Second-trimester pregnancy termination: Induction (medication) termination
- Cassing Hammond, MD
Cassing Hammond, MD
- Associate Professor in Obstetrics & Gynecology
- Northwestern University
Second-trimester (14 to <28 weeks of gestation) pregnancy terminations comprise 10 to 15 percent of the approximately 42 million abortions performed annually worldwide . 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 .
Induction abortion (also referred to as medication or medical abortion) is performed by inducing labor with medications. Women have historically relied upon a variety of herbal and other substances to stimulate labor to abort an undesired pregnancy. Women may choose medication abortion if they prefer more awareness of the termination process, if they prefer an intact fetus, or they want to avoid surgery. An intact fetus may be desirable if the patient desires to hold the fetus or, in cases of fetal anomalies, if an intact fetus is beneficial for a morphologic evaluation. In some healthcare settings, there is more access to second-trimester induction abortion than surgical abortion.
Second-trimester induction termination is reviewed here. An overview of second-trimester pregnancy termination and the technique for surgical abortion are discussed separately. First trimester medication abortion is also discussed separately. (See "Overview of second-trimester pregnancy termination" and "First-trimester medication abortion (termination of pregnancy)".)
Women desiring second-trimester induction termination require preoperative evaluation to establish gestational age, assess general medical status, and identify any medical factors that may impact the choice of induction versus surgical termination. Many of the medical factors favoring medical abortion are "provider-dependent" in that they derive from a specific provider’s skill in a particular situation.
Choice of procedure is discussed in detail separately. (See "Overview of second-trimester pregnancy termination", section on 'Choosing dilation and evacuation versus induction termination'.)
- Sedgh G, Henshaw S, Singh S, et al. Induced abortion: estimated rates and trends worldwide. Lancet 2007; 370:1338.
- Jatlaoui TC, Ewing A, Mandel MG, et al. Abortion Surveillance - United States, 2013. MMWR Surveill Summ 2016; 65:1.
- Achilles SL, Reeves MF, Society of Family Planning. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception 2011; 83:295.
- Borgatta L, Chen AY, Vragovic O, et al. A randomized clinical trial of the addition of laminaria to misoprostol and hypertonic saline for second-trimester induction abortion. Contraception 2005; 72:358.
- Jain JK, Mishell DR Jr. A comparison of misoprostol with and without laminaria tents for induction of second-trimester abortion. Am J Obstet Gynecol 1996; 175:173.
- Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol 1999; 94:139.
- Kafrissen ME, Barke MW, Workman P, et al. Coagulopathy and induced abortion methods: rates and relative risks. Am J Obstet Gynecol 1983; 147:344.
- Kapp N, Todd CS, Yadgarova KT, et al. A randomized comparison of misoprostol to intrauterine instillation of hypertonic saline plus a prostaglandin F2alpha analogue for second-trimester induction termination in Uzbekistan. Contraception 2007; 76:461.
- Elami-Suzin M, Freeman MD, Porat N, et al. Mifepristone followed by misoprostol or oxytocin for second-trimester abortion: a randomized controlled trial. Obstet Gynecol 2013; 122:815.
- Nuthalapaty FS, Ramsey PS, Biggio JR, Owen J. High-dose vaginal misoprostol versus concentrated oxytocin plus low-dose vaginal misoprostol for midtrimester labor induction: a randomized trial. Am J Obstet Gynecol 2005; 193:1065.
- Owen J, Hauth JC. Vaginal misoprostol vs. concentrated oxytocin plus low-dose prostaglandin E2 for second trimester pregnancy termination. J Matern Fetal Med 1999; 8:48.
- Chen QJ, Hou SP, Meads C, et al. Mifepristone in combination with prostaglandins for termination of 10-16 weeks' gestation: a systematic review. Eur J Obstet Gynecol Reprod Biol 2011; 159:247.
