Second-trimester pregnancy termination: Medication abortion

INTRODUCTION — 

Second-trimester medication abortion (also referred to as medical abortion, medication termination, or induction abortion) is the termination of pregnancy by using medications to induce contractions to deliver the fetus and placenta. It is an alternative to dilation and evacuation (D&E; also known as procedural abortion or surgical abortion), which requires dilating the cervix followed by surgical extraction of products of conception. Both methods are safe and effective, and each offers different advantages and disadvantages.

Second-trimester medication abortion is reviewed here. How to choose between medication abortion and D&E, a description of the D&E procedure, and other related topics are discussed separately.

●(See "Second-trimester pregnancy termination: Choosing medication abortion or dilation and evacuation".)

●(See "Second-trimester pregnancy termination: Dilation and evacuation".)

●(See "Overview of pregnancy termination".)

●(See "First-trimester pregnancy termination: Medication abortion".)

●(See "First-trimester pregnancy termination: Uterine aspiration".)

●(See "Abortion after 24 0/7 weeks of gestation".)

●(See "Counseling in abortion care".)

PATIENT SELECTION — 

Patient selection for second-trimester medication abortion, including indications, establishing the correct gestational age, identifying any medical factors (eg, bleeding diatheses, placenta previa) that may impact the choice of procedure, counseling, and informed consent are discussed in detail separately. (See "Second-trimester pregnancy termination: Choosing medication abortion or dilation and evacuation".)

Laws regarding abortion vary by country and by state in the United States. Clinicians offering abortions must be familiar with restrictions in their locality. (See "Overview of pregnancy termination", section on 'Legal issues'.)

PREPROCEDURE PREPARATION

Alloimmunization prevention and laboratory testing — RhD-negative patients undergoing second-trimester pregnancy termination should receive anti-D immune globulin to prevent alloimmunization. This is discussed in detail separately. (See "Overview of pregnancy termination", section on 'Alloimmunization prevention'.)

The role of other laboratory testing (eg, hemoglobin or hematocrit; chlamydia and/or gonorrhea) is also described separately. (See "Overview of pregnancy termination", section on 'Laboratory testing'.)

Induced fetal demise — Clinicians may induce demise prior to second-trimester medication abortion to ensure fetal demise prior to delivery, which is not ensured by standard methods of medication abortion [1,2]. Induced fetal demise may also shorten induction-to-abortion times, but data are limited. (See "Induced fetal demise", section on 'Medication abortion'.)

When used, KCl, digoxin, and lidocaine are the most common drugs to induce fetal asystole.

The indications, outcomes, and procedures for induced fetal demise are discussed separately. (See "Induced fetal demise".)

Pain management — Pain management for patients undergoing medication abortion is similar to that used for obstetric labor induction and includes regional (eg, epidural) or systemic (eg, opioids, mixed opioid agonists-antagonists, inhaled nitrous oxide) analgesia.

As with obstetric labor induction, the way pain is experienced reflects the individual’s circumstances, and no individual should be expected to experience severe pain (that is amenable to safe pain relief) while under a physician’s care.

Pain management during labor and delivery is discussed in detail separately. (See "Pharmacologic management of pain during labor and delivery".)

Limited role of prophylactic antibiotics — Prophylactic antibiotics are not typically used prior to second-trimester medication abortion. This is consistent with guidance from the National Abortion Federation (NAF) [3], the American College of Obstetricians and Gynecologists (ACOG) [4], and the World Health Organization (WHO) [5]. This is also consistent with medication abortion at earlier gestations. (See "First-trimester pregnancy termination: Medication abortion", section on 'Limited role of prophylactic antibiotics'.)

Prophylactic antibiotics are administered in selected patients in whom cervical preparation (eg, osmotic dilators, intracervical Foley balloon) is used. This is discussed separately. (See 'Patients without cervical dilation' below and "Pregnancy termination: Cervical preparation for procedural abortion", section on 'Procedure'.)

Limited role of mechanical cervical preparation — In our practice, we do not routinely use mechanical cervical preparation (ie, with osmotic dilators) prior to second-trimester medication abortion.

