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Overview of second-trimester pregnancy termination

Author: Cassing Hammond, MD


Section Editor: Jody Steinauer, MD, MAS
Deputy Editor: Sandy J Falk, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: May 24, 2017.

INTRODUCTION — Second-trimester pregnancy termination comprises 10 to 15 percent of the approximately


42 million abortions performed annually worldwide [1,2]. The United States Centers for Disease Control and
Prevention (CDC) reported that 7.1 percent of abortions were performed between 14 to 20 weeks and 1.3
percent at or after 21 weeks [3].

Second-trimester abortion is associated with more morbidity and mortality and, for some women, more social or
emotional challenges than first-trimester abortion [4]. Legal induced abortion is rarely associated with death; from
2008 to 2012, the CDC reported 36 deaths associated with abortions in the United States, the case-fatality-ratio
was 0.80 [3]. The mortality risk increases by 38 percent for each successive gestational week after eight weeks
[5].

Similar to first-trimester abortion, second-trimester procedures can be performed either with dilation and
evacuation (D&E) or medication. An overview of second-trimester pregnancy termination and the procedure for
surgical termination are reviewed here. Second-trimester induction termination and second-trimester D&E, as
well as first-trimester pregnancy termination and other topics regarding induced abortion, are discussed
separately. (See "Second-trimester pregnancy termination: Induction (medication) termination" and "Second-
trimester pregnancy termination: Dilation and evacuation" and "Surgical termination of pregnancy: First trimester"
and "First-trimester medication abortion (termination of pregnancy)" and "Overview of pregnancy termination".)

PROCEDURE PLANNING

Indications and contraindications — Women terminate pregnancies in the second-trimester for many reasons.
Procedures are often performed in the second trimester because of a delay in diagnosis of the pregnancy or
delay in obtaining an abortion. As an example, at one large United States public hospital, 58 percent of patients
having second-trimester procedures were already beyond the first trimester by the time they obtained a
pregnancy test [6].

For some women, a fetal anomaly or maternal illness (eg, early onset severe preeclampsia) is not recognized or
does not present until the second-trimester. Midtrimester preterm premature rupture of membranes may also be
an indication for pregnancy termination.

There are no contraindications to second-trimester abortion, although some women with medical comorbidities
have an increased risk of complications. However, ongoing pregnancy and delivery are also usually associated
with a risk of complications in these patients. Women with significant medical conditions should be managed by
an experienced surgeon and may require consultation with an appropriate specialist (eg, cardiologist,
pulmonologist).
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Laws regarding abortion vary by country and by state in the United States [7]. Most states restrict abortion after
fetal viability, though the definition of viability varies by state and maternal-fetal exemptions that countermand the
viability statute vary by state. Clinicians offering abortion need to become familiar with local restrictions.

Preoperative evaluation — Determining gestational age is a critical part of providing appropriate care. (See
"Overview of pregnancy termination", section on 'Determining gestational age'.)

The preprocedure evaluation for pregnancy termination is discussed in detail separately. (See "Overview of
pregnancy termination", section on 'Preoperative considerations'.)

Counseling and informed consent — Women planning second-trimester pregnancy termination should be
offered counseling regarding the decision to terminate or continue the pregnancy. Surgical and induction options
for the procedure should be reviewed. Women should be counseled about follow-up care and potential
complications of the procedure. This discussion should be documented on the procedure consent form and in the
medical record. (See "Counseling regarding pregnancy termination", section on 'Overview' and "Counseling
regarding pregnancy termination", section on 'Preprocedure counseling' and "Counseling regarding pregnancy
termination", section on 'Introduction'.)

CHOOSING DILATION AND EVACUATION VERSUS INDUCTION TERMINATION — Second-trimester


pregnancy termination can be performed by dilating the cervix and evacuating products of conception (dilation
and evacuation; D&E) or by using medication to induce delivery of the fetus and placenta. D&E accounts for the
great majority of second-trimester abortions in the United States (US) [8,9]. The US Centers for Disease Control
and Prevention reported that, in 2010, uterine curettage was used in 96 to 98 percent of abortions at 9 to 17
weeks of gestation, 94.1 percent at 18 to 20 weeks, and 91 percent at ≥21 weeks [3,10].

