When a woman changes her mind about having a pregnancy termination—Pregnancy outcomes after laminaria tent removal Adelicia Yu, MD, Helen Pymar, MD, MPH. University of Manitoba, Women’s Hospital Health Science Centre, St. Boniface Hospital Abstract Methods Continued Results Continued Discussion Continued OBJECTIVE: Assess the effect of laminaria tent insertion and removal on pregnancy outcomes. STUDY METHODS: A retrospective cohort study of women who continued a pregnancy after presenting for an abortion at Women’s Hospital, Winnipeg, Manitoba, from April 1999 to March 2010, compared pregnancy outcomes between women who had laminaria tents inserted (LT) and women who had no cervical ripening (no-LT). Hospital chart codes and a survey of abortion providers identified 109 cases. Twenty-eight charts were coded incorrectly, two charts were lost, and fifteen patients’ abortions were cancelled or delayed by the physician. Of the remaining 64 patients, 39 women had laminaria tents and 25 had no cervical ripening. RESULTS: The two groups were similar in age (LT 25.5 years, SD=7.8, n=39; no-LT 24 years, SD=6.1, n=25) and gravidity (LT 3.7, range=19, n=38; no-LT 4.2, range=115, n=24). At the scheduled abortion, the LT group’s mean gestational age was 12.7wk (range=7.3wk20.6wk, n=36) and no-LT’s, 10.7wk (range=6wk17.7wk, n=26). Pregnancy outcomes were found for 74% (29/39) of the LT group and 96% (24/25) of the no-LT group. Nine women (31%) who had LTs terminated their pregnancies compared to eight (33%) in the no-LT group. The LT group who continued their pregnancies (n=20) had five (25%) spontaneous abortions, five (25%) preterm deliveries (mean=31wks, range=23wk35.6wk), and ten (50%) term deliveries. The no-LT group (n=16) had two (12.5%) spontaneous abortion, two (12.5%) preterm deliveries (30wks&36.1wk), and twelve (75%) term deliveries. Both groups had one pregnancy loss after 20 weeks. CONCLUSION: After deciding to continue with a pregnancy, those with LTs inserted were less likely to carry to term. • Pregnancy Outcomes: • Terminations: • A similar proportion of patients eventually decided to terminate their pregnancies in both groups. • Outcomes of the Patients who Decided to Continue the Pregnancy: • The LT group had more spontaneous abortions, more preterm deliveries, and less term deliveries. • The GA was earlier in the preterm LT group (LT 31wk; no-LT 33wk). • These findings help quantify the risk to the pregnancy after LTs are inserted and removed. • The cervix may be affected by the physical trauma of LTs being placed. • Ascending infection may affect the pregnancy, despite the cervical preparations and antibiotics. • Our findings are less optimistic than the literature regarding pregnancy outcomes after laminaria insertion and removal. • Van Le and Darney, 1987 reported two term deliveries after LT insertion. • Schneider et al in 1991, retrospective study had 21 patients, of which 4/21 (19%) patients had a TA. Of those continuing the pregnancy, there were 14/17 (82%) term deliveries, 2/17 (12%) preterm deliveries, and only 1/17 (6%) spontaneous abortions. • Siedhoff and Cremer in 2009, reported 4 patients, of which two had term deliveries. • PPROM: • The LT group had more cases of PPROM. • Two patients ruptured their membranes shortly after the LTs were removed (LT removed 18.7wk, PPROM at 18.9wk; LT removed 13.6wk, PPROM at 13.9wk). • The other two PPROMs occurred more remotely from time of LT removal (LT removed 13.1wk, PPROM at 17wk; LT removed 15.3wk, PPROM at 34.6wk). • One PPROM in the no-LT group occurred at 30 weeks gestation; the TA was scheduled at 9.1 weeks. • All PPROM cases were prescribed antibiotics at time of LT removal. • As half the PPROMs occurred within a few days of LT insertion and removal, there could be an element of mechanical forces damaging the membranes as well as ascending infection. 109 cases identified by hospital code for patient changing her mind or identified by the provider from April 1, 1999 to March 31, 2010. 2 charts lost 107 charts reviewed 28 charts coded incorrectly Background 79 cases • Cervical Priming and Pregnancy Outcome: • Abortion providers often prime the cervix prior to dilation and evacuating the uterus. • Cervical priming methods are misoprostol or osmotic dilators, such as laminaria tents (LT) and dilapan. • Therapeutic Abortions in Winnipeg: • Health Sciences Center Women’s Hospital is the only hospital in Winnipeg, Manitoba that performs therapeutic abortions (TA). • The catchment area is Manitoba, Nunavut, and Northwestern Ontario. • In 1999, Women’s Hospital began tracking patients that presented for the scheduled abortion to cancel the procedure and continue the pregnancy. • There are multiple providers of first and second trimester procedures. • There is no set protocol for cervical priming at Women’s Hospital. • The majority of cases of cervical preparation with misoprostol, LTs, or dilapan. 