Midtrimester abortion may be accomplished by a variety of techniques, alone or in combination. Comprehensive care of patients who require or request pregnancy termination in the second trimester must include careful assessment of medical and psychological conditions. Special attention needs to be paid to gestational age, and for many cases ultrasonography should be part of the evaluation. With the variety of techniques and combinations available, physicians can now individualize patient care to minimize morbidity and mortality while improving patient comfort and well being.
PIP: The development of new techniques for 2nd trimester abortion procedures enables physicians to individualize care to meet specific needs and, at the same time, decrease morbidity and mortality. This paper reviews the procedures and preoperative and postoperative considerations in midtrimester abortions. Reasons for midtrimester pregnancy termination include fetal abnormalities, failed 1st trimester abortions, selected maternal medical conditions, fetal death in utero, and elective abortion requests in which the pregnancy was not recognized earlier. Careful assessment of medical and psychological conditions should be made. Ultrasonography is often useful in the preoperative evaluation of midtrimester abortion patients to prevent misjudgments of gestational age. Midtrimester abortion procedures include prostaglandins (PGs), amnioinfusion, and dilatation-evacuation. PGE2 suppositories, placed in the posterior vaginal fornix every 3-4 hours, seem to have high efficacy and few side effects. Amnioinfusion methods should be performed after 15 weeks of gestation, since it may be difficult to enter the amniotic cavity before that time. Care should be taken to avoid intravenous, intraperitoneal, or intramyometrial injection of the abortifacient. Dilatation-evacuation has become the most common method of 2nd-trimester pregnancy termination. Use of laminaria tents for adequate preoperative cervical dilatation, specialized instruments, and gradual acquisition of surgical skill starting with the early 2nd trimester contribute to the greater safety of this method. Other surgical methods include hysterotomy and hysterectomy. There are also many possible combinations of midtrimester abortion techniques. For example, laminaria tents can be used with most procedures, and oxytocin infusion may improve results when used simultaneously with amnioinfusion or hypertonic saline or urea. Hypertonic urea can be used prior to dilatation-evacuation, especially in cases of advanced gestational age. Retained tissue and Rh isoimmunization are among the postoperative considerations. The effects of 2nd trimester abortion on future fertility have not been analyzed; however, care should be taken to avoid trauma to the cervix and uterus, to maximize removal of retained products of conception, and to minimize postabortal infection.