Randomized trials have shown similar or longer induction-to-abortion intervals and/or increased requirements for analgesia in patients treated with osmotic dilators [6-8]. In one randomized trial including 347 patients undergoing medication abortion between 15 0/7 and 27 6/7 weeks gestation, those receiving cervical preparation with osmotic dilators (Dilapan-S) plus misoprostol compared with misoprostol alone had similar induction-to-abortion intervals; complication rates were also similar between groups [8]. However, data regarding cervical preparation with osmotic dilators in this setting are conflicting, and shorter induction-to-abortion intervals have been described in observational studies. This is described separately. (See "Abortion after 24 0/7 weeks of gestation", section on 'Cervical preparation'.)

Cervical preparation with osmotic dilators may be used if cervical dilation does not occur with misoprostol. (See 'Patients without cervical dilation' below.)

Cervical preparation with an intrauterine balloon catheter may reduce induction-to-abortion intervals [9], but further study is needed.

OUR PROTOCOL

Combination mifepristone plus misoprostol — Protocols for second-trimester medication abortion typically include mifepristone and a prostaglandin, usually misoprostol. Our approach is shown in the algorithm (algorithm 1).

The combined regimen of mifepristone and misoprostol has been consistently found to be safe and the most effective method of inducing abortion in the second trimester [10-13]. Regimens utilizing both mifepristone and misoprostol typically result in fetal expulsion within 24 hours in most (>90 percent) patients [14,15]. This combined regimen is recommended by expert guidelines including the World Health Organization (WHO), American College of Obstetricians and Gynecologists (ACOG), National Abortion Federation (NAF), Society of Family Planning (SFP), Society of Maternal-Fetal Medicine (SMFM), and Royal College of Obstetricians and Gynaecologists (RCOG) [3-5,16-18].

In a meta-analysis of randomized trials including patients undergoing pregnancy termination between 12 and 28 weeks of gestation, mifepristone plus misoprostol compared with misoprostol-alone resulted in lower rates of ongoing pregnancy at 24 (4 versus 32 per 100 events; risk ratio [RR] 0.12, 95% CI 0.04–0.35; five trials) and 48 hours (2 versus 10 per 100 events; RR 0.22, 95% CI 0.08–0.6; four trials) [19]. Combination regimens also had shorter mean time to pregnancy expulsion (approximately six hours shorter) and higher rates of complete abortion at 24 (RR 1.42, 95% CI 1.01–1.99) and 48 hours (RR 1.13, 95% CI 1.01–1.26). Adverse events were similar among groups.

Administer mifepristone — Administer mifepristone 200 mg orally in the outpatient setting. (See "First-trimester pregnancy termination: Medication abortion", section on 'Mifepristone'.)

Mifepristone is an antiprogestin that competitively blocks both progesterone and glucocorticoid receptors. In the United States mifepristone is available only with Risk Evaluation and Mitigation Strategy (REMS) restrictions. (See "Overview of pregnancy termination", section on 'REMS restrictions'.)

When administered prior to (or with) a prostaglandin (see 'Timing' below), mifepristone elicits a variety of effects that make the uterus more susceptible to medication abortion [20]. These effects include cervical dilation, decidual necrosis, increased endogenous prostaglandin production, and increased uterine sensitivity to exogenously administered prostaglandin. The synergy between mifepristone and prostaglandin also permits greater efficacy of prostaglandin at lower doses, potentially minimizing side effects [21].

Administer misoprostol — Misoprostol, a synthetic prostaglandin E1 (PGE1), is the most common prostaglandin used for pregnancy termination as it is widely available, can be stored at room temperature, and is associated with lower rates of adverse effects (eg, reduced need for narcotic analgesia, less frequent need for surgical evacuation) and less expensive than other prostaglandins [22].

