A' The .** &cg dose is eCui%alent to !lace&ent o4 one &ediu& la&inaria 4or 4our hours, but causes less !atient disco&4ort @..A' /n Euro!e, the BLE+ analog ge&e!rost 5+ &g !er %agina& three hours be4ore surgery7 is co&&only used 4or cer%ical ri!ening, but this drug is not a%ailable in the 2nited States' 8hen &iso!rostol $as used in 4irst tri&ester !rocedures, =? !ercent o4 !atients had cer%ical dilation o4 at least E && @,.A' Ho$e%er, in second tri&ester !rocedures at +, to +: $ee#s o4 gestation, sa&e day &iso!rostol $as not as e44ecti%e as la&inaria !laced the day be4ore the !rocedure @.*A' A rando&ized trial co&!aring these t$o techniCues 4ound that use o4 la&inaria resulted in greater &ean initial dilation 5., %ersus ,, French @each French unit eCuals *',, && in dia&eterA7, less need 4or additional dilation 5)+ %ersus E* !ercent o4 !atients7, and 4aster !rocedure ti&es in nulli!arous $o&en 5,'. %ersus ='< &inutes7' Although the !rocedure $as technically easier $hen la&inaria $ere used, !atients generally !re4erred the co&4ort and con%enience o4 sa&e day &iso!rostol' Mi4e!ristone 3 The anti!rogesterone &i4e!ristone !ro&otes cer%ical dilation 4or uterine e%acuation, and &ay 4acilitate &anual and os&otic dilation @,<,,:A' This is an o44-label use and is not reco&&ended outside o4 clinical in%estigations' /sosorbide dinitrate 3 /sosorbide dinitrate has also been used 4or cer%ical ri!ening, $ith &i9ed results co&!ared to !rostaglandins @.+,.),.<,.:A' The &aHor side e44ect is headache' Regardless o4 the &ethod used to dilate the cer%i9, !reo!erati%e cer%ical dilation $ith os&otic dilators or &iso!rostol is sa4e and e44ecti%e 4or second-tri&ester uterine e%acuation !rocedures @.?A' A0ESTHES/A 3 Many $o&en e9!erience !ain des!ite use o4 a !aracer%ical bloc#, !reo!erati%e ad&inistration o4 analgesics, or conscious sedation @.E,.=A' Li&ited e%idence 4ro& histological and neuro!hysiological studies suggests that the 4etus does not !ercei%e !ain be4ore the third tri&ester @<*A' There are no !ro%en regi&ens 4or !ro%iding 4etal analgesiaDanesthesia either %ia direct 4etal inHection or trans!lacentally'

Local anesthesia 3 Local anesthesia 5eg, !aracer%ical or uterosacral bloc#7 $ith or $ithout intra%enous sedation is su44icient 4or &ost 4irst tri&ester !rocedures' Most second tri&ester !rocedures reCuire so&e sedation' 1!tions 4or conscious sedation include &idazola& 5) &g /F7 or 4entanyl 5+** &cg /F7' Sedation ad&inistered orally &edications is not as e44ecti%e as intra%enously @<+A' /4 conscious sedation is !lanned, the !atient should 4ast 4or at least si9 hours !rior to the !rocedure and ha%e so&eone acco&!any her on the day o4 the !rocedure because she should not go ho&e alone' Analgesia 3 Ad&inistration o4 a nonsteroidal antiin4la&&atory drug 5eg, ibu!ro4en :** to E** &g7 one hour !rior to the !rocedure a!!ears to di&inish intrao!erati%e and !osto!erati%e disco&4ort' /bu!ro4en !ro%ided better analgesia than tra&adol 4or 4irst tri&ester surgical abortions in one rando&ized trial @<)A' 2se o4 these agents does not a!!ear to inter4ere $ith the actions o4 !rostaglandins used 4or ter&ination o4 !regnancy @,=-.+A' Baracer%ical bloc# 3 Baracer%ical bloc# is !laced by inHecting a total dose o4 a!!ro9i&ately +* to )* &L o4 anesthetic agent 5eg, + !ercent lidocaine or *')< !ercent bu!i%acaine7 dee! into the cer%ical stro&a at the +), ., and E oGcloc# !ositions 54igure )7 @<,,<.A' The dose o4 +* &L o4 + !ercent lidocaine 5+** &g7 @&a9i&u& dose .'< &gD#g body $eight or )* &L 4or a <* #g $o&anA achie%es a !ea# !las&a le%el $ell belo$ the to9ic range and occurs +* to +< &inutes 4ollo$ing the inHection @<<A' /4 la&inaria or synthetic dilators $ere inserted, the !aracer%ical bloc# can be de4erred until a4ter their re&o%al' e4ore inHecting, negati%e !ressure should be !laced on the syringe to ensure that the needle is not $ithin a blood %essel' /nad%ertent inHection into the highly %ascular gra%id uterus can result in serious cardiogenic co&!lications and con%ulsions' So&e o!erators !re4er chloro!rocaine to lidocaine because the ra!id &etabolis& o4 chloro!rocaine con4ers a sa4ety bene4it in the e%ent o4 an unintentional intra%ascular inHection' Faso%agal synco!e 5or 6cer%ical shoc#67 can occur a4ter ad&inistration o4 a !aracer%ical bloc#' These e!isodes are sel4-li&ited and can be di44erentiated 4ro& seizure acti%ity by bradycardia, ra!id reco%ery, and lac# o4 a !ostictal state' Atro!ine 5*'< to + &g e%ery 4i%e &inutes, not to e9ceed a total o4 , &g or *'*. &gD#g7 can be used to treat such !atients or can be added to the ad&inistered anesthetic agent to !re%ent %aso%agal synco!e @<:A' Many o!erators add synthetic %aso!ressin 5Bitressin7 or other %asoacti%e substances to the inHectable anesthetic to reduce intra- and !ost-o!erati%e blood loss @.EA' 0eura9ial or general anesthesia 3 S!inal, e!idural, or general anesthesia &ay be used i4 the !atient strongly desires or i4 reCuired because e9tensi%e intrauterine &ani!ulation is e9!ected 5eg, !resence o4 sub&ucosal leio&yo&as, ad%anced gestational age7' These ty!es o4 anesthesia ha%e usually been considered to be less sa4e than local anesthesia due to increased ris# o4 he&orrhage and %isceral inHury related to uterine !er4oration @<?,<EA' 0onetheless, &ore &odern techniCues and &aterials ha%e considerably reduced the &orbidity associated $ith such anesthesia !rocedures'

The CDC re!orted that anesthesia related co&!lications accounted 4or ,< !ercent o4 4irst tri&ester abortion related deaths, $hile he&orrhage, in4ection, and thro&boe&bolis& accounted 4or only +< !ercent @<=A' A re%ie$ o4 the ris#s and bene4its o4 the %arious analgesiaDanesthesia o!tions should be included in the !reo!erati%e discussion and consent' CH1/CE 1F TECH0/b2E 3 The !ri&ary 4actors in choosing a !articular surgical techniCue are the %olu&e and content o4 intrauterine tissue and the e9!erience o4 the surgeon' /n )**,, the ty!es and 4reCuencies o4 !rocedures !er4or&ed in the 2nited States $ere( suction or shar! curettage 5=*'= !ercent @4e$er than ) !ercent by shar! curettageA7, intrauterine instillation 5*'. !ercent7, &edical 5?'? !ercent7, and other 5+ !ercent7 @:*A' Surgical 3 Dilation and e%acuation 5DIE7 !rocedures in%ol%e &echanically o!ening the uterine cer%i9 4ollo$ed by e%acuation o4 intrauterine contents' They can be !er4or&ed in a uterus o4 al&ost any size 4or re&o%al o4 &ost ty!es o4 intrauterine contents 5eg, !lacenta, &olar tissue, 4etal tissue7' These !rocedures are the &ost co&&on &ethod o4 !regnancy ter&ination at Z+. $ee#s o4 gestation' S#illed !hysicians !er4or& e9traction !rocedures at later gestational ages' Hysteroto&y and hysterecto&y are no$ rarely !er4or&ed 4or abortion and ha%e been sho$n to be less sa4e than e9traction !rocedures and nonsurgical &ethods' 0onsurgical 3 0onsurgical &ethods &ay be e&!loyed in %ery early 5[? to = $ee#s7 and late !regnancy ter&inations 5c+< $ee#s7; surgical &ethods are reco&&ended 4or !regnancies bet$een these gestational ages'

