UNASSIGNED: Uterine rupture is a rare condition that typically occurs in a scarred uterus and can happen during late pregnancy, labor, or the early postpartum period. Since most cases are seen in patients with a history of cesarean surgery, the anterior lower uterine segment is the most affected area. Most patients present with acute symptoms that compromise the fetus and the mother in a life-threatening manner.
METHODS: We present a case of uterine rupture with subacute symptoms occurring in the second trimester, which is extremely rare. The patient was a stable second-trimester multiparous woman with chronic abdominal pain, but without any signs of peritoneal bleeding or instability. No history of previous cesarean section was present, and she had recently undergone a non-complicated hysteroscopic polypectomy. Transabdominal and transvaginal ultrasounds were performed, revealing a significant full-thickness myometrial defect in the posterior uterine lower segment. This defect allowed the amniotic sac to protrude into the posterior cul-de-sac. No abdominopelvic hematoma was detected. These findings were confirmed in an urgent MRI, and the patient underwent a laparotomy during which a significant full-thickness defect was discovered at the posterior of the uterus. As it was impossible to continue the pregnancy, the fetus was surgically removed and then prepared using multiple layers.
UNASSIGNED: The difference between our case and the previously reported one is in the aspect of gradual stable presentation and lacks of vaginal bleeding.
CONCLUSIONS: Previous hysteroscopy carries a risk for future pregnancy complications, such as uterine rupture.

BACKGROUND: Abdominal pregnancy, a rare form of ectopic pregnancy, is associated with high morbidity and adverse consequences for future fertility. Early recognition and management reduce mortality and allow minimal invasive and conservative treatment. In modern medicine, primitive prevention to unexpected fatal pregnancies is crucial.
METHODS: A divorced 33-year-old \"self-identified\" infertile polycystic ovary woman diagnosed as repeated implantation failure in previous in vitro fertilization with her ex-husband ever presented in surgery department with a history of 15-day abdominal pain, nausea, and vomiting and 3-h worsening abdominal pain. The serum beta-human chorionic gonadotropin value was more than 10,000 m-international units per milliliter. Sonogram findings were significant for the absence of intrauterine gestation; a placenta and well-formed living fetus of second-trimester gestation were seen in the abdomen, accompanied by hemoperitoneum. A unique spontaneously second-trimester tubo-abdominal pregnancy was confirmed in emergent laparotomy by gynecologists, she received a removing of the living fetus, a right total salpingectomy, resection of partial omentum and blood transfusion. The patient recovered uneventfully and her serum beta-human chorionic gonadotropin returned to normal range on the 30th postoperative day, till now, she has weak fertility awareness because of her catastrophic experiences in the unexpected abdominal pregnancy.
CONCLUSIONS: This case highlights woman with a previous in vitro fertilization history may be in is a high risk to be delayed or missed in diagnosis in an intended ectopic pregnancy due to a fixed belief in infertility. Educational interventions and contraceptive care should be provided by fertility and healthcare practitioner. The possibility of abdominal pregnancy must always be suspected and dealt with promptly and appropriately by the astute clinician.

OBJECTIVE: The aim of this work was to compare different local cutoff values (LCV) and inline cutoff values (ICV) in pregnant women in the second trimester at high risk for carrying fetuses with trisomy 21.
METHODS: This retrospective cohort study analyzed prenatal screening outcomes in pregnant women (n = 311,561). The receiver operating characteristic curve was used to evaluate the diagnostic significance of the trisomy 21 risk value, alpha-fetoprotein, and free beta human chorionic gonadotropin multiple of the median for predicting trisomy 21 risk. The cutoff value corresponding to the maximal Youden index was taken as the LCV. The screening efficiency of both cutoff values was compared.
RESULTS: The LCV cutoff value was lower than the ICV cutoff value (1/643 vs 1/270). The sensitivity increased by 19.80%, the positive predictive value decreased by 0.20%, and the false-positive rate increased by 6.50%.
CONCLUSIONS: The LCV should be used to determine trisomy 21 risk, which can increase the detection rate of trisomy 21 in the second trimester.

BACKGROUND: We examined providers, methods employed, cost, and other determinants of availability of second-trimester abortion services in health facilities in Accra, Ghana in 2019 to inform policy and program decisions.
METHODS: A two-stage mixed quantitative and qualitative study designs were employed in the conduct of the study. The first stage was a short interaction of the mystery client with a clinical care provider to identify health facilities that provide second trimester induced abortion, the cost, and referral practices, where the facility did not have the service. The second stage was in-depth interviews of second-trimester abortion care providers and non-providers in various health facilities. For internal validity, it also explored the procedure cost, referral, and other practices at the health facilities included in the study, independent of what was captured in the mystery client survey.
RESULTS: Second-trimester abortion services in Accra, Ghana are widely unavailable even in most facilities that provided abortion services. Referral policies and practices indicated by the service providers at various facility levels were inadequate. Criminalization of the procedure, social stigma, and fear of complications are the main factors that adversely influence the availability of second-trimester abortion in health facilities in Accra.
CONCLUSIONS: Albeit increasing demand for second-trimester abortion in health facilities in Accra, services are not readily available due to the ambiguity of the law, its interpretation, and limited flow of accurate information on providers. Policies and programs that limit access to Second-trimester abortions in Ghana are amendable to ensure safe services.

