Abstract
Objective
Compare complication rates of second trimester induction for abortion or fetal demise
for patients with and without prior cesarean delivery.
Study design
Retrospective cohort study examining induction for abortion or fetal demise for pregnancies
from 14w0d to 23w6d gestation at 2 urban academic medical centers from 2009 to 2019.
Exclusion criteria included preterm labor or cervical insufficiency, neonatal interventions,
or if misoprostol was not the primary induction method. Complication rates were compared
between those with no prior, 1 prior, and 2 or more (2+) prior cesarean deliveries.
Complications analyzed were retained placenta, failed induction, infection, hemorrhage,
blood transfusion, uterine rupture, intensive care unit admission, death, and readmission.
Secondary analysis included cumulative misoprostol dosages and complete abortion rate
within 24 hours.
Results
Of 520 patients, 411 patients had no prior cesarean delivery, 77 had 1 prior cesarean
delivery, and 32 had 2+ prior cesarean deliveries. Eleven patients had a prior vertical
uterine incision. About 26.5% of all patients received mifepristone. The 2+ prior
cesarean delivery group was significantly older (35 vs 32 vs 32, p < 0.001) and more likely to be induced for fetal demise (62.5 vs 41.56 vs 39.17%,
p = 0.04). Both cesarean groups were more likely to be obese (58.62 vs 49.35 vs 34.26%,
p = 0.003). Patients with 2+ prior cesarean deliveries were more likely to experience
uterine rupture (6.25 vs 0 vs 0%, p = 0.004), and require ICU admission (6.45 vs 1.3 vs 0.49%, p = 0.02). Secondary analysis outcomes were similar. Logistic regression showed patients
with 2+ prior cesarean deliveries were more likely to experience a complication than
those with 1 prior (adjusted odds ratio [aOR] 2.71, confidence interval [CI] 1.09–6.86,
p = 0.03) or 0 prior cesarean deliveries (aOR 3.00, CI 1.30–7.02, p = 0.01). Patients with 1 prior or no prior cesarean deliveries had a similar risk of
experiencing a complication (aOR 1.11, CI 0.64–1.89, p = 0.7).
Conclusions
Most patients with prior cesarean deliveries can safely undergo induction in the second
trimester for abortion or fetal demise. Patients with 2+ prior cesarean deliveries
had a higher rate of at least 1 complication when compared to those with one or no
prior cesarean delivery, despite similar misoprostol dosages and rates of complete
abortion.
Implications
This large 10-year retrospective study examines the impact of prior cesarean delivery
on the safety of second trimester induction. While second trimester labor induction
abortion remains an option for all patients, specialized counseling for patients with
2 or more prior cesarean deliveries may be warranted.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to ContraceptionAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
Vital statistics of the United States, 1990, vol I, natality. Washington: 1994. https://www.cdc.gov/nchs/data/vsus/nat90_1acc.pdf.
- Births: final data for 2009.Natl Vital Stat Rep. 2011; 60: 1-70
- Births: final data for 2019.Natl Vital Stat Rep. 2021; 70: 1-51
- Safe prevention of the primary cesarean delivery.Am J Obstetr Gynecol. 2014; 210: 179-193https://doi.org/10.1016/j.ajog.2014.01.026
- NIH consensus development conference draft statement on vaginal birth after cesarean: new insights.NIH Consens State Sci Statements. 2010; 27: 1-42
- Abortion incidence and service availability in the United States, 2014.Perspect Sex Reprod Health. 2017; 49: 17-27https://doi.org/10.1363/psrh.12015
- Women's decision making regarding choice of second trimester termination method for pregnancy complications.Int J Gynecol Obstetr. 2012; 116: 244-248https://doi.org/10.1016/j.ijgo.2011.10.016
- Risk of uterine rupture during labor among women with a prior cesarean delivery.N Engl J Med. 2001; 345: 3-8https://doi.org/10.1056/NEJM200107053450101
- Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.N Engl J Med. 2004; 351: 2581-2589https://doi.org/10.1056/NEJMoa040405
- Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review.BJOG. 2009; 116: 1151-1157https://doi.org/10.1111/j.1471-0528.2009.02190.x
- Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery.Obstetr Gynecol. 2009; 113: 1117-1123https://doi.org/10.1097/AOG.0b013e31819dbfe2
- Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies.Am J Obstetr Gynecol. 2016; 215: 177-194https://doi.org/10.1016/j.ajog.2016.03.037
- Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion.Obstetr Gynecol. 2011; 118: 601-608https://doi.org/10.1097/AOG.0b013e318227214e
- Mifepristone in second-trimester medical abortion.Obstetr Gynecol. 2007; 110: 1304-1310https://doi.org/10.1097/01.AOG.0000289577.32274.a5
Illinois Maternal Morbidity and Mortality Report. 2018.
- Misoprostol complications in second-trimester termination of pregnancy among women with a history of more than one cesarean section.Obstetr Gynecol Sci. 2020; 63: 323-329https://doi.org/10.5468/ogs.2020.63.3.323
- Misoprostol for second trimester pregnancy termination in women with prior caesarean section.BJOG. 2005; 112: 97-99https://doi.org/10.1111/j.1471-0528.2004.00285.x
- Midtrimester abortion using vaginal misoprostol for women with three or more prior cesarean deliveries.Int J Gynecol Obstetr. 2010; 110: 50-52https://doi.org/10.1016/j.ijgo.2010.02.008
Article Info
Publication History
Published online: June 24, 2022
Accepted:
June 17,
2022
Received in revised form:
June 13,
2022
Received:
March 22,
2022
Footnotes
Conflict of interest: None.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
