Complication rates of dilation and evacuation and labor induction in second-trimester - PowerPoint Presentation

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Complication rates of dilation and evacuation and labor induction in second-trimester abortion for fetal indications: A retrospective cohort study

Authors: Laura Jacques  1 , Megan Heinlein  2 , Jessika Ralph  4 , Amy Pan  3 , Melodee Nugent  3 , Kristina Kaljo  2 , Rahmouna Farez  2 Affiliations 1 Department of Obstetrics and Gynecology, University of Wisconsin - Madison 2 Department of Obstetrics and Gynecology, Medical College of Wisconsin 3 Section of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin4 Department of Obstetrics and Gynecology, University of Minnesota Medical SchoolPresenting Author: Rahmouna Farez, MDEmail: rfarez@mcw.edu

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Objective: To compare complication rates of dilation and evacuation (D&E) to mifepristone and misoprostol labor induction for second trimester abortion for fetal indications. Study design: We performed a retrospective cohort study comparing complication rates with D&E and labor induction abortion for fetal indications at 14 weeks 0 days through 23 weeks and 6 days gestation between January 1, 2009, and August 31, 2017. We extracted demographic, procedural, and outcome data, focusing specifically on complications of maternal hemorrhage, infection, emergency department visit, hospital readmission, retained tissue requiring dilation and curettage (D&C), manual placental removal, or thromboembolism. We compared complication rates between the D&E and induction groups using univariate and multivariate analyses. Results: We included outcomes from 75 (48%) D&E and 81 (52%) labor induction abortions. We identified any complication in 1 (1%) and 7 (7%) of patients, respectively (p = 0.12). The only complication in the D&E group was hemorrhage with an estimated blood loss of 1000 mL not requiring transfusion. Labor induction complications included retained tissue requiring manual removal (n = 2) or D&C (n = 1) and hemorrhage (n = 2). Conclusion: There was no difference in complication rates between the D&E group and the labor induction group. Implications: This study compared outcomes between D&E and labor induction using mifepristone and misoprostol for second trimester abortion. Our complication rate for labor induction using mifepristone and misoprostol, and particularly our rate of retained placenta requiring D&C, was lower than what has been previously reported for second trimester labor induction termination using other methods. This study suggests there is a benefit for the routine use of mifepristone with misoprostol for second trimester labor induction. Additionally, the low rate of major complications in this study for both D&E and labor induction further validates the safety of both procedures for second trimester abortion.

Abstract

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IntroductionDilation and evacuation (D&E) and labor induction are the two most common abortion methods in the second trimester. In the United States, most second-trimester abortions are performed via D&E. Various reasons lead to one abortion method being chosen over the other, including : D&E access patient preference based on the different emotional experiences involved potential complications Although lower complication rates are generally reported with D&E (3–15%) than labor induction (24–44%), most data comes from studies where the labor induction protocol did not include misoprostol and/or mifepristone The most common complications in these reports are retained placenta for both D&E (1–6%) and labor induction (12–33%).We performed this study to compare the complication rates using modern protocols in women at 14 weeks 0 days through 23 weeks and 6 days gestation having procedures for fetal indications. We hypothesized that both methods would have low overall complication rates and that the routine use of mifepristone prior to labor induction would lead to a smaller difference in complication rates.

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MethodsRetrospective cohort study of all abortions at 14 weeks 0 days to 23 weeks 6 days gestation performed for fetal anomalies or demise at academic institution from January 1, 2009, through August 31, 2017. We used an existing departmental abortion procedure database to identify patients, and we reviewed all charts to identify those who met the gestational age and indication criteria. Patients underwent D&E or labor induction at their own discretion.We identified the occurrence of any complication as our primary outcome. Complications included: maternal hemorrhage (estimated blood loss of 500 cc or greater)infection (clinical diagnosis of endometritis, chorioamnionitis, or maternal fever requiring antibiotics) emergency department visit or hospital readmission after procedureretained tissue requiring dilation and curettage (D&C) or manual placental removalthromboembolism.We used a chi-square test or the Fisher exact test to compare categorical variables and the Mann-Whitney U test to compare continuous variables. We considered a P value < 0.05, without multiple testing corrections, as significant. We performed statistical analyses using SAS 9.4 (SAS Institute, Cary, NC) and SPSS 24.0 (Armonk, NY: IBM Corp).

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MethodsD&E procedures performed in the hospital operating room under moderate sedation and paracervical block with vasopressin. Second- or fourth-year residents performed the procedure with ultrasound guidance under direct faculty supervision. Patients received doxycycline 100 mg orally within 1 hour of the procedure start time and 200 mg orally in the recovery room postoperatively as antibiotic prophylaxis. Surgeons provided cervical preparation with misoprostol 400 mcg buccally 2–4 hours preoperatively for patients under 18 weeks gestation and overnight osmotic dilators at 18 or more weeks gestation.Labor induction abortions routinely performed in the labor and delivery unit using mifepristone 200 mg orally 24 to 48 hours prior to admission. Patients typically received misoprostol 800 mcg vaginally at admission followed by 400 mcg vaginally or buccal every three hours until delivery (maximum of 5 doses). After delivery of the fetus, providers typically allowed up to 6 hours for placental delivery in the absence of infection or hemorrhage, with provision of an additional misoprostol 400 mcg vaginally while awaiting placental expulsion if more than three hours elapsed since the last dose.

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Results

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Results

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Results

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DiscussionStrengthsContemporary abortion methods, using mifepristone and misoprostol for labor inductionRelatively high number of patients who had a labor induction in the second trimesterWeaknessesAs this is retrospective study, we could not control for variations in D&E and labor induction treatment due to surgeon preference. Selection bias due to patient self-selection of procedures as well as physician procedure bias. There were several demographic variables missingThis study compared outcomes between D&E and labor induction using mifepristone and misoprostol for second trimester abortion. Our complication rate for labor induction using mifepristone and misoprostol, and particularly our rate of retained placenta requiring D&C, was lower than what has been previously reported for second trimester labor induction termination using other methods. This study suggests there is a benefit for the routine use of mifepristone with misoprostol for second trimester labor induction. Additionally, the low rate of major complications in this study for both D&E and labor induction further validates the safety of both procedures for second trimester abortion.

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