This "training note" and "Safe Abortion Procedures, "a material for press roundatable, are treasure trove of information on abortion methods in Japan
For those who don't read Japanese, please use these translations for "Training Note" and a powerpoint material "press roundtable" you can download from Japan Association of Obstetricians and Gynecologists webcite.
Japanese mid-term abortions (after 12 weeks and under 22 weeks) are artificial abortions using gemeprost. The "Training Note" on the website of the Japanese Society of Obstetricians and Gynecologists, in discussing "late-term abortion treatment," explains that mid-term abortions are to be handled in the same way, and no other methods are indicated.
Here is the translation of concerned parts:
5. late-term miscarriage procedures
(1) Procedures
〇In the case of a late miscarriage (stillbirth) after 12 weeks' gestation, a stillbirth certificate is prepared in accordance with Article 12 of the Ministerial Ordinance on Stillbirth Notification, Stillbirth Certificate, and Stillbirth Examination (Fig. 12). (A stillbirth cremation permit is issued when the patient submits an application for a stillbirth (burial) cremation permit to the municipal office together with the stillbirth notification and stillbirth certificate.)
〇If the uterine contents are not in the shape of a fetus or cannot be recognized as a fetus, or if the pregnant woman is dead and the fetus is certain to die, a stillbirth certificate is not required, even if the stillbirth occurred after 12 weeks of pregnancy.
〇If this is performed as an abortion procedure, a written consent of the couple is required under Article 14 of the Maternal Protection Law (Fig. 13). In addition, notification to the prefectural governor is required under Article 25 of the Maternal Protection Law. This notification is made using the separate report form No. 13 (Fig. 14), which is based on Article 27 of the Enforcement Regulations of the Maternal Protection Law.
〇When a person insured by the health insurance system gives birth, a lump-sum maternity and childbirth allowance is paid. In this case, the term "childbirth" refers to a birth after 85 days (4 months) of pregnancy, stillbirth (miscarriage), and artificial abortion.
(2) Miscarriage treatment
The procedure consists of three steps: cervical dilation, administration of uterine contractions, and confirmation of uterine contents. The procedure is explained to the woman and her partner, and written consent is obtained.1 ) Cervical dilation
〇The most important procedure for the safe treatment of miscarriage after the 12th week of pregnancy is cervical dilation.
〇The most important procedure for safe miscarriage treatment after the 12th week of pregnancy is cervical dilatation.
〇The available cervical dilatation materials and their details are described in the next section "III-6. Figure 15 shows an example of a specific schedule for cervical dilation.
2 ) Uterine contractions
① Gemeprost (Gemeprost, Preglandin®)
〇Insert 1 mg of gemeprost (1 piece) into the posterior vaginal canal every 3 hours.
〇The maximum daily dose is 5 mg(5 pieces). If the drug is ineffective, it should be discontinued and resumed the next day or later, or switched to another method.
〇The dosage should be administered by a physician designated under the Maternal Protection Law (for details, see the October 1, 2009 issue of Nissan Women's Medical Association Bulletin, p. 16).
〇The package insert states that administration is contraindicated in the presence of placenta previa or pelvic infection.
〇In the second trimester, it is not uncommon to find a placental limbus near the endocervical opening on transvaginal ultrasonography. In such a situation, the patient should be carefully treated with caution in case of abortion or intrauterine fetal death, paying attention to massive hemorrhage.
〇If there is a history of previous cesarean section, especially if the abortion is performed after 12 weeks of gestation in a pregnant woman who has had two or more previous cesarean sections, special precautions should be taken to prevent uterine rupture, including adequate cervical dilatation. Although gemeprost is not contraindicated in pregnant women with a history of cesarean section, other prostaglandins with a similar structure, such as dinoprost (Dinoprost, Prostalmon F®) and dinoprostone (Dinoprostone, Prostaglandin E2® Tablets 0.5 mg), are contraindicated in patients with a history of cesarean section or hysterectomy.
〇Gemeprost is contraindicated in pregnancies complicated by bronchial asthma because of its potential to induce asthma attacks. Gemeprost is not contraindicated, but theoretically can induce attacks and should be administered with caution.
②Oxytocin (Oxytocin, Atonin®-O Note)
〇After delivery of the fetus and fetal appendages following administration of gemeprost, 5 to 10 units should be injected slowly intramuscularly.
