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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Westchester Medical Center, Valhalla, New York.
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Abstract |
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Methods: A retrospective chart review of all vaginal PG E2-induced abortions at Westchester Medical Center between January 1996 and April 1998 was done. Only women who sought terminations between 18 and 24 weeks’ gestation by prostaglandin induction were included. These abortions were predominantly secondary to fetal structural and chromosomal anomalies. The study population was subdivided into groups based on the use of pretreatment cardiac puncture with potassium chloride. The groups were compared for maternal, fetal, and procedural characteristics. The 
2 test, Student t test, and Wilcoxon rank-sum test were used for analysis.
Results: There were no differences between the cardiac puncture and control groups when compared for various maternal and procedural characteristics, fetal weight, and the need for curettage for retained products of conception. However, the required median doses of PG and the E2 initiation to expulsion interval were significantly lower in the cardiac puncture group compared with the control group (2.0 doses compared with 3.0 doses, P < .001; 570 minutes compared with 890 minutes, P = .006).
Conclusion: Pretreatment-induced fetal death significantly reduced the interval to expulsion and doses of PG E2 required for late second-trimester abortion.
Prostaglandin (PG) E2 by vaginal suppository is approved by the Food and Drug Administration for second-trimester abortion and is generally favored over other methods in late second-trimester terminations. The mean initiation to expulsion interval is reportedly shortened in spontaneous fetal death compared with intact pregnancies.1–4 However no study has evaluated the effect of pretreatment-induced fetal demise. Our objective was to compare late mid-trimester terminations with PG E2, with and without pretreatment cardiac puncture with potassium chloride.
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Materials and Methods |
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AbstractMaterials and MethodsResultsDiscussionReferences |
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Uniform guidelines for the treatment of second-trimester terminations with PG E2 during the study period were used, except for the use of pretreatment cardiac puncture with potassium chloride. The pretreatment induction of fetal death involved the transabdominal insertion of a 20-gauge spinal needle into the fetal cardiac chambers by ultrasound guidance and instillation of 2 to 3 mL of potassium chloride in a concentration of 2 mEq/mL. Cardiac standstill was observed in all cases within 1 to 3 minutes, and absence of cardiac activity was assured by continuous observation by ultrasound for at least 5 minutes. The women were given a 20-mg PG E2 vaginal suppository every 4 hours until expulsion of gestational products. Women in the cardiac puncture group had the first vaginal suppository inserted within an hour after the procedure. All women were premedicated 30 minutes before the first PG E2 suppository with the antipyretic acetaminophen, 650 mg orally, the antidiarrheal diphenoxylate plus atropine, 10 mg orally, and the antiemetic prochlorperazine, 10 mg intramuscularly. Parenteral analgesics with sedation in the form of 50 mg of meperidine and 25 mg of promethazine were administered on demand. Vital signs were monitored every 2 hours, and adverse effects, such as pyrexia, vomiting, and diarrhea, were noted. Immediately after passage of the fetus, irrespective of whether the placenta was expelled, intravenous oxytocin was administered as 20 units in 1 L of lactated Ringer’s solution at the rate of 125 mL per hour.
Gestational age was estimated using the last menstrual period where reliable or by an ultrasound done in the first 20 weeks of pregnancy. The initiation-to-expulsion interval was defined as the time from the insertion of the first vaginal suppository until expulsion of the fetus. Complete abortion was considered to have occurred when the gestational products were expelled in their entirety. Incomplete abortion was considered to have occurred when placental tissue was retained for at least 2 hours and surgical intervention in the form of completion curettage was required.
The study population was divided into groups based on the use of pretreatment cardiac puncture. The cardiac puncture group was compared with the control group for maternal age, weight, parity, race, pretreatment laminaria use, indication for termination, and cervical examination at initiation of PG E2 treatment. In addition, the groups were compared for mean gestational age at termination, mean fetal weight, the need for curettage of retained products, doses of PG E2, and initiation-to-expulsion interval.
