Prior cesarean delivey is not a contraindication for 0 & E and may be preferred over prostaglandins for those with multiple prior hysterotomies (Ben-Ami, 2009; Schneider, 1994). During medical abortion, the uterine rupture rate is 0.4 percent with one prior cesarean delivery (Berghella, 2009). From fewer data, the rate may reach 2.5 percent with two or more prior cesarean deliveries (Andrikopoulou, 2016). If a medical agent is elected in those with prior cesarean hysterotomy, misoprostol is an option. Prostaglandin E2 (PGE2) appears to pose similar risk (Ie Roux, 2001; Reichman, 2007).
Of these, dilation and extraction (D & ) is similar to 0 & E except that a suction cannula is used to evacuate the intracranial contents after delivery of the fetal body through the dilated cervix. This aids extraction and minimizes uterine or cervical injury from large instruments or fetal bones. 0 & X is also called an intact D & . In political parlance, this procedure has been termed partial birth abortion.
In some women with second-trimester pregnancies who desire sterilization, hysterotomy with tubal ligation is reason able. If there is signiicant uterine disease, then hysterectomy may provide ideal treatment. In some cases of a failed second trimester medical induction, either of these may be considered.
Principal among noninvasive methods is a mifepristone plus misoprostol regimen or misoprostol alone (see Table 18-7). Of these two options, the combined regimen yields a shorter termination duration (Kapp, 2007; Ngoc, 201l). Hygroscopic dilators may speed the time to delivery with this combined regimen (Mazouni, 2009; Vincienne, 2017). In selecting misoprostol routes, oral administration leads to a longer time to delivery compared with vaginal or sublingual routes (Dickinson, 2014). Prophylactic antibiotics are not typically given, and infection surveillance during labor is instead applied (Achilles, 2011).
Another induction agent, PGE2, shows similar eicacy and side efects compared with misoprostol Gain, 1994; Jansen, 2008). Simultaneous administration of an antiemetic such as metoclopramide (Reglan), an antipyretic such as acetaminophen, and an antidiarrheal such as diphenoxylate/atropine (Lomotil) will help prevent or treat symptoms. Dinoprostone (Prostin) is an available PGE2 in the United States. However, its greater cost and poor pharmacologic stability at room temperature may make it less attractive than misoprostol.
Of other agents, high-dose intravenous oxytocin in saline will result in second-trimester abortion in 80 to 90 percent of cases (see Table 18-7). However, by comparison, misoprostol leads to higher successful induction rates and faster delivery times (Alavi, 2013).
Rarely used, ethacridine lactate is an organic antiseptic that activates myometrial mast cells to release prostaglandins (Olund, 1980). Placed extraovularly, that is, extraamnionically, it is associated with longer times to delivery and greater complication rates compared with misoprostol (Boza, 2008).
For second-trimester gestations, D & E or medical induction is suitable clinically and psychologically. Thus, patient input and clinical indication guide selection (Burgoine, 2005; Kerns, 2012). Once delivered, viewing and holding the fetus mayior may not be desired by the patient (Sloan, 2008).