Second trimester medical abortion. Use of Mifepristone, Misoprostol, and Oxytocin.

1. Medical Abortion in Second
Trimester
Polyphile Ntihinyurwa, MD,MMED
Family Planning & Reproductive health Fellow
St Paul’s Hospital Millennium Medical College

2. Contents
• Introduction
• Choice of medication
• Feticidal
• Special considerations
• Conclusions
• References

3. Introduction
• The second trimester marks the end of organogenesis
• The placenta assumes the full responsibility of progesterone production
over corpus luteum
• High cervical integrity
• Highly bond decidual interface to facilitate gradient of nutrients
• Shallow concentration of PGE2 at the cervix, repressed by 15-HPGD
• The uterus has grown in size and has more receptors for CAP
• The woman has started feeling the quickening

4. Mifepristone
• A competitive progesterone receptor antagonist (relative binding affinity
>2x of progesterone)
• Antagonizes the endometrial and myometrial effects of progesterone
• Causes endometrial decidual degeneration,
• Cervical softening and dilatation,
• Release of endogenous PG, and an increase in the sensitivity of the
myometrium to the contractile effects of prostaglandins
• Alone can also reach successful abortion in 54-90% within 1-2 weeks
• Evidence suggest its combination with PGE1 analogue as the most
effective of pregnancy termination.

5. Misoprostol
• PGE1 analogue
• Most preferred
• Fewer or no side effects
• Cost-effective
• Availability
• Several routes of administration with one formulation
• Its ability to treat haemorrhage
• Can be used alone or following mifepristone

6. Misoprostol
With Mifepristone 200mg
• 200mcg-400mcg depending on GA
• Given 24-48 hours after
mifepristone
• Sublingual route is more effective
• Given every 3 hours
Alone
• 200-400mcg depending on GA
• Can be used alone if mifepristone is
not available
• As effective (>90%) but longer
induction to expulsion period
• Given every 3 hours

7. Misoprostol
Mean plasma concentrations of misoprostol acid over time
(arrow bars = 1 SD) Source: Rebecca Allen, 2009
Routes:
• Sublingual
• Buccal
• Oral
• Vaginal
• buccal has higher bioavailability
and fewer adverse effects than
oral.
• Sublingual administration has
similar efficacy to vaginal dosing.

8. • 298 patients from 2009-2018
• 94 (31.5%) received same-day mifepristone.
• Expulsion within 24 hours:
• 93.6% of the mifepristone-plus-misoprostol group
• 79.9% of the misoprostol-only group (RR 1.17,
95%CI 1.07−1.28).
• Expulsion within 12 hours:
• 56.4% of the mifepristone-plus-misoprostol group
• 34.0% of the misoprostol-only group (RR 1.66,
95%CI 1.28−2.16).
• After adjusting for demographic and clinical
characteristics:
• Expulsion within 24 hours: similar (RR 1.07,
95%CI 0.92−1.26),
• Expulsion within 12 hours remained different
(RR 1.69, 95%CI 1.01−2.83).
• Median time to expulsion was shorter in the
mifepristone-plus-misoprostol group (689
minutes vs 901 minutes, p < 0.001).
Published: September 13, 2021 DOI: https://doi.org/10.1016/j.contraception.2021.09.006

9. Oxytocin
• Mifepristone 200mg 24 hours prior
• 1 hour of no oxytocin after each 500ml of
oxytocin-containing N9 to allow diuresis
• Success rate is 100% but no significant
difference relative with misoprostol (96%)
• fever and shivers was lower with Oxytocin
regimen
• Time to expulsion
• Oxytocin: 13.3 hours
• Misoprostol: 7 hours
Williams Obstetrics, v24

10. The use of foley catheter
• No sufficient literature on the use of foley catheter for abortion
• In Egypt: A comparison of 100 women (16±3W) on misoprostol 400μg q4hours PV
and 100 women (17±3W) with combined foley bulb inflated with 50mml saline
• Induction to abortion: 12.76 ± 1.63 vs 8.16 ± 1.52 hours
• No significant difference in complications and acceptability
• The combined group were more likely to recommend the method
• Higher satisfaction in the combined group
Mohamed R. et. al, 2015

11. Pregnancy above 20 weeks
• Considered in much literature as preterm delivery
• The term abortion remains used if the intention is to terminate
the progression to a live birth
• 35% of neonates born 20-23Weeks present signs of survival for a
few hours

12. Survival rates
Among 106 neonates born 22-23 weeks in Germany (Katrin M. et al, 2016)
• 86 infants (81%) received active care.
• 22 (26%) survived without severe complications
In USA, data from 2013-2018 among 10 877 infants born at 22-28
weeks: (Bell, E. F., et al, 2022)
• 78.3% survived to discharge
• 10.9% at 22 weeks
• 94.2% at 28 weeks

13. Combinations of signs of life in the first hour after delivery at
20–23 weeks gestation (CESDI data only).
P I Macfarlane et al. Arch Dis Child Fetal Neonatal Ed
2003;88:F199-F202
Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
Data in UK 1995-200 on deliveries
between 20-23W
• 869 fetuses were recorded
• 65% (565) died before delivery
• 35% Were live births
• 8% survived the first year of life
• Survival time at 20W: 80min median
• Survival time at 23W: 6hrs median,
Observed signs of life

14. Preventing transient survival
• Evidence demonstrates that digoxin, KCL, and lidocaine are all effective in inducing fetal
demise. Intra-fetal administration of digoxin is superior to intra-amniotic digoxin
administration.
• Administration of feticide using intracardiac KCL may shorten the abortion experience.
• Limited data from observational studies also supports an increase in maternal side
effects and/or complications related to the administration of digoxin.
Tesfaye H. Tufa. et. al. 2020

15. Incomplete abortion
• Clinical evaluation for the
need to give mifepristone
• If bleeding, surgical is
best recommended to
evacuate the uterus and
control the bleeding
WHO, Abortion care guidelines, 2022

16. Missed abortion
WHO, Abortion care guidelines, 2022

17. Pain management
• Analgesia or anesthesia similar to other laboring clients
• Intermittent narcotic administration
• Tramadol
• Pethidine
• Some clients may prefer epidural analgesia
• NSAID
• Ibuprofen
• Diclofenac

18. Advantages of 2nd Term Medical Abortion
• Allows morphologic evaluation in case of malformation
• Gives a chance to the mother to hold the fetus if desired
• Offers awareness of the abortion process to the mother as
the essential of labor and delivery experience

19. References
• Mehler K, Oberthuer A, Keller T, et al. Survival Among Infants Born at 22 or 23
Weeks’ Gestation Following Active Prenatal and Postnatal Care. JAMA
Pediatr. 2016;170(7):671–677. doi:10.1001/jamapediatrics.2016.0207
• Bell EF, Hintz SR, Hansen NI, et al. Mortality, In-Hospital Morbidity, Care
Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-
2018 [published correction appears in JAMA. 2022 Jun 7;327(21):2151]. JAMA.
2022;327(3):248-263. doi:10.1001/jama.2021.23580
• Shay RL, Benson LS, Lokken EM, Micks EA. Same-day mifepristone prior to
second-trimester induction termination with misoprostol: A retrospective cohort
study. Contraception. 2022;107:29-35. doi:10.1016/j.contraception.2021.09.006