Second Trimester Abortion From Every Angle

Second

Trimester

.6.L\.bortion:

Fl.om Every Angle Fall Risk Management Seminar September13-14, 1992 Dallas,Tex.as

.~ 1.-

U

~

NW

...I~

w--=M;-.=.

~

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De!:J.';gr~prucs of Second Trimester ..\bortion -Stanley Henshaw, Second Trimester .A.bortions in the United States (Grimes)

PhD ...

Genetic Indications -Nathan Slotnick.. MD Medical Genetics for the Practitioner (Slotnick.) Designing

an Appropriate

Facility

-Jacqueline

..7

Barbic

WhenClinic.sNeedHelp(DHHS) Second Trimester

11

D&:E, 14-19 \Vks -E. Steven I..ichtenberg,

F..arly D&:E Procedure,

13.5-

19.0 \Vb

MD, MPH

(I.ichtenberg)

l7

Second Trimester D&:F., 14-19 'W1c.s -Gene Click, MD Secong-'-

iJGlick)

~

21

Second Trimester D&:X. 20 Wk.s and Beyond -Martin HaskeU. MD D &. E for Late Second Trimester Abortion (HaskeU) Trimester D&cX. 20 WU and Beyond .james T. McMahon, Late Pregnancy Interruption: Key Points (McMahon)

27 MD .35

Second Trimester D&:E. 20 WkJ and Beyond. Paul Wright. MD Method for Late Trimester Abortions (Wright)

.37

Second Trimester Techniques: Abortion: Epidemiology,

.39

Medial Inducnon. Vanessa Cu1linJ, .\m S~r.ety& Technique (Blumenthal)

Prevention of Complications. Warren Hem. MD. MPH. PhD Correlation of Fetal Age &c Measurements (Hem) Serial Multiple T ~rn;naria &c Adjunctive Ure.a (Hem) Use of Prostaglandins

as Abortifacients

47 55 61

Etbicallssues in Second Trimester Abortions -joan Callahan, PhD Elective Abortion: The Mor2l Debate (Knight &cCaDahan)

69

Patient. Responses to Late Procedures -Anne Baker, MA Reasons for Second Trimester Abortion (Baker)

83

Com~r~h~nsiv~

87

Biblio~~h~

on Second

Trimester

Abortion.

Dilation and E~tr3.ction for Late Second Trimester .01..bol"tion Martl.1 Haskeil. M.D

Presented at the ~ational AbortIon Federatlon Risk Manarement Semlnar. September l3. 1992

INTRODUCTION .-/

The surgical method described in this paper dif!ers from classic D&E in that it does not rely

upon dismem~rment

to remove

the

fetus.

Nor are lDductlons

or

infUS10M used to expel the intact fetus

adequately dilated cervix. The author has coined the term Dilaliol\ and Eztractiol\ or D&X to distinguish it from dismembennent.type D&E's. This p~dUJ'e

can be perfonned in a properly e~pped

\Ulder local anesthesia.

It can be U3ed successfully

physician's office

in patients

20.26 weeks 1n

pregnancy, The

author

hu

performed

oyer

700 of these

pn)CSdures

with

a low

rate

of

oomplications.

BACKGROUND

D&E evolved u an alternative trimester hospital pirt

abortion facilities

in the mid allowiDr

1970's.

a "right

abortionl

now~ ~lution

started in the second trimester

27

methods for second

This happened in part because of lack of

second trlmester

because surgeon.s ~ded

inadvertently

to i.nductioD or inatillatioD

in some glocraphic

areas. in

to complete suction abortIons

and in part to provide a means 0( early

se~ond

tnrnestcr

abortlon

to avoId

North Carolin3

Conference

s9cond trlmester

abortlons

~e.;eS.5ary delays

in 19i5 established

ior

be difficult Consequently,

the fetus inslde the uterus 'Nlth

the pieces through M (Jdequate!y dilated cervix.5

most surgeons find dismemberment

due tO the

:

in the U .5.2, 3, 4

and removing

However.

methods.

D&.E as the preferred method :or

Classic D&E is accomplished by dismemberIng Instruments

instIllatIon

toughness

most la~

0{ fetal

second trimester

tissue!

abortions

at twenty at thl-'

weeks and beyond to 8tage of development

are performed

by an indu(:tion

method.6, 7, 8 Two techniques

of late sea:;nd trimester

D&E's have been descnbed at preV1OUS

The r1rSt relies on sterile urea intra.amniotic

NAF mHtlngS.

demise and lysis (or softaning) The second technique

and cut the umbilical There are attendant In 8wnmary, to induce early r.tal

of fetal twues is to rupture

cord.

prior to surgery.9 the membranes

Fetal death and ensuing

risks of infectjon with ~ approaches demi"

24 hours prIor to surgery

autolyw

soften the tissues.

method.

to late second trimester

to ~ften

infusion to cause fetal

D&£'8 rely upon ~me means

the fetal ti88ues making dismemberment

easier

PATIENT SELEcrION

The author I weeka patienta

LMP

with

25 throurb The autbor

routinely certain

exceptions.

