Version July 2025
INTRODUCTION —
Second-trimester pregnancy termination can be performed by using medication to induce labor and deliver the fetus and placenta (medication abortion) or by dilating the cervix and evacuating products of conception (dilation and evacuation [D&E]). Second-trimester pregnancy termination comprises approximately 10 to 15 percent of abortions performed annually worldwide [1,2]. In 2021, the United States Centers for Disease Control and Prevention (CDC) reported that approximately 6 percent of all abortions were performed between 14 to 20 weeks and 1 percent at or after 21 weeks [3]. The majority (68 percent) of these abortions were performed with D&E.
While second-trimester abortion is associated with more morbidity and mortality and, for some patients, more social or emotional challenges than first-trimester abortion [4], abortion always remains significantly safer than childbirth in the United States [5,6].
This topic reviews the various factors that contribute to the choice between medication abortion and D&E. The procedure details for second-trimester termination with medication or D&E, cervical preparation prior to D&E, as well as abortions earlier and later in pregnancy, are discussed separately:
●(See "Second-trimester pregnancy termination: Medication abortion".)
●(See "Second-trimester pregnancy termination: Dilation and evacuation".)
●(See "Pregnancy termination: Cervical preparation for procedural abortion".)
●(See "Abortion after 24 0/7 weeks of gestation".)
●(See "Overview of pregnancy termination" and "First-trimester pregnancy termination: Medication abortion" and "First-trimester pregnancy termination: Uterine aspiration".)
INDICATIONS —
Patients terminate pregnancies in the second trimester for many reasons.
For many, pregnancy termination is 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 [7].
For others, a fetal anomaly, maternal illness (eg, malignancy), or obstetric complication (eg, preterm prelabor rupture of membranes, early onset preeclampsia with severe features) is not recognized or does not present until the second trimester.
There are no contraindications to second-trimester abortion. While some medical comorbidities may increase the risk of complications associated with pregnancy termination, such comorbidities are also often associated with complications during an ongoing pregnancy and/or delivery. In such cases, consultation with a specialist (eg, cardiologist, pulmonologist, maternal-fetal-medicine) is often helpful.
PREPROCEDURE PLANNING —
Preprocedure planning, including legal issues, counseling and informed consent, determining gestational age, and the role of laboratory testing (for hemoglobin or hematocrit, Rh typing [and administration of anti-D immune globulin to Rh-negative individuals], and chlamydia and/or gonorrhea) is described in detail separately.
●(See "Overview of pregnancy termination", section on 'Legal issues'.)
●(See "Counseling in abortion care" and "Overview of pregnancy termination", section on 'Counseling and informed consent'.)
●(See "Overview of pregnancy termination", section on 'Determining gestational age'.)
●(See "Overview of pregnancy termination", section on 'Preparation for procedure'.)
FACTORS THAT TYPICALLY AFFECT CHOICE —
As both medication abortion and D&E are safe procedures throughout the second trimester (see 'Outcomes' below), the choice of procedure is often determined using shared decision-making based on multiple factors, including patient preferences about setting, duration and timing, and experience (table 1). The availability of a clinician with the skills and experience to provide one or both approaches is also critical to the method chosen.
Setting — The setting in which second-trimester pregnancy termination varies by procedure type.
Medication abortion most commonly occurs within a hospital, either in a labor and delivery or family planning unit. An outpatient setting can be utilized, provided appropriate medical staff and equipment are available to provide ongoing management, including administration of medications and analgesia; monitoring patient status; delivery of the fetus and placenta (the timing of which is often unpredictable); emergency surgical management or emergency transport to an inpatient facility (if needed). By contrast, D&E is typically performed in an outpatient setting, either a specialty clinic, a clinician's office equipped with a procedure room, or an ambulatory surgery center. As such, medication abortion is associated with a higher cost compared with D&E [8].
The various types of settings appear to be similarly safe. In a study of a United States private insurance database including over 12,000 second-trimester abortions (including both medication and D&E), the incidence of any adverse events was similar for procedures performed in either an ambulatory surgery center or office-based setting [9].