BACKGROUND: Post-abortion family planning counselling and provision are known high impact practices preventing unintended pregnancies. Little is known, however, about specific needs in the second trimester. Our study aims to assess post-abortion family planning uptake and its associated factors among women with second-trimester incomplete abortion.
METHODS: We conducted a cross-sectional survey of 1191 women with incomplete second trimester abortion that received treatment at 14 comprehensive emergency obstetric care public health facilities in central Uganda from August 2018 to November 2021. We computed the post-abortion uptake of family planning within 2 weeks of treatment, described the types of methods accepted, and the reasons for declining family planning. We described the socio-demographic, reproductive, abortion-related, and health facility characteristics. We used mixed effects generalized linear models to obtain percentage differences for factors independently associated with post-abortion family planning uptake.
RESULTS: Second-trimester post-abortion family planning uptake was 65.6%. Implants (37.5%) and progestin only injectables (36.5%) were the commonly chosen methods; natural (0.1%), permanent (0.8%), and condoms (4%) were the least chosen methods. 45.2% of the women who declined family planning desired another pregnancy soon. Women whose spouses were aware of the pregnancy or had planned pregnancy had 11% (- 10.5, 95% CI - 17.1 to - 3.8) and 12% (- 11.7, 95% CI - 19.0 to - 4.4) less uptake compared to women whose spouses were not aware of the pregnancy or those with unplanned pregnancies respectively. Uptake was 8% (- 7.8, 95% CI - 12.6% to - 3.0%) lower among Islamic women compared to Anglicans. Women who received post-abortion family planning counselling or had more than four live births had 59% (59.4, 95% CI 42.1 to 76.7) and 13% (13.4, 95% CI 4.0 to 22.8%) higher uptake compared to women who did not receive counselling or women with no live births, respectively.
CONCLUSIONS: The uptake of second-trimester post-abortion family planning in Uganda was higher than previous estimates. Post-abortion family planning counselling, grand multiparity, and the need to avoid an unplanned pregnancy enhance post-abortion family planning uptake in the second trimester. Ministry of Health should strengthen post-abortion family planning counselling, especially couple counselling; at all health facilities in the country and also ensure an adequate and accessible supply of a wide contraceptive method mix.

BACKGROUND: Trisomy 21 is a serious chromosome abnormality. The conventional Down\'s screening test is the most widely used for trisomy 21 screening. However, this method could lead to a higher false positive rate. Therefore, we aim to analyze steroid profile in second-trimester pregnant women and identify novel serum biomarkers of trisomy 21.
METHODS: We employed an LC-MS/MS method to measure the steroid profile. The concentrations and product-to-substrate ratios in 71 second-trimester pregnant women were determined and statistically analyzed to identify novel biomarkers for trisomy 21 screening.
RESULTS: We found that there were significant differences in levels of E3, 11-deoxycortisol, and 11-deoxycortisol /17-hydroxyprogesterone between two groups. The OPLS-DA plots revealed obvious separation between two groups. Combining VIP analysis (VIP > 1.0) with volcano plot (P < 0.05 and fold change >1.2 or < 0.83), 11-deoxycortisol was identified as a novel biomarker for trisomy 21. After controlling for confounders, we found 11-deoxycortisol was associated with trisomy 21 (adjusted P = 0.009), and the fully adjusted OR (95 % CI) was 0.098 (0.016-0.593) in highest quartile versus lowest quartile of 11-deoxycortisol (P = 0.011).
CONCLUSIONS: Steroid profile analysis for the first time showed that steroid hormones perturbations occurred in pregnant women carrying a fetus affected by trisomy 21 and decreased 11-deoxycortisol levels were associated with trisomy 21.

BACKGROUND: While it is clear that first trimester congenital cytomegalovirus (CMV) infection can lead to serious neonatal and childhood adverse outcome, the extent of the effect of second and third trimester congenital CMV infection is still unclear. Our aim was to study the short- and long-term outcomes following second and third trimester infection and to evaluate the contribution of prenatal imaging in a prospective cohort.
METHODS: We studied pregnant women with primary CMV infection in the second and third trimesters, as diagnosed by well-dated seroconversion, and proof of vertical CMV transmission. All patients underwent serial prenatal ultrasound (US) and most of them fetal magnetic resonance imaging (MRI). Follow-up information was obtained from hospital charts and by telephone interviews with parents.
RESULTS: Primary CMV infection occurred in 135 patients, 107 and 28 with second and third trimester infection, respectively. The incidence proportion of composite outcome (hearing loss or neurodevelopmental impairment) following second trimester infection was 7% (7/100, after excluding cases that were terminated) with a 3% incidence of partial unilateral sensory neural hearing loss and a 5% incidence of minor neurodevelopmental abnormalities, including slight verbal and motor delay. Following third trimester infection, there was one case of a very mild motor delay. The incidence proportion of abnormal prenatal findings on US or MRI was not significantly correlated to hearing loss or neurodevelopmental abnormalities.
CONCLUSIONS: Second trimester infection is associated with a slight risk of developing mild childhood sequelae, mostly partial unilateral hearing loss, which may develop late in childhood. Prenatal imaging failed to predict the development of childhood adverse outcome.

