Medical Interruption of Pregnancy in the Second Trimester at the Principal Clinic of the Togolese Association of Family Well-Being Planning Center (ATBEF): About 25 Cases ()
1. Introduction
Medical termination of pregnancy (MTP) is an induced abortion based on medical indications given by two independent experts in case of danger to the mother to continue the pregnancy or risk of giving birth to a child with a disease or malformation incompatible with life [1].
With the development of ultrasound and prenatal diagnostic techniques, the foetus has become a patient in its own right and the number of medical terminations of pregnancy is increasing [2]. Prenatal diagnosis in the first and second trimester is increasingly used and allows early detection of fetal anomalies [2]. Apart from foetal and maternal indications for termination, obstetric and exogenous indications are increasingly found [3]. This medical termination of pregnancy considerably reduces the number of obstetrical complications that can lead to maternal death and the number of births of children with a disease or malformation that is incompatible with life.
Nearly ten years after the start of maternity activities, this study is conducted to:
➢ determine the frequency of medical termination of pregnancy;
➢ describe the indications for medical termination of pregnancy;
➢ describe the different techniques used in medical termination of pregnancy.
2. Methodology
This was a retrospective and descriptive study conducted at the Principal Clinic of the Togolese Association of Family Well-Being Planning Center (ATBEF) covering the period from May 1st, 2012 to April 30th, 2021, i.e. a period of 9 years.
All patients who underwent a medical termination of pregnancy during the study period and whose term of pregnancy was <28 weeks of amenorrhea were included in this study. Information was collected on a survey form from the patients’ clinical records, admission and hospitalisation registers, referral forms and operative report registers.
Data were entered and analysed using Excel, World and epi-info 7.2.2.
The main variables studied were hospital frequency, diagnostic facilities, main indications, means of evacuation and maternal prognosis. For the study, the following were considered:
- Medical termination of pregnancy (MTP): any termination of pregnancy for medical reasons before 28 weeks of amenorrhoea on the basis of the date of the last menstrual period or on the basis of the ultrasound of the first trimester of pregnancy.
- Fetal termination when the cause was of fetal origin.
- Maternal termination when the cause was related to the mother’s health condition.
- Medical termination of pregnancy for obstetrical reasons when the cause was related to an obstetrical complication.
In the case of a situation requiring a Medical termination of pregnancy, the case was presented to the staff of all three gynaecologist-obstetricians, including the head of department and the seven midwives, before the decision was made. Once the decision was made, a discussion was held with the couple to obtain their consent. This consent was most often verbal and the length of this consent varied from patient to patient, especially when the clinical picture did not present an emergency situation. After having obtained the couple’s consent, the medical termination of pregnancy was carried out following the steps of the protocol in the department:
The first step consisted in carrying out a basic check-up such as a blood count, uremia, creatininemia, glycemia, prothrombin rate and activated partial thromboplastin time.
The second step was preparation for uterine evacuation. An emergency caesarean section was performed if the clinical picture did not allow evacuation by medical means.
When the clinical picture allowed it, medicated evacuation was performed: either with misoprostol alone or the combination of mifepristone and misoprostol. Three protocols were used in the center. The choice of protocol depended on the woman’s clinical condition, the term of the pregnancy, the parity and condition of the cervix, and the history of surgery on the uterus.
When the term of the pregnancy was less than 24 weeks of amenorrhoea, the protocol was used:
- Mifepristone and misoprostol protocol
This protocol consisted of 200 mg of Mifepristone administered orally followed 36 hours later by 400 µg of Misoprostol administered sub lingually. If after 3 - 6 hours there was no contraction or expulsion, a further 400 μg of misoprostol could be given every 6 hours up to a maximum of five doses.
- Sublingual Misoprostol Protocol
This protocol consists of giving 400 µg of Misoprostol sub lingually. If after 3 - 6 hours there is no contraction or expulsion, another 400 μg of misoprostol can be given every 6 hours up to a maximum of five doses.
When the term of pregnancy is greater than 24 weeks of amenorrhoea, only misoprostol was used according to the Intravaginal Misoprostol Protocol
- Intravaginal Misoprostol Protocol
This protocol consists of using misoprostol at 25 to 50 μg in the posterior vaginal pouch every 6 hours up to a maximum of five doses.
Regardless of the protocol used, to decrease the duration of labour, an active attitude of amniotomy is recommended as soon as the membranes are accessible, regardless of the term and presentation, and even if the cervix is still long and posterior.
An emergency caesarean section was performed if the clinical picture did not allow evacuation by medical means. The Pfannenstiel technique was used. The type of anaesthesia was determined by the patient’s haemodynamic status. As the lower segment was not formed in the 2nd trimester, the caesarean section was low transverse corporal.
- Psychological support
Women who had to undergo a medical termination of pregnancy were given psychological support by the psychologist, midwives and obstetricians before and after the operation.
