Second Trimester Abortion practices in Eastern Hilly District of Nepal: A Cross-Sectional Study

Introduction: Second-trimester abortion comprises 10-15% of total cases worldwide because of maternal disease, fetal anomalies, and delay in obtaining first trimester services during unintended pregnancies. The availability of legal safe abortion services with skilled hands is limited in rural hilly areas of Nepal. Unsafe and delays in seeking abortion services in resources poor countries like Nepal are contributing to maternal mortality and morbidity. This study aims to describe the demographic profile of patients, indications, and methods of second-trimester abortion with possible complications and family planning acceptance in the rural hilly areas of Nepal. Methods: A retrospective cross-sectional study was conducted at Ilam District Hospital in Province 1 of Nepal. The study sample comprises 75 patients who were admitted for abortion services in 1 fiscal year period from 16th July 2017 to 15th July 2018. Data for all the patients who received second-trimester abortion services were retrieved from Health Management Information System (HMIS) logbook maintained by the Hospital. Descriptive analysis was performed. Ethical approval for this study was obtained from the Nepal Health Research Council (Ref. No- 1921). Results: Most common age group seeking second-trimester abortion were 20-24 years(26.66%) and the majority of women who participated in this study were literate up to secondary level education(58.66%). Most participants belonged to janajati/adibasi caste(73.33%) and were from Ilam districts(72%).Most of the cases were in the early second trimester (62.66%) and were multiparous (60%). Common indications for termination of pregnancy were mental/maternal cause(82.66%) and medical induction was most (69.33%) common method. No major complications were found following abortion. The majority of participants chose short-term contraception (36%) following the termination of pregnancy. Conclusions: Awareness and availability of legal safe abortion services at local health facilities can reduce delays in seeking abortion services, prevent unsafe abortion practices, and reduce maternal morbidity and mortality.

Availability of Safe Second-Trimester Abortion Services in Health Facilities in Accra, Ghana

Background Despite a liberal abortion law, access to safe second trimester abortion services in Ghana are challenging for many women. This study sought to examine providers, methods employed, cost, and other determinants of availability of second-trimester abortion services in health facilities in Accra, Ghana in 2019 to inform policy and program decisions. Methods A two-stage mixed quantitative and qualitative study designs were employed in the conduct of this study. The first stage was a short interaction of the mystery client with a clinical care provider to identify health facilities that provide second trimester induced abortion, the cost, and referral practices, where the facility did not have the service. The second stage was in-depth interviews of second-trimester abortion care providers and non-providers in various health facilities. For internal validity, it also explored the procedure cost, referral, and other practices at the health facilities included in the study, independent of what was captured in the mystery client survey. Results Second-trimester abortion services in Accra, Ghana are widely unavailable even in most facilities that provided abortion services. Referral policies and practices indicated by the service providers at various facility levels were inadequate. Criminalization of the procedure, social stigma, and fear of complications are the main factors that adversely influence the availability of second-trimester abortion in health facilities in Accra. Conclusions Albeit increasing demand for second-trimester abortion in health facilities in Accra, services are not readily available due to the ambiguity of the law, its interpretation, and limited flow of accurate information on providers. Policies and programs that limit access to Second-trimester abortions in Ghana are amendable to ensure safe services.

Induction of Abortion in the Second Trimester by Misoprostol or Misoprostol with Letrozole

Background Abortion is the termination of pregnancy by any means (surgical or medical) before the age of viability. The definition varies in duration of gestational age according to the countries and available facilities. Estrogen is important in the maintenance of pregnancy. Aromatase inhibitors such as letrozole, suppress the peripheral conversion of androgen to estrogen, the use of letrozole combined with vaginal misoprostol was more effective than misoprostol alone in termination of pregnancy. Objective Assessing the efficacy of addition of letrozole to Misoprostol in medically induced abortion in the second trimester of pregnancy in the Maternity hospital of Ain Shams University. Methods This clinical trial was conducted at Ain Shams University Maternity hospital in the period between December 2018 and May 2019. Patients that seem to be fulfilling the inclusion criteria were recruited, then informed written consent was taken from every patient before starting the examination That was followed by detailed history and examination of all patients to confirm fulfilling the inclusion and exclusion criteria. Results This study demonstrated that 10 mg letrozole for three days followed by 800 mcg of vaginal misoprostol is more effective than misoprostol alone for second trimester abortion. In the total of 72 women were recruited the complete abortion rate of the letrozole group was significantly higher than that of the control group (61,1% in the letrozole group compared with 33,3% in the control group). Conclusion s: The use of letrozole in addition to misoprostol was associated with a higher complete abortion rate, shorter induction to abortion interval and shorter curettage rates compared to a placebo followed by misoprostol in patients undergoing induction of abortion between 12 & 24 weeks gestation.

