In the management of second-trimester medical terminations of pregnancy, it is a commonly accepted practice to allow 2 hours for the third stage of labor. This practice is based on data from terminations with saline solution as the abortifacient. Herein we report our experience with the use of prostaglandin E2 vaginal suppositories for midtrimester terminations, with particular regard to placental delivery rates and associated complications. Ninety-six patients underwent prostaglandin E2 vaginal suppository terminations. Fifty-eight percent of patients had spontaneous placental delivery within 2 hours of the passage of the fetus; approximately two thirds of these were expelled within 30 minutes. Previous work involving elective saline solution-induced terminations suggested the 2-hour time limit for the third stage of labor. This was based on an unacceptable complication rate of greater than 4% beyond 2 hours. The present study of the use of prostaglandin E2 suppositories for a variety of indications demonstrated a similar complication rate of 4% at 30 minutes. These findings suggest expectant management beyond this time limit may produce unacceptably high complication rates.
PIP: On the basis of experience with 2nd-trimester abortions induced by saline solution, a consensus has been reached that a retained placenta should be surgically removed if complete spontaneous passage does not occur within 2 hours of fetal delivery. The purpose of this study was to analyze the management and complications of the 3rd stage of labor when abortion is induced by prostaglandin (PG) E2 vaginal suppositories--at present the most widely used abortifacient. 96 women who underwent PGE2 pregnancy termination in 1984-87, for indications such as anatomic abnormalities, chromosomal abnormalities, and fetal death, were included in the study. The mean induction length (time from placement of the 1st PGE2 suppository to fetal delivery) was 15 hours, 33 minutes. 58 patients (60%) delivered the placenta spontaneously within the 2-hour time limit. An additional 10 patients delivered the placenta spontaneously while awaiting surgical intervention. Retained placenta was more likely to occur in patients with fetuses of an earlier gestational age (15-16 weeks). Previous uterine surgery, previous induced abortion, and gravidity did not have an effect on placental delivery. Hemorrhage, the major complication of 2nd-trimester pregnancy termination, occurred with significantly greater frequency when the 3rd stage of labor was of increasing duration. At 2 hours, there was a 3-fold increase in the complication rate compared with placental delivery at 15 minutes. Analysis of the likelihood of spontaneous placental delivery suggests that more than 50% of placentas that are destined to pass spontaneously do so within 15 minutes and 64% pass within 30 minutes. Given both the likelihood of spontaneous placental delivery by 30 minutes and the increasing complication rate with further expectant management, it is recommended that 30 minutes be accepted as the appropriate time limit for expectant management of the 3rd stage of labor when pregnancies are terminated by PGE2.