Clinics or hospitals that provide pregnancy termination must have the appropriate medical staff, equipment, and medication to perform the procedure, manage complications, provide analgesia and anesthesia, and have written protocols to address emergencies (indications for emergency transport, contact information for personnel who can be immediately available to facilitate transport). This is described separately. (See "Overview of pregnancy termination", section on 'Guidelines for staff and equipment'.)
Duration and timing — Medication abortion may take 24 hours or longer, and the timing of delivery is unpredictable. (See "Second-trimester pregnancy termination: Medication abortion", section on 'Our protocol'.)
By contrast, D&E is associated with a shorter duration and more predictable timing of the procedure itself; experienced surgeons can perform uterine evacuation in less than 30 minutes once the cervix is dilated. Many patients favor this shorter procedural duration and predictability [10-12]. However, the entire patient experience may be just as long or longer than medication abortion, as patients undergoing D&E typically receive one to two days of cervical preparation (to decrease cervical trauma and facilitate the evacuation of the uterus). (See "Pregnancy termination: Cervical preparation for procedural abortion" and "Second-trimester pregnancy termination: Dilation and evacuation".)
Patient experience — Some patients choose medication abortion to have a greater awareness of the process of terminating the pregnancy. This includes awareness of bleeding, cramping, and other symptoms (eg, nausea, vomiting) which occur throughout the medication abortion process. Most patients also experience heavier and/or longer duration of bleeding and cramping after medication abortion compared with D&E [13]. Other patients may have a desire to hold the fetus or want to avoid fetal destruction associated with D&E. Medication abortion also allows for morphologic evaluation of an intact fetus, which may be important when congenital anomalies are present. It is important to note, however, that pathologic examination may be possible with D&E, depending on the diagnosis in question [14]. (See 'Fetal anomaly' below.)
By contrast, patients may choose D&E to avoid prolonged labor and may find D&E to be less emotionally burdensome than medication abortion [10-12]. For some, the process of labor and viewing the fetus may intensify their trauma about the pregnancy and complicate their grieving process [15].
Availability of services — Many settings lack the availability of a clinician with the skills and experience to provide one or both approaches, especially at later gestational ages. Thus, a patient will either need to choose the available option or travel to an often-distant health care facility that provides the procedure of their choice [15]. This lack of access may disproportionately affect vulnerable populations (eg, patients of lower socioeconomic status who may not be able to travel, pregnant minors, underrepresented groups). This is discussed separately. (See "Overview of pregnancy termination", section on 'Legal issues'.)
OTHER FACTORS THAT MAY AFFECT CHOICE
Maternal medical comorbidities — Certain medical conditions may affect procedure choice. Furthermore, patients with different medical histories might have reason to fear one type of procedure more than another, influencing their choice.
Some patients (eg, bleeding diathesis, history of venous thromboembolism [VTE] with current use of an anticoagulant) may benefit from the controlled timing of D&E. However, data are limited [16], and no studies directly compare the risk of hemorrhage in patients on anticoagulation undergoing second-trimester pregnancy termination with either D&E or medication abortion. Thus, the Society of Family Planning (SFP) recommends individualizing care through shared decision-making, citing a lack of evidence to justify a single approach [17].
Whether to temporarily interrupt anticoagulation therapy should also follow an individual risk assessment that weighs the relative risks of VTE if the anticoagulant is held with the risk of hemorrhage should anticoagulation be continued. In our practice, we typically continue anticoagulation throughout first-trimester pregnancy termination but interrupt anticoagulation prior to most second-trimester procedures due to increasing concerns of exacerbating hemorrhage as a result of uterine atony, or in the event of a complication (eg, uterine perforation, cervical injury). Medical consultation (with the patient's hematologist or primary care physician) is often helpful to help determine the patient’s individual risk and plan for anticoagulation management.