Timing — In our practice, we typically admit the patient and administer misoprostol 24 hours after mifepristone, but shorter (eg, simultaneous dosing, 12 hours prior) and longer (eg, 48 hours prior) intervals are also safe and effective [23]. The actual interval is often determined by patient factors (eg, preference for shorter induction-to-abortion interval). Representative studies include:

●In a systematic review of 20 randomized trials and nine observational studies evaluating the use of mifepristone and misoprostol for second-trimester medication abortion, administration of misoprostol at 12 to 24 hours compared with 36 to 48 hours after mifepristone modestly increased induction-to-abortion intervals by one to two hours [24]. The total abortion time (ie, the time from administration of mifepristone to expulsion) was substantially lower in the 12- to 24-hour group, as inductions began earlier in this group.

●In a randomized trial including over 500 patients between 13 and 22 weeks of gestation, those receiving mifepristone 24 hours prior to misoprostol compared with simultaneous dosing had increased rates of complete abortion 24 hours (94 versus 85 percent, relative risk 1.11, 95% CI 1.05–1.18); at 48 hours, rates of complete abortion were similar [25]. Total time (from mifepristone to delivery) was longer in the 24-hour group.

●In a randomized trial including 80 patients undergoing medication abortion between 12 and 28 weeks of gestation, those receiving mifepristone 24 compared with 12 hours prior to misoprostol had shorter induction-to-abortion times (9.5 versus 12.5 hours, median) [26]. Complete abortion rates at 12, 24, and 48 hours after the first dose of misoprostol were similar between groups, as were rates of additional medication or surgical intervention, and patient satisfaction.

Administration of the first dose of misoprostol at home rather than in the hospital has also been described. In a randomized trial of 457 patients undergoing medication abortion between 12 and 21 weeks of gestation, administration of the first dose of misoprostol (800 mcg) at home compared with in the hospital resulted in more patients completing the abortion process in <9 hours (71 versus 46 percent); all patients received mifepristone 24 to 48 hours before the first dose of misoprostol [27]. Fetal expulsion before admission to the hospital occurred in four patients in the home group (two after mifepristone alone, two after the first dose of misoprostol) and five patients in the hospital group (all after mifepristone alone). Adverse events were otherwise similar between groups.

Dose, route, and dosing interval — The dose, route, and dosing interval of misoprostol vary across protocols and there are limited high-quality data to establish the optimal protocol.

●Dose – In our practice, we start with a misoprostol dose of 400 mcg. This is consistent with guidelines from the SFP and SMFM [18].

Historically, a higher loading dose of misoprostol (eg, 800 mcg) was administered [4,17]; however, a loading dose is not associated with reduced induction-to-abortion times nor improved outcomes [18].

Lower doses of misoprostol (eg, 200 mcg) may also be effective [13,28-30].

●Route – We administer misoprostol vaginally, though sublingual or buccal administration are reasonable alternatives [31,32].

●Dosing interval – Misoprostol (400 mcg) is typically repeated at intervals of three hours, but longer intervals (eg, six hours) have been described [33,34]. Induction-to-abortion times often decrease with more frequent dosing, but increase with increasing gestational age [11].

In one randomized trial of 148 patients undergoing second-trimester medication abortion with misoprostol (400 mcg vaginally), a dosing interval of every three compared with six hours resulted in shorter induction-to-abortion times (eg, 15 versus 19 hours, median) [33]. Side effects were similar among groups, with the exception of fever, which occurred more frequently in the three-hour group (32 versus 12 percent). In a subsequent randomized trial including 178 patients undergoing second-trimester medication abortion, those receiving misoprostol every three compared with six hours also demonstrated shorter induction-to-abortion times [34].

Pretreatment with analgesics and antidiarrheal medications may reduce the severity of bothersome side effects (eg, fever, nausea/vomiting).

●Total number of doses – In our practice, we administer misoprostol 400 mcg every three hours until the fetus delivers.

