Practice Bulletin No. 135: Second-Trimester Abortion

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In the United States, more than one half of pregnancies are unintended, with 3 in 10 women having an abortion by age 45 years (1). In 2008, 1.2 million abortions occurred in the United States, of which 6.2% took place between 13 weeks of gestation and 15 weeks of gestation, and 4.0% took place at 16 weeks of gestation or later (2, 3). Only 1.3% of abortions are performed at 21 weeks of gestation or later (4). The proportion of abortions performed in the second trimester, usually defined as between 13 weeks of gestation and 26 weeks of gestation (as calculated from the last menstrual period), has remained stable during the past two decades (4). The purpose of this document is to provide evidence-based guidelines for the medical and surgical methods of second-trimester termination as well as for the management of associated complications.BackgroundIndications for Second-Trimester AbortionSecond-trimester abortion is an important component of comprehensive women’s health care, and women seek termination later in pregnancy for a variety of medical and social reasons. Circumstances that can lead to second-trimester abortion include delays in suspecting and testing for pregnancy, delay in obtaining insurance or other funding, and delay in obtaining referral, as well as difficulties in locating and traveling to a provider (5). Poverty, lower education level, and having multiple disruptive life events, have been associated with higher rates of seeking second-trimester abortion (3). In addition, major anatomic or genetic anomalies may be detected in the fetus in the second trimester and women may choose to terminate their pregnancies (47–95%) (6–8). The identification of major anatomic or genetic anomalies in the fetus through screening and diagnostic testing most commonly occurs in the second trimester, although first-trimester screening and chorionic villus sampling can enable first-trimester diagnosis of aneuploidy. Some obstetric and medical indications for second-trimester termination include preeclampsia and preterm premature rupture of membranes, among other conditions. Additional indications for uterine evacuation in the second trimester are pregnancy failure before 20 weeks of gestation and fetal demise. In 2005, the U.S. fetal mortality rate was 6.22 fetal deaths at 20 weeks of gestation or more per 1,000 live births and fetal deaths, and this rate was higher for teenagers; women aged 35 years and older; and among non-Hispanic black, Hispanic, and American Indian or Alaska Native women (9).Methods of Second-Trimester AbortionBoth surgical and medical methods of pregnancy termination can be used in the second trimester. Limited evidence suggests that the vast majority (95%) of second-trimester abortions in the United States are performed by dilation and evacuation (D&E); however, terminations by medical abortion may be underreported (10, 11).In many areas of the United States, women have limited access to second-trimester abortion, in general, and may not have the option to choose between D&E and medical abortion. In a census of abortion providers, 64% reported offering some services after 12 weeks of gestation, and only 23% reported providing abortions at 20 weeks of gestation and later (2). In another survey of clinics providing second-trimester abortion, only 33% offered medical abortion in addition to D&E (11). Some women with fetal anomalies or medical complications of pregnancy are directed toward medical abortion because of a lack of skilled D&E providers nearby (12). Dilation and evacuation training is not available in all residency programs, and many residents trained in D&E have not performed a sufficient number of procedures to achieve competency in the technique (13–15).

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