64 cases with the patient deciding to continue with the pregnancy 15 cases cancelled or delayed by the physician Discussion • Incidence: • The patients who decided to continue the pregnancy are 0.19% of all abortions performed at Women’s Hospital over 12 years. • The 39 patients with LT insertion and removal are 0.12% of all abortions or 0.16% of abortions with LTs (using a conservative estimate of 2000 abortions with LTs each year). • Schneider et al, 1991, reported 1.1% out of all abortions with laminaria tents inserted. • The number of ambivalent women from outside of Winnipeg may be reduced because only motivated women surpass the barriers to care, such as arranging travel, accommodations, and appointments. • Dedicated nurses and social workers counsel patients regarding their pregnancy options, decreasing the number of ambivalent patients. • Patients receive specific counselling about risks of LTs. • LTs may be removed by another physician or be spontaneously expelled. • Demographics: • The two groups are fairly similar overall. • The patients with laminaria tents (LT group) had more smokers. • The LT group was approximately 2 weeks further along in mean GA at time of intended TA. • This likely reflects the practice to dilate to a greater diameter with a higher GA. • There are more cases lost to follow up in the LT group. • Removal of Laminaria Tents: • Eighty-nine percent (34/38) of patients had their LTs removed by a physician. • Most patients (29/33, 88%) were prescribed antibiotics after LT removal. • Three patients (13%) were admitted and administered IV antibiotics with symptoms of a septic abortion, such as fever, chills, foul vaginal discharge, and tender uterus. • All of these pregnancies ended, either spontaneously or by dilation and curetting, within 1-3 days of the LTs being removed at 14.9wk, 15.1wk, and 17.3wk. • No patients in the no-LT group had any symptoms suggestive of a septic abortion. • LT insertion and removal increases the risk of septic abortion. 39 cases of LT insertion and removal 25 cases with no cervical ripening • 8 cases of patients not being NPO • 4 cases of GA >20 weeks • 1 case of no parental consent • 1 case required anesthesia support • 1 case of patient being in active thyroid storm • 9 had a TA • 5 had SA • 5 delivered preterm • 10 delivered at term • 10 cases were lost to follow up • 8 had a TA • 2 had SA • 2 delivered preterm • 12 delivered at term • 1 case was lost to follow up Results Conclusions * From Statistics Canada; # From Women’s Hospital • The majority of patients deciding to continue a pregnancy after having a TA scheduled carry to term, whether or not LTs were placed and removed. • A larger proportion of pregnancies are term deliveries if they do not have LTs placed. • Patients should be counselled that after LT insertion and removal, they are more likely to have a SA, preterm delivery, PPROM, or septic abortion, despite the findings that half of the deliveries are carried to term. • Misoprostol taken by the patient upon arrival to the facility can be an alternate cervical ripening method to prevent these iatrogenic outcomes. • This is the largest study regarding pregnancy outcomes after LT placement and removal. Methods • Patients electing to continue a pregnancy after presenting for a therapeutic abortion were identified by hospital chart codes and by surveying abortion providers. • Demographics and information about the intended abortion and outcome of the pregnancy were collected. • If the Health Science Center chart did not have the pregnancy outcome, the chart at the other Winnipeg obstetrical hospital was reviewed. • Pregnancy outcomes in those who had cervical ripening before they decided to continue the pregnancy were compared to those who did not have cervical ripening. • The study was approved by the Bannatyne Campus Health Research Ethics Board. • The research protocol was approved by the Department of Research at Health Sciences Centre and the Research Review Committee at St. Boniface General Hospital. References Van Le, L, Darney PD. Successful pregnancy outcome after cervical dilation with multiple laminaria tents in preparation for second-trimester elective abortion: A report of two cases. Am J Obstet Gynecol. 1987. 156(3): 612-613. Schneider, D, Golan, A, Langer, R, Caspi, E, Bukovsky, I. Outcome of continued pregnancies after first- and second- trimester cervical dilation by laminarian tents. ObstetGyneocol. 1991. 78(6): 1121-1123. Siedhoff, M, Cremer, ML. Pregnancy outcomes after laminaria placement and second-trimester removal. ObstetGyneocol. 2009. 114(2, Part 2): 456-458.