While protocols from ACOG, WHO, and RCOG have not provided specific instruction on how to proceed beyond five doses of misoprostol (see 'Other protocols' below), guidelines from the SFP and SMFM suggest that additional doses beyond five doses of misoprostol are safe and effective [18]. Most patients require fewer than six doses of misoprostol and deliver the fetus within 48 hours [35]. In a retrospective study of 468 patients between 14 and 24 weeks of gestation undergoing medication abortion with misoprostol (2 percent also received mifepristone), 17 percent of patients required six or more doses of misoprostol [36]. Of these patients, 60 percent required one or two additional doses; the maximum dose required was 12. Complication rates (eg, chorioamnionitis, postpartum hemorrhage, retained placenta) were similar among those who received ≤5 versus ≥6 misoprostol tablets.

The dose, route, and dosing interval of misoprostol are discussed in more detail separately. (See "Misoprostol as a single agent for medical termination of pregnancy", section on 'Drug administration'.)

Subsequent management

Patients without cervical dilation — If cervical dilation does not occur after 48 hours, options include:

●Proceed with cervical preparation (eg, osmotic dilators, intracervical Foley balloon) followed by either administration of misoprostol or oxytocin. (See "Induction of labor: Techniques for preinduction cervical ripening", section on 'Hygroscopic dilators' and "Induction of labor: Techniques for preinduction cervical ripening", section on 'Balloon catheter'.)

●Switch induction agents and try oxytocin. (See 'Other protocols' below.)

●Convert to a procedural abortion if cervical dilation is adequate and a skilled provider is available. (See "Second-trimester pregnancy termination: Dilation and evacuation".)

Management of placenta — After the fetus is delivered, we continue misoprostol and wait for up to four hours for the placenta to deliver before intervening (eg, manual extraction, suction curettage). However, practice varies, and some clinicians discontinue misoprostol upon delivery of the fetus. Patients with heavy bleeding require prompt treatment.

While traditionally clinicians performed suction curettage if the placenta remained in situ 30 to 120 minutes following delivery of the fetus, this was based on older reports that used hyperosmolar saline and prostaglandin E2 (PGE2) [37,38]; such agents are now infrequently used because of their associations with higher rates of complications and increasing intervals from delivery of the fetus to the placenta. (See 'Other medications' below.)

Waiting at least four hours before intervening is supported by limited observational data [16]. In one retrospective study of 233 patients who underwent second-trimester medication abortion with misoprostol, the overall rate of surgical intervention for retained placenta was 6 percent; all patients requiring surgical intervention had a placenta retained for >4 hours [39]. Expectant management up to 4 hours was not associated with increased morbidity. In addition, the majority (79 percent) of surgical procedures were performed to expedite hospital discharge rather than for other reasons (eg, bleeding).

ALTERNATIVES

Other protocols — Other protocols for second-trimester medication abortion include the following:

●American College of Obstetricians and Gynecologists (ACOG) [4]:

•Mifepristone 200 mg, administered orally, followed by:

-Misoprostol 800 mcg, administered vaginally, followed by 400 mcg, administered vaginally or sublingually every three hours for up to a maximum of five doses.

or

-Misoprostol 400 mcg, administered buccally every three hours for up to a maximum of five doses.

•If mifepristone is not available (see 'Misoprostol-only protocols' below):

-Misoprostol 400 mcg, administered vaginally or sublingually every three hours for up to five doses.

or

-A vaginal loading dose of 600 to 800 mcg of misoprostol, followed by 400 mcg administered vaginally or sublingually every three hours.

•If misoprostol is not available:

-Oxytocin 20 to 100 units, infused intravenously over three hours, followed by one hour without oxytocin to allow diuresis. Oxytocin dose may be slowly increased to a maximum of 300 units over three hours. (See 'Other medications' below.)

●Royal College of Obstetricians and Gynecologists (RCOG) [17]:

•Mifepristone 200mg, administered orally, followed 24 to 48 hours later by:

-Misoprostol 800 micrograms vaginally, buccally, or sublingually, followed by misoprostol 400 micrograms vaginally, buccally, or sublingually every 3 hours until abortion occurs.

•If mifepristone is not available:

-Misoprostol 800 micrograms followed by misoprostol 400 micrograms every 3 hours until abortion occurs.

