Termination Processes of Pregnancies Due to Intrauterine Mort Fetus and Fetal Anomaly

Abstract

Objective:

To compare pregnancy terminations for two reasons: intrauterine fetal death (IUFD) and fetal anomaly, focusing on obstetric data and termination processes to optimize clinical management.

Methods:

This retrospective, single-center study included singleton pregnancies terminated for intrauterine fetal death or fetal anomaly (≥ 10 weeks’ gestation) between January 2020 and December 2021. Demographic, obstetric, and procedural data were collected. Termination methods included misoprostol, balloon catheter, curettage, and hysterotomy, following FIGO guidelines. Feticide was performed when indicated. Statistical analysis was conducted using t-test, chi-square test, and Pearson correlation; significance was set at P < 0.050.

Results:

A total of 173 termination cases (104 IUFD, 69 fetal anomalies) were analyzed. Mean gestational age was 16.6 ± 4.2 weeks. Termination and hospitalization times were longer in anomaly cases (P < 0.001). Gravida and parity were lower in the anomaly group (P = 0.005, P = 0.011). Misoprostol use showed a positive correlation with termination time (r = 0.251, P = 0.001); parity was negatively correlated (r = –0.175, P = 0.021). Balloon, curettage, and feticide rates were higher in anomaly cases (all P < 0.001). Complications occurred in 4 patients (2.3%).

Conclusion:

Clinical approaches to pregnancy termination differ based on the underlying condition. Obstetric history and fetal pathology influence the methods and timing of the procedure, emphasizing the need for individualized care to improve patient outcomes.

Introduction

In Türkiye, voluntary termination of pregnancy is governed by Population Planning Law No. 2827, which permits termination up to 10 weeks of gestation.¹ Beyond this limit, termination is allowed only under specific medical circumstances, such as when the mother’s life is at risk or in cases where fetal conditions may result in severe disability in the child or future generations. Termination can be performed based on objective findings provided in a report² by an obstetrician-gynecologist, under one of the following four primary medical indications: Maternal request (up to 10 weeks); Medical reasons (related to maternal and/or fetal health); Retrieval of fetal tissue; Genetic disorders in the fetus, whether compatible or incompatible with life.³

Prenatal diagnostic techniques play a crucial role in detecting congenital anatomical anomalies.⁴ Ultrasonographic imaging, a cost-effective method of prenatal screening, is widely used to inform expectant mothers of potential deviations in fetal development.⁵ Neonatal morbidity and mortality are significantly impacted by congenital anomalies and genetic disorders, which may arise from environmental factors, chromosomal abnormalities, single-gene mutations, or multifactorial inheritance. However, the etiology of many such conditions remains unknown.⁶ The detection of fetal anomalies during pregnancy increasingly places women in the position of considering termination. Because most antenatal screening and diagnostic procedures—including biochemical tests, ultrasonography, chorionic villus sampling, and amniocentesis—are typically conducted in the second trimester, terminations due to fetal anomalies often occur later in pregnancy compared to those based on social reasons.⁷

In this study, we retrospectively evaluated women who underwent pregnancy termination and categorized them into two groups according to indication: intrauterine fetal death and fetal anomaly. We analyzed their obstetric characteristics, termination procedures, the medical methods employed, and any complications encountered in order to inform and optimize clinical management practices.

Materials and methods

This single-center, retrospective observational study aimed to evaluate and improve the management of medical pregnancy terminations by analyzing patient data from the Obstetrics and Gynecology Clinic at Istanbul Medipol University, Medipol Mega University Hospital, between January 2020 and December 2021.

We included all cases of pregnancy termination managed at our hospital due to either intrauterine fetal death (IUFD) or fetal anomaly. These cases were categorized accordingly for analysis. Terminations were included for pregnancies at ≥ 10 weeks of gestation and above. There was no upper gestational age limit. Twin pregnancies were not included in this study. None of the cases were excluded based on clinical condition. Patients who underwent medical termination were categorized into two groups based on the indication for termination: intrauterine fetal death and fetal anomalies. Comparative analyses were conducted between these two groups. Demographic and obstetric characteristics, including maternal age, gravidity, parity, number of previous abortions, and history of ectopic pregnancy, were extracted from the hospital’s electronic medical record system. Termination and hospitalization durations (in hours) were also recorded.