3. Results
3.1. Frequency
During the study period, 25 cases of Medical termination of pregnancy were registered. During the same period 4867 deliveries were performed. This corresponds to a hospital frequency of 0.5%.
3.2. Indication of Medical Terminations of Pregnancy
3.2.1. Category of Indications for Termination and Circumstances of Diagnosis
Fetal, maternal and obstetric causes were the main indications for medical termination of pregnancy in respectively 28%, 20% and 52%.
Obstetrical ultrasound was performed in 100% of patients. These scans allowed assessment of fetal vitality, approximate gestational age, and the identification of some fetal malformations (28%) and abnormalities in the fetal adnexa (48%). Clinical examination alone was diagnostic in 24% of indications. In 68% of cases, the clinical examination and ultrasound were used to establish the indication.
3.2.2. Fetal Indications
The fetal indications were all fetal malformations (Table 1).
3.2.3. Maternal Indications
Maternal indications were: eclampsia (1 case), severe pre-eclampsia (2 cases), acute lung oedema (1 case) and SS haemoglobinopathy (1 case) (Table 2).
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Table 1. Different cases related to fetal causes.
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Table 2. Different cases in relation to maternal cause.
3.2.4. Obstetrical Indications
Concerning obstetrical indications, premature rupture of membranes complicated by anamnios was the most frequent in 69.2% of cases, followed by haemorrhagic central placenta in 23% (Table 3).
3.3. Techniques for Medical Termination of Pregnancy
3.3.1. Patient Preparation
All patients had given their consent for medical termination of pregnancy. The assessment was carried out for those who opted for medical evacuation, i.e. 88%. Those who had undergone an emergency caesarean section had not undergone this assessment.
3.3.2. Caesarean Section
Caesarean section was performed as an emergency in 3 patients, i.e. 12% of cases.
The main indications for caesarean section were: low hemorrhagic placenta (2 cases), eclampsia (1 case).
3.3.3. Medicated Evacuation
Three protocols were used:
Mifepristone and misoprostol protocol in 6 cases (24%), sub lingual misoprostol protocol in 7 cases (28%) and intra vaginal misoprostol protocol in 9 cases (36%).
Regardless of the protocol the number of misoprostol administrations did not exceed three doses.
3.3.4. Time from Misoprostol to Expulsion
The average time from first misoprostol administration to expulsion was 25 hours with extremes of 10 and 48 hours. Almost 36% of the patients had expelled within 10 hours (Table 4).
3.4. Maternal Prognosis
Haemorrhagic expulsion was noted in 3 cases (12%). Post abortal endometritis was noted in 2 cases (8%). Five patients (20% of cases) were transfused with two bags of packed red blood cells.
All patients were alive with a percentage of 100%.
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Table 3. Different cases in relation to obstetric causes.
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Table 4. Distribution of respondents according to induction/expulsion time.
4. Discussion
4.1. Incidence
The hospital frequency of Medical termination of pregnancy was 0.5% of deliveries. This rate is lower than that found by Mothe in France where its frequency was 2% [4]. This non-negligible rate can be explained by the ultrasound examinations carried out on pregnant women, since in the study, ultrasound enabled some situations to be found that led to medical termination of pregnancy in 70% of cases. The authors are unanimous on the importance of ultrasound in diagnosing the causes of medical termination of pregnancy [3] [4].
4.2. Indications for Medical Termination of Pregnancy
In this study, fetal indications accounted for 28% of cases. All these indications were fetal malformations. Mothe in his series found 94.4% fetal indications [4], Marret reported 84% in his series [3] and Dommergues found 46% of cases in his series [5]. All the foetal malformations were lethal. This justifies this medical termination of pregnancy in our context. In some publications, the pregnancy is continued to term by the wish of the couple despite the lethal nature of the fetus [6] [7]. This situation can be explained on the one hand by the importance that the parents attach to the time of life, even if brief, with the living child and the constitution of memorial times and on the other hand by religious and socio-cultural obstacles. The decision taken in our context is justified by the often unfavourable outcomes during the evolution, most often marked by intrauterine fetal death, perpartum fetal death, of newborns who will need palliative care as has been noted in the literature. Although the causes of these malformations are investigated by karyotic and genetic studies in some studies [6] [7] [8] [9], this could not be done in our context because of the technical facilities that do not allow these examinations to be performed.
Maternal indications represented 20% of cases. Marret found 3% of cases [3]. These indications were justified because the maternal prognosis was already compromised. Indications for maternal toxoplasmosis and rubella or patients living with HIV+ have almost disappeared with the advent of mono and then dual therapy in HIV+ patients and the practice of prophylactic caesarean sections having reduced in utero transmission [3].
The obstetrical indications, premature rupture of membranes (PMR) at an early stage of pregnancy were relatively important in our study (75% of cases). Marret found 69.2% obstetrical indications [3] and Dommergues found 6.5% [4]. These were always premature ruptures of the membranes before 24 SA with severe oligohydramnios for which the chances of fetal survival were low and the risks of infection were greater.