A co&bination o4 &ethotre9ate and &iso!rostol can also been used 4or ter&ination o4 !regnancies under E $ee#s' 5See 6Mi4e!ristone 4or the &edical ter&ination o4 !regnancy6, section on GAlternati%e &edical &ethodsG'7 /n early !regnancy, &iso!rostol-alone regi&ens &ay be the treat&ent o4 choice in settings in $hich &i4e!ristone or &ethotre9ate are not a%ailable or are too costly' Miso!rostol is co&&only used as a single agent 4or second tri&ester induced abortion in the 2nited States and &any other !arts o4 the $orld' 5See 6Miso!rostol as a single agent 4or &edical ter&ination o4 !regnancy6'7 For uterine e%acuation c+< $ee#s o4 gestation, syste&ic or intraa&niotic aborti4acients 5eg, intra%aginal !rostaglandins, intraa&niotic saline or !rostaglandin F) al!ha7 are ad&inistered to induce labor' 5See 6Ter&ination o4 !regnancy( Second tri&ester6'7

Bhysicians $ho use nonsurgical &ethods &ust be !re!ared to e&!loy surgical techniCues o4 uterine e%acuation $hen there are retained !roducts o4 conce!tion, a co&&on occurrence 4ollo$ing labor induction &ethods' B1ST1BERAT/FE CARE 3 Batients are obser%ed 4or at least ,* &inutes to &onitor 4or %aginal he&orrhage or changes in %ital signs suggesti%e o4 intraabdo&inal bleeding' 8o&en $ho are Rh5D7-negati%e and unsensitized should recei%e ,** &cg Rh5D7i&&une globulin 4ollo$ing the !rocedure 5<* &cg is su44icient 4or !rocedures in the 4irst tri&ester7' Methylergono%ine &aleate 5*') &g orally e%ery 4our hours 4or as &any

as 4i%e doses7 is gi%en by so&e !ro%iders to decrease !ostabortal bleeding resulting 4ro& uterine atony and to hel! !re%ent the de%elo!&ent o4 he&ato&etra @:+-:,A' Most $o&en e9!erience &ild lo$er abdo&inal cra&!ing 4or t$o to 4our days a4ter the !rocedure, $hich can be treated $ith nonsteroidal antiin4la&&atory drugs' 8o&en should be in4or&ed that %aginal !assage o4 s&all a&ounts o4 tissue and blood can be e9!ected 4ollo$ing the !rocedure' They are instructed to e9!ect so&e lo$er abdo&inal cra&!ing and %aginal bleeding co&!arable to &enstrual 4lo$ in %olu&e' Se%ere &ani4estations o4 these signs and sy&!to&s or 4e%er &ay !resage serious co&!lications and reCuire i&&ediate e%aluation by a !hysician' All !atients should recei%e a ).-hour contact nu&ber in case o4 e&ergency' The !hysician should be called i4 hea%y bleeding, 4e%er, or abdo&inal !ain de%elo!' Most such co&!lications occur $ithin one $ee# o4 the !rocedure' The !hysician should also be contacted i4 !regnancy sy&!to&s ha%e not resol%ed $ithin one $ee# or i4 &enses ha%e not returned by si9 $ee#s a4ter the !rocedure @:.A' Faginal intercourse and use o4 ta&!ons are restricted 4or t$o $ee#s !ost!rocedure to reduce the ris# o4 in4ection, es!ecially to9ic shoc# syndro&e' Routine discharge instructions can be 4ound se!arately' 5See 6Batient in4or&ation( Care a4ter gynecologic surgery 5 eyond the asics76'7 C1MBL/CAT/10S 3 First tri&ester suction curettage is the sa4est &ethod 4or surgical !regnancy ter&ination; second-tri&ester techniCues o4 e9traction, intraa&niotic instillation o4 aborti4acients, and hysteroto&y or hysterecto&y all carry higher co&!lication rates @:<-:?A' Early co&!lications 3 Suction curettage !rocedures !er4or&ed in an out!atient setting ha%e lo$ rates o4 &orbidity and &ortality, co&!arable to !rocedures !er4or&ed $ithin a hos!ital setting @:EA' /&&ediate co&!lications include he&orrhage, cer%ical laceration, and uterine !er4oration' These co&!lications occurred in only *'*: !ercent o4 +?*,*** consecuti%e cases re!orted in one series 4ro& Blanned Barenthood @))A' /n this series, *'*? !ercent o4 $o&en reCuired hos!italization because o4 inco&!lete abortion, se!sis, uterine !er4oration, he&orrhage, inability to co&!lete the !rocedure, or co&bined 5intrauterine and tubal7 !regnancy' Minor co&!lications, such as &ild in4ection, inco&!lete abortion reCuiring re-suction in an a&bulatory setting, cer%ical stenosis or laceration, or con%ulsi%e seizure due to ad&inistration o4 local anesthetic, occurred in *'E. !ercent' Ho$e%er, t$o other series that &ay better re4lect the co&!lication rate in the a%erage clinic re!orted i&&ediate &inor co&!lication rates 5in4ection, laceration, inco&!lete abortion7 o4 + to < !ercent, and &aHor co&!lications rates o4 *'+ to ) !ercent @:=,?*A' He&orrhage 3 Bostabortal he&orrhage &ay result 4ro& cer%ical or %aginal lacerations, uterine !er4oration, retained tissue, or uterine atony' 1ther causes o4 he&orrhage include in4ection, uterine arterio%enous &al4or&ation, !lacenta accreta, and coagulo!athy 5secondary to release o4 tissue thro&bo!lastin into the &aternal %enous syste&7'

The Society o4 Fa&ily Blanning 5SFB7 guidelines ad%ise the 4ollo$ing general a!!roach to !ostabortal he&orrhage @?+A(

Assess&ent and e9a&ination 2terine &assage and &edical thera!y Resuscitati%e &easures $ith laboratory e%aluation and !ossible re-as!iration or balloon ta&!onade Additional inter%entions 5eg, e&bolization, surgery7