Misoprostol-only protocols — Misoprostol-only regimens are often used in settings where mifepristone is not available or is too costly. This is discussed separately. (See "Misoprostol as a single agent for medical termination of pregnancy", section on 'Accepted regimens'.)

Other medications

●Other prostaglandins

•Gemeprost – Gemeprost, also a PGE1 analog, is another common prostaglandin studied for medication abortion. It is used less frequently than misoprostol because it is more expensive and requires refrigeration.

In comparative studies, misoprostol and gemeprost induce labor at a variety of gestational ages more effectively and with fewer side effects than other prostaglandins (eg, carboprost, sulprostone) and oxytocin [10,22,40-43]. [22]. As with misoprostol, the dose of gemeprost can decrease as pregnancy advances because the uterus becomes more sensitive to prostaglandins as pregnancy advances.

Gemeprost and misoprostol have been found to have similar efficacy in most randomized trials, though some suggest an advantage with the use of misoprostol [31,44-47]. In a meta-analysis of six randomized trials including patients undergoing second-trimester medication abortion, those receiving misoprostol (with or without mifepristone) compared with gemeprost had similar induction-to-abortion intervals and completed abortion at 24 hours [47]. Those receiving misoprostol, however, were less likely to require narcotic analgesia (risk ratio [RR] 0.64 95% CI 0.49-0.84; three trials) or need surgical evacuation of the uterus (RR 0.71 95% CI 0.53-0.95; five trials).

•Carboprost – Carboprost, a PGF2alpha analog, results in more systemic side effects than PGE analogs [48].

•Sulprostone – Sulprostone, a PGE2 analog, is infrequently used because it has been associated with myocardial infarction [40].

●Oxytocin – Oxytocin, the most commonly used induction agent for term pregnancies, fails to induce labor as effectively in the second trimester because the uterus has relatively fewer oxytocin receptors at less than 20 weeks of gestation. Thus, oxytocin is associated with longer induction-to-abortion intervals compared with other methods (eg, mifepristone plus misoprostol, misoprostol alone) [49,50].

In one randomized trial, use of mifepristone plus oxytocin compared with mifepristone plus misoprostol resulted in similar success rates (100 and 96 percent, respectively) [49]. Time to fetal expulsion was longer in the oxytocin group (11.3 versus 7 hours), but the rate of fever was lower.

●Instillation abortion – Instillation abortion with saline or urea has been largely abandoned due to increased risks of hypernatremia, coagulopathy, hemorrhage, and retained placenta [51,52].

Instillation abortion is also associated with longer abortion times and higher failure rates. In a systematic review of 15 randomized trials evaluating methods of second-trimester medication abortion, mifepristone plus misoprostol compared with intraamniotic injection of ethacridine lactate resulted in lower failure rates (2 to 6 percent versus 7 to 21 percent; risk ratio 0.37, 95% CI 0.17-0.8) and shorter time of labor (average of 1.9 hours shorter) [53]. More gastrointestinal side effects occurred in the mifepristone plus misoprostol group, but cervical injury was more frequent in the ethacridine lactate group.

COMPLICATIONS — 

Second-trimester medication abortion is a safe procedure and is most often completed successfully and without complications.

Incomplete abortion — Incomplete abortion is more common in second-trimester medication abortion than in procedural abortion (1 to 12.5 versus <1 percent) [4,54-56] or first-trimester medication abortion. (See "Overview of pregnancy termination", section on 'Ongoing pregnancy'.)

In such cases, options include another cycle of mifepristone and misoprostol, placement of cervical preparation (eg, osmotic dilators, intracervical Foley balloon) followed by either administration of misoprostol or oxytocin, switching induction agents, or procedural abortion. (See 'Patients without cervical dilation' above.)

Retained placenta — Retained placenta occurs in 2 to 10 percent of patients undergoing second-trimester medication abortion [11,57,58]. Protocols that include misoprostol, compared with other agents, typically require fewer surgical interventions for delivery of the placenta, though rates of retained placenta are higher for all medical methods compared with D&E [54,55,59].