For all patients, the methods employed during termination were documented, encompassing both medical and surgical approaches. Medical methods included the administration of misoprostol for cervical ripening and the use of intrauterine balloon catheters as a mechanical method. Surgical interventions, such as curettage or hysterotomy, were also noted. Majority of our patients initially underwent medical management with misoprostol, administered vaginally, orally, or through a combined approach, depending on clinical considerations. The dosage, route, and frequency of administration were determined in accordance with the updated International Federation of Gynecology and Obstetrics (FIGO) Guidelines⁸, ensuring evidence-based and standardized care. In cases where misoprostol did not result in adequate cervical dilation, balloon catheter placement was employed. The decision to proceed with this intervention was based on clinical examination and physician expertise, particularly in instances of cervical resistance or suboptimal response to medical induction. If there was clinical suspicion of retained products following expulsion, curettage was performed to ensure uterine evacuation and prevent complications.

When medical induction was deemed less favorable due to maternal status or gestational considerations, hysterotomy was performed as determined by a multidisciplinary assessment of maternal and fetal factors. For cases of termination due to fetal anomalies, particular attention was given to whether feticide was performed prior to the procedure. All feticide procedures were carried out by Maternal-Fetal Medicine specialists using ultrasound-guided administration of potassium. The injection site, drug type, and timing were adhered to institutional protocols. Each procedure was documented in a separate recording system by the performing subspecialist. Any intra- or post-procedural complications were systematically documented.

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics (version 25). Continuous variables were summarized as mean ± standard deviation if normally distributed or as median (interquartile range, IQR) if non-normally distributed, with normality assessed by the Shapiro-Wilk test. Categorical variables were expressed as frequencies and percentages and analyzed using chi-squared test or Fisher’s exact test as appropriate. Pearson correlation coefficients assessed relationships between continuous variables. A P value < 0.050 was considered statistically significant.

Ethical approval

Ethical approval for this study was obtained from Istanbul Medipol University on November 25, 2021 (Approval No. 1166). The corresponding author was officially affiliated with Istanbul Medipol University during the data collection period, and the approval was granted to her personally. Given the retrospective design of the study and its reliance on anonymized chart review, informed consent was not required. All patients’ medical records were accessed through the hospital information system in accordance with institutional protocols and privacy regulations. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki as revised in 2013. Patient confidentiality and data protection were maintained throughout the research process.

Results

We retrospectively reviewed the medical records of 173 female patients who underwent pregnancy termination at the Obstetrics and Gynecology Clinic of Istanbul Medipol University, Medipol Mega University Hospital, prior to 2022.

Patient obstetric characteristics

The overall mean patient age was 31.1 ± 5.5 years. Indications for termination included IUFD in 104 cases (60.1%) and fetal anomaly in 69 cases (39.9%). Among the patients, 35.8% (62/173) were gravida 1 (Table 1), and 41.6% (72/173) were nulliparous. The median (IQR) termination time for the anomaly group was 17 (10, 29) hours, while the median hospitalization time was 30 (22, 46) hours; the mean hospitalization duration was 26.8 ± 20.3 hours (range: 1–120). Most patients (75.7%, 131/173) had no history of abortion, and ectopic pregnancy was rare, occurring in only 2.9% (5/173) of cases.

Table 1.

Comparison of demographic and characteristics between patients with and without fetal anomalies.

Characteristics	No anomaly (n = 104)	Anomaly (n = 69)	Statistical values	P
Maternal age (years)	31.52 ± 5.11	30.67 ± 6.17	0.988	0.324*
Gravidity
1	29 (27.9)	33 (47.8)	7.361	0.025†
2	32 (30.8)	17 (24.6)
≥ 3	43 (41.3)	17 (24.6)
Parity
0	37 (35.6)	35 (50.7)	3.917	0.048†
≥ 1	67 (64.4)	34 (49.3)
Abortus
0	75 (72.1)	56 (81.2)	1.846	0.174†
≥ 1	29 (27.9)	13 (18.8)
Ectopic pregnancy	4 (3.8)	1 (1.4)	0.849	0,649†
Gestational age (weeks)	15.61 ± 3.23	18.19 ± 5.05	–4.105	0.001*
Termination time (hours)	8 (5,17)	17 (10,29)	2252	< 0.001‡
Hospitalization stay (hours)	16 (9,30)	30 (22,46)	1976	< 0.001‡

Data were expressed as n (%), mean ± standard deviation or median (interquartile range).

^*Student’s t test.

^†Chi-square test.

^‡Mann-Whitney U test.