26 w..k.s reCen

performs

this

procedure

The author

on all patients

20 through

performs the procedure on selected

L..\fP .

for induc~n

patients

falling

into the r~owinr

categories:

, Pt'eviou, C-l8Ction ove'lr 22 weeks Obese pattent.s (more than 20 pound. over larle Cram. ide~ weight) Twin pregnancy over 21 weeks Pat.ient.l 26 weeks and over 28

24

DESCRIP!'rOS

Dilation

OF DII-A.TION

and extraction

A.1'.[DEXTRACTIO~

METHOD

takes place over three days. In a nutShell. D&X can be

described as follows Dilation MORE DILATION R.eal.time ultra.sound v~ualization Vers1On (a.s n~ded) IntactextractioD Fetal sk\.Lll ~mpreso&ion Removal Clean-up Recovery Dav

1. Dilation

The patient

is evaluated

scales are used to interpret In the operating mm.

an ultrasound.

all ultrasound

2 .More

and Rh.

Hadl0<:k ,

measu~ments.

hydroscopic dilators

and dilated to 9.11

are pl~ced in the cervix.

goe.i home or to ,a motel overni(bt.

Dilation

The patient are rvmoved.

hemoglobin

room, the cervix is prepped. anesthesized

Five. six or $even large Dilapan

The patient

Da!

with

retUmI

The cervix

tQ the operating illCrUbbed

room where the previous

and anesthesiz.ed.

Between

day's Di1Apan

l~ and 25 Dilapan

are placed in the cemcaJ canal. The patient returns home or to a motel overnight.

Da~

3 .The

Oneration

The patient

returns

to the operating

room where the previous

day's Dilapan

are removed. The surgical asaistant administers 10 IU Pitocin intramuscularly ~rvix

ia scrubbed. anestb..ized

and grasped with a tenaculum

ruptW'8d. if they are not already.

29

The

The membranes are

The surgical

assistant

places an ul~rasound

and scans the fetus. locatlng

the IowfT' ex~remlties.

information

about the orientation

extremities.

The trnnducer

The surgeon through

probe on che patient-'.; abcQrr.e:,. This

scan

provlde.s

of the fetU-' and approxlma~

is then held in po$ition over the lower extremltles

introduces

of fetal orientation.

the fetal lower extremitjes.

a large grasping

forcep. $uch as a Bierer

he moves the tip of the instrument When the instrument

The surgeon then applies firm traction

or Hern

Based upon his

ca.refully toward3

appears on the sonogram

the surgeon is able to open and close its jaws to finnly extremity.

~urgec

location of ..he lower

the vaginal and cer'V1cal canaLs into the corpus of the uterus.

knowledge

the

and reliably

to the instrument

screec.

grasp a lower

c.ausing a version

of the fetus (if necessary) and pulls the extremity into the vagina. By observing

the ultruound

the movement

~.

inappropriately

of the lower extremity

the surgeon is auured

rruped

his instrument

has not

a matemaJ 3tnlcture.

With a lawer extremity

in the vagina. the ~n

the opposite lc'wer extremity, then the to~, The akull

that

and version of the fetUS on

IodCM at the internal

ua.

hia' fingers

to deliver

the show den and the upper extremltles

~rviea1

08.

Usually the"

i.s not enough

dilation for it to p... through. The fetus ~ oriented dorsum or'lpine up. At th1a point.

the back at the fe~ finl.rs

(palm

down).

the right.handed

surgeon

the fin~n

and ~hooks- t.h. shoulden of the fetus .ith

of the left

had along

the index and ring

Next he slides the tip or the middle finger along the sp1Ile

towarda the 1ku11 while applYlng traction

middle finllr

slidu

tQ the .houlden

and Jower extremitle!.

The

lil'ta and pushes the anterior cervical lip out of the way.

Wbile maintaining this tension. lil\inr

the cervix and Ipplyinr

tracuon to the

shoulden with the rInSers of the left hand, the I'Urweon tak.. a pair of blunt curved Metzenbaum ICiIIon in the right hand. He careCully advances the tip. curved down.

30

.-" ...~

Rea$sessmg proper placement 0( ~he closed SClS.iOrStlp and ~afe elevatIon of the

the opening.

hole and evacuates the skull contents. With traction

to the fetus. removin&,

It compietely

the catheter

from

still

in place. he applies

the patIent.