- Andersen LF, Poulsen HK, Sørensen SS, et al. Termination of second trimester pregnancy with gemeprost vaginal pessaries and intra-amniotic PGF2 alpha. A comparative study. Eur J Obstet Gynecol Reprod Biol 1989; 31:1.
- Cameron IT, Baird DT. The use of 16,16-dimethyl-trans delta 2 prostaglandin E1 methyl ester (gemeprost) vaginal pessaries for the termination of pregnancy in the early second trimester. A comparison with extra-amniotic prostaglandin E2. Br J Obstet Gynaecol 1984; 91:1136.
- Su LL, Biswas A, Choolani M, et al. A prospective, randomized comparison of vaginal misoprostol versus intra-amniotic prostaglandins for midtrimester termination of pregnancy. Am J Obstet Gynecol 2005; 193:1410.
- Blanchard K, Clark S, Winikoff B, et al. Misoprostol for women's health: a review. Obstet Gynecol 2002; 99:316.
- Nor Azlin MI, Abdullah HS, Zainul Rashid MR, Jamil MA. Misoprostol (alone) in second trimester terminations of pregnancy: as effective as Gemeprost? J Obstet Gynaecol 2006; 26:546.
- Nuutila M, Toivonen J, Ylikorkala O, Halmesmäki E. A comparison between two doses of intravaginal misoprostol and gemeprost for induction of second-trimester abortion. Obstet Gynecol 1997; 90:896.
- Wong KS, Ngai CS, Wong AY, et al. Vaginal misoprostol compared with vaginal gemeprost in termination of second trimester pregnancy. A randomized trial. Contraception 1998; 58:207.
- Dodd JM, Crowther CA. Misoprostol versus cervagem for the induction of labour to terminate pregnancy in the second and third trimester: a systematic review. Eur J Obstet Gynecol Reprod Biol 2006; 125:3.
- Wildschut H, Both MI, Medema S, et al. Medical methods for mid-trimester termination of pregnancy. Cochrane Database Syst Rev 2011; :CD005216.
- Hammond C. Recent advances in second-trimester abortion: an evidence-based review. Am J Obstet Gynecol 2009; 200:347.
- Dickinson JE, Jennings BG, Doherty DA. Mifepristone and oral, vaginal, or sublingual misoprostol for second-trimester abortion: a randomized controlled trial. Obstet Gynecol 2014; 123:1162.
- Ashok PW, Templeton A, Wagaarachchi PT, Flett GM. Midtrimester medical termination of pregnancy: a review of 1002 consecutive cases. Contraception 2004; 69:51.
- Wong KS, Ngai CS, Yeo EL, et al. A comparison of two regimens of intravaginal misoprostol for termination of second trimester pregnancy: a randomized comparative trial. Hum Reprod 2000; 15:709.
- Pongsatha S, Tongsong T. Intravaginal misoprostol for pregnancy termination. Int J Gynaecol Obstet 2004; 87:176.
- Bygdeman M, Swahn ML. Progesterone receptor blockage. Effect on uterine contractility and early pregnancy. Contraception 1985; 32:45.
- Tang OS, Chan CC, Kan AS, Ho PC. A prospective randomized comparison of sublingual and oral misoprostol when combined with mifepristone for medical abortion at 12-20 weeks gestation. Hum Reprod 2005; 20:3062.
- Kapp N, Borgatta L, Stubblefield P, et al. Mifepristone in second-trimester medical abortion: a randomized controlled trial. Obstet Gynecol 2007; 110:1304.
- Borgatta L, Kapp N, Society of Family Planning. Clinical guidelines. Labor induction abortion in the second trimester. Contraception 2011; 84:4.
- Ngoc NT, Shochet T, Raghavan S, et al. Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion: a randomized controlled trial. Obstet Gynecol 2011; 118:601.
- ACOG Practice Bulletin No. 135: Second-trimester abortion. Obstet Gynecol 2013; 121:1394. Reaffirmed 2017.