Significant positive correlations were observed between misoprostol use and termination time (r = 0.251, P = 0.001), balloon use and termination time (r = 0.486, P < 0.001), and termination time and hospitalization duration (r = 0.833, P < 0.001). In comparing patients who underwent termination for fetal anomaly versus IUFD, the results showed no significant differences in age (P = 0.343). Gravida and parity were significantly lower in the anomaly group (P = 0.005 and P = 0.011, respectively). Gestational age, termination time, and hospitalization time were all significantly shorter in the non-anomaly group (all P < 0.001).

Among those who had deliveries, 21.4% (37/173) had a history of vaginal delivery, 34.1% (59/173) had undergone cesarean section, and 2.3% (4/173) had experienced both (Table 2). Vaginal delivery history was significantly less common in the anomaly group (P = 0.017).

Table 2.

Comparison of previous delivery methods between groups.

Previous delivery method	No anomaly (n = 104)	Anomaly (n = 69)	Statistical values	P
No prior birth	38 (36.5)	35 (50.7)	3.422	0.064*
NVD only	29 (27.9)	8 (11.6)	6.547	0.011*
CS	33 (31.7)	26 (37.7)	0.654	0.419*
NVD and CS	4 (3.8)	0	2.701	0.152†

Data were expressed as n (%).

^*Chi-squared test.

^†Fisher test.

NVD: Normal vaginal delivery; CS: Cesarean section; NVD and CS: Refers to patients who have delivered both via normal vaginal delivery and cesarean section.

Termination methods and procedures

Balloon use, curettage application, hysterectomy, and feticide rates were significantly higher in the anomaly group (P < 0.001). No significant differences were found in misoprostol usage (P = 1.000) or complication rates (P = 0.303) between the groups (Table 3). Regarding termination methods, misoprostol was used in 91.3% (153/173) of cases, balloon catheterization in 14.5% (25/173), and dilatation and curettage in 93.1% (161/173).

Table 3.

Comparison of termination-related interventions by fetal anomaly status.

Intervention	No anomaly (n=104)	Anomaly (n=69)	Overall (n=173)	Statistical values	P
Misoprostol use	95 (91.3)	63 (91.3)	158 (91.3)	0	1.000*
Balloon use	5 (4.8)	20 (29.0)	25 (14.5)	–	< 0.001†
Hysterotomy	0	10 (14.5)	10 (5.8)	–	< 0.001†
Curettage	103 (99.0)	58 (84.1)	161 (93.1)	14.429	< 0.001*
Feticide	1 (1.0)	13 (18.8)	14 (8.1)	17.828	< 0.001†
Complication	1 (1.0)	3 (4.3)	4 (2.3)	2.106	0.303†

Data were expressed as n (%).

^*Chi-squared test.

^†Fisher test.

–: Not applicable.

Relationship between obstetric history and termination-related outcomes

Termination time was significantly shorter in patients with previous births (P = 0.013), while no significant differences were observed in gestational age or hospitalization time (P > 0.05). A negative correlation was identified between parity and termination duration (r = –0.175, P = 0.021). When evaluating the effects of prior delivery method (vaginal, cesarean, or none), there were no significant differences in gestational age, termination time, or hospitalization time (all P > 0.05).

Discussion

Pregnancy termination refers to the cessation of pregnancy via medical or surgical interventions. In instances where termination is indicated due to fetal anomalies, particularly beyond 22 weeks of gestation, performing feticide is prioritized.⁷ In our cohort, feticide usage was significantly higher in cases where fetal anomaly was the indication for termination (P < 0.001).

For terminations occurring after 12 weeks, medical methods—comprising pharmacological agents and mechanical approaches—are generally favored over surgical techniques.⁹ Medical terminations are associated with lower morbidity and facilitate fetal genetic analysis.¹⁰ Despite longstanding literature emphasizing the need for consensus on optimal cervical ripening methods—an issue persisting for several decades—no definitive resolution has been achieved, and debate continues.¹¹

Prenatal diagnosis enables detection of numerous fetal anomalies, with earlier identification facilitated by advances in ultrasonography and first-trimester serum biochemical screening, allowing earlier clinical decision-making.¹² According to Centers for Disease Control and Prevention data from 2022, the majority (78.6%) of abortions were performed at or before 9 weeks’ gestation, with nearly all (92.8%) occurring at or before 13 weeks.¹³

Misoprostol has gained prominence due to its ease of use, affordability, rapid action, and reliability.¹⁴ Vaginal administration is generally preferred over other routes during pregnancy termination.¹⁵ Behrashi et al.¹⁶ reported higher success rates with vaginal misoprostol administration, while Danielsson et al.¹⁷ demonstrated that vaginal misoprostol induces more sustained and intense uterine contractions than oral administration. In our cohort, both oral and vaginal misoprostol were administered according to recommended dosages outlined in the FIGO Guidelines and under direct supervision of attending physicians. These guidelines were updated in 2023, subsequent to the completion of this study.⁸

