3-12 hours given vaginally; 3-4 hours given sublingually. dEficacy similar for routes of administration. eSimilar efficacy when given on day 3 versus day 5. BSA = body surface area. Pymar, 2001; Raghavan, 2009; Schaff, 2000; Shannon, 2006; von Hertzen, 2003, 2007, 2009, 2010; Winikof, 2008.
due to concern for failed abortion or for bleeding, unnecessary surgery can be avoided if scans are interpreted appropriately. Specifically, if no gestational sac is seen and there is no heavy bleeding, then intervention is unnecessary. This is true even when, as is common, the uterus contains sonographically evident debris (Paul, 2000). vleasurements < 15 mm and < 30 mm have been used as thresholds to signal evacuation success (Nielsen, 1999; Zhang, 2005). Another study reported that a multilayered sonographic pattern indicated a successful abortion (Tzeng, 2013). Last, hCG values may be informative. Compared with preprocedural levels, Barnhart and coworkers (2004b) found declines of 88 percent at day 3 and 82 percent at day 8 following misoprostol administration correlated with a 95-percent rate of successful abortion completion.
In the second trimester, fetal anomaly or death, maternal health complications, inevitable abortion, or desired termination may be indications for uterine evacuation. As in the irst trimester, available options are medical or surgical. But, in the second trimester, dilation and evacuation (D & E) rather than suction D & C is dictated because of fetal size and bony structure.
Of options, D & E is a common means of second-trimester induced abortion in the United States. Of legally obtained abortions in 2013, 9 percent were performed by D & E at gestational agesi> 13 weeks Oarlaoui, 2016). Many of the surgical and medical steps for second-trimester abortion mirror those in the irst trimester, and diferences are emphasized here.
With D & E, wide mechanical cervical dilation precedes evacuation of fetal parts. he degree needed rises with fetal gestational age, and inadequate dilatation risks cervical trauma, uterine perforation, or tissue retention (Peterson, 1983). Thus, presurgical cervical preparation is advised, and main options include hygroscopic dilators or misoprostol.
With laminaria, overnight preparation ofers optimal cervical dilation (Fox, 2014). Uncommonly, laminaria may fail to adequately dilate the cervix, and serialilaminaria insertion with an increasing number of tents over several days is one option (Stubblefield, 1982). Supplementing laminaria with misoprosrol or mifeprisrone is another choice (Ben-Ami, 201i5).
Dilapan-S is also suitable for cervical preparation. It may be preferable for same-day procedures as this device achieves its maximal efect in 4 to 6 hours (Newmann, 2014).
Misoprostol can be used instead of hydroscopic dilators for cervical preparation. The typical dose is 400 1g given vaginally or buccally 3 to 4 hours prior to D & E. Randomized trials vary regarding the ability of misoprostol to achieve results equal to that with hydroscopic dilators (Bartz, 2013; Goldberg, 2005; Sagiv, 2015). vIisoprostol added to laminaria ofers small increases in dilation but also greater side efects (Edelman, 2006).