These tools will no longer be maintained as of December 31, 2024. Archived website can be found here. PubMed4Hh GitHub repository can be found here. Contact NLM Customer Service if you have questions.


Pubmed for Handhelds

PUBMED FOR HANDHELDS

Search MEDLINE/PubMed

  • Title: Intrauterine administration of drugs for termination of pregnancy in the second trimester.
    Author: Toppozada M, Ismail AA.
    Journal: Baillieres Clin Obstet Gynaecol; 1990 Jun; 4(2):327-49. PubMed ID: 2225603.
    Abstract:
    Medical methods have been used for many years to terminate mid-trimester pregnancy, ranging from irritant chemicals and traditional plants to ecbolic agents and solutions instilled locally into the uterus. These methods had serious limitations, with relatively high rates of maternal mortality and morbidity. Surgical evacuation requires special skills not available to all practitioners and many doctors consider second trimester dilatation and evacuation as a surgical taboo. In recent years several approaches evolved and reached the clinics, presenting safer and more effective options. Intra-amniotic instillation of hypertonic solutions, particularly saline or urea, proved in many hands to be a good method for pregnancies beyond 15 weeks of gestation. Due to a long latency period after instillation, these agents are often supplemented by an intravenous oxytocin infusion. Extraovular hypertonic saline or ethacridine (Rivanol) have their advocates, particularly in the grey-zone of pregnancy range from 13-15 weeks. In the last two decades, intrauterine prostaglandins were added to the methods in current use. Extra-amniotic prostaglandins (E2, F2 alpha or 15-methyl F2 alpha) were originally given in repeated doses or as a continuous local drip, but later a single instillation was used, usually mixing the drug with a viscous solution or gel. Intra-amniotic prostaglandins, in much higher doses, particularly the 15-methyl analogue, proved highly effective and relatively safe, especially when combined with laminaria tent insertion in the cervix. Various combinations of methods have provided a wide spectrum of data which is difficult to evaluate at present. Studies comparing different methods were mainly attempted in the mid-seventies. The outcome raised many pertinent questions and left many major issues unresolved. Most of the comparisons were not randomized or well-controlled and only referred to the natural prostaglandin compounds. The analogues, however, seem to offer several advantages and the role of additional methods such as laminaria or antiprogestins remains to be further evaluated. There are several medical methods of inducing 2nd trimester abortion, each with merits and drawbacks, difficult to compare, especially when supplemental techniques are used. Drugs used are hypertonic saline, urea, natural and synthetic prostaglandins (PGs), mannitol, formalin, ethacridine lactate (Rivanol) and others for intraamniotic route; saline, PGs, Rivanol, utus paste and other extraamniotically; and the above methods combined with oral antiprogestins, iv oxytocics, in or intravaginal PGs, or mechanical cervical dilators. Few double-blind studies exist comparing drugs. About 50,000 mid-trimester abortions are done in the US yearly, about 10% of all terminations, but these cause 2/3 of all complications and half of the deaths. Saline can be used after 15 weeks, can cause hypernatremia or coagulopathy, and takes up to 72 hours unless augmented with ocytocin and/or laminaria. Urea may have less risk of coagulopathy. Rivanol is considered safer than both in some countries, e.g., Scandinavia, Eastern Europe, Israel, India and Japan. It can be instilled transcervically. Various intrauterine PGs have been compared in several doses and routes by WHO Task Force research groups and others. Extraamniotic PGs require a lower dose, cause fewer cervical lacerations, and can be used when membranes are ruptured, in molar pregnancy, at Weeks 13-15, and in cases of fibroids. This route is somewhat less effective than intraamniotic PGs, and may require multiple doses. Intraamniotic PGs act slower but are more effective, after only 1 dose. Laminaria speed up the process, but adding oxytocin increases risk of injury. PGs may be safer than saline, especially if intramuscular route is used, because there is no danger of coagulation, cardiovascular, renal or hypernatremic complications or inadvertent injection. It is possible that some of the higher complications attributed to PGs are related to selection of patients with more severe medical conditions. PGs are more expensive, and require medication for side effects.
    [Abstract] [Full Text] [Related] [New Search]