The ris# o4 cer%ical laceration can be reduced by using cer%ical !re!aration $ith os&otic dilators or !rostaglandins 5see GCer%ical !re!arationG abo%e7 @?)A' Atony can be treated $ith uterotonic agents 5eg, &ethylergono%ine &aleate *') &g intra&uscularly; carbo!rost )<* &cg intra&uscularly &ay re!eat at +< to =* &inute inter%als to a total dose o4 ) &g; &iso!rostol +*** &cg !er rectu&7' Acti%ely bleeding lacerations and !er4orations &ust be re!aired and retained tissue e9tracted' Bel%ic e&bolization has also been success4ul 4or treat&ent o4 he&orrhage $hen the !atient is stable @?,,?.A' As a te&!orizing &easure to ta&!onade bleeding, a Foley catheter can be !laced into the uterine ca%ity and the ,* &L balloon e9!anded $ith <* to :* &L saline or $ater' Treat&ent o4 !ostabortion he&orrhage is si&ilar to !ost!artu& he&orrhage 4ollo$ing %aginal deli%ery' 5See 6Manage&ent o4 !ost!artu& he&orrhage at %aginal deli%ery6'7 /4 la!arosco!y or la!aroto&y is reCuired, &easures to control he&orrhage in gynecologic surgery are described se!arately' 5See 6Manage&ent o4 he&orrhage in gynecologic surgery6'7 2terine !er4oration 3 For both 4irst and second tri&ester !rocedures, the re!orted rate o4 uterine !er4oration is less than *': !ercent @?<-??A' The s!eci4ic location o4 a uterine !er4oration deter&ines the e9tent o4 he&orrhage and e9!ression o4 sy&!to&s' T$o 4actors associated $ith a decreased ris# o4 !er4oration during !regnancy ter&ination are 5+7 !er4or&ance by an e9!erienced surgeon 5ine9!erienced !hysicians ha%e a <'<-4old increase in !er4orations as co&!ared to attending sta447 and 5)7 use o4 !reo!erati%e cer%ical dilation $ith os&otic dilators @?EA' 2terine !er4oration is discussed in detail se!arately' 5See 62terine !er4oration during gynecologic !rocedures6'7 He&ato&etra 3 /&&ediate !osto!erati%e !ain $ithout o%ert bleeding 4ro& the %agina &ay indicate de%elo!&ent o4 he&ato&etra' He&ato&etra 5also #no$n as uterine distension syndro&e or !ostabortal syndro&e7 usually !resents $ith co&!laints o4 dull, aching lo$er abdo&inal !ain, so&eti&es acco&!anied by tachycardia, dia!horesis, or nausea' The onset is usually $ithin the 4irst hour a4ter co&!letion o4 the !rocedure' Bel%ic e9a&ination re%eals a large &idline globular uterus that is tense and tender' Treat&ent reCuires i&&ediate uterine e%acuation, !er&itting the uterus to contract to a nor&al !ost!rocedure size' Ad&inistration o4 intra&uscular &ethylergono%ine &aleate 5*') &g7 is then gi%en to ensure continued contraction o4 the uterus @:+A'

Maternal &ortality 3 Esti&ated &aternal &ortality by !regnancy outco&e is sho$n in the table 5table ,7' First tri&ester !rocedures are sa4er than second tri&ester !rocedures 5*'+ to *'. deaths !er +**,*** 4irst tri&ester !rocedures %ersus +'? to E'= deaths !er +**,*** second tri&ester !rocedures7 @?=A' Suction curettage has the lo$est &aternal &ortality rate o4 any surgical !regnancy ter&ination &ethod' 1ne study re!orted no &aternal deaths in +?*,*** consecuti%e 4irst-tri&ester suction curettage !rocedures @))A' Moreo%er, the o%erall death rate 4ro& all legal abortions 5*': !er +**,*** o!erations7 $as 4ar less than the &aternal &ortality rate o4 E'E !er +**,*** li%e births in the 2nited States 4ro& +==E to )**< @?=,E*A' /n )**), a total o4 nine $o&en died as a result o4 legal induced abortions in the 2nited States, and none died as a result o4 illegal induced abortions @E+A' /n contrast, deaths 4ro& unsa4e illegal abortion account 4or a signi4icant !ercentage o4 all &aternal deaths $orld$ide' The 8orld Health 1rganization esti&ated that one &aternal death in eight $as due to abortion-related co&!lications @E)A' /n so&e de%elo!ing countries $here abortion is illegal, c)< !ercent o4 all &aternal deaths are abortion-related @E,A' Maternal &ortality is lo$est be4ore E $ee#s o4 gestation, and increases ra!idly a4ter +E $ee#s o4 gestation 5[*', !er +**,*** induced abortions at ZE $ee#s %ersus ? !er +**,*** at +: to )* $ee#s and ++ !er +**,*** at c)+ $ee#s7 @?=A' Fro& +=EE to +==?, the distribution o4 causes o4 death $as in4ection 5)? !ercent7, he&orrhage 5). !ercent7, e&bolis& 5+? !ercent7, anesthesia co&!lications 5+: !ercent7, other 5+< !ercent7, and un#no$n 5+ !ercent7' The 4reCuency o4 each co&!lication %aried according to the gestational age at the ti&e o4 the !rocedure' A&ong second tri&ester !rocedures, the "oint Brogra& 4or the Study o4 Abortion 5"BSA7 re!orted e9traction to be associated $ith the lo$est &aternal deathDcase ratio $hen co&!ared to instillation techniCues or hysteroto&yDhysterecto&y @<E,E.A' The &aternal &ortality rate 4ro& e9traction !rocedures increases $ith ad%ancing gestational age @E<A, and beco&es si&ilar to that o4 instillation !rocedures later in the second tri&ester @<EA' y co&!arison, second-tri&ester e9traction is as sa4e 4or the $o&an as ha%ing a nor&al !regnancy and deli%ery @E:A' 1%erall, electi%e abortion at any gestational age is sa4er 4or the &other than carrying a !regnancy to ter&' Delayed co&!lications 3 Late co&!lications o4 suction curettage are those occurring &ore than ?) hours a4ter the !rocedure; they de%elo! in a!!ro9i&ately + !ercent o4 cases' Fe%er, in4ection, he&orrhage, and retained !roducts o4 conce!tion are the &ost co&&on delayed co&!lications @)),E?A' /n4ectionDretained !roducts o4 conce!tion 3 Bostabortal endo&etritis occurs in < to )* !ercent o4 $o&en not gi%en !ro!hylactic antibiotics; this rate &ay be reduced by about one-hal4 i4 !ro!hylactic antibiotics are gi%en @+:A' Retained tissue is an unco&&on co&!lication o4 !regnancy ter&ination' /n one series $ith 4ollo$-u! in4or&ation on E* !ercent o4 !atients $ho under$ent !regnancy ter&ination, retained !roducts o4 conce!tion $ere !resent in . o4 :?) 4irst tri&ester !rocedures @:=A'