Historically, in the 1970s to 1980s, D&E was preferred because it was found to result in fewer complications than
the method used for induction termination at the time, hyperosmolar instillation or oxytocin alone [11-16]. Most of
the morbidity originally associated with second-trimester induction termination derived from prolonged induction
times. The introduction of induction regimens with prostaglandins and progesterone antagonists has narrowed
the safety gap between surgical and medical methods by shortening the interval from induction to complete
abortion.

Induction termination and D&E are both safe procedures throughout the second trimester; types of morbidity
vary. For example, patients undergoing D&E risk uterine perforation with need for surgical repair, whereas
patients undergoing medical abortion confront higher rates of hemorrhage and infection. Patients with different
medical histories might have reason to fear one type of complication more than another, influencing their
selection of procedure.

Given the available data and other considerations, the choice depends mainly upon patient preference and the
availability of a clinician with the skills and experience to provide one or both approaches. The clinician and
patient should engage in shared decision-making to consider all the factors. For women planning second-
trimester pregnancy termination, we suggest D&E for those who prefer a procedure with greater control over
timing and less experience of the procedure. We suggest induction (medication) abortion for women who place a
high value on avoiding surgery or have a reason to prefer an intact fetus and who are willing to accept more
discomfort and awareness during the procedure, a larger blood loss, and a chance of additional surgical
intervention.

Outcomes — Both D&E and induction abortion in the second trimester are safe and effective, but D&E is
preferred by most women [17]. In addition, approximately 8 percent of women who undergo induction abortion
require a surgical procedure for retained placenta. (See "Second-trimester pregnancy termination: Induction
(medication) termination", section on 'Retained placenta'.)

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There are few well-designed studies comparing the two approaches [17,18]. Randomized trials are difficult to
conduct because women often decline to be randomly assigned due to a strong preference for D&E (eg, in one
trial, 38 percent of the women recruited declined randomization and 67 percent of these wanted D&E [18]).

The only completed randomized trial found that complication rates were comparable, but induction abortion was
associated with more adverse effects and a risk of subsequent D&E for retained products of conception. This trial
(n = 122) compared D&E and induction abortion (mifepristone and misoprostol) at 13 to 20 weeks of gestation
[18]. In terms of efficacy, 10 percent of women in the induction group underwent a subsequent procedure for
retained products of conception. The rate of complications was comparable for surgical and induction procedures
(12.0 versus 11.5 percent), but the type of complication varied by the type of abortion: Blood loss >500 mL was
more likely in the surgical group and retained placenta in the induction group. As noted, induction abortion was
more likely to result in a subsequent procedure (10 percent compared with 2 percent in the surgical group).
Women in the surgical group experienced significantly lower rates of some adverse effects: unexpected
overnight stay (0 versus 31 percent) and uterine bleeding heavier than menses (4 versus 37 percent); moderate
to severe pain was also less common in the surgical group, but this did not reach statistical significance (23
versus 43 percent). Women in the surgical group found the procedure more acceptable (100 versus 53 percent
would choose the same procedure in the future). This trial was limited by a lack of statistical power and a low
follow-up rate (60 percent).

Advantages and disadvantages

Dilation and evacuation

Advantages of D&E include:

● Decreased procedure duration and predictable timing – Although patients usually undergo one to two
days of cervical preparation, experienced surgeons can perform uterine evacuation in less than 30 minutes
once the cervix is dilated. Induction abortion, by contrast, may take as long as 24 hours or longer.

● Decreased cost – D&E usually occurs in an outpatient facility. Induction abortion often requires admission
to a higher-cost labor and delivery unit [19].

● Medical conditions that required controlled timing of the procedure – The controlled timing of D&E
permits planned procedures for patients whose medical conditions may worsen peripartum. Patients with
bleeding diatheses, cardiac, and other maternal conditions often benefit from scheduled surgical procedures
rather than less-predictable induction procedures. Patients with multiple prior uterine surgeries and placenta
previa can also undergo safe D&E, reducing risks of uterine rupture or hemorrhage.