Earlier literature has raised concerns regarding uterine rupture risks associated with misoprostol induction in patients with prior cesarean sections. For example, Aslan et al.¹⁸ (2004) identified an increased risk in this population. Conversely, Velipasaoglu et al.¹⁹ reported no uterine ruptures when misoprostol and balloon catheter were used simultaneously in cesarean scar patients. Similarly, Dickinson et al.²⁰ studied 720 patients, including 101 with prior cesarean deliveries, with no uterine rupture cases observed. In our study, among three uterine rupture cases, two involved patients with a history of cesarean delivery.

Bleeding remains a notable complication of termination procedures, often linked to mechanical methods such as balloon catheter use.²¹ Ercan et al.²² demonstrated that combining misoprostol with Foley catheter shortened induction-to-termination intervals compared to misoprostol alone. Comparable findings were reported by Rezk et al.²³ and Velipasaoglu et al.¹⁹ who both observed reduced induction-termination intervals with combined methods. Demirezen et al.²⁴ compared Foley and double balloon catheters, concluding that Foley catheters shortened the induction period. Later, Xing et al.²⁵ compared single and double balloon catheters in patients with prior cesarean sections, noting similar findings. These studies suggest that the degree of catheter inflation may not significantly impact outcomes.

Mechanistically, the Foley catheter promotes cervical ripening by exerting pressure on the lower uterine segment and cervix, facilitating prostaglandin release and membrane separation. In contrast, the double balloon catheter applies pressure to both the internal and external cervical os without requiring traction.²⁶ In our clinical practice, no patients received double balloon catheter treatment. Notably, balloon catheter use was more frequent in the fetal anomaly group compared to the intrauterine fetal death group, correlating with a more advanced gestational age in the former. This gestational difference influenced treatment choices, with curettage and hysterotomy also performed more frequently in the anomaly group. Consequently, the anomaly group exhibited longer termination durations, consistent with these findings.

In patients with prior deliveries, termination duration was significantly shorter compared to nulliparous patients. Additionally, normal vaginal delivery was significantly less frequent in the anomaly group relative to the non-anomaly group. When comparing termination methods, misoprostol use did not differ significantly between groups. However, balloon catheter use was markedly higher in the anomaly group, while hysterotomy—a surgical procedure—was significantly less frequent in the non-anomaly group. Curettage was more commonly performed in the anomaly group. Feticide procedures were exclusively observed in the anomaly group.

Complications occurred in 4 of 173 patients (2.3%). A cervical tear was noted in a primigravida with no obstetric history. One uterine rupture occurred in a patient with a single prior cesarean section; another patient with two previous cesarean deliveries sustained combined uterine and bladder rupture. In a separate case, curettage for retained placenta was complicated by suspected visceral injury, necessitating immediate diagnostic laparoscopy. This procedure was performed by a multidisciplinary team comprising a gynecologic oncologist, general surgeon, primary attending obstetrician-gynecologist, and a resident. Intraoperative findings revealed uterine and bowel perforations, both promptly repaired. Notably, this patient’s history included a complicated prior abortion and spontaneous vaginal delivery, possibly contributing to the clinical course.

Although termination duration was longer in the fetal anomaly group, total hospitalization time was shorter. This paradox likely reflects multiple factors: the expertise of a highly experienced clinical team accustomed to private-university hospital workflows; alignment of obstetric and gynecologic surgeons with patients’ preferences for expedited care in anomaly cases; and a departmental culture facilitating early, multidisciplinary consultation, particularly with Maternal-Fetal Medicine specialists. Importantly, all cases were managed by a consistent, well-coordinated clinical team.

Data were retrospectively extracted from electronic medical records at the Obstetrics and Gynecology Clinic of Istanbul Medipol University, Medipol Mega University Hospital. We conducted a comparative analysis of 173 pregnancy terminations, differentiating cases indicated by intrauterine fetal death versus fetal anomalies, aiming to inform clinical management based on institutional experience. As a single-center study, generalizability is limited; however, Medipol Mega University Hospital, a tertiary referral center with a distinguished Maternal-Fetal Medicine division, provides a diverse clinical population from across Istanbul, enhancing the relevance of our dataset. Authors participated directly in patient care during data collection, enabling contextual insights grounded in real-world clinical practice. The socio-cultural context of this private institution introduces potential financial barriers; nonetheless, we observed families’ strong commitment to accessing high-quality care despite economic constraints, underscoring the societal emphasis on maternal-fetal health—a consideration pertinent to health systems research.

