Pre-procedure medications for fetal demise
It is not medically necessary to induce fetal demise prior to a second-trimester abortion.17,18 Feticide does not decrease D&E procedure time or complications.19,20 Digoxin injection prior to D&E is associated with increased rates of infection, hospital admission, and spontaneous expulsion.20 For induction abortion, limited evidence suggests feticide injection may shorten induction-to-delivery time.17,21 When asked, patients report discomfort and difficulty with feticide injections, but also reassurance.22
Digoxin or potassium chloride may be administered as a feticide injection. Complications with digoxin are unusual; when shared decision-making results in use of digoxin, it is administered as a dose of 1 to 2 mg injected into the fetus or into the amniotic fluid on the first day of osmotic dilator placement. Intrafetal digoxin injection is more likely to cause fetal asystole within 24 hours than intra-amniotic injection; doses lower than 1 mg are less likely to cause asystole.23,24 Potassium chloride is more commonly used for selective fetal reduction and must be administered directly into the umbilical cord or into a fetal cardiac chamber, requiring more technical skill to administer than digoxin. The dose of potassium chloride required for effectiveness varies between 6 and 20 mEq.17
Prior uterine surgery
History of cesarean delivery is one of the most common conditions potentially complicating second-trimester abortion. The placenta should be evaluated for all women with prior uterine surgery and specialist referral is indicated in cases where there is concern for morbidly adherent placenta. D&E is safe for women with prior uterine surgery and normal placentation. Two or more cesarean deliveries increases the risk of major complications with D&E compared with one or no cesareans.25
Uterine rupture with second-trimester induction abortion with misoprostol is a rare event, with a risk of less than 0.5% in women with one prior cesarean delivery compared with less than 0.1% with no uterine surgery.26 Risk of uterine rupture for women with two or more cesarean deliveries (2.5%) is significantly increased compared with no prior uterine surgery.26 For women with a history of one or more cesarean deliveries, risk of retained placenta and of needing blood transfusion is also increased during induction abortion.26 Regimens for misoprostol dosing can be modified based on gestational age, with use of higher doses early in the second trimester and lower doses between 24 and 28 weeks.
Spontaneous fetal demise and pPROM
Pregnancies complicated by spontaneous intrauterine fetal demise (IUFD) for longer than 4 weeks or measuring greater than 20 weeks are at increased risk of hemorrhage and/or transfusion.27,28 D&E is safer than labor induction for IUFD in the second trimester; women should be offered both methods when available.28,29 Coagulation studies do not appear to predict risk of hemorrhage, although research is limited.27
For women with previable prelabor rupture of membranes (PROM), cervical preparation for D&E is often easier because membrane rupture may cause prostaglandin release. Both D&E and induction are safe for women with previable PROM. Induction-to-delivery time is shorter for women with previable PROM and with IUFD.30,31 In one large cohort, women who underwent D&E for fetal anomalies, IUFD, or previable PROM were less likely to have a subsequent preterm birth (6.9%) than women who chose induction (30.2%).32
The authors report no potential conflicts of interest with regard to this article.
- Guttmacher Institute. State bans on abortion throughout pregnancy. Available at https://www.guttmacher.org/print/state-policy/explore/state-policies-later-abortions on 7-7-19.
- Jatlaoui TC, Boutot ME, Mandel MG, et al. Abortion surveillance – United States, 2015. MMWR Surveill Summ. 2018;67(No. SS-13):1-45.
- Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119(2):215-219.
- National Academies of Sciences, Engineering, and Medicine. The safety and quality of abortion care in the United States. Washington, DC: The National Academies Press. 2018.
- Upadhyay UD, Weitz TA, Jones RK, Barar RE, Foster DG. Denial of abortion because of provider gestational age limits in the United States. Am J Public Health. 2014;104(9):1687-1694.
- Grimes DA, Smith SS, Witham AD. Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: a pilot randomised controlled trial. Brit J Obstet Gynecol. 2004;111:148-153.
- Kelly T, Suddes J, Howel D, Hewison J, Robson S. Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial. Brit J Obstet Gynecol. 2010;117:1512-1520.
- Fox MC, Krajewski CM. Society of Family Planning guideline: cervical preparation for second-trimester surgical abortion prior to 20 weeks’ gestation. Contraception. 2014;89(2):75-84.
- Goldberg AB, Fortin JA, Drey EA, et al. Cervical preparation before dilation and evacuation using adjunctive misoprostol or mifepristone compared with overnight osmotic dilators alone: a randomized controlled trial. Obstet Gynecol. 2015;126(3):599-609.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131(6):e172-e189.
- Schulz KF, Grimes DA, Christensen DD. Vasopressin reduces blood loss from second-trimester dilatation and evacuation abortion. Lancet. 1985;2(8451):353-356.
- Whitehouse K, Tschann M, Soon R, et al. Effects of prophylactic oxytocin on bleeding outcomes in women undergoing dilation and evacuation: a randomized controlled trial. Obstet Gynecol. 2019;133(3):484-491.
- Darney PD, Sweet RL. Routine intraoperative ultrasonography for second trimester abortion reduces incidence of uterine perforation. J Ultrasound Med. 1989;8(2):71-75.
- Abbas DF, Blum J, Ngoc NTN, et al. Simultaneous administration compared with 24-hour mifepristone-misoprostol interval in second-trimester abortion: a randomized controlled trial. Obstet Gynecol. 2016;128(5):1077-1083.
- Ngoc NTN, Shochet T, Raghavan, et al. Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion. Obstet Gynecol. 2011;118(3):601-608.
- Borgatta L, Kapp N. Society of Family Planning guideline: labor induction abortion in the second trimester. Contraception. 2011;84(1):4-18.
- Diedrich J, Drey E. Society of Family Planning guideline: induction of fetal demise before abortion. Contraception. 2010;81(6):462-473.
- Lee SJ, Ralston, HJP, Drey EA, Partridge JC, Rosen MA. Fetal pain: a systemic multidisciplinary review of the evidence. JAMA. 2005;294(8):947-954.
- Jackson RA, Teplin VL, Drey EA, Thomas LJ, Darney PD. Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial. Obstet Gynecol. 2001;97(3):471-476.
- Dean G, Colarossi L, Lunde B, Jacobs AR, Porsch LM, Paul ME. Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation. Contraception. 2012;85(2):144-149.
- Akkurt MO, Akkurt I, Yavuz A, Yalcin SE, Coskun B, Sezik M. The utility of feticide procedure to shorten the induction-to-abortion interval in medical abortion. Gynecol Obstet Invest. 2019;84(1):64-70.
- McNamara B, Russo J, Chaiken S, Jacobson J, Kerns J. A qualitative study of digoxin injection before dilation and evacuation. Contraception. 2018;97(6):515-519.
- White KO, Nucatola DL, Westhoff C. Intra-fetal compared with intra-amniotic digoxin before dilation and evacuation. Obstet Gynecol. 2016;128(5):1071-1076.
- Molaei M, Jones HE, Weiselberg T, McManama M, Bassell J, Westhoff C. Effectiveness and safety of digoxin to induce fetal demise prior to second-trimester abortion. Contraception. 2008;77(3):223-225.
- Frick AC, Drey EA, Diedrich JT, Steinauer JE. Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications. Obstet Gynecol. 2010;115(4):760-764.
- Andrikopoulou M, Lavery JA, Ananth CA, Vintzileos AM. Cervical ripening agents in the second trimester of pregnancy in women with a scarred uterus: a systematic review and metaanalysis of observational studies. Am J Obstet Gynecol. 2016;215(2):177-194.
- Fontenot Ferriss AN, Weisenthal L, Sheeder J, Teal SB, Tocce K. Risk of hemorrhage during surgical evacuation for second-trimester intrauterine fetal demise. Contraception 2016;94(5):496-498.
- Edlow AG, Hou MY, Maurer R, Benson C, Delli-Bovi L, Golberg AG. Uterine evacuation for second-trimester fetal death and maternal morbidity. Obstet Gynecol. 2011;117(2):307-316.
- Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death. Obstet Gynecol. 2011;117(4):788-792.
- Nakintu N. A comparative study of vaginal misoprostol and intravenous oxytocin for induction of labor in women with intrauterine fetal death in Mulago Hospital, Uganda. Afr Health Sci. 2001;1(2):55-59.
- Goldberg AB, Carusi D, Westhoff C. Pregnancy Loss. In: Paul M, et al, eds. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care. Chichester, UK: Wiley-Blackwell; 2009:264-279.
- Little SE, Janiak E, Bartz D, Smith NA. Second trimester dilation and evacuation: a risk factor for preterm birth? J Perinatol. 2015;35(12):1006-1010.
- Nash E. Abortion rights in peril: what clinicians need to know. NEJM. 2019;381:497-499.
- Cohen SA. Facts and consequences: Legality, incidence and safety of abortion worldwide. Guttmacher policy review. 2009;12(4). Accessed 8-18-19 at https://www.guttmacher.org/gpr/2009/11/facts-and-consequences-legality-i....
- Reingold RB, Gostin LO. State abortion restrictions and the new Supreme Court: Women’s access to reproductive health services. JAMA. 2019;322(1)21-22.