Perioperative anticoagulation management is discussed in detail separately. (See "Perioperative management of patients receiving anticoagulants".)
Congenital uterine anomalies — There is insufficient evidence to suggest that a congenital uterine anomaly (eg, uterine septa, bicornuate uteri, complete duplication of both uterus and cervix) necessitates a change in a medication abortion protocol.
However, a congenital uterine anomaly may make D&E more difficult and increase the likelihood of a failed evacuation [18,19]. Similarly, as many congenital uterine anomalies go undiagnosed, a failed D&E procedure may lead to a diagnosis of a uterine malformation [20]. When a D&E is performed, intraoperative ultrasound should be performed to facilitate uterine evacuation. (See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Uterine evacuation'.)
Uterine anomalies are discussed in detail separately. (See "Congenital uterine anomalies: Overview".)
Placental abnormalities
●Placenta previa and low-lying placenta – The optimal method for termination (ie, medication abortion or D&E) of pregnancies complicated by placenta previa and low-lying placenta is unclear.
•Placenta previa – Given the concern for hemorrhage, the author performs D&E for all patients with placenta previa. While several observational studies report successful outcomes of patients with placenta previa managed with medication abortion, such patients are at high risk of hemorrhage and the patient must be counseled about this increased risk, as well as the risk of transfusion and emergency surgical intervention [21].
The presence of previa does not appear to preclude the use of cervical preparation, although data are limited. In one retrospective study including 11 patients with placenta previa undergoing pregnancy termination at 12 to 20 weeks, those managed with D&E (36 percent) compared with medication abortion (with gemeprost) had similar rates of blood loss [22]. One patient in the medication group required a blood transfusion. Most patients (73 percent) had laminaria placed before the procedure, and none of these patients experienced significant bleeding before, during, or after insertion. Similarly, in two earlier retrospective studies including 31 patients with placenta previa undergoing second-trimester pregnancy termination by D&E after laminaria placement, none experienced excessive bleeding with laminaria insertion or required a blood transfusion due to procedure-related hemorrhage; operative time was comparable to patients without complete previa [23,24]. Cervical preparation prior to procedural abortion is described separately. (See "Pregnancy termination: Cervical preparation for procedural abortion", section on 'Approach by gestational age'.)
In the setting of placenta previa, uterine artery embolization (UAE) or feticide prior to the procedure may help reduce blood loss, but the data are even more limited [25-27]. Until additional information is available regarding the safety and efficacy of these methods prior to termination, use should be considered on an individualized basis.
•Low-lying placenta – For most patients with low-lying placenta (placental edge ≤20 mm from, but not over, the internal os), we also perform D&E. However, medication abortion is a reasonable alternative for patients with a low-lying placenta, especially those 11 to 20 mm from the internal os, or who prefer to avoid surgical management.
Clinicians contemplating medication abortion in the setting of low-lying placenta might extrapolate from data for inducing term gestations complicated by low-lying placenta, especially those with a placenta 11 to 20 mm from the cervical os. In a meta-analysis including 10 cohort studies (approximately 600 patients) of vaginal births in patients with low-lying placenta (defined as a distance of 0 to 10 and 11 to 20 mm from the internal os) versus without (ie, >20 mm from the internal os), patients with placentas ≤10 mm compared with 11 to 20 mm and >20 mm from the cervical os had a higher risk of emergency cesarean birth due to intrapartum hemorrhage (45, 14, and 10 percent, respectively) [28]. Rates of postpartum hemorrhage were similar between groups. This is discussed in more detail separately. (See "Placenta previa: Management", section on 'Delivery of patients with a low-lying placenta'.)
●Placenta accreta spectrum (PAS) – For patients with suspected PAS, management depends on the degree of concern for placental invasion and the patient's future reproductive plans. In our experience, most patients are managed with gravid hysterectomy (ie, hysterectomy with the fetus remaining in situ) or a "double set-up" D&E (in which the patient and operating room are prepped for emergency hysterectomy, if needed). These procedures should be performed in hospitals capable of managing life-threatening hemorrhage.