4.3. Techniques of Medical Termination of Pregnancy
In 88% of cases, patients had expelled vaginally and in 12% of cases, they had undergone an emergency caesarean section. The technique of uterine evacuation depends on the haemodynamic status and the speed of extraction of the product of conception to save the woman. In our study, hemorrhage due to the central placenta and the hemodynamic status imposed this evacuation route in order to save the women. The same attitude was found in the work of Marret where caesarean section was necessary in 0.8% and Mothe performed it in 2% of cases [3] [4]. The main indication for caesarean section was the haemorrhagic central overlying placenta. In fact, the haemorrhagic central placenta is an exceptional situation in the case of a medical termination of pregnancy but presents a twofold problem for mothers: that of avoiding a risk of haemorrhage during vaginal delivery and that of avoiding the morbidity of a caesarean section often performed in the second trimester on a non-amplified lower segment.
For marginal forms, prostaglandin-induced hypertension, combined with early artificial rupture of the membranes, generally avoids major bleeding [10]. For overlying placenta previa, this may be an indication for an immediate caesarean section. Prior foeticide, lasting a few days, can sometimes help to avoid this by reducing the utero-placental flow, but the risk of haemorrhage remains high [11]. It is the extent of the genital bleeding that has allowed a caesarean section to be performed for maternal rescue.
Apart from emergency situations, the medicinal route is favoured in the literature [3] [4] [12]. In fact, the WHO recommends the combination of mifepristone and misoprostol in IMG [12]. To reduce the duration of labour, an active attitude of amniotomy is recommended as soon as the membranes are accessible, whatever the term and presentation, and even if the cervix is still long and posterior. This attitude was adopted whatever the protocol used in our study as in some studies [4].
4.4. Complications
Haemorrhagic expulsion was noted in 3 cases (12%). Post abortal endometritis was noted in 2 cases (8%). These complications are also found in other studies [3] [4].
Externalized haemorrhage occurs during the operation or even in the hours or days that follow, and its importance may require a transfusion as was found in our study. Infections were represented by endometritis which would probably be due to the absence of correct asepsis and incomplete evacuation of the uterus.
4.5. Limitations of the Study
The retrospective nature of the study and the centre’s technical facilities did not allow the causes of the foetal malformations to be identified. The psychological follow-up, as well as the repercussions and experiences of the patients who had benefited from this treatment could not be assessed because of the retrospective nature of the study.
5. Conclusion
Medical termination of pregnancy is a type of abortion that is performed in the centre. The indications are fetal, maternal and obstetric. The most commonly used evacuation technique is the medicated route. Despite some differences, our practices remain in line with the literature. This series has allowed us to highlight our singularities, and will allow us to improve the management of our patients, in the prevention of haemorrhage and other complications.
Annex: Survey Sheet
1. SOCIO-DEMOGRAPHIC CHARACTERISTICS
· Age (years):
· Occupation:
· Level of education:
· Marital status:
· Place of origin:
2. BACKGROUND INFORMATION
Personal history
· Medical (illnesses): .......................................
· Obstetrical: Gestity:..................Parity:..................A history of abortion:...............
· Surgical: Caesarean section Yes□ No□
· If yes, specify: Date ............ Number of times......
· Specific Family History: ......................................................
3. INDICATION/CAUSAL PATHOLOGY:
Maternal indication:
· terminal stage maternal cancer □
· Cardiac disease □
· Eclampsia□
· Preclampsia □
· HELLP Syndrome □
· Other □ If other, specify:……………………..
Fetal indication:
· Fetal malformations□ if malformation, specify:……………………………..
· Chromosomal□
· Genetic□
· Other □ If other, specify:……………………..
Obstetrical indication:
· low inserted hemorrhagic placenta □
· rupture of membranes □
· anamnios/oligoamnios □
· Chorioamniotitis □
· other □ if other, specify:…………………….
Diagnosis methods:
· ultrasound □
· clinical examination: □
· clinical examination and ultrasound □
· Specify gestational age .............
4. INTERVENTION
Medication evacuation: Yes □ No □
If yes specify protocol used..........................................
Specify time in hours from 1st dose of misoprostol to expulsion:……................
Caesarean section: yes □ no □
Specify indication for caesarean section
Incidents: ..............................................
Pathology workup: Yes □ No □
5. COMPLICATIONS:
· None □
· Delivery haemorrhage□
· Placental retentions□
· Endometritis□
· Uterine rupture□
· other □ if other, specify:…………………….
6. PROGNOSIS
Maternal morbidity:
· Anemia □
· Blood transfusion: Yes□ No□ If yes, specify the number of packed red blood cells: .............
· Infections □
· Hysterectomy □
· other □ if other, specify:…………………….
Maternal Mortality:
· Deceased □
· Alive □