Management of retained placenta is described separately. (See "Retained products of conception in the first half of pregnancy" and "Retained placenta after vaginal birth".)

Uterine rupture — Uterine rupture is rare but can occur in patients with a scarred or unscarred uterus [60].

In a systematic review of 16 retrospective studies including over 3500 patients undergoing second-trimester abortion with misoprostol (two studies also used mifepristone), uterine rupture occurred in three (0.08 percent) patients [61]. Of these three patients, two had a history of cesarean birth, and one had no history of cesarean birth. In a subsequent meta-analysis of seven randomized trials and 15 cohort studies (two of which were included in the systematic review) that included over 7000 patients between 14 to 28 weeks of gestation undergoing pregnancy termination with misoprostol plus mifepristone, uterine rupture occurred in 12 (0.17 percent) patients; the majority of all pregnancies were <24 0/7 weeks [62]. Of these twelve patients, 10 had a history of cesarean birth (1.1 percent), and two (0.01 percent) had no history of cesarean birth; the risk difference was 1.23 percent (95% CI 0.46-2).

No studies have evaluated the safety of medication abortion among patients with uterine scarring secondary to prior myomectomy or surgery for correction of müllerian uterine anomalies.

Infection — Infection after medication abortion is difficult to quantify, given the high incidence of medication-induced pyrexia. One literature review reported a 1 to 3 percent incidence of infection following second-trimester medication abortion [63]. However, higher rates have also been reported. In one cohort study including 681 patients undergoing second-trimester abortion, clinical chorioamnionitis (defined as maternal temperature of ≥39°C or temperature of 38 to 38.9°C for ≥30 minutes with the presence of purulent cervical discharge, uterine tenderness, maternal tachycardia, or leukocytosis) occurred in 15 percent of patients; induction intervals ≥17 compared with <17 hours were associated with higher rates of chorioamnionitis [64].

As mentioned above, infection must be differentiated from noninfectious pyrexia, as medications used for medication abortion, particularly misoprostol, often result in fever. (See "Misoprostol as a single agent for medical termination of pregnancy", section on 'Side effects'.)

Fever associated with misoprostol should subside within several hours; those with fever persisting beyond 24 hours should be evaluated for infection (eg, infected retained products of conception). (See "Overview of pregnancy termination", section on 'Infection/retained products of conception'.)

Hemorrhage — Hemorrhage resulting in transfusion complicates less than 1 percent of medication abortions [4]. The risk of hemorrhage increases with gestational age and longer induction-to-abortion intervals. Causes of hemorrhage include retained products of conception, uterine atony, and trauma to the lower genital tract [65]. (See "Overview of pregnancy termination", section on 'Hemorrhage'.)

Although clinicians often treat uterine atony after medication abortion similar to postpartum atony, the second-trimester uterus has fewer oxytocin receptors, limiting response to high-dose oxytocin. Thus, other options, such as carboprost (0.25 mg intramuscularly every 15 minutes up to eight doses), methylergonovine (0.2 mg intramuscularly at two- to four-hour intervals, as needed), and additional doses of misoprostol should be promptly considered (see "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Administer additional uterotonic medications'). Low-dose cervical vasopressin has also been described [66].

Other interventions, such as intrauterine tamponade, uterine compression sutures, and angiographic embolization, might be necessary in more severe cases of hemorrhage [67-69]. Intractable hemorrhage refractory to such therapies can require a hysterectomy. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device" and "Postpartum hemorrhage: Management approaches requiring laparotomy".)

Other — Cervical laceration may occur with either medication or procedural abortion. To decrease this risk, cervical preparation (eg, osmotic dilators, intracervical Foley balloon) in patients without cervical dilation after administration of misoprostol should be considered. (See 'Patients without cervical dilation' above.)

Given a very low number of deaths reported annually for all abortions, it is unlikely that any commonly used medication regimen confers a significant risk of maternal death. (See "Overview of pregnancy termination", section on 'Maternal mortality' and "Second-trimester pregnancy termination: Choosing medication abortion or dilation and evacuation", section on 'Introduction'.)