Signs and sy&!to&s are si&ilar 4or isolated endo&etritis and endo&etritis $ith retained !roducts o4 conce!tion 5!lacental tissue, 4etal 4rag&ents, 4etal &e&branes7, and include 4e%er, an enlarged tender uterus, lo$er abdo&inal !ain, and uterine bleeding greater than e9!ected !ostabortion' 2ltrasonogra!hy can hel! distinguish these t$o grou!s i4 retained !roducts are %isualized in the uterine ca%ity @EEA' Any !hysical or sonogra!hic e%idence o4 retained !roducts o4 conce!tion should !ro&!t consideration o4 suction curettage to co&!lete e%acuation o4 the uterus' /n the absence o4 detectable retained &aterial, a !resu&!ti%e diagnosis o4 endo&etritis &ay be &ade and treated $ith a trial o4 broad s!ectru& antibiotic thera!y, $ith co%erage o4 anaerobes 5eg, ce4otetan @) g intra%enouslyA !lus do9ycycline @+** &g intra%enously or orallyA e%ery +) hours7' This regi&en can be co&!leted as an out!atient oral regi&en 4or a +.-day course' An alternati%e out!atient regi&en is ce4tria9one )<* &g intra&uscularly in a single dose !lus do9ycycline +** &g orally t$ice a day 4or +. days $ith or $ithout &etronidazole <** &g orally t$ice a day 4or +. days' Leneralized abdo&inal tenderness, guarding, tachycardia, high 4e%er, and !rostration suggest ad%anced se!sis' These !atients reCuire aggressi%e thera!y $ith broad s!ectru& intra%enous antibiotics, uterine re-e%acuation, assess&ent 4or uterine !er4oration, and &onitoring and su!!ort in an intensi%e care unit' 1ngoing !regnancy 3 1ngoing !regnancy is &ore li#ely to be a co&!lication o4 early rather than late abortion' All $o&en $ill continue to ha%e an ele%ated le%el o4 hCL 4or a short !eriod 4ollo$ing !regnancy ter&ination' Return o4 the seru& hCL concentration to undetectable 4ollo$ing !regnancy ter&ination %aries $idely 4ro& ? to :* days @E=A' The !eriod o4 ti&e de!ends !ri&arily u!on the hCL concentration at the ti&e o4 ter&ination' The hCL concentration !ea#s at E to ++ $ee#s at a!!ro9i&ately =*,*** &/2' This is in contrast $ith ter& !regnancy, 4or $hich the hCL concentration is lo$er' The decline in seru& hCL is ra!id 4or the 4irst se%eral days 5hal4-li4e = to ,+ hours7 and then !roceeds &ore slo$ly 5hal4-li4e << to :. hours7 @=*-=)A' 5See 6Hu&an chorionic gonadotro!in testing6'7 An ongoing intrauterine !regnancy &ay occur a4ter an atte&!ted !regnancy ter&ination i4 the !roducts o4 conce!tion are not closely e9a&ined by an e9!erienced clinician at the ti&e o4 the !rocedure 5and by a !athologist7 to %eri4y success4ul co&!letion' 5See 6Surgical ter&ination o4 !regnancy( First tri&ester6, section on GE9a&ination o4 tissueG'7 Alternati%ely, ongoing !regnancy &ay rarely result 4ro& a &ulti!le gestation in $hich only one o4 the sacs $as aborted' /n one series o4 +),+,E consecuti%e abortions $ith care4ul e9a&ination o4 the !athologic s!eci&en, three continuing !regnancies $ere later diagnosed and attributed to !hysician error @=,A' T$o $ere at : $ee#s and one $as at E $ee#s o4 gestation' A second series re!orted an ongoing !regnancy rate o4 +', !er +*** !rocedures 4or !regnancies less than : $ee#s o4 gestation @=.A' The ty!e and ris# o4 !ossible da&age to the ongoing !regnancy 4ro& an atte&!ted abortion cannot be Cuanti4ied' Direct or indirect inHury to the de%elo!ing e&bryo could occur' 1ne !reli&inary re!ort suggested there &ay be an increased ris# o4 Moebius seCuence $ith autis& in children e9!osed to &iso!rostol in the 4irst tri&ester @=<A' Moebius seCuence is a clinical condition characterized by o!hthal&ic-4acial !alsy and &uscle or bone &al4or&ations in the li&bs' /t re!resents a cascade o4 e%ents resulting 4ro& e&bryo trau&a 4ro& %aried etiologies 5eg, genetic 4actors, en%iron&ental inHuries,

!rolonged &e&brane ru!tures and chorion %illus sa&!ling7' 5See 6Miso!rostol as a single agent 4or &edical ter&ination o4 !regnancy6, section on GTeratogenicityG'7 Future !regnancies 3 Con4licting results ha%e been re!orted 4ro& studies e%aluating $hether !rior induced abortion is a ris# 4actor 4or !reter& deli%ery in a subseCuent !regnancy' A re%ie$ o4 ten studies o4 the long-ter& i&!act o4 %acuu& as!iration 4or 4irst tri&ester induced abortion 4ound that $o&en $hose 4irst !regnancy ended in induced abortion had no greater ris# o4 bearing lo$ birth $eight babies, deli%ering !re&aturely, or su44ering s!ontaneous abortions in subseCuent !regnancies than $o&en $ho carried their 4irst !regnancy to ter& @=:-=EA' Bregnancy ter&ination did not ha%e the sa&e salutatory e44ects on the 4ollo$ing !regnancy 5eg, shorter labor, lo$er rate o4 !reecla&!sia7 as a 4ull ter& nor&al !regnancy' 1n the other hand, a &eta-analysis o4 ,? studies re!orted that $o&en $ith %ersus $ithout a history o4 !regnancy ter&ination had a signi4icantly increased ris# o4 lo$ birth $eight in4ants 51R +'., =<> C/ +')-+'<7 and !reter& deli%ery 51R +'., =<> C/ +')-+'<7, but not in4ants $ho $ere s&all 4or gestational age 51R *'E?, =<> C/ *'?-+'+7 in subseCuent !regnancies @==A' The only t$o series addressing 4uture !regnancy in $o&en $ho ha%e undergone a !rior second tri&ester e%acuation !rocedure using la&inaria did not re!ort any cases o4 s!ontaneous &idtri&ester loss nor an increased ris# o4 s!ontaneous !reter& birth @+**,+*+A' Ho$e%er, other studies ha%e suggested abortion &ay increase the ris# o4 subseCuent !reter& birth' All o4 these retros!ecti%e studies are 4la$ed because they are subHect to recall bias and inadeCuate adHust&ent o4 other ris# 4actors 4or ad%erse !regnancy outco&e 5eg, se9ually trans&itted disease, s&o#ing7' 5See 6Ris# 4actors 4or !reter& labor and deli%ery6, section on GHistory o4 abortionG'7 The !ossibility o4 a lin# bet$een induced abortion and subseCuent !lacental !roble&s has also been studied' A re!ort o4 all !ri&igra%id $o&en deli%ering in Den&ar# 4ro& +=E* to +=E) used data 4ro& the Danish irth, Hos!ital Discharge, and /nduced Abortion Registries to co&!are the ris# o4 !lacental co&!lications in subseCuent !regnancy a&ong +<,?)? $o&en $ho under$ent 4irst tri&ester ter&ination and .:,*): $o&en did not ha%e a ter&ination @+*)A' There $as no di44erence in the ris# o4 !lacenta !re%ia, but $o&en $ith a !re%ious ter&ination had a slightly higher rate o4 retained !lacenta 51R +'+?, =< !ercent C/ +'*) to +',<7' reast cancer 3 The Early Re!roducti%e E%ents and reast Cancer 8or#sho! con%ened by the 0ational Cancer /nstitute in )**, concluded /nduced abortion is not associated $ith an increase in breast cancer ris# @+*,A' Data 4ro& studies !ublished subseCuent to this $or#sho! ha%e con4ir&ed this conclusion @+*.-+*?A' C10TRACEBT/10 3 Contrace!tion should be discussed !rior to and re%ie$ed i&&ediately a4ter the ter&ination' 1%ulation can occur t$o $ee#s a4ter a 4irst tri&ester abortion, thus i&&ediate contrace!tion is i&!ortant 5i4 desired7 and can be initiated the day o4 the !rocedure' A 4ull discussion o4 !ost-ter&ination contrace!tion can be 4ound se!arately' 5See 6Bost!artu& and !ostabortion contrace!tion6'7 F1LL18 2B 3 Bregnancy sy&!to&s generally should ha%e dissi!ated $ithin one $ee# o4 the !regnancy ter&ination and nor&al &enses should return $ithin si9 $ee#s' The absence o4 these 4indings could suggest ongoing intrauterine or ecto!ic !regnancy or inco&!lete abortion'