Other management options, including UAE (prophylactic or postprocedure), fetal extraction via hysterotomy, and medication abortion, have been described in small series [29-31]. In a few cases, the placenta was removed, but in most cases, the placenta was left in situ, with hysteroscopic resection performed under ultrasound or laparoscopic guidance at a later date when the placenta was nonfunctional (ie, normal human chorionic gonadotropin [hCG] level; reduced blood flow on Doppler at the placental interface). Representative studies include the following:
•In one retrospective study including 29 patients with PAS undergoing second-trimester termination, patients were managed with prophylactic UAE plus hysterotomy with removal of the placenta or medication abortion followed by adjuvant treatment (eg, UAE, methotrexate, mifepristone, or dilation and curettage) for the remaining placenta [30]. Three patients (10 percent) required hysterectomy, all of whom were in the hysterotomy group. Although this study utilized adjuvant multi-dose methotrexate, there are limited data that methotrexate improves outcomes in these patients, and there is a risk for potential harm (eg, methotrexate-related toxicity) [32]. (See "Therapeutic use and toxicity of high-dose methotrexate".)
•In another retrospective study including seven patients with PAS undergoing second-trimester D&E with UAE (the majority of which occurred postprocedure), three patients (43 percent) were treated successfully, and the remaining four patients required hysterectomy [31]. Placentas were removed at the time of D&E in all patients.
The diagnosis and management of PAS disorders are discussed in more detail elsewhere. (See "Placenta accreta spectrum: Clinical features, diagnosis, and potential consequences" and "Placenta accreta spectrum: Management".)
Prior uterine scar — A prior uterine scar is not a contraindication to medication abortion, and uterine rupture can occur in patients with or without a scarred uterus. However, the risk of uterine rupture is higher in patients with increasing gestational age and in those with multiple uterine scars [33]; thus, D&E may be preferred for patients at later gestational ages with a uterine scar. This is discussed in more detail separately. (See "Second-trimester pregnancy termination: Medication abortion", section on 'Uterine rupture' and "Misoprostol as a single agent for medical termination of pregnancy", section on 'Patients with a uterine scar'.)
It is uncertain whether D&E eliminates the risk of uterine rupture. During the process for a D&E, the uterus contracts in response to insertion of osmotic dilators and the use of a uterotonic agent (eg, misoprostol). Theoretically, some events that are classified as uterine perforation at the time of D&E on a scarred uterus may represent an occult uterine rupture. (See "Second-trimester pregnancy termination: Dilation and evacuation".)
Inducing fetal demise — Physicians may induce demise prior to second-trimester medication abortion and some second-trimester D&E procedures. This may be done to ensure fetal demise prior to delivery, which is not ensured by standard methods of medication abortion, to minimize concerns regarding compliance with federal and state abortion regulations, or because of patient preference (perhaps to eliminate concerns regarding fetal pain). These issues are discussed in detail separately. (See "Induced fetal demise" and "Second-trimester pregnancy termination: Medication abortion", section on 'Induced fetal demise' and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Injection to induce fetal demise'.)
Fetal anomaly — Second-trimester abortion is often performed for the indication of a fetal anomaly. While medication abortion and D&E are both typically options for such patients, more patients with fetal anomalies choose D&E [34].
The need for pathologic examination of an intact fetus is often a reason for medication abortion. However, it is important to note that pathological examination may also be possible with D&E, depending on the diagnosis in question. (See 'Patient experience' above and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Uterine evacuation'.)
Diagnosis of fetal anomalies and counseling for patients undergoing termination for a fetal anomaly are discussed separately. (See "Pregnancy termination and potential psychiatric outcomes", section on 'Termination for fetal anomalies'.)