Disadvantages of D&E include:

● Risk of uterine perforation – Uterine perforation is a potential risk of D&E and requires further surgical
intervention. (See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Uterine
perforation'.)

Induction abortion

Advantages of induction include:

● Desire for an intact fetus – Some patients choose labor induction to avoid fetal destruction associated with
D&E. This may be due to a desire to hold the fetus or to provide an intact fetus for morphologic evaluation
(this may be important when congenital anomalies are present). However, this may also be possible with
intact D&E.

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Disadvantages of induction include:

● Increased experience of the procedure – In induction abortion, the patient experiences uncomfortable
effects (bleeding, cramping, nausea, vomiting) and these occur over a longer period of time during and after
the procedure than with D&E [18]. The patient also has a greater awareness of the process of terminating
the pregnancy. Many patients find that the predictability of D&E and avoiding the memory of prolonged labor
make D&E less emotionally burdensome than induction abortion [20-22].

● Unpredictability of the timing of delivery

● Risk of hemorrhage and infection – Second-trimester induction termination is generally associated with a
higher volume of blood loss than D&E in most studies, although the opposite was found in the trial described
above [18,23-25]. Induction abortion is also typically associated with a higher risk of infection [26]. (See
"Second-trimester pregnancy termination: Dilation and evacuation", section on 'Hemorrhage'.)

Procedure setting — Second-trimester D&E is typically performed in an outpatient setting, either a specialty
women's health clinic, a clinician's office equipped with a procedure room, or an ambulatory surgery center.

Second-trimester induction most commonly occurs in hospitals on a labor and delivery unit or a family planning
unit within the hospital. Induction procedures can be performed in outpatient settings, with the appropriate
medical staff and equipment to provide ongoing administration of induction agents, analgesia and anesthesia,
monitoring of patient status, delivery of the fetus and placenta (timing is often unpredictable), and, if needed,
emergency surgical management (in case of a need for immediate evacuation of either fetus or placenta) or
emergency transport to an inpatient facility.

Clinics or hospitals that provide pregnancy termination must have the appropriate medical staff, equipment, and
medication to perform the procedure and manage complications and to provide analgesia and anesthesia. The
National Abortion Federation, a professional organization of abortion providers in the United States, Canada,
Mexico, and Colombia, has issued clinical policy guidelines regarding medical personnel and facilities that
provide pregnancy termination [27]. These stipulate that abortions should be provided by a licensed practitioner.
The minimum requirements for a facility include presence on-site of a medical staff member with updated basic
life support certification; an oxygen delivery system, oral airways, self-inflating respirator bags, and
bronchodilators; and uterotonics and vasopressors, including epinephrine. In settings in which opioids or
benzodiazepines are used, appropriate antagonists must be available.

It is useful for outpatient clinics to have written protocols to address emergencies, particularly indications for
emergency transport to a hospital and contact information for personnel who are able to be immediately available
to facilitate transport.

ABORTION TECHNIQUES AND PROTOCOLS

Dilation and evacuation — Second-trimester dilation and evacuation is discussed separately. (See "Second-
trimester pregnancy termination: Dilation and evacuation".)

Induction abortion — Second-trimester induction abortion, also referred to as medication or medical abortion, is
discussed separately. (See "Second-trimester pregnancy termination: Induction (medication) termination".)

FOLLOW-UP — Many clinicians schedule a follow-up visit at two weeks. In settings where patients live a long
distance from abortion facilities, it is appropriate to schedule follow-up with another clinician, to offer routine
phone follow-up 24 to 48 hours afterwards, or to offer patient follow-up on an as-needed basis [28].

Complications are likely to present before a routine scheduled follow-up visit. The patient should be given
detailed instructions regarding signs and symptoms of complications. Patients should be advised to call their
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provider if they experience any of the following symptoms:

● Vaginal bleeding that soaks one to two pads hourly for two consecutive hours
● Fever >100.4°F
● Pelvic or abdominal pain that is severe or persistent

Most abortion patients should be counseled about contraception. Postabortal contraception is discussed
separately. (See "Postabortion contraception".)