- World Health Organization. Safe abortion: technical and policy guidance for health systems. World Health Organization, Geneva, Switzerland 2003.
- Royal College of Obstetricians and Gynecologists. The care of women requesting induced abortion. Royal College of Obstetricians and Gynecologists, London 2004.
- Rose SB, Shand C, Simmons A. Mifepristone- and misoprostol-induced mid-trimester termination of pregnancy: a review of 272 cases. Aust N Z J Obstet Gynaecol 2006; 46:479.
- Cohen AL, Bhatnagar J, Reagan S, et al. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol 2007; 110:1027.
- Shaw KA, Topp NJ, Shaw JG, Blumenthal PD. Mifepristone-misoprostol dosing interval and effect on induction abortion times: a systematic review. Obstet Gynecol 2013; 121:1335.
- Perritt JB, Burke A, Edelman AB. Interruption of nonviable pregnancies of 24-28 weeks' gestation using medical methods: release date June 2013 SFP guideline #20133. Contraception 2013; 88:341.
- Hou SP, Fang AH, Chen QF, et al. Termination of second-trimester pregnancy by mifepristone combined with misoprostol versus intra-amniotic injection of ethacridine lactate (Rivanol®): a systematic review of Chinese trials. Contraception 2011; 84:214.
- Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for second-trimester abortion. Am J Obstet Gynecol 2002; 187:393.
- Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011; 117:788.
- Patel A, Talmont E, Morfesis J, et al. Adequacy and safety of buccal misoprostol for cervical preparation prior to termination of second-trimester pregnancy. Contraception 2006; 73:420.
- Castleman LD, Oanh KT, Hyman AG, et al. Introduction of the dilation and evacuation procedure for second-trimester abortion in Vietnam using manual vacuum aspiration and buccal misoprostol. Contraception 2006; 74:272.
- Whitley KA, Trinchere K, Prutsman W, et al. Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes. Am J Obstet Gynecol 2011; 205:386.e1.
- Berger GS, Kerenyi TD. Analysis of retained placenta associated with saline abortion: clinical considerations. Am J Obstet Gynecol 1974; 120:484.
- Kirz DS, Haag MK. Management of the third stage of labor in pregnancies terminated by prostaglandin E2. Am J Obstet Gynecol 1989; 160:412.
- Green J, Borgatta L, Sia M, et al. Intervention rates for placental removal following induction abortion with misoprostol. Contraception 2007; 76:310.
- Berghella V, Airoldi J, O'Neill AM, et al. Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review. BJOG 2009; 116:1151.
- Goyal V. Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery: a systematic review. Obstet Gynecol 2009; 113:1117.
- Kapp N, von Hertzen H. Medical methods to induce abortion in the second trimester. In: Management of unintended and abnormal pregnancy: comprehensive abortion care, Paul M, Lichtenberg ES, Borgatta L, et al. (Eds), Wiley-Blackwell, Hoboken 2009. p.186.
- Lichtenberg ES, Grimest DA. Surgical complications: Prevention and Management. In: Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care, Paul M, Lichtenberg ES, Borgatta L, et al. (Eds), Wiley-Blackwell, Hoboken 2009. p.232.
- Baskett TF. Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy. Obstet Gynecol 2007; 110:68.
- Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynaecol Obstet 2001; 74:139.
- Steinauer JE, Diedrich JT, Wilson MW, et al. Uterine artery embolization in postabortion hemorrhage. Obstet Gynecol 2008; 111:881.
- PREPROCEDURE PREPARATION
- Prophylactic antibiotics
- Cervical preparation
- Induced fetal demise
- Type of prostaglandin
- Route and regimen
- - Use of mifepristone
- Medical society protocols
- Use of other medications
- OUTCOME AND COMPLICATIONS
- Incomplete abortion
- Retained placenta
- Uterine rupture
- Cervical laceration
- Other complications
- SPECIAL CIRCUMSTANCES
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS