الفهرس 
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Abstract
Second-trimester miscarriage refers to the ending of a pregnancy between the 13th and 28th weeks of gestational age. This period is further split into two sub-periods: an early period spanning from 13 to 20 weeks, and a late phase spanning from 20 to 28 weeks. It accounts for around 10 to 15 percent of losses conducted globally each year and is the cause of two-thirds of significant miscarriage problems.
Various techniques have been suggested as alternatives for terminating a pregnancy in the second trimester, particularly when the cervix is not favorable, and to also reduce the need for cesarean sections and other procedures involving the uterus. The approaches were classified as pharmacological, mechanical, or surgical. Nevertheless, there is still no worldwide consensus on the optimal approach for inducing a second trimester miscarriage in a uterus that is experiencing fear or anxiety.
This study was conducted in the prenatal and fetomaternal clinics of the Obstetrics & Gynecology department at Minia Maternity & Children University Hospital.
The present study comprised 102 pregnant women in good health, at a gestational age of 13-28 weeks, who had previously undergone one or two caesarean deliveries and were diagnosed with either miscarriage, intrauterine fetal death, or congenital fetal defects that were incompatible with sustaining life. The patients were randomly categorized into three groups using a sequential randomization procedure. Each group consisted of 34 patients: Group-1 (Pharmacological), Group-2 (Mechanical), and Group-3 (Combined pharmacological and mechanical).
The objective of this study is to assess the rate of success, effectiveness, and problems associated with three treatment plans for ending pregnancies in the second trimester among women who have previously undergone a cesarean section.
The study’s objective and methodology were clearly communicated to the patients, and formal consent was obtained from each patient, verifying their voluntary agreement.
The ladies that were enlisted underwent the following:
6) Thoroughly gather information about the individual’s personal, menstrual, medical, surgical, and obstetrical history.
7) Comprehensive assessment: o Includes assessment of blood pressure, pulse, and temperature.
Measure and calculate height, weight, and BMI.
Perform a thorough check of the chest and heart.
The skin was inspected for petechiae or ecchymosis in order to rule out any coagulation abnormalities or blood disorders.
8) The abdominal examination: - Abdominal inspection: Place the patient in a supine position on the bed, with arms across the body and legs not crossed, in order to visually examine the abdomen and then perform palpation. Observe for any abnormalities or signs of distress. Abdominal scars come in many forms and can offer insights into a patient’s surgical history (such as previous laparotomy), as well as indicate pain or stiffness.
The measurement of the uterine size (in centimeters above the symphysis pubis) is determined.
9) The local examination should involve assessing uterine size using bimanual examination, as well as evaluating cervical dilatation, consistency, effacement, and location.
During the bimanual examination, the examiner uses the index and middle finger of one hand to do the examination. Place the other hand on the abdomen, using the ulnar edge and fingertips for palpation. The cervix was examined manually to ascertain its shape, structure, and texture. The uterine fundus was palpated by examining the vaginal fornix above the cervix. The hand positioned over the abdomen was shifted towards the lower side of the body, namely towards the outside region. The hand positioned over the pelvis was moved towards each corresponding side of the body.
10) Investigations: - Utilizing ultrasound to evaluate the gestational age.
- Ultrasound is used to confirm a missed miscarriage, intrauterine fetal death, congenital fetal defects that are not compatible with life, as well as to assess the amniotic fluid levels and confirm the location of the placenta.
CBC.
- Rh-typing is being performed.
- Blood reservation
- Glucose concentration in the bloodstream.
- Evaluation of blood clotting function.
- Tests to evaluate kidney function.
- Hepatic function assessments.
The 102 patients were separated into 3 groups, with each group consisting of 34 patients, as follows:
D The initial cohort underwent miscarriage induction utilizing Misoprostol, a Prostaglandin E1 analogue, in the form of Cytotec® 200 microgram tablets. These pills were imported and sold by Pfizer INC. Egypt. The administration of Misoprostol was carried out either vaginally or sublingually.The dosage of misoprostol varies based on the gestational age. For pregnancies between 14-20 weeks, the recommended dose is 400 µg every 6 hours. For pregnancies between 20-25 weeks, the recommended dose is 200 µg every 6 hours. For pregnancies at 26-27 weeks, the recommended dose is 100 µg every 6 hours (Morris et al., 2017).
In the second group, miscarriage was induced using Foley’s catheter.
A 16F silicon coated Foley’s catheter, produced by Ultra for medical goods Co, is implanted in a small operation room with strict aseptic measures, without the need of anesthesia.
The patient was positioned in lithotomy. Following the sterilization of the vulva and vagina with iodine betadine, a sterile Cusco’s speculum was introduced into the vagina to provide a clear view of the cervix. A sponge holding forceps were used to grasp the front lip of the cervix.