FOLLOW-UP — 

Follow-up for second-trimester medication abortion, including contraception options (if desired) and methods to suppress lactation, is the same as for procedural abortion and is discussed in detail separately. (See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Follow-up care' and "Contraception: Postabortion".)

SPECIAL CIRCUMSTANCES

Patients with prior hysterotomy — In our practice, we do not change management for patients with a prior hysterotomy (eg, cesarean birth, myomectomy). While these patients are at risk of uterine scar dehiscence, there is insufficient evidence to support a change in medication abortion regimen in the setting of a prior uterine incision [16]. (See 'Uterine rupture' above.)

Other patients — Management of patients with uterine anomalies, low-lying placenta, multiple gestation, or chorioamnionitis is discussed separately. (See "Second-trimester pregnancy termination: Choosing medication abortion or dilation and evacuation".)

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 5^th to 6^th 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 10^th to 12^th 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: Medication abortion (The Basics)" and "Patient education: Deciding to have an abortion (The Basics)")

●Beyond the Basics topic (see "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Clinical significance – Second-trimester medication abortion (also referred to as medical abortion, medication termination, or induction abortion) is the termination of pregnancy by using medications to induce contractions to deliver the fetus and placenta. It is an alternative to dilation and evacuation (D&E). Both methods are safe and effective, and each offers different advantages and disadvantages. (See 'Introduction' above and "Second-trimester pregnancy termination: Choosing medication abortion or dilation and evacuation".)

●Preprocedure preparation

•Alloimmunization prevention and laboratory testing (See 'Alloimmunization prevention and laboratory testing' above.)

-RhD-negative patients undergoing second-trimester pregnancy termination should receive anti-D immune globulin to prevent alloimmunization. This is discussed in detail separately. (See "Overview of pregnancy termination", section on 'Alloimmunization prevention'.)

-The role of other laboratory testing (eg, hemoglobin or hematocrit; chlamydia and/or gonorrhea) is also described separately. (See "Overview of pregnancy termination", section on 'Laboratory testing'.)

•Induced fetal demise – Inducing demise prior to second-trimester medication abortion ensures fetal demise prior to delivery and may shorten induction-to-abortion times, but data are limited. The indications, outcomes, and procedures for induced fetal demise are discussed in detail separately. (See 'Induced fetal demise' above and "Induced fetal demise", section on 'Medication abortion'.)

•Prophylactic antibiotics – Prophylactic antibiotics are not typically administered prior to second-trimester medication abortion. (See 'Limited role of prophylactic antibiotics' above.)

•Cervical preparation – Cervical preparation (with osmotic dilators or intracervical Foley balloon) is not typically used prior to second-trimester medication abortion. Osmotic dilators may be used if cervical dilation does not occur with misoprostol. (See 'Limited role of mechanical cervical preparation' above and 'Patients without cervical dilation' above.)

●Our protocol (See 'Our protocol' above.)

•For patients undergoing second-trimester medication abortion, we suggest the use of misoprostol plus mifepristone rather than misoprostol alone (Grade 2B). Regimens utilizing both mifepristone and misoprostol typically result in fetal expulsion within 24 hours in most patients. (See 'Combination mifepristone plus misoprostol' above.)

•Our protocol is as follows (algorithm 1):

-Administer mifepristone 200 mg orally. (See 'Administer mifepristone' above.)

-After 24 hours, we admit the patient and administer misoprostol 400 micrograms every three hours until the fetus delivers. (See 'Administer misoprostol' above.)

-For patients without cervical dilation after 48 hours, options include proceeding with mechanical cervical preparation, switching induction agents (eg, oxytocin), or converting to D&E. (See 'Subsequent management' above.)

-After delivery of the fetus, we continue misoprostol and wait for up to four hours for the placenta to deliver before intervening. (See 'Management of placenta' above.)

●Complications – Second-trimester medication abortion is a safe procedure and is most often completed successfully and without complications. However, potential complications include retained placenta, uterine rupture, infection, and hemorrhage. (See 'Complications' above.)