A routine 4ollo$-u! %isit t$o to 4our $ee#s a4ter the !rocedure is intended to con4ir& that the abortion is co&!lete and to diagnose and treat co&!lications' /n addition, general re!roducti%e health care 5eg, contrace!ti%e !lans, cer%ical cytology7 &ay be !er4or&ed i4 not initiated !reo!erati%ely or at the ti&e o4 the !regnancy ter&ination' Ho$e%er, there is no e%idence that routine in-!erson 4ollo$-u! a4ter 4irst tri&ester abortion is necessary to detect conditions that the $o&en the&sel%es could not be taught to recognize @:.A' Tele!hone 4ollo$-u! ). to .E hours a4ter the !rocedure and !atient education about signs o4 inco&!lete abortion, ecto!ic !regnancy, and in4ection &ay be adeCuate, $ith &ore intensi%e 4ollo$-u! o4 higher ris# !atients 5eg, uterine ano&aly, !sychose9ual issues7 and those $ith second tri&ester !rocedures' Fe%er, !el%ic !ain, uterine enlarge&ent, hea%y bleeding, !assage o4 tissue, and on-going !regnancy sy&!to&s reCuire 4urther e%aluation' A4ter induced abortion, hCL is detectable 4or as long as :* days, $ith a &edian o4 ,* days a4ter uterine e%acuation @E=,+*E-+++A; there4ore, the !resence o4 hCL is not generally use4ul 4or diagnosis o4 inco&!lete abortion and should not be ordered 4or this indication' 81ME0GS FEEL/0LS AFTER BREL0A0CO TERM/0AT/10 3 The &ost co&&on e&otional reactions a4ter !regnancy ter&ination are relie4, transient guilt, sadness, and a sense o4 loss @++)A' There is no good e%idence 4ro& large sur%eys that choosing to ter&inate an un$anted 4irst !regnancy !laces a $o&an at higher ris# o4 subseCuent de!ression than choosing to deli%er an un$anted 4irst !regnancy @++,,++.A' The 4reCuency o4 !sychiatric diagnoses in $o&en $ho ha%e undergone an abortion !rocedure is si&ilar to that in $o&en $ith no such history' Ris# 4actors 4or !ostabortal !sychosocial !roble&s include !re%ious or concurrent !sychiatric illness, coercion, &edical indications that 4orce the !atient to chose bet$een !ossible li4e threatening co&!lications and ter&ination o4 a $anted !regnancy, increasing length o4 gestation, a&bi%alence, and lac# o4 social su!!ort @++.-++:A' /n +==,, the A&erican Bsychiatric AssociationGs Diagnostic and Statistical Manual o4 Mental Disorders re%ised 5DSM-/F-R7 ceased to recognize abortion as a ty!e o4 !sychosocial stressor' /0F1RMAT/10 F1R BAT/E0TS 3 2!ToDate o44ers t$o ty!es o4 !atient education &aterials, MThe asicsN and M eyond the asics'N The asics !atient education !ieces are $ritten in !lain language, at the <th to :th grade reading le%el, and they ans$er the 4our or 4i%e #ey Cuestions a !atient &ight ha%e about a gi%en condition' These articles are best 4or !atients $ho $ant a general o%er%ie$ and $ho !re4er short, easy-to-read &aterials' eyond the asics !atient education !ieces are longer, &ore so!histicated, and &ore detailed' These articles are $ritten at the +*th to +)th grade reading le%el and are best 4or !atients $ho $ant in-de!th in4or&ation and are co&4ortable $ith so&e &edical Hargon' Here are the !atient education articles that are rele%ant to this to!ic' 8e encourage you to !rint or e-&ail these to!ics to your !atients' 5Oou can also locate !atient education articles on a %ariety o4 subHects by searching on M!atient in4oN and the #ey$ord5s7 o4 interest'7

asics to!ics 5see 6Batient in4or&ation( Abortion 5The asics767

eyond the asics to!ics 5see 6Batient in4or&ation( Abortion 5!regnancy ter&ination7 5 eyond the asics767

S2MMARO A0D REC1MME0DAT/10S

Bhysicians !er4or&ing any uterine e%acuation !rocedure should obtain a co&!rehensi%e !atient history, !er4or& a co&!lete !hysical e9a&ination $ith s!ecial attention to the uterine size and !osition, and obtain con4ir&ation o4 !regnancy' The gestational age should be deter&ined by both &enstrual history and bi&anual e9a&ination; ultrasound e9a&ination is use4ul i4 there is any uncertainty and at ad%anced gestational ages' 5See GBreo!erati%e considerationsG abo%e'7 Antibiotic !ro!hyla9is is reco&&ended because it signi4icantly reduces the 4reCuency o4 !ostabortal endo&etritis' 1!tions include do9ycycline 5+** &g orally t$ice !er day on the day o4 the !rocedure7, o4lo9acin 5.** &g orally t$ice !er day on the day o4 the !rocedure7, or ce4tria9one 5+ g intra%enously ,* &inutes !rior to the !rocedure7' 5See GAntibiotic !ro!hyla9isG abo%e'7 The !atientGs he&atocrit 5or he&oglobin7 and Rh5D7 status should be deter&ined' Rh5D7-negati%e !atients should recei%e anti-D i&&une globulin a4ter the !rocedure' 5See GBosto!erati%e careG abo%e'7 Mi4e!ristone 5R2-.E:7, an anti!rogestin, can be used 4or the &edical ter&ination o4 early !regnancies 5ty!ically u! to :, days o4 gestation7' 5See GChoice o4 techniCueG abo%e'7 Cer%ical !re!aration &ay be !er4or&ed $ith os&otic dilators or !rostaglandins, de!ending on clinician and !atient !re4erence' 5See GCer%ical !re!arationG abo%e'7 Bhysicians $ho use nonsurgical &ethods 4or !regnancy ter&ination &ust be !re!ared the&sel%es or in conHunction $ith another !hysician to e&!loy surgical techniCues 4or e%aluation and treat&ent o4 co&!lications such as he&orrhage and retained !roducts o4 conce!tion' 5See GCo&!licationsG abo%e'7

2se o4 2!ToDate is subHect to the Subscri!tion and License Agree&ent'

REFERENCES
+' Bazol T, Pane S , Bar#er 8O, et al' Abortion sur%eillance--2nited States, )**E' MM8R Sur%eill Su&& )*++; :*(+' )' htt!(DD$$$'gutt&acher'orgDdatacenterD!ro4ilesD2S'Hs! 5Accessed on "anuary ++, )*+,7' ,' Sedgh L, Singh S, Shah /H, et al' /nduced abortion( incidence and trends $orld$ide 4ro& +==< to )**E' Lancet )*+); ,?=(:)<' .' Montouchet C, Trussell "' 2nintended !regnancies in England in )*+*( costs to the 0ational Health Ser%ice 50HS7' Contrace!tion )*+,; E?(+.=' <' "ones RT, Darroch "E, Hensha$ ST' Batterns in the socioecono&ic characteristics o4 $o&en obtaining abortions in )***-)**+' Bers!ect Se9 Re!rod Health )**); ,.()):' :' Finer L , Polna MR' 2nintended !regnancy in the 2nited States( incidence and dis!arities, )**:' Contrace!tion )*++; E.(.?E'