Recovery

timu

they are Deeded.

ANESTHESIA

l.L~-il!.

anesthesiL

1% with

epinephrine

NitroQ-oxideloxyien

For the Di~pan

inaert and Dilapan

admimstered

analgesia

~

intra-cervlcally

is administered

nasally

~

u

the

standard

an adjunct.

change. 12cc's is u.Ied in 3 equidi8tant

locatlons

around the cervix. For the surgery , 24cc's is used at 6 equidistant spota. CarbocaiII.

1" is iubstitutad

for lidocaine

sensitivity.

31

for patienu

who expreaaed lidocaine

.\1ED I CA TIONS

All patIents

not allerg1c

to tetracycline

by mouth daily for 3 days beginning Patients disease

receive

additional

with

WI

history

additional

analog-ues receive

doxycycline

200 m~

Day 1 0( gonorrhea.

doxycycline.

chlamydia

lOOmgm

or pelvic inflammatory

by mo\lth

twice

daily

for six

days

Patienu Ergotra~

allergic

to tetracyclines

are DOt given proplylactic

0.2 mg'm by mouthrour

antibiotic.s

times daily for three days is dispensed to

each patient. Pitocin 10 IU intram\LSCularly is administsred upon removal of the Dilapan on Day

3.

Rhogam intramuscalarly Ibuprofen

i.$ provided to all Rh negative patients on Day 3

orally is provided liberally

at a rate 0{ 100 mgm per hour from Day 1

onward. Patienta with

.vere

crampa with Dilapan

dilation are provided Phenertan' 2S

mgm suppOIitorias rectally evel1 4 houn ~s needed. Rare patients

Patients

with

require

Synalogos

a hemoglobin

DC in order

tD sleep during

Dilapan

leas than 10 g/dl prior to sUllery

red blood cell traD8fUlions.

32

dilation

receive packed

-

or

to

All patientS

.

ow

.r

_4..

are glven a 24 hour

~~ 1.-.

phy51clan's

number

to cali in ca~

0( a problem

or concern. At least surgery

three

attempts

to contact

each patient

by phone one week after

are made by the office staff. All

patients

are

asked

to return

for

check-up

three

week.!

following

thelr

jurwery.

THIRD

TRIMESTER

The author is aware of one other surgeon who uses a conceptually similar technjque.

He adds additional

dila con period.

changes 0( Dila~an

Coupled with other reflnemlnts

and/or lamineria

in the 48 hour

and a slower o't'~ra!'.n~ time, be

SUMMARY

In conclusion. late second mmuter

Dilation

and Extraction

abortions to 26 weeks.

Amonr ita advantacu

~ an alternative

It can be U88d in th. third trimester.

are that it i.$ a quick. surlical outpatient method that

can be performed on a scheduJedbasis \.Inder local anesthesia.

and may not be appropriate

method for achievini

for a few pa tients.

33

REFERE~CES

1 Cates, w. Jr., ~ulz,

K.F.. Grimes O.A.. et al:

Tn.

Methcd of Choice on the ~isk of AbortIon Morbidity .Family 9:~FJ6..1977. 2 Borel" U.. Emberey, Dilation and Evacuation 131:232. 1978.

M.P., Bygdeman.

(Letter),

M.. et al:

AmerlC'an Joumal

3 Centers for Ciaease Control:

Effects of Delay and Planning Perspectives.

Mid trimester Abortion by

of Obstetnc.s and G/"ecology.

Abortion S," 't'eil/snce 1978. p. 30, November,

1980, 4 Grimes. D.A.. Cates. W. Jr.. (8erger. G.S.. et at. ed): Dilation ind EvaC\Jation. Second Trimester Aborlio'.'-Perspecti~s Wnght-PSG. 1981, p. 132. 5

lbid,

p.

121-128.

e

Ibid,

p.

121.

7 Kerenyi, T.O. (8erg.n. Trimester AbortionPSG, 1981, p. 79.

After 8 Deeaae of Expenence, Boston. Jonn

G.S.. et II. ed)= Hypertonic Saline Instillation. Second

Pef'$pecti~s

8 Hanson. M.S. (Zatuchni,

A~er a o.cad.

of Ex~ri./7C8.

Boston, John Wright-

G. I., .t a!, ed): Midtlimester Abortion:

!X'b'adion Preceded by Laminari8. Pregnancy Tem'lination Pr~edu'..r, New De\18/opment.r, Hagerstown, H~r and Row, 1979. p. 192.

9 Hem, W.M., Abortion Practice, Pt1iJadeIphia,J.S. Up~ 1~.

10 McMIhon, J., personal communications, 1992.

34

Dilation and Safety and

1990, p. 127,