〇It is sometimes used instead of gemeprost in miscarriage and abortion.
〇For intravenous infusion, 5 to 10 units of oxytocin are usually mixed with 5% glucose injection solution (500㎖), etc., and the dosage is adjusted accordingly while observing uterine contractions and other conditions.
〇Because oxytocin is administered without fetal heart rate monitoring and because it is difficult to monitor uterine contractions during miscarriage due to the small uterus, careful attention should be paid to the presence of excessive labor pains.
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In Japan, mechanical cervical dilation (laminaria is the most common) is performed in principle for all cases of induced abortion with curettage or aspiration in early pregnancy and gemeprost in mid-pregnancy.
See the April 13, 2022(Reiwa 4) document from the 162nd JAOG's regularly scheduled press roundtable. It is titled "Safe Abortion Procedures". There are two slides pasted on each page.
At the bottom of the second page (fourth slide) is titled "Abortion Methods Differences by Time of Pregnancy," and on the left side below it says:
Up to 12 weeks gestation:
Cervical dilation
↓
Removal of uterine contents under general anesthesia
On the right side below, it says:
After 12 weeks of pregnancy (mid-term abortion)
(stillbirth notification required)
↓
Form of delivery with uterine contractions (labor contractions)
The first slide (No.5) next page (p.3) is titled "dilatation of cervix (pretreatment)" with the following explanations:
On the left side, "the cervix is closed tightly to prevent delivery of the baby even if the pregnancy progresses.
On the right side:
・How to open the cervix slowly and safely
・Necessary for both early and mid-term procedures
At the bottom, Dylapan is cited as an example.
The following slide (No.6 ) on the same page is titled: Mid-term abortion method (same method as for induction of live birth)
Translation of the numbered words on the far left:
(2) Uterine contractions (vaginal suppositories)
i) Cervical dilator (pretreatment)
Translation of the procedure on in the middle of the left side:
Uterine contractions
↓
descent of the head of the baby
↓
cervical canal extension
↓
cervical ripening
↓
cervical canal ripeness
↓
onset of labor
Translation of the right side:Because the cervix is open
・Greater effect of uterine contractions
・Smaller risk of uterine rupture due to contractionsExplanation of the side of the picture of Preglandin:
For a mid-term abortion, a designated doctor of the Maternal-body Protection Act inserts a vaginal suppository every 3 hours.
On the next page (p.4) , you can find the explanation of D&C and EVA as "Methods of Early Abortion."
>>
During the Japanese D&C, the contents are generally pinched out using forceps before curettage. For this reason, physicians sometimes confuse D&C with D&E. In the upper left corner of both slides, it says: "general anesthesia (intravenous anesthesia)". Also, the third line of the upper slide says: (cervical dilation, removal of uterine contents and curettage) and the third line of the lower slide says: (cervical dilation, aspiration of uterine contents and curettage).
Thus, in Japan, general anesthesia and cervical dilatation are also used even the suction method is used.
Furthermore, the description of MVA on the next page (p. 5) similarly states "anesthesia (anesthesia methods vary)" in the upper left corner, suggesting that it may not necessarily be general anesthesia. The third line of the description is: (cervical dilation, aspiration and curettage of uterine contents), which again indicates that cervical dilation is performed even for MVA.
You can see how many D&C were used in 2012. At the bottom of this page, under the title "Abortion Methods in Our Country," the results of a nationwide abortion survey conducted during the year 2012 are presented. The response rate was 58.6%, with 108,148 abortions counted.
The results are tabulated for pregnancies less than 12 weeks (93.3%) and more than 12 weeks (6.7%), with the left-hand headings in order:
Percentage of clinics 84.2%, 53.5%
Abortion Method
Combined curettage and aspiration 46.8%, -
Curettage method 32.7%, 8.1%
Aspiration method 20.3% -
Drug method -, 78.5%
Combination of drug and curettage -, 12.2%
This means that at least as of 2012, curettage alone was used in 32.7% of cases and the combination of curettage and aspiration in 46.8%, for a total of 79.5% of cases. This is a slight improvement over the previously reported figures.
Furthermore, you can see that the overwhelming majority of mid-term abortions at 12 weeks gestation or more were performed with "drugs".