?' "ones RT, Polna MR, Hensha$ ST, Finer L ' Abortion in the 2nited States( incidence and access to ser%ices, )**<' Bers!ect Se9 Re!rod Health )**E; .*(:' E' Finer L , Froh$irth LF, Dau!hinee LA, et al' Reasons 2'S' $o&en ha%e abortions( Cuantitati%e and Cualitati%e !ers!ecti%es' Bers!ect Se9 Re!rod Health )**<; ,?(++*' =' Lri&es DA, Cates 8 "r, Seli# RM' Abortion 4acilities and the ris# o4 death' Fa& Blann Bers!ect +=E+; +,(,*' +*' Cher%ena# FA, McCullough L ' Ethics in 4etal &edicine' aillieres est Bract Res Clin 1bstet Lynaecol +===; +,(.=+' ++' $$$'agi-usa'orgD!ubsDibg&inorsD&inorsgtable'ht&l' 5Accessed :D:D*<7' +)' htt!(DD$$$'!rochoice'orgD!ubsgresearchD!ublicationsDclinicalg!olicy'ht&l 5Accessed on "uly *E, )*+,7' +,' 0ichols M, Morgan E, "ensen "T' Co&!aring bi&anual !el%ic e9a&ination to ultrasound &easure&ent 4or assess&ent o4 gestational age in the 4irst tri&ester o4 !regnancy' " Re!rod Med )**); .?(E)<' +.' Mercer M, S#lar S, Shariat&adar A, et al' Fetal 4oot length as a !redictor o4 gestational age' A& " 1bstet Lynecol +=E?; +<:(,<*' +<' AC1L Co&&ittee on Bractice ulletins' AC1L Bractice ulletin 0o' ?.' Antibiotic !ro!hyla9is 4or gynecologic !rocedures' 1bstet Lynecol )**:; +*E())<' +:' Sa$aya LF, Lrady D, Terli#o$s#e T, Lri&es DA' Antibiotics at the ti&e o4 induced abortion( the case 4or uni%ersal !ro!hyla9is based on a &eta-analysis' 1bstet Lynecol +==:; E?(EE.' +?' Lichtenberg ES, Shott S' A rando&ized clinical trial o4 !ro!hyla9is 4or %acuu& abortion( , %ersus ? days o4 do9ycycline' 1bstet Lynecol )**,; +*+(?):' +E' DarH E, Strhlin E , 0ilsson S' The !ro!hylactic e44ect o4 do9ycycline on !osto!erati%e in4ection rate a4ter 4irst-tri&ester abortion' 1bstet Lynecol +=E?; ?*(?<<' +=' Le%allois B, Riou9 "E' Bro!hylactic antibiotics 4or suction curettage abortion( results o4 a clinical controlled trial' A& " 1bstet Lynecol +=EE; +<E(+**' )*' Thazardoost S, Hantoushzadeh S, Madani MM' A rando&ised trial o4 t$o regi&ens o4 %aginal &iso!rostol to &anage ter&ination o4 !regnancy o4 u! to +: $ee#s' Aust 0 P " 1bstet Lynaecol )**?; .?()):' )+' Cates 8 "r, Schulz TF, Lri&es DA' The ris#s associated $ith teenage abortion' 0 Engl " Med +=E,; ,*=(:)+' ))' Ha#i&-Elahi E, To%ell HM, urnhill MS' Co&!lications o4 4irst-tri&ester abortion( a re!ort o4 +?*,*** cases' 1bstet Lynecol +==*; ?:(+)=' ),' Taunitz AM, Ro%ira EP, Lri&es DA, Schulz TF' Abortions that 4ail' 1bstet Lynecol +=E<; ::(<,,' ).' Ferris, LE' Can Med Assoc "; +<.(+:??' )<' Schulz TF, Lri&es DA, Cates 8 "r' Measures to !re%ent cer%ical inHury during suction curettage abortion' Lancet +=E,; +(++E)' ):' Hul#a "F, Le4ler HT "r, Anglone A, Lachenbruch BA' A ne$ electronic 4orce &onitor to &easure 4actors in4luencing cer%ical dilation 4or %acuu& curettage' A& " 1bstet Lynecol +=?.; +)*(+::' )?' Chanda M, Mac#enzie B, Day "H' Hy!ersensiti%ity reactions 4ollo$ing la&inaria !lace&ent' Contrace!tion )***; :)(+*<' )E' Hale R8, Bion R"' La&inaria( an underutilized clinical adHunct' Clin 1bstet Lynecol +=?); +<(E)='

)=' 2ldbHerg 0, 2l&sten 2' The !hysiology o4 cer%ical ri!ening and cer%ical dilatation and the e44ect o4 aborti4acient drugs' aillieres Clin 1bstet Lynaecol +==*; .():,' ,*' Hern 8M' La&inaria %ersus Dila!an os&otic cer%ical dilators 4or out!atient dilation and e%acuation abortion( rando&ized cohort co&!arison o4 +**+ !atients' A& " 1bstet Lynecol +==.; +?+(+,).' ,+' Sut#in L, Ca!elle SD, Schlie%ert BM, Creinin MD' To9ic shoc# syndro&e a4ter la&inaria insertion' 1bstet Lynecol )**+; =E(=<=' ,)' Lin SO, Cheng 8F, Su O0, et al' Se!tic shoc# a4ter intracer%ical la&inaria insertion' Tai$an " 1bstet Lynecol )**:; .<(?:' ,,' Acharya BS, Lluc#&an S"' actere&ia 4ollo$ing !lace&ent o4 intracer%ical la&inaria tents' Clin /n4ect Dis +===; )=(:=<' ,.' Singh T, Fong OF, Brasad R0, Dong F' Rando&ized trial to deter&ine o!ti&al dose o4 %aginal &iso!rostol 4or !reabortion cer%ical !ri&ing' 1bstet Lynecol +==E; =)(?=<' ,<' Asho# B8, Flett LM, Te&!leton A' Mi4e!ristone %ersus %aginally ad&inistered &iso!rostol 4or cer%ical !ri&ing be4ore 4irst-tri&ester ter&ination o4 !regnancy( a rando&ized, controlled study' A& " 1bstet Lynecol )***; +E,(==E' ,:' 0gai S8, Oeung TC, Lao T, Ho BC' 1ral &iso!rostol %ersus &i4e!ristone 4or cer%ical dilatation be4ore %acuu& as!iration in 4irst tri&ester nulli!arous !regnancy( a double blind !ros!ecti%e rando&ised study' r " 1bstet Lynaecol +==:; +*,(++)*' ,?' Shar&a S, Re4aey H, Sta44ord M, et al' 1ral %ersus %aginal &iso!rostol ad&inistered one hour be4ore surgical ter&ination o4 !regnancy( a rando&ised controlled trial' "1L )**<; ++)(.<:' ,E' 1!!egaard TS, b%igstad E, 0eshei& /' 1ral %ersus sel4-ad&inistered %aginal &iso!rostol at ho&e be4ore surgical ter&ination o4 !regnancy( a rando&ised controlled trial' "1L )**:; ++,(<E' ,=' Lu!ta "T, "ohnson 0' Should $e use !rostaglandins, tents or !rogesterone antagonists 4or cer%ical ri!ening be4ore 4irst tri&ester abortionR Contrace!tion +==); .:(.E=' .*' Loldberg A , Drey EA, 8hita#er AT, et al' Miso!rostol co&!ared $ith la&inaria be4ore early second-tri&ester surgical abortion( a rando&ized trial' 1bstet Lynecol )**<; +*:(),.' .+' Tho&son A", Lunan C , Ledingha& M, et al' Rando&ised trial o4 nitric o9ide donor %ersus !rostaglandin 4or cer%ical ri!ening be4ore 4irst-tri&ester ter&ination o4 !regnancy' Lancet +==E; ,<)(+*=,' .)' Ledingha& MA, Tho&son A", Lunan C , et al' A co&!arison o4 isosorbide &ononitrate, &iso!rostol and co&bination thera!y 4or 4irst tri&ester !reo!erati%e cer%ical ri!ening( a rando&ised controlled trial' "1L )**+; +*E()?:' .,' 0ucatola D, Roth 0, Saulsberry F, Latter M' Serious ad%erse e%ents associated $ith the use o4 &iso!rostol alone 4or cer%ical !re!aration !rior to early second tri&ester surgical abortion 5+)-+: $ee#s7' Contrace!tion )**E; ?E().<' ..' Mac/saac L, Lross&an D, alistreri E, Darney B' A rando&ized controlled trial o4 la&inaria, oral &iso!rostol, and %aginal &iso!rostol be4ore abortion' 1bstet Lynecol +===; =,(?::' .<' Li CF, Chan C8, Ho BC' A co&!arison o4 isosorbide &ononitrate and &iso!rostol cer%ical ri!ening be4ore suction e%acuation' 1bstet Lynecol )**,; +*)(<E,'