The catheter was delicately placed into the cervical canal, traversing the internal os. A sponge-holding forceps was used to hold the catheter and then it was inserted into the endocervical canal. The catheter is filled with 20-30 ml of normal saline, depending on the stage of pregnancy: 14-20 weeks gestation requires 40-50 ml, while 20-27 weeks gestation requires 40-50 ml. The location of the catheter was checked by TAS.
The catheter was extended until the balloon was tightly positioned against the internal cervical OS and secured to the medial thigh using a plaster. The catheter location was verified by transabdominal sonography (TAS).
The catheter was retained for a duration ranging from 6 to 48 hours. In situations where there was no reaction within 48 hours, the catheter was emptied and carefully pulled lower for removal. However, if a response occurred, the catheter fell out and was then withdrawn.
The administration of oxytocin infusion (using Oxytocin® 10 IU Ampoules, manufactured by Minapharm in Egypt) will begin following the removal of the catheter.
In the third group, miscarriage was induced by inserting Foley’s catheter and applying traction. Additionally, misoprostol was administered intrauterine through the catheter lumen, following the same previously described dosage based on gestational age.
The cervical dilation was assessed via manual examination and documented.
In order to prevent premature delivery, it is necessary to maintain any of the aforementioned methods for a continuous duration of 24 hours.
All patients will be administered an oxytocin infusion of 20 units in 500 ml of normal saline following the ejection of the fetus in order to prevent the occurrence of placental retention and post-abortion hemorrhage.
The process might be extended for a further 24 hours or concluded with hysterotomy or dilatation and curettage (D&C).
Manual vacuum aspiration (MVA) is necessary for incomplete evacuation when there are retained pieces of the placenta or membranes. This is determined by vaginal ultrasonography, which measures intrauterine leftovers exceeding 2 cm after oxytocin infusion has been completed.
Failure was defined as the absence of cervical dilatation or the lack of response to oxytocin during a 48-hour period.
The participants are confined to the ward and undergo reassessment based on the hospital’s procedure for handling the termination of second trimester pregnancies in individuals with prior uterine scars.
The present investigation yielded the following outcomes:
The patient’s demographic data, such as age, domicile, and BMI, do not exhibit any statistically significant differences (p value > 0.05) among all groups.
Concerning the crucial data prior to intervention, there was a notable disparity among the three groups in terms of pulse rate, with group-1 exhibiting a greater rate compared to the other groups. There was no discernible disparity among the three groups in terms of body temperature, systolic blood pressure, and diastolic blood pressure.
Regarding the post-intervention data, there was a significant difference between the groups in terms of body temperature (p value 0.004*). This suggests that fever is a common side effect of misoprostol.
No notable variations were seen across the groups in terms of gravidity, parity, and average gestational age.
The criteria for termination of pregnancy (TOP) were same across all three groups, which included missed miscarriage, intrauterine fetal death (IUFD), and congenital fetal abnormalities. The most prevalent reason for termination of pregnancy (TOP) was missed miscarriage, however, there were no notable distinctions among the categories in terms of the reasons for TOP.
In relation to the consequences of the intervention, it was observed that nausea and vomiting were prevalent in 85.3% of participants in group-1, which was substantially different from the other two groups. Furthermore, a total of 4 individuals (11.8%) in group-1 and 1 case (2.9%) in group-3 reported experiencing headache and dizziness. In addition, there were two instances of uterine rupture in group-2.
There was a negligible disparity among the three groups in terms of evacuation following the removal of the fetus. The majority of cases in group-2, namely 17 instances (50%), required evacuation after the fetus was expelled. In group-1, 14 cases (41.17%) required evacuation after fetal expulsion, while in group-3, 9 cases (26.5%) required evacuation after fetal expulsion. Evacuation following expulsion was carried out in all instances to provide confidence and guarantee the full removal of uterine contents.
Hysterotomy was required in 5.6% of instances in group-2, and in 2.9% of cases in group-1. However, it was not necessary in any cases in group-3. Further investigation was required with group-2, which consisted of 2 instances.
The primary discovery of this study is that the group-3 participants had the lowest induction-abortion-interval (IAI) of 32.5 ± 10.9 hours, which was significantly different (p value 0.013) from the other two groups. The group-2 participants had an IAI of 36.7 ± 14.8 hours, while the group-1 participants had an IAI of 43.1 ± 17.5 hours. Furthermore, the success rate for group-3 was 34 out of 34 (100%), for group-1 it was 33 out of 34 (97.05%), and for group-2 it was 30 out of 34 (88.2%).
The present study has determined that the combined approach, using both pharmacological and mechanical methods, is more effective than alternative treatment regimens for terminating second trimester pregnancies in women who have previously undergone a caesarean section.
The combined strategy, which used both pharmacological and mechanical approaches, had the shortest IAI (Interval between Administrations) when compared to the other groups.
• Mechanical techniques for terminating second trimester pregnancies in women with past uterine scars carry a higher risk of uterine rupture. • The use of misoprostol and Foley’s catheter in combination is particularly advised for patients with a history of caesarian section.