Patients may lactate following second-trimester abortion and should be counseled about comfort measures,
including use of ice, compression with a tight sports bra, and avoiding breast stimulation. (See "Overview of
postpartum care", section on 'Breast engorgement'.)

SPECIAL CIRCUMSTANCES

Uterine anomaly — Approximately 2 to 4 percent of women have some type of congenital uterine anomaly,
including uterine septa, bicornuate uteri, or complete duplication of both uterus and cervix [29]. Uterine
anomalies increase the likelihood of failed dilation and evacuation (D&E) [30,31]. Indeed, failed abortion may
lead to a diagnosis of a uterine malformation [32]. Intraoperative ultrasound greatly facilitates surgical evacuation
in the setting of uterine anomalies.

There is no evidence that induction abortion requires a different regimen for women with uterine anomalies.

Uterine anomalies are discussed in detail separately. (See "Clinical manifestations and diagnosis of congenital
anomalies of the uterus".)

Low-lying placenta — Given the risk of hemorrhage associated with induction of labor, D&E is the standard of
care for most patients with placenta previa (referred to as low-lying placenta before 20 weeks of gestation). (See
"Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality".)

Patients with isolated low-lying placenta can undergo D&E without increased risk of hemorrhage. Osmotic
dilators may be inserted on the usual outpatient basis, and no special precautions are required [33].

Placenta accreta complicates roughly one in four pregnancies in which previa occurs following prior cesarean
section. If a placenta accreta is suspected, the procedure should be performed in a hospital setting to assure
availability of blood products, appropriate anesthesia support, and the capability to perform a hysterectomy if
necessary. (See "Clinical features and diagnosis of the morbidly adherent placenta (placenta accreta, increta,
and percreta)", section on 'Risk factors'.)

Prior uterine scar — A uterine scar from a prior cesarean delivery or myomectomy is not an absolute
contraindication to induction abortion, but many clinicians prefer D&E for these patients. Uterine rupture is a risk
of misoprostol use at any time during pregnancy. The risk is higher in women with a uterine scar from a prior
cesarean delivery [34]. (See "Second-trimester pregnancy termination: Induction (medication) termination",
section on 'Uterine rupture' and "Misoprostol as a single agent for medical termination of pregnancy", section on
'Risk factors for uterine rupture'.)

It is uncertain whether a surgical approach entirely eliminates the risk of uterine rupture. During the process for a
D&E, the uterus contracts in response to the insertion of osmotic dilators and the surgery itself, and with use of
misoprostol or other agents as pharmacologic ripening agents or uterotonics. Theoretically, some events that are
classified as a uterine perforation at the time of D&E on a scarred uterus may represent an occult uterine rupture.

Multifetal gestation — Multifetal gestation is managed in the same way as a singleton pregnancy for second-
trimester abortion. There is no evidence that a modification is required of the surgical technique or medication
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regimen, though patients might confront a higher risk of uterine atony and hemorrhage due to greater uterine
size. Operators should manage uterine atony as they do at similar gestational size.

Fetal anomaly or fetal demise — Second-trimester abortion is often performed for the indication of a fetal
anomaly. Diagnosis of fetal anomalies and counseling for women undergoing termination for a fetal anomaly are
discussed separately. (See "Overview of antepartum fetal surveillance" and "Psychiatric aspects of pregnancy
termination", section on 'Termination for fetal anomalies'.)

For fetal demise, management of uterine evacuation is generally the same as induced abortion and morbidity is
similar, except that risk of transfusion may be higher with intrauterine fetal demise [26] Management of fetal
demise is discussed in detail separately. (See "Fetal death and stillbirth: Maternal care".)

Chorioamnionitis — Midtrimester chorioamnionitis may develop in the presence of preterm premature rupture
of membranes. This may occur spontaneously and, in some cases, midtrimester rupture of membranes is the
indication for pregnancy termination. Alternatively, it may develop after insertion of osmotic dilators or during a
prolonged induction procedure. (See "Midtrimester preterm premature rupture of membranes", section on
'Chorioamnionitis'.)