.:' Arteaga-Troncoso L, Fillegas-Al%arado A, el&ont-Lo&ez A, et al' /ntracer%ical a!!lication o4 the nitric o9ide donor isosorbide dinitrate 4or induction o4 cer%ical ri!ening( a rando&ised controlled trial to deter&ine clinical e44icacy and sa4ety !rior to 4irst tri&ester surgical e%acuation o4 retained !roducts o4 conce!tion' "1L )**<; ++)(+:+<' .?' 0e$&ann S", Dal%e-Endres A, Diedrich "T, et al' Cer%ical !re!aration 4or second tri&ester dilation and e%acuation' Cochrane Database Syst Re% )*+*; (CD**?,+*' .E' Teder LM' est !ractices in surgical abortion' A& " 1bstet Lynecol )**,; +E=(.+E' .=' Stubble4ield BL, Carr-Ellis S, orgatta L' Methods 4or induced abortion' 1bstet Lynecol )**.; +*.(+?.' <*' Lee S", Ralston H", Drey EA, et al' Fetal !ain( a syste&atic &ultidisci!linary re%ie$ o4 the e%idence' "AMA )**<; )=.(=.?' <+' Allen RH, Fitz&aurice L, Li44ord TL, et al' 1ral co&!ared $ith intra%enous sedation 4or 4irst-tri&ester surgical abortion( a rando&ized controlled trial' 1bstet Lynecol )**=; ++,()?:' <)' Ro&ero /, Turo# D, Lillia& M' A rando&ized trial o4 tra&adol %ersus ibu!ro4en as an adHunct to !ain control during %acuu& as!iration abortion' Contrace!tion )**E; ??(<:' <,' Llantz "C, Sho&ento S' Co&!arison o4 !aracer%ical bloc# techniCues during 4irst tri&ester !regnancy ter&ination' /nt " Lynaecol 1bstet )**+; ?)(+?+' <.' 8iebe ER' Co&!arison o4 the e44icacy o4 di44erent local anesthetics and techniCues o4 local anesthesia in thera!eutic abortions' A& " 1bstet Lynecol +==); +:?(+,+' <<' lanco L", Reid BR, Ting TM' Blas&a lidocaine le%els 4ollo$ing !aracer%ical in4iltration 4or as!iration abortion' 1bstet Lynecol +=E); :*(<*:' <:' Stubble4ield, BL' Bregnancy ter&ination' !' +,*,' /n Labbe SL, 0iebyl "R, Si&!son "L 5eds7( 1bstetrics( 0or&al and Broble& Bregnancies' )nd Ed' Churchill Li%ingstone, 0e$ Oor#, +==+' <?' Beterson H , Lri&es DA, Cates 8 "r, Rubin LL' Co&!arati%e ris# o4 death 4ro& induced abortion at less than or eCual to +) $ee#sG gestation !er4or&ed $ith local %ersus general anesthesia' A& " 1bstet Lynecol +=E+; +.+(?:,' <E' Lri&es DA, Schulz TF' Morbidity and &ortality 4ro& second-tri&ester abortions' " Re!rod Med +=E<; ,*(<*<' <=' Ho!#ins, E, Lreen, C, erg, C, et al' Abortion &ortality, 2nited States +=?)+==+( Lestational age and cause o4 death' /n( Broceedings o4 0ational Abortion Federation Annual Meeting; oston( May .-:, +==?' :*' La&ble S , Strauss LT, Bar#er 8O, et al' Abortion sur%eillance--2nited States, )**<' MM8R Sur%eill Su&& )**E; <?(+' :+' Shul&an, LB, Elias, S, Si&!son, "L' /nduced abortion 4or genetic indications( techniCues and co&!lications' !' ?)+' /n Miluns#y A 5ed7( Lenetic Disorders and the Fetus( Diagnosis, Bre%ention and Treat&ent' "ohns Ho!#ins 2ni%ersity Bress, alti&ore, +==)' :)' Sands R`, urnhill MS, Ha#i&-Elahi E' Bostabortal uterine atony' 1bstet Lynecol +=?.; .,(<=<' :,' de Lroot A0, %an Dongen B8, Free T , et al' Ergot al#aloids' Current status and re%ie$ o4 clinical !har&acology and thera!eutic use co&!ared $ith other o9ytocics in obstetrics and gynaecology' Drugs +==E; <:(<),'

:.' Lross&an D, Ellertson C, Lri&es DA, 8al#er D' Routine 4ollo$-u! %isits a4ter 4irst-tri&ester induced abortion' 1bstet Lynecol )**.; +*,(?,E' :<' Hodgson "E' MaHor co&!lications o4 )*,).E consecuti%e 4irst tri&ester abortions( !roble&s o4 4rag&ented care' Ad% Blan Barent +=?<; =(<)' ::' 0athanson 0' A&bulatory abortion( e9!erience $ith ):,*** cases 5"uly +, +=?*, to August +, +=?+7' 0 Engl " Med +=?); )E:(.*,' :?' Hodgson "E, Bort&ann TC' Co&!lications o4 +*,.<, consecuti%e 4irst-tri&ester abortions( a !ros!ecti%e study' A& " 1bstet Lynecol +=?.; +)*(E*)' :E' Castadot RL' Bregnancy ter&ination( techniCues, ris#s, and co&!lications and their &anage&ent' Fertil Steril +=E:; .<(<' :=' Thonneau B, Fougeyrollas , Ducot , et al' Co&!lications o4 abortion !er4or&ed under local anesthesia' Eur " 1bstet Lynecol Re!rod iol +==E; E+(<=' ?*' 8est4all "M, So!hocles A, urggra4 H, Ellis S' Manual %acuu& as!iration 4or 4irst-tri&ester abortion' Arch Fa& Med +==E; ?(<<=' ?+' Terns ", Steinauer "' Manage&ent o4 !ostabortion he&orrhage( release date 0o%e&ber )*+) SFB Luideline f)*+,+' Contrace!tion )*+,; E?(,,+' ?)' Atienza, MF, ur#&an, RT, Ting, TM' Forces associated $ith cer%ical dilatation at suction abortion( Cualitati%e and Cuantitati%e data in studies co&!leted $ith a 4orce-sensing instru&ent' !' ,.,' /n 0a4tolin F, Stubble4ield BL 5eds7( Dilatation o4 the 2terine Cer%i9' Ra%en Bress, 0e$ Oor#, +=E*' ?,' orgatta L, Chen AO, Reid ST, et al' Bel%ic e&bolization 4or treat&ent o4 he&orrhage related to s!ontaneous and induced abortion' A& " 1bstet Lynecol )**+; +E<(<,*' ?.' Steinauer, "E' 2terine Artery E&bolization in Bostabortion He&orrhage, 1bstet Lynecol )**E; +++(EE+' ?<' Lross&an D, lanchard T, lu&enthal B' Co&!lications a4ter second tri&ester surgical and &edical abortion' Re!rod Health Matters )**E; +:(+?,' ?:' A&arin P1, adria LF' A sur%ey o4 uterine !er4oration 4ollo$ing dilatation and curettage or e%acuation o4 retained !roducts o4 conce!tion' Arch Lynecol 1bstet )**<; )?+()*,' ??' en- aruch L, Menczer ", Shale% ", et al' 2terine !er4oration during curettage( !er4oration rates and !ost!er4oration &anage&ent' /sr " Med Sci +=E*; +:(E)+' ?E' Lri&es DA, Schulz TF, Cates 8" "r' Bre%ention o4 uterine !er4oration during curettage abortion' "AMA +=E.; )<+()+*E' ?=' artlett LA, erg C", Shul&an H , et al' Ris# 4actors 4or legal induced abortion-related &ortality in the 2nited States' 1bstet Lynecol )**.; +*,(?)=' E*' Ray&ond EL, Lri&es DA' The co&!arati%e sa4ety o4 legal induced abortion and childbirth in the 2nited States' 1bstet Lynecol )*+); ++=()+<' E+' $$$'cdc'go%D&&$rD!re%ie$D&&$rht&lDss<<++a+'ht&RsgcidKss<<++a+ge 5Accessed 0o%e&ber )?, )**:7' E)' Abortion( A Tabulation o4 A%ailable /n4or&ation, ,rd edition' 8orld Health 1rganization, Lene%a, +==?' E,' $$$'$ho'intDdocstoreD$orld-health-dayDenD!ages+==ED$hd=Eg+*'ht&l' E.' Atrash HT, MacTay HT, in#in 0", Hogue C"' Legal abortion &ortality in the 2nited States( +=?) to +=E)' A& " 1bstet Lynecol +=E?; +<:(:*<' E<' La$son H8, Frye A, Atrash HT, et al' Abortion &ortality, 2nited States, +=?) through +=E?' A& " 1bstet Lynecol +==.; +?+(+,:<' E:' Ro%ins#y ""' Abortion on de&and' Mt Sinai " Med +=E.; <+(+)'

