INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY Int[ J[ Geriatr[ Psychiatry 04\ 0917Ð0922 "1999#J[ B[ GRACE0 \ M[ P[ WALKER1 AND I[ G[ MCKEITH20 Lecturer in Psychiatry \ Department of Old A`e Psychiatry \ Wolfson Research Unit \ Newcastle General Hospital \1 MRC Research Assistant \ MRC Neuropatholo`y Unit \ Newcastle General Hospital \ Newcastle upon Tyne \ UK 2 Professor of Old
Womenscenter.comEarly and Late Second Trimester Abortion in an Outpatient Clinic
Completed in Less Than 24 hours
The performance of second trimester abortion between 17 to 34 weeks in an outpatient clinic setting is only safe in the hands of Physicians who are experienced with abortion care. Normally, it usually takes two to four days to complete the abortion procedure. That is because the majority of Physicians use older methods of preparation of the cervix which al ows the cervix to dilate (open) over a two to four day period of time before the abortion. The further the weeks of gestation, the more days that are needed in order for the cervix to be adequately dilated with laminaria. There is no doubt that the use of multiple, serial laminaria has shown to be safe. The problem with the serial laminaria abortion procedure, is the length of time the patient is inconvenienced in having to return to the office up to 4 days in a row, in order for the abortion procedure to be complete. I have been performing early to late second trimester abortion procedures for over 10 years using a different technique where the procedure is complete in less than 24 hours in 99% of the time. With the introduction of additional techniques over the past 2 years, the initiation to completion of the abortion has been decreased to a median of 8 hours from initial onset to completion of the abortion. For the extremely small percentage of patients that the medical induction technique I use does not work, it is followed by surgical removal of the gestational tissue, or a high dose oxytocin (pitocin) protocol that wil allow delivery to take place must be considered. A Physician that is competent and familiar with complications of abortion is the only one who should perform this type of medical induction procedure. Misoprostol (cytotec) is a prostaglandin medication used to help prevent ulcers in individuals who use non-steroidal anti-inflammatory medications (aspirin, motrin, indomethacin, naproxen, advil, etc.) In certain dosages it wil cause the uterus to contract which causes the woman to abort her pregnancy. This medication has been used for abortion for more than 20 years. In the past 10 years in the United States, misoprostol has been used in term pregnancies to allow the cervix to soften, allowing labor to occur, or making it easier to induce labor. This helps decrease the incidence of C-sections. Mifeprex (RU486) was then added to the regimen two years ago after reading multiple European studies where the abortion time was shortened when the patient took mifeprex prior to initiating labor with misoprostol. Since starting the mifeprex, there are no patients that have gone past 24 hours of their abortion being completed. Al patients 22 week’s gestation or greater receive fetal intracardiac injection of a combination of digoxin and potassium chloride to stop the fetal heart. If the fetal heart cannot be injected then a higher amount of digoxin is injected into the fetus or is instil ed in the amniotic fluid. Less than 10 percent of patients require pain medication while in labor. Less than 10 percent of patients require a D&E procedure after delivery or have a retained placenta. The patients are observed for an hour after delivery or the D&E procedure and are discharged home with follow-up in our office or their personal physician in 3 weeks. There have been no major complications with the use of this medical protocol of patients greater than 22 week’s gestation. No hospitalizations have been necessary. Following only a few minor complications, we have modified our protocol where laminaria are placed in the cervix in patients who have had c-sections prior to giving the patient misoprostol. Since starting the laminaria protocol on patients with previous c-sections, there have been no further complications. In summary, the medical induction of late second trimester terminations using mifeprex (RU486, misoprostol, with placement of laminaria in patients with previous c-section prior to giving misoprostol) has been found not only to be safe, but allows completion of the abortion in a median time of 14 hours. Completion of the abortion in less than 24 hours has many advantages. Less time to perform an abortion decreases the incidence of maternal morbidity. There is less expense in travel, time away from the job, and stress on the patient and the family. The faster an abortion can take place as long as the way the abortion is performed is safe, the better for the patient. To achieve a high level of safety in late second trimester terminations, one must have all the necessary precautions in place to minimize the risk to patient. The level of physician skill, the extent of knowledge of new medications that are safe and can reduce the time it takes to perform the abortion. When a medically induced abortion cannot be performed, preoperative preparation, use of laminaria, special surgical instruments and medications, properly trained staff, and the proximity to a full service hospital is needed to assure patient safety. Our offices are located within 1 to 5 minutes of hospitals. Please visit our web site below for further information.
1. Approvazione Verbale n.250 del 23 luglio 2002 ; 2. Comunicazioni; 3. Biblioteca dell’Area Letteraria, Storica, Filosofica; 4. Proposta di nomina ad emerito del prof. Benedetto Ristretto ai rappresentanti ricercatori 6. Ratifica designazione membro di competenza della Facoltà per la procedura di valutazione comparativa per 1 posto di ricercatore per il settore M-STO/04 (G.U. 16/07/200