Endometrial Osseus Metaplasia during Infertility Evaluation: A Case Series

Aims: To highlight the pathogenesis of endometrial osseus metaplasia, its importance as a rare cause of infertility and the benefit of hysteroscopic evaluation of infertile women with risk factors for osseus metaplasia. Presentation of Case: A diagnosis of endometrial osseus metaplasia was confirmed histologically in three women undergoing diagnostic hysteroscopy as part of infertility evaluation. They all had chronic vaginal discharge and a preceding history of induced second trimester abortion. Two of the patients were referred for evaluation before in-vitro-fertilization (IVF). Hysteroscopy was done with a 30° telescope, initially using a 2-channel diagnostic sheath, which was later replaced with a 4-channel operating sheath for tissue retrieval. Discussion: Endometrial osseus metaplasia is a rare condition characterized by the presence of mature or immature bone in the endometrial cavity. Endometrial retention of embryonic tissue following an abortion is the commonest theory of etio-pathogenesis. It is an important cause of infertility and while other causes of infertility can be easily by-passed in an IVF cycle, endometrial factors may not be addressed by IVF alone, as a defective endometrium is a risk for failure. Although there is no consensus on routine hysteroscopy for women undergoing IVF, it is the mainstay of evaluation and treatment of women with endometrial osseus metaplasia. Conclusion: Only complete removal of metaplastic tissue would restore fertility, in patients with osseus metaplasia. Hysteroscopy done in infertile women with risk factors for endometrial osseus metaplasia may enhance early treatment and ultimately increase successful spontaneous and IVF pregnancy rates.

Disruptions to Abortion Care in Louisiana During Early Months of the COVID-19 Pandemic

Objectives. To examine changes in abortions in Louisiana before and after the COVID-19 pandemic onset and assess whether variations in abortion service availability during this time might explain observed changes. Methods. We collected monthly service data from abortion clinics in Louisiana and neighboring states among Louisiana residents (January 2018–May 2020) and assessed changes in abortions followin pandemic onset. We conducted mystery client calls to 30 abortion clinics in Louisiana and neighboring states (April–July 2020) and examined the percentage of open and scheduling clinics and median waits. Results. The number of abortions per month among Louisiana residents in Louisiana clinics decreased 31% (incidence rate ratio = 50.69; 95% confidence interval [CI] = 50.59, 0.79) from before to after pandemic onset, while the odds of having a second-trimester abortion increased (adjusted odds ratio [AOR] = 51.91; 95% CI = 51.10, 3.33). The decrease was not offset by an increase in out-of-state abortions. In Louisiana, only 1 or 2 (of 3) clinics were open (with a median wait >.2 weeks) through early May. Conclusions. The COVID-19 pandemic onset was associated with a significant decrease in the number of abortions and increase in the proportion of abortions provided in the second trimester among Louisiana residents. These changes followed service disruptions. (Am J Public Health. Published online ahead of print June 29, 2021: e1–e9. https://doi.org/10.2105/AJPH.2021.306284 )

Abdominal ectopic pregnancy complicated with a large bowel injury: a case report

Background Abdominal pregnancy accounts for 0.6 to 4% of all ectopic pregnancies. Due to delays in diagnosis and difficulties in the management of abdominal pregnancy, the risk of mortality is significantly higher than for uncomplicated ectopic pregnancies. Case summary A 23 years-old gravida-II, ectopic-I Ethiopian woman was initially managed as a case of missed second trimester abortion. Later on, abdominal ectopic pregnancy was diagnosed with ultrasound and she underwent a laparotomy. Though fetus and placenta was removed successfully without significant hemorrhage, there was inadvertent sigmoid colon injury. Conclusion In the management of abdominal ectopic pregnancy, the possibility of bowel injury during entry to the abdominal cavity at laparotomy should always be considered and an experienced general surgeon should always be in attendance before opening the abdomen, to prevent it from happening.

A Rare Presentation of Transvaginal Septum in Second Trimester Abortion: A Case Report

Background: A transvaginal septum occurs if these two tissue groups do not fuse properly by 5 months of embryonic life. The recommended mode of safe termination for second trimester pregnancy with a diagnosis of high transverse vaginal septum is cervical preparation followed by septostomy and dilation and curettage. Case Summary: A 28 years-old gravida-II Para-I (alive by CS for unknown indication) presented at gestational age 15 weeks plus 6. Hysterotomy was done for an indication of septic inevitable missed second trimester abortion plus presumptive diagnosis of high vaginal septum. Conclusion: According to the case reports that has been reported, the recommended management for safe termination of second trimester pregnancy with a diagnosis of transvaginal septum is good cervical preparation followed by septostomy and dilation and curettage (D&E).