E?' Tietze C' Re!ort o4 the S$edish Abortion Co&&ittee' Stud Fa& Blann +=?); ,()E' EE' 8ol&an /, Lordon D, Oaron O, et al' Trans%aginal sonohysterogra!hy 4or the e%aluation and treat&ent o4 retained !roducts o4 conce!tion' Lynecol 1bstet /n%est )***; <*(?,' E=' Steier "A, ergsHW B, My#ing 1L' Hu&an chorionic gonadotro!in in &aternal !las&a a4ter induced abortion, s!ontaneous abortion, and re&o%ed ecto!ic !regnancy' 1bstet Lynecol +=E.; :.(,=+' =*' illieu9 MH, Betignat B, Anguenot "L, et al' Early and late hal4-li4e o4 hu&an chorionic gonadotro!in as a !redictor o4 !ersistent tro!hoblast a4ter la!arosco!ic conser%ati%e surgery 4or tubal !regnancy' Acta 1bstet Lynecol Scand )**,; E)(<<*' =+' Moc# B, Chardonnens D, Sta&& B, et al' The a!!arent late hal4-li4e o4 hu&an chorionic gonadotro!in 5hCL7 a4ter surgical treat&ent 4or ecto!ic !regnancy' A ne$ a!!roach to diagnose !ersistent tro!hoblastic acti%ity' Eur " 1bstet Lynecol Re!rod iol +==E; ?E(==' =)' Midgley AR "r, "a44e R ' Regulation o4 hu&an gonadotro!ins' //' Disa!!earance o4 hu&an chorionic gonadotro!in 4ollo$ing deli%ery' " Clin Endocrinol Metab +=:E; )E(+?+)' =,' Fielding 8L, Lee SO, orten M, Fried&an EA' Continued !regnancy a4ter 4ailed 4irst-tri&ester abortion' 1bstet Lynecol +=E.; :,(.)+' =.' Ed$ards, ", Creinin, MD' Surgical abortion 4or gestations o4 less than : $ee#s' Curr Brobl 1bstet Lynecol Fertil +==?; )*(++' =<' andi& "M, Fentura L1, Miller MT, et al' Autis& and Mibius seCuence( an e9!loratory study o4 children in northeastern razil' ArC 0euro!siCuiatr )**,; :+(+E+' =:' Hogue C", Cates 8 "r, Tietze C' /&!act o4 %acuu& as!iration abortion on 4uture childbearing( a re%ie$' Fa& Blann Bers!ect +=E,; +<(++=' =?' Hogue C", Cates 8 "r, Tietze C' The e44ects o4 induced abortion on subseCuent re!roduction' E!ide&iol Re% +=E); .(::' =E' Atrash HT, Hogue C"' The e44ect o4 !regnancy ter&ination on 4uture re!roduction' aillieres Clin 1bstet Lynaecol +==*; .(,=+' ==' Shah BS, Pao ", Tno$ledge Synthesis Lrou! o4 Deter&inants o4 !reter&DL 8 births' /nduced ter&ination o4 !regnancy and lo$ birth$eight and !reter& birth( a syste&atic re%ie$ and &eta-analyses' "1L )**=; ++:(+.)<' +**' Talish R , Chasen ST, Rosenz$eig L , et al' /&!act o4 &idtri&ester dilation and e%acuation on subseCuent !regnancy outco&e' A& " 1bstet Lynecol )**); +E?(EE)' +*+' Schneider D, Hal!erin R, Langer R, et al' Abortion at +E-)) $ee#s by la&inaria dilation and e%acuation' 1bstet Lynecol +==:; EE(.+)' +*)' Phou 8, 0ielsen LL, Larsen H, 1lsen "' /nduced abortion and !lacenta co&!lications in the subseCuent !regnancy' Acta 1bstet Lynecol Scand )**+; E*(+++<' +*,' eral F, ull D, Doll R, et al' reast cancer and abortion( collaborati%e reanalysis o4 data 4ro& <, e!ide&iological studies, including E,R*** $o&en $ith breast cancer 4ro& +: countries' Lancet )**.; ,:,(+**?' +*.' Michels T , `ue F, Colditz LA, 8illett 8C' /nduced and s!ontaneous abortion and incidence o4 breast cancer a&ong young $o&en( a !ros!ecti%e cohort study' Arch /ntern Med )**?; +:?(E+.'

+*<' Ree%es LT, Tan S8, Tey T, et al' reast cancer ris# in relation to abortion( Results 4ro& the EB/C study' /nt " Cancer )**:; ++=(+?.+' +*:' Fried&an E, Totso!oulos ", Lubins#i ", et al' S!ontaneous and thera!eutic abortions and the ris# o4 breast cancer a&ong RCA &utation carriers' reast Cancer Res )**:; E(R+<' +*?' Co&&ittee on Lynecologic Bractice' AC1L Co&&ittee 1!inion 0o' .,.( induced abortion and breast cancer ris#' 1bstet Lynecol )**=; ++,(+.+?' +*E' Aral T, LSr#an Porlu C, Li#&en 1' Blas&a hu&an chorionic gonadotro!in le%els a4ter induced abortion' Ad% Contrace!t +==:; +)(++' +*=' Torhonen ", Al4than H, Olistalo B, et al' Disa!!earance o4 hu&an chorionic gonadotro!in and its al!ha- and beta-subunits a4ter ter& !regnancy' Clin Che& +==?; .,()+<<' ++*' Marrs RB, Tletz#y 1A, Ho$ard 8F, Mishell DR "r' Disa!!earance o4 hu&an chorionic gonadotro!in and resu&!tion o4 o%ulation 4ollo$ing abortion' A& " 1bstet Lynecol +=?=; +,<(?,+' +++' arnhart TT, Sa&&el MD, Rinaudo BF, et al' Sy&!to&atic !atients $ith an early %iable intrauterine !regnancy( HCL cur%es rede4ined' 1bstet Lynecol )**.; +*.(<*' ++)' Stotland 0L' The &yth o4 the abortion trau&a syndro&e' "AMA +==); ):E()*?E' ++,' Sch&iege S, Russo 0F' De!ression and un$anted 4irst !regnancy( longitudinal cohort study' M" )**<; ,,+(+,*,' ++.' Sit D, Rothschild A", Creinin MD, et al' Bsychiatric outco&es 4ollo$ing &edical and surgical abortion' Hu& Re!rod )**?; ))(E?E' ++<' Stotland 0L' Bsychosocial as!ects o4 induced abortion' Clin 1bstet Lynecol +==?; .*(:?,'