2.4 Administration of anti-progesterone: the so-called abortion pill, Mifegyn® or RU486. Only effective in young pregnancies and available in most countries of the E.U, the USA and the PRC. The method is described in Chapter 6

3. SURGICAL EVACUATION OF THE UTERUS (HYSTEROTOMY)

3.1 Sectio parva. A Caesarean Sectio, but with a smaller incision, is done to remove the contents of the uterus .

3.2 Vaginal Sectio. Vaginally the uterus is incised under the cervix and the contents removed.

Both methods must be considered obsolete because there are much safer and less complicated methods.

4. MECHANICAL METHODS WHICH DISTURB THE PREGNANCY

4.1 Opening the amniotic sac to tap the amniotic fluid. This Knitting Needle Method is a well known back street method. It seldom leads to an early abortion so that the treatment has to be repeated several times, increasing largely the complication-rate. Main complications: infection, blood loss (if the placenta is penetrated), perforation of the uterine wall eventually with bowel damage resulting in peritonitis. Clostridium infection is particularly dangerous and mostly fatal. But in countries with a rstrictive law this method is often adopted by doctors. The amniotic sac is penetrated with a sterile instrument, and the patient is admitted in a hospital under the diagnosis incomplete abortion.

Reasonably safe if the patient indeed goes to the hospital and if she is promptly treated and not left in bed to wait for a spontaneous abortion.

4.2 Balloon method. A balloon catheter is brought into the uterus and then filled with fluid (preferably sterile isotone salt solution). The balloon lodges outside the amniotic sac. The pressure may lead to contractions and spontaneous abortion. Not always effective. Infection is possible, especially if the amniotic sac is ruptured.

4.3 IUD method. An IUD is brought in the uterus hoping that this will lead to a spontaneous abortion. Very unreliable. If applied in advanced pregnancies there is a grave risk of infection. If the pregnancy grows the IUD will be drawn into the uterus so that it can not be removed.

4.4 Dilation of the cervix with Laminaria Tents. Laminaria digitata is a seaweed, which is dried and compressed into tents. The tent is brought into the cervix where it expands during six to eight hours by absorbing fluid till about six times its original size and so dilates the cervix. Dilation may be increased by replacing the dilated tent for several new ones and waiting another six to eight hours. Eventually, after many hours if not days, a spontaneous abortion may arise. In most cases the evacuation has to be done manually. Apart from the long duration the procedure may lead to infection, considerable blood loss, disintegration of the tent, dumpbelling, displacement of the tent from the cervical canal into the vagina or into the uterus. The main cause of infection was the use of unsterilised laminaria pegs. The only reliable way to sterilise them is by gamma radiation.

Since Dr Rene from the Ginemedic Clinica in Barcelona showed slides of cervical tissue removed after Uterus exptirpation post abortus, (ISAD meeting Amsterdam 2003) that this gradually overstreching of the cervical tissue by osmotic dilators is harmful , clinics in Europe refrain from this procedure.

In the USA laminaria tents are still widely used.

Hazardous is the situation in which the patient does not show up anymore after insertion of the laminaria. Recently an american patient returned to the clinic, the day after laminaria insertion, and told the astonished provider that she prefered to leave the further procedure to God. The doctor said: "as you wish, so let us take the laminaria out", but the patient did not want the doctor to touch her anymore, and left the clinic. She ended up in a hospital 8 days later with a very serious peritonitis.

A modern version is an osmotic sterile peg with the same properties as laminaria. In the USA the use of these osmotic pegs: Dilapam®, or Lamicel® became popular. In advanced pregnancies sometimes 20 pegs are placed in the cervix in three stages, some six or more hours apart. This results in a dilation of 40 mm or over, where after the fetus can be removed manually like a minor version and extraction delivery. Apart from the very long duration of the procedure there is a definite risk of cervical incompetence.

Some other specific complications of the use of this type of dilators is is discussed later.

Again D&E is a much safer and quicker method. The only permissible use of osmotic dilators is to facilitate dilation in a very rigid cervix as described in Chapter 9 (page 29) and Chapter 11 (page 36). For this indication it seems better to use Misoprostol. Cytotec® Artrotec®

5. MECHANICAL EVACUATION OF THE UTERUS

 

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