The distributional characteristics of variables were examined. The Student t test was used to analyze continuous data. The interval to expulsion and the required doses of PG E2 were not distributed normally. Therefore, comparisons between the cardiac puncture and the control groups were done by using the Wilcoxon rank-sum test. Chi-square tests were used for categoric variables; Fisher exact test was used when expected cell frequencies were small. A P value of <.05 was considered statistically significant.
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Results |
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There were no significant differences between the cardiac puncture and control groups in maternal age, weight, parity, race, pretreatment laminaria, indication for termination, and cervical examination at initial insertion of PG E2 (Table 1
). In addition, the groups did not differ significantly when compared for mean fetal weight and the need for curettage for retained products. However the mean gestational age at termination in the cardiac puncture group (21.7 ± 1.7 weeks) was statistically different from the mean gestational age (20.3 ± 1.4 weeks) in the control group.
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The required median doses of PG E2 (2.0 comparedwith 3.0, P < .001) and the initiation-to-expulsion interval (570 minutes compared with 890 minutes, P = .006) were significantly lower in the cardiac puncture group compared with the control group, respectively.
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Discussion |
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The mechanism by which spontaneous or induced fetal death augments the action of prostaglandin used as abortificant is not known. However, we believe that the seesaw theory of Csapo7,8 might be correct. Csapo postulates that there are two major endogenous regulators of the myometrium exerting opposing effects on the uterine muscle. Prostaglandin causes contraction whereas progesterone causes relaxation. Progesterone reportedly binds calcium and consequently raises the threshold of excitability of the myometrium, whereas prostaglandin exerts the opposite effect but only when the progesterone level is low. According to this theory, prostaglandin exerts sustained myometrial effects after severing the protection offered by progesterone by causing an increased uterine tone that results in decreased blood flow and placental damage. Spontaneous or induced death by cardiac puncture with potassium chloride presumably lowers progesterone production and level allowing exogenous prostaglandin to exert maximal effect on the uterine musculature.
The retrospective nature and lack of randomization are obvious limitations of our study. It is doubtful whether randomization involving such a personal issue is feasible without preliminary reports of observational studies. The results of our study showed that besides the advantage of ensuring cardiac asystole, induction time was reduced when potassium chloride was given before PG-induced abortion.
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Footnotes |
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Received September 28, 1998. Received in revised form January 4, 1999. Accepted January 20, 1999.
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References |
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2. Hagar DL, Valley MT, Rayburn WF, Carey JC. Midtrimester pregnancy termination for fetal malformations: Use of intravaginal prostaglandin E2. J Reprod Med 1997;42:497–500.[Medline]
3. Triolo O, Fattori A, Commisso S, Maimone A, Granese D. Therapeutic abortion intrauterine fetal death in the second trimester: Treatment with a gemeprost-sulprostone combination. Minerva Ginecol 1997;49:383–91.[Medline]
4. Jain JK, Mishell DR. A comparison of intravaginal misoprostol with prostaglandin E2 for termination of second-trimester pregnancy. N Engl J Med 1994;331:290–3.
5. Evans MI, Goldberg JD, Dommergues M, Wapner RJ, Lynch L, Dock BS, et al. Efficacy of second-trimester selective termination for fetal abnormalities: International collaborative experience among the world’s largest centers. Am J Obstet Gynecol 1994;171:90–4.[Medline]
6. Berkowitz RL, Stone JL, Eddleman KA. One hundred consecutive cases of selective termination of an abnormal fetus in a multifetal gestation. Obstet Gynecol 1997;90:606–10.[Abstract]
7. Csapo AI. The see-saw theory of parturition. Ciba Found Symp 1997;47:159–210.
8. Schulman H, Saldana L, Chin-chu L, Randolph G. Mechanism of failed labor after fetal death and its treatment with prostaglandin E2. Am J Obstet Gynecol 1979;133:742–52.[Medline]
This article has been cited by other articles:
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  S. Lalitkumar, M. Bygdeman, and K. Gemzell-Danielsson Mid-trimester induced abortion: a review Hum. Reprod. Update, January 1, 2007; 13(1): 37 - 52. [Abstract] [Full Text] [PDF]
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