SECOND TRIMESTER ABORTION
Three or Four-day Outpatient Procedure
Second trimester abortion patients (up to 27 weeks) receive an ultrasound exam at the beginning of their appointment at Boulder Abortion Clinic. Among the features of the pregnancy evaluated at this time include the diagnosis of fetal age, position of the placenta, quantity of amniotic fluid, the presence of visible fetal anomalies, and pathology such as fibroids in the uterine wall.
The second trimester abortion patient experiences the same preoperative procedures as the first trimester patient: ultrasonography, blood tests, and counseling. Between 16 and 25 weeks, we perform a three-day outpatient procedure. At or after 26 weeks, we perform a four-day outpatient procedure.
Every patient’s care is individualized, and patients with obesity, prior cesareans, or other medical conditions may require a four-day procedure earlier than 26 weeks. Your safety is our first priority.
16 To 19 Weeks – Three Day Outpatient Procedure
- First day: preoperative care as above, followed by a single laminaria being placed in the cervix.
- Second day: the laminaria is removed, and multiple laminaria are placed in the dilated cervix under local anesthesia.
- Third day: second trimester abortion procedure.
20 to 25 weeks – Three Day Outpatient Procedure with Induced Fetal Demise
- First day: preoperative care as above. Fetal demise is induced, and a single laminaria is placed in the cervix.
- Second day: fetal demise is confirmed, the laminaria is removed, and multiple laminaria are placed in the dilated cervix under local anesthesia.
- Third day: procedure.
26 weeks and above – Four Day Outpatient Procedure with Induced Fetal Demise
- First day: preoperative care as above. Fetal demise is induced
- Second day: fetal demise is confirmed, and a single laminaria is placed in the cervix.
- Third day: The laminaria is removed, and multiple laminaria are placed in the dilated cervix under local anesthesia.
- Fourth day: procedure.
Induced Fetal Demise
At 20 weeks and later, an injection is done on the first day that stops the fetal heart. This injection is done through the patient’s abdomen, into the fetus, under local anesthesia. The injection itself usually takes less than a minute, although the strict attention to sterile technique means that the patient will be in the procedure room for longer than that.
Laminaria are placed into the cervix using a speculum. Most patients feel mild or no discomfort with the first laminaria. We have been able to accommodate patients who have a difficult time with speculum exams, and have experience with pediatric patients. Patients usually feel mild or no cramps while they have one laminaria in their cervix.
When multiple laminaria are being placed on the second or third day, we first numb the cervix with local anesthesia.
On the second trimester abortion procedure day, we start with placing an IV and often provide some medication for anxiety if patients request it. The laminaria and gauze are removed, and the amniotic membrane is ruptured (“breaking the water”). The amniotic fluid is drained as completely as possible.
In some early second-trimester cases, dilation may be adequate at this time to perform the procedure. Otherwise, medications such as misoprostol and pitocin are used to help the uterus contract and help the cervix dilate until it is open enough to perform the procedure. During this time, our patients rest in rooms near the procedure rooms, often with a family member or friend with them. We use IV medications to keep our patients comfortable.
When the cervix is dilated enough, the uterine contents are evacuated surgically by using forceps and other instruments. Patients are observed for up to two hours to ensure that their bleeding is light and that they are recovering well.
Dr. Hern developed this technique for the following reasons:
- Removal of the amniotic fluid reduces if not eliminates the risk of amniotic fluid embolism (AFE), probably the most dangerous possible complication of late abortion.
- Release of the amniotic fluid allows the uterus to contract and become firm, reducing the risk of perforation of the uterus with instruments.
- Contraction of the uterus reduces blood loss.
Release of the amniotic fluid and contraction of the uterus enhances movement of the fetus and placenta into the cervix, the opening of the uterus, thereby adding safety and reducing discomfort of the procedure.
This maneuver permits the accurate measurement of blood loss, which is usually minimal. However, heavy bleeding may occur in late abortion, and it is absolutely necessary to know accurately the volume of this bleeding in order to guide fluid or blood replacement if this should become necessary.*
As with the earlier second trimester procedures (15-19 weeks), the later second trimester procedure (20-26 weeks) may require that the physician perform a surgical evacuation of the uterus (“dilation and evacuation” or “D&C”) using instruments such as forceps to remove the fetus and placenta. All the other steps taken up to that point, such as use of laminaria, induced fetal demise, and medical induction, serve to enhance the safety of the late second trimester abortion procedure. The choice of procedures is dictated by the woman’s safety needs at the time.
* Less than 1 in 2000 patients has needed a blood transfusion in second trimester and later abortions at Boulder Abortion Clinic.
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