Second-Trimester Surgical Abortion

Although 88% of abortions are done in the first 14 weeks of pregnancy, approximately 11% occur during the second trimester (Elam-Evans et al., 2002). There may be several reasons for this, including medical complications, fetal deformities that were not revealed earlier, divorce or marital problems, miscalculation of date of last menstrual period, finan­cial or geographic problems (such as not living near a clinic that offers the procedure), or a denial of the pregnancy until the second trimester. Second-trimester abortions are riskier than first-trimester procedures and involve more potential problems.

Between 13 and 16 weeks of pregnancy, a dilation and evacuation (D&E) is the most commonly used procedure. The procedure is similar to a vacuum aspiration, but it is done in a hospital under general anesthesia. Dilators, such as laminaria (lam-in-AIR-ree-uh), may be used to help begin the dilation process and may be inserted into the cervix 12 to 24 hours prior to the procedure. When a woman returns to the hospital, she may first be given intravenous pain medication and local anesthesia, which is injected into the cervix. The dilators are removed, and the uterus is then emptied with suction and various in­struments. This procedure is more complicated than a first-trimester procedure because the fetus is larger. Generally, a D&E takes between 15 and 30 minutes. The risks associ­ated with this type of abortion include increased pain, blood loss, and cervical trauma.

In the late part of the second trimester, some physicians may use induced labor pro­cedures, including saline or prostaglandin, instead of a D&E. In these cases, a needle is injected into the amniotic sac, and amniotic fluid is removed. Then an equal amount of saline or prostaglandin can be injected into the amniotic sac. Prostaglandins can also be used orally to induce labor (Wiseman, 2003). When prostaglandins are used, uterine con­tractions force the fetus out of the uterus. Usually, after a saline or prostaglandin injection, the fetus is delivered within 19 to 22 hours. Both of these procedures are very painful emo­tionally and physically. Complications may include nausea, diarrhea, cervical problems, and uterine rupture; and the risk of death from a second-trimester abortion procedure is 25 times greater than from an abortion in the first trimester (Tyler, 1981). Overall, D&E pro­cedures are safer, less painful, quicker, and less expensive than induced labor procedures.

A hysterotomy (hiss-stur-ROT-oh-mee) is a second-trimester abortion procedure that may be used if either of the aforementioned methods is contraindicated or if the woman’s life is in immediate danger. In this procedure, the abdominal cavity is opened up to remove the fetus, similar to a cesarean section. This is done under general anes­thesia and requires a hospital stay of between 5 and 7 days. Because it is a major opera­tion, the possible risks are much greater and include problems with general anesthesia, prolonged recovery, and possible death. These risks have significantly reduced the use of this procedure. Another procedure that is rarely used today is a hysterectomy, which is a removal of the fetus and uterus.

 

dilation and evacuation (D&E) A second-trimester abortion procedure that in­volves cervical dilation and vacuum aspiration of the uterus.

 

laminaria Seaweed used in second-trimester abortion pro­cedures to dilate the cervix. Used dried, it can swell three to five times its original diameter.

 

induced labor procedure Using artificial means, such as drugs, to start labor.

 

saline abortion A second-trimester abortion procedure in which amniotic fluid is removed and replaced with a saline solution, which causes premature delivery of the fetus.

 

I prostaglandin Oral or injected drug taken to cause uterine contractions.

 

hysterotomy A second-trimester abortion procedure that in­volves a surgical removal of the fetus through the abdomen.

 

ReviewQuestion Differentiate between first — and second- trimester surgical abortion procedures.

 

Question: How much does an abortion cost? The average cost for a first-trimester surgical abortion is $372 (Henshaw & Finer, 2003). These fees usually include an examination, laboratory tests, anesthesia, the procedure, and a follow-up examina­tion. In a private physician’s office, this procedure is more expensive. The average cost of an early medical abortion, using drugs (such as RU — 486), is $490. A second-trimester abortion can run much higher, depending on whether the procedure is done in a private clinic or hospital.

 

Medical Abortion A medical abortion involves the use of medicine to end a pregnancy. A woman works closely with a healthcare provider when taking these medications. Today two drugs have been used for medical abortion, Mifepristone (RU-486) and Methotrexate.