Chorioamnionitis — Chorioamnionitis (ie, fever with or without other findings such as uterine tenderness and purulent vaginal discharge) may develop as a result of preterm prelabor rupture of membranes (which in some cases is the indication for pregnancy termination), a prolonged medication abortion procedure, or after cervical preparation with osmotic dilators (uncommon). (See "Prelabor rupture of membranes before and at the limit of viability", section on 'Chorioamnionitis' and "Pregnancy termination: Cervical preparation for procedural abortion", section on 'Complications'.)
While uterine evacuation is the cornerstone of treating chorioamnionitis, no studies have evaluated the relative benefits of medication abortion compared with D&E in the setting of second-trimester pregnancy termination.
●For hemodynamically stable patients without sepsis (most patients), we administer antibiotic therapy and proceed with either medication abortion or D&E in the same manner as for patients without infection. While D&E may expedite evacuation and thus be preferred in some patients, providers with the skills and experience to provide D&E may not be available. In such settings, medication abortion is very reasonable. In our practice, we use the same antibiotics as those used for chorioamnionitis during labor. (See "Clinical chorioamnionitis", section on 'Antibiotic therapy'.)
●For hemodynamically unstable patients or those with concern for sepsis, evacuation should be expedited; infection can progress rapidly in such patients and be lethal. Management for such patients must be individualized, and the physician should choose the technique that best expedites uterine evacuation. In addition to resuscitation and initiation of broad-spectrum antibiotics (see "Septic abortion: Clinical presentation and management", section on 'Start broad-spectrum intravenous antibiotics'), approaches to uterine evacuation include:
•Place osmotic dilators to prepare for D&E. Osmotic dilators may be used in patients with chorioamnionitis and, in our experience, do not exacerbate infection. Some patients with sepsis may be in the process of laboring and, therefore, may require less cervical preparation than patients without infection.
•Initiate medication abortion. Mifepristone may be administered concurrently with misoprostol (rather than waiting the typical 24 hours) (see "Second-trimester pregnancy termination: Medication abortion", section on 'Timing'). In addition, cervical dilators may be placed to allow the flexibility to convert to D&E in cases of a prolonged medication abortion procedure. Unfortunately, placement of osmotic dilators may prolong medication abortion intervals in some cases [35-37].
The evaluation and management of patients with septic abortion are discussed in detail separately. (See "Septic abortion: Clinical presentation and management".)
Other
●Transabdominal cerclage – Pregnancy termination in patients with an abdominal cerclage in place can be challenging. Historically, both medication abortion and D&E were avoided in such patients, and hysterotomy was performed.
However, cases of successful D&E in patients with a transabdominal cerclage have been described [38], and in our practice, we typically offer D&E to patients with prior abdominal cerclage and reserve hysterotomy for the rare cases in which adequate dilation cannot be achieved. This is discussed in detail separately. (See "Transabdominal and laparoscopic cervicoisthmic cerclage", section on 'Early- to mid-second-trimester demise' and "Transabdominal and laparoscopic cervicoisthmic cerclage", section on 'Late second-trimester and third-trimester demise'.)
●Multifetal gestation – Second-trimester termination of a multifetal gestation is managed similarly to a singleton pregnancy, and a modification of either medication abortion or D&E is not warranted. However, with either technique, the patient is at a higher risk of uterine atony and hemorrhage due to greater uterine size. Management of hemorrhage related to uterine atony is discussed in detail separately. (See "Overview of pregnancy termination", section on 'Hemorrhage' and "Second-trimester pregnancy termination: Medication abortion", section on 'Hemorrhage'.)
Issues related to multifetal pregnancy reduction or selective termination are described separately. (See "Multifetal pregnancy reduction and selective termination".)
OUTCOMES —
Historically, D&E was associated with fewer complications compared with medication abortion [39]. However, changes in practice (eg, discontinuation of instillation abortion [with saline or urea]) and introduction of combination medication regimens (prostaglandins plus progesterone antagonists) have narrowed the safety gap between methods by using safer medications and shortening the duration of medication abortion [40-45]. As such, both second-trimester trimester medication abortion and D&E are now safe and effective.