Another limitation of our study was the inability to subclassify fetal anomalies into structural or chromosomal categories due to institutional protocols restricting such classifications to Maternal-Fetal Medicine specialists, with related data maintained separately. While this limited the granularity of our analysis, it underscores the need for future integrated data collection and comprehensive analysis. Additionally, although comparisons between anomaly and non-anomaly groups showed no significant difference in maternal age, and gravidity and parity were lower in the anomaly group, the analysis did not control for potential confounding factors through multivariable logistic regression or stratified analyses. History of ectopic pregnancy did not differ significantly between groups. Gestational age at termination was significantly more advanced in the anomaly group.

As this was a retrospective study, the sample size was determined by the number of available cases. We recognize the value of logistic regression analysis in identifying predictors of complications and differences in management strategies between the two groups. However, given the low incidence of complications in our cohort, such an analysis would not have produced statistically robust or reliable results. We acknowledge this as a limitation and suggest it as a direction for future research involving larger sample sizes.

The coordinated multidisciplinary approach, continuity of care, and adherence to standardized protocols likely contributed to successful management. Nonetheless, further research is warranted to strengthen the evidence base. We anticipate that our findings, highlighting outcomes associated with various termination methods, will inform and improve clinical care for patients undergoing pregnancy termination for diverse indications.

Conclusion

In this retrospective analysis of pregnancy terminations due to fetal anomalies and intrauterine fetal death, we observed notable differences in clinical management shaped by gestational age, patient history, and institutional protocols. Misoprostol remained the primary method across both groups, while adjunctive interventions such as balloon catheterization, curettage, and hysterotomy were more commonly used in anomaly-related terminations. Although complication rates were low, their occurrence underscores the need for vigilant, multidisciplinary care. The greater gestational age and complexity of anomaly cases required more tailored approaches, highlighting the importance of clinical experience and coordinated management in high-risk terminations. While the low complication rate precluded logistic regression to identify predictive variables, we acknowledge this limitation and propose further research to assess whether certain management strategies are more frequently applied in one indication group and whether these patterns persist after adjusting for confounders. These findings provide valuable insight into optimizing termination practices in tertiary care, reinforcing the need for individualized, evidence-based approaches.

Acknowledgements

This research is derived from the medical specialty thesis submitted by the corresponding author, under the supervision of the co-author, to Istanbul Medipol University as part of the requirements for the completion of the residency program in Obstetrics and Gynecology. The thesis was formally presented and successfully defended on September 8, 2022, at the Medipol Mega Hospitals Complex in Istanbul, Türkiye. It is officially archived in the National Thesis Center under the registration number 769380 and as of June 2025, is accessible via https://tez.yok.gov.tr/UlusalTezMerkezi/, as well as through the university’s open-access platforms. Further information is available through the thesis record on the Academic Data Management System (AVESIS) at: https://avesis.medipol.edu.tr/yonetilen-tez/315500a9-1724-4063-b0fa-b3a5df8535d3/intrauterin-mort-fetus-ve-fetal-anomali-nedeniyle-tibbi-terminasyon-yapilan-hastalarin-tahliye-sureclerinin-karsilastirilmasi and the Istanbul Medipol University. Academic Archive at: https://acikerisim.medipol.edu.tr/.

In addition, a preliminary abstract of this research, titled “Termination Processes of Pregnancies Due to Intrauterine Mort Fetus and Fetal Anomaly”, was accepted as an e-poster (ID: EP.1452) at the Royal College of Obstetricians and Gynaecologists World Congress, held in London, United Kingdom, on 12–14 June 2023. The abstract was published under the theme “Abortion Care” in the ePosters section of the official RCOG Congress website and remains accessible as of July 2025 at: https://epostersonline.com/rcog2023/authors?title=T+AKCAOGLU.

The authors would like to express their sincere gratitude to Dr. Burak Eren, Dr. Birzat Emre Golboyu, and editor Jue Li for their valuable guidance on the validation of the statistical analyses conducted in this study.

Funding

None.

Author Contributions

TA: Conceptualization, methodology, ethics approval, data collection, writing – original draft.

ECE: Conceptualization, methodology, data collection, supervision.

Conflicts of Interest

None.

Data Availability

Data is available upon reasonable request from the corresponding author.