Although both drugs have been used in the United States for other medical purposes, neither had been approved for use in pregnancy termination. When one of these drugs is used in conjunction with a prostaglandin (Misoprostol), the uterus will contract and expel the contents.

Mifepristone was first approved for use in pregnancy termination in France in 1988. It was then approved in the United Kingdom in 1991, and in Sweden in 1992. The po­litical climate in the United States during the early 1990s convinced RU-486’s manu­facturer not to seek approval in the United States (Planned Parenthood Federation of America, 2004). At about this same time, the Bush administration ruled that Mifepristone could not be brought into, or used in, the United States (Aguillaume & Tyrer, 1995). In an attempt to have this decision overruled, a woman named Leona Benten brought RU-486 into the United States in 1992, and the drug was immediately seized. The Supreme Court quickly upheld the confiscation (Talbot, 1999).

In 1994, the Clinton administration requested a reevaluation of the import ban from the FDA, and at the same time RU-486’s manufacturer donated research rights to the United States Population Council, one of the world’s leading laboratories for con­traceptive development (Planned Parenthood Federation of America, 2004). The Population Council found that RU-486 was not only safe but highly effective as well. Based on this research, the FDA Advisory Committee recommended that Mifepristone be approved. However, it wasn’t until 2000 that Mifepristone was formally approved for use in the United States.

A woman taking Mifepristone will usually begin bleeding within 4 to 5 hours, and bleeding will continue for up to 13 days, whereas a woman taking Methotrexate may continue bleeding for 4 weeks or more. Mifepristone is often more popular because it in­volves a shorter duration of bleeding; however, a physician will decide which method would work best for the patient. A medical abortion involves two or three office visits, testing, and exams, and costs $350 to $650.

The advantages of medical abortion include the fact that no anesthesia is used and women often report feeling more in control (F. H. Stewart, Ellertson, & Cates, 2004). Because the abortion is more like a miscarriage, some women report it feels more natural. The disadvantages include the fact that the woman must be prepared to undergo a surgical abortion if necessary. There has also been some concern over the increased risk of bacterial infection using Mifepristone (Centers for Disease Control, 2005a; Day & Bisset, 2004).

Mifepristone® (RU-486) Although Mifepristone (MYFE-priss-tone; RU-486) has only been FDA-approved in the United States since 2000, it has been used in sev­eral European countries for more than a decade. RU-486 is an antiprogestin, which blocks the development of progesterone, causing a breakdown.

Three RU-486 pills are taken, and 2 days later a woman takes an oral dose of prostaglandin (typically Misoprostol). This causes uterine contractions that expel the fertilized ovum. Effectiveness rates range between 95% and 97%. RU-486 can safely and effectively be used to terminate a pregnancy up until 63 days (9 weeks) from a woman’s last menstrual period (F. H. Stewart, Ellertson, & Cates, 2004). There are some poten­tial side effects, however, which include nausea, cramping, vomiting, and uterine bleed­ing for anywhere from 1 to 3 weeks (F. Stewart et al., 2004). The prolonged bleeding and the length of time to expulsion (days compared with minutes) make RU-486 less ap­pealing than a vacuum aspiration abortion. However, with RU-486, surgery is unneces­sary (unless there are complications), and there is no possibility of uterine perforation.

Methotrexate Methotrexate (METH-oh-trecks-ate) can also be used as an early option for nonsurgical abortion. It was approved by the FDA in 1953 as a breast cancer drug and is also used to treat psoriasis and rheumatoid arthritis. Methotrexate is often given in the form of an injection; and, when it is used in combination with Misoprostol, it has been found to cause a drug-induced miscarriage (Bygdeman & Danielsson, 2002). Methotrexate works by stopping the development of the developing cells of the zygote, and the prostaglandin is used to contract the uterus to expel the pregnancy. As with Mifepristone, Methotrexate can safely and effectively be used to terminate a pregnancy up to 63 days past a woman’s last menstrual period.

Question: If you had an abortion, could that make you infertile later on?

Women who undergo an abortion can become pregnant and give birth later on in their life without complications (P. L. Frank, 1991). However, repeated abortions may create an incompetent cervix and could cause future miscarriages. Also, there are rare cases of unex­pected complications of abortion that can lead to infertility or even hysterectomy, such as uterine perforation or severe infection. Women who use medical abortions may have less risk to future fertility because these are nonsurgical abortion options.