Patients with chorioamnionitis present with fever and other possible findings (pelvic and abdominal pain, uterine
contractions, purulent cervical discharge). Uterine evacuation is the cornerstone of treating second-trimester
chorioamnionitis. No studies have evaluated the relative benefits of surgical versus medical abortion in this
setting.

For patients who are hemodynamically stable and have early chorioamnionitis, surgical or induction abortion may
proceed in the same manner as for other patients. In our practice, if a patient develops a persistent temperature
elevation >100.4°F, we treat with antibiotics, in the same manner as chorioamnionitis during obstetric induction.
(See "Intra-amniotic infection (clinical chorioamnionitis or triple I)", section on 'Antibiotic therapy'.)

Given high mortality rates associated with septic abortion, evacuation should be expedited for patients who are
overtly septic. The best option for the patient must be individualized, and the surgeon should choose the one that
best expedites uterine evacuation. Approaches include:

● Place osmotic dilators to prepare for D&E. There is no evidence that use of osmotic dilators exacerbates
infection in patients with chorioamnionitis. Some patients with overt sepsis have already begun laboring and
might require less cervical preparation than uninfected patients.

● Initiate an effective induction protocol. Osmotic dilators may be placed or mifepristone administered
concurrent with initiation of uterotonics to begin the induction to allow the flexibility to convert to D&E if
induction becomes prolonged. Unfortunately, placement of osmotic dilators may prolong induction abortion
intervals in some cases [35-37].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries
and regions around the world are provided separately. (See "Society guideline links: Pregnancy termination".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

● Basics topic (see "Patient education: Abortion (The Basics)")

● Beyond the Basics topic (see "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Second-trimester (14 to <28 weeks of gestation) pregnancy termination comprises 10 to 15 percent of the
approximately 42 million abortions performed annually worldwide. (See 'Introduction' above.)

● Indications for second-trimester abortion include socioeconomic and psychosocial factors (often in cases of
a delay in diagnosis of the pregnancy or delay in obtaining an abortion), fetal anomaly, preterm premature
rupture of membranes, or maternal illness. There are no contraindications to second-trimester abortion,
although some women with medical comorbidities have an increased risk of complications. (See 'Indications
and contraindications' above.)

● Second-trimester pregnancy termination can be performed as a surgical evacuation of the uterus (dilation
and evacuation; D&E) or by using medication to induce delivery of the fetus and placenta. (See 'Choosing
dilation and evacuation versus induction termination' above.)

● Both D&E and induction methods are safe and effective options for second-trimester pregnancy termination.
The choice depends mainly upon patient preference and the availability of a clinician with the skills and
experience to provide one or both approaches. For women planning second-trimester pregnancy termination
(see 'Choosing dilation and evacuation versus induction termination' above):

• We suggest D&E for those who prefer a procedure with greater control over timing and less experience
of the procedure (Grade 2C).

• We suggest induction (medication) abortion for women who place a high value on avoiding surgery or
have a reason to prefer an intact fetus and who are willing to accept more discomfort and awareness
during the procedure, a larger blood loss, and a chance of additional surgical intervention (Grade 2C).

● The patient should be given detailed instructions regarding signs and symptoms of complications, including
fever, excessive vaginal bleeding, or severe or persistent pelvic or abdominal pain. Many clinicians schedule
a follow-up visit at two weeks after second-trimester pregnancy termination. Options for contraceptives are
typically part of counseling before and after the procedure. (See 'Follow-up' above.)

● Additional expertise or consultation may be required depending upon the clinical context (eg, elective
abortion, preterm premature rupture of membranes) and special circumstances (eg, comorbidities, uterine
anomaly, low-lying placenta). (See 'Special circumstances' above.)

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Topic 14194 Version 13.0

Contributor Disclosures
Cassing Hammond, MD Nothing to disclose Jody Steinauer, MD, MAS Nothing to disclose Sandy J Falk,
MD, FACOG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Conflict of interest policy

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