There are few randomized trials comparing the two approaches [13,46], as randomized trials are difficult to conduct because patients have declined to be randomly assigned to a delivery method due to a strong preference for one method over another. In one randomized trial including patients between 13 0/7 and 19 6/7 weeks gestation undergoing pregnancy termination, almost half (107 of 229 patients) declined to participate, given a strong preference for one procedure; the majority of such patients chose D&E [13]. Of the 122 patients that were randomized, those undergoing medication abortion (with mifepristone and misoprostol) compared with D&E experienced similar psychological distress and preference outcomes (as measured by the impact of events scale [IES]) at two weeks postprocedure. In addition, while overall complication rates were similar, the type of complication varied by the type of abortion. For example, more patients in the medication group required subsequent evacuation for retained placenta (10 percent compared with 2 percent in the procedure group) and required an unexpected overnight stay (31 versus 0 percent), while more patients in the D&E group experienced blood loss >500 mL. Patients in the D&E group also experienced lower rates of moderate to severe pain (23 versus 43 percent), but this did not reach statistical significance. Patients in the D&E group found the procedure more acceptable (100 would choose the same procedure in the future compared with 53 in the medication group). This trial was limited by a lack of statistical power and a low (60 percent) follow-up rate. Another randomized trial was stopped early because of low enrollment [46].
Specific outcomes (eg, retained products of conception, uterine perforation, infection, hemorrhage) as they relate to medication abortion and D&E are presented separately. (See "Second-trimester pregnancy termination: Medication abortion", section on 'Complications' and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Outcome and complications'.)
FOLLOW-UP CARE —
Follow-up for second-trimester medication abortion and D&E, including contraception options, methods to suppress lactation, and future reproductive outcomes, are discussed separately. (See "Contraception: Postabortion" and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Follow-up care' and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Future obstetric outcomes'.)
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.
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 topics (see "Patient education: Deciding to have an abortion (The Basics)" and "Patient education: Medication abortion (The Basics)" and "Patient education: Procedural abortion (The Basics)")
●Beyond the Basics topic (see "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Scope – Second-trimester pregnancy termination comprises 10 to 15 percent of the abortions performed annually worldwide. It can be performed by using medication to induce delivery of the fetus and placenta or by dilating the cervix and evacuating products of conception (dilation and evacuation [D&E]). (See 'Introduction' above.)
●Preprocedure planning – Preprocedural counseling, determination of gestational age, and the role of laboratory testing (for hemoglobin or hematocrit, Rh typing [and administration of anti-D immune globulin to Rh-negative individuals], and chlamydia and/or gonorrhea) are described in detail separately. (See "Overview of pregnancy termination", section on 'Determining gestational age' and "Overview of pregnancy termination", section on 'Preparation for procedure'.)
●Factors that typically affect choice – Choice of procedure is often determined using shared decision-making based on multiple factors (eg, setting, duration and timing, patient experience, availability of services), which are detailed in the table (table 1). (See 'Factors that typically affect choice' above.)
●Other factors – Other factors that may affect choice include maternal comorbidities (eg, bleeding diathesis, anticoagulation use), congenital uterine anomalies, selected placental abnormalities, presence of a uterine scar, need for inducing fetal demise, presence of fetal anomalies, and chorioamnionitis. Choice is usually not affected by the presence of a multifetal gestation. (See 'Other factors that may affect choice' above.)
●Outcomes – Both medication abortion and D&E in the second trimester are safe and effective. Specific outcomes (eg, retained products of conception, uterine perforation, infection, hemorrhage) as they relate to medication abortion and D&E are presented separately. (See 'Outcomes' above and "Second-trimester pregnancy termination: Medication abortion", section on 'Complications' and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Outcome and complications'.)
●Follow-up care – Follow-up for second-trimester medication abortion and D&E, including contraception options, methods to suppress lactation, and future reproductive outcomes, are discussed separately. (See "Contraception: Postabortion" and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Follow-up care' and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Future obstetric outcomes'.)