Although only 1.3% of abortions in the United States are between 20 and 24 weeks\' gestation, these procedures are associated with elevated risks of morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20-24 weeks\' gestation reduces procedural risk. For this gestational range, at least one day of cervical preparation with osmotic dilators is recommended before D&E. The use of overnight osmotic dilators alone is sufficient for most D&Es at 20-24 weeks\' gestation. Dilapan-S® dilators require a shorter time to achieve maximum dilation, may be more effective than laminaria and may increase the likelihood of success on the first D&E attempt. The use of adjunctive mifepristone administered one-day pre-operatively at the time of osmotic dilator placement, should be considered because evidence demonstrates that it makes D&E subjectively easier at 20-24 weeks without increasing side effects. While older studies suggest that two-days of serial osmotic dilators provide greater dilation than one day of dilators, adjunctive mifepristone may be comparable to a second day of dilators. Adjunctive misoprostol administered on the day of D&E does not appear to affect initial cervical dilation and procedure time and compared with mifepristone is associated with more side effects, such as pain and nausea. Using overnight mifepristone and same-day misoprostol without osmotic dilators at 20-24 weeks\' gestation lengthens D&E procedure time and appears to increase immediate complications, at least among less experienced providers. Some evidence shows the feasibility of same-day cervical preparation before D&E at 20-24 weeks using Dilapan-S® with adjunctive misoprostol or serial repeat dosing of misoprostol, but same-day preparation should be limited to providers with significant experience with these regimens. The Society of Family Planning recommends preoperative cervical preparation before D&E at 20-24 weeks\' gestation. Further studies are needed to clarify the best means of preparing the cervix in order to minimize abortion complications and improve outcomes in this gestational range.

BACKGROUND: Retained placenta is the most common second-trimester delivery complication. As the optimal third stage of labor duration remains undefined, complications associated with retained placentas are difficult to study.
OBJECTIVE: To determine the optimal third stage of labor duration in second-trimester deliveries based on estimates of time-specific probabilities of placental delivery, placental intervention, and postpartum complication.
METHODS: We retrospectively studied adult women with singleton second-trimester vaginal deliveries. We identified third stage of labor duration, placental delivery method (spontaneous vs. manual/operative intervention), and indication for intervention. Postpartum complication was examined as a composite outcome. Differences among groups defined by delivery method and postpartum complication were tested using parametric and nonparametric tests. Probability curves describing the time-specific probabilities of placental delivery were derived using lifetable methods with group differences tested using the log-rank test. Probability of placental intervention and complication by time to placental delivery were examined using logistic regression with adjustment for confounders and other predictors.
RESULTS: We identified 215 second-trimester placental deliveries (77% spontaneous, 23% intervention). Overall, 27% experienced postpartum complication, primarily hemorrhage (91%). Complication rates differed significantly between spontaneous placental deliveries (16%) and interventions (61%, P < 0.01). Both placental intervention and postpartum complication were strongly associated with longer time to placental delivery. Spontaneous placental deliveries occurred earlier than deliveries requiring intervention (P < 0.01). At 2 h, placental delivery rates were 93% in spontaneous deliveries and 39% in those requiring intervention. The overall postpartum complication rate for spontaneous placental deliveries (16%) was used as the threshold of tolerable risk and the criterion for placental intervention. Adjusted probability curves for deliveries of average gestational age (21.6 weeks) suggested that most patients (63.9%) may not require intervention until approximately 2 h following fetal delivery. Patients with PPROM would require intervention by 34 min, and those with intrapartum fever or delivery EBL ≥500 mL would already exceed the risk threshold at fetal delivery.
CONCLUSIONS: Our study suggests that an optimal third stage of labor duration of approximately 2 h maximizes probability of spontaneous delivery and minimizes complication risk. Timing of intervention may be further individualized for patients based on maternal characteristics and intrapartum conditions.

OBJECTIVE: To evaluate the effects of sequential vaginal and sublingual misoprostol after a vaginal loading dose for second-trimester abortion.
METHODS: From January 2006 to December 2011, 173 women received an 800-μg vaginal loading dose of misoprostol. After the loading dose, 103 patients received 800 mg of misoprostol vaginally and 70 patients received 400 mg of misoprostol sublingually every 12 h until the delivery of the fetus.
RESULTS: In the vaginal group, the average abortion time was 1.07 ± 1.29 days; that was 0.82 ± 0.66 days in the sublingual group. Sequential sublingual misoprostol after a vaginal loading dose of 800 mg with an administration interval of 12 h had a similar abortion rate and time to abortion. In addition, this protocol reduced unnecessary digital pelvic examinations and speculum examinations.
CONCLUSIONS: This sequential sublingual misoprostol regimen might be a suitable regimen for mid-trimester abortion.