Although abortions should be done when they are safest and easiest, during the first trimester (and about 95 percent of them are), sometimes circumstances make that impossible. A primary reason for a second-trimester abortion is the discovery through prenatal testing that the fetus has a serious abnormality. Other reasons include late realization of pregnancy: some women, especially those with irregular or widely spaced menstrual periods, may not recognize that they are pregnant until many weeks have passed. Or women may not realize that a generally reliable method of birth control, for example oral contraceptives, has failed. Or women, especially teenagers, may psychologically deny that they are pregnant until the second trimester is upon them. Sometimes financial problems prevent women from seeking abortion in the early weeks.

How are second-trimester abortions done?

During the second trimester, there are the same two general options, medical and surgical. The surgical procedure is similar to the D&C, though beyond thirteen weeks of pregnancy it is often called a D&E (dilation and evacuation). A second-trimester medical abortion, comparable to an early abortion using methotrexate or mifepristone, means inducing labor with drugs and letting the process continue until the fetus is expelled through the vagina.

What are the advantages and disadvantages of each approach?

A D&E, which can be done with general anesthesia, is less painful than induced labor and the procedure takes less time, usually under an hour.

Induced labor can take a long time, a day or occasionally even longer. It poses the risks of bleeding and infection, even though there is less surgical interference with the uterus than with a D&E. Despite its greater pain and longer duration, some women prefer for psychological reasons to have labor induced. For example, some women who have chosen to terminate a pregnancy because the fetus is abnormal find that going through labor gives them closure. The baby, though it is not perfect, is born whole. The mother can see it and hold it, and this act can help with the healing process. Also, from a medical point of view, it is useful to have a pathologist examine fetal abnormalities that might impact a later pregnancy.

Talk frankly with your health care provider to see which option is best for you. Often, I find, women who ask to terminate a pregnancy involving an abnormal fetus have thought through the issue beforehand, at least in theoretical terms, and know which procedure they want.

Second- Trimester D&E

A surgical abortion after thirteen weeks of gestational age is more complex and somewhat riskier than a D&C done earlier. The uterus has stretched more and is softer, so there is greater danger of perforation. The procedure takes longer and may require more anesthesia.

How is the procedure performed?

Basically it is performed the same way as a first-trimester D&C, but because there is more fetal tissue to remove, the cervix needs to be more fully dilated. Some physicians will stretch it a day or two before the procedure, using laminaria, which are small strips of dried seaweed (about 2 inches long and 1/8 inch wide). The vagina is held open with a speculum and the laminaria are inserted in the cervix. The seaweed absorbs moisture from the vagina and from the cervix, which then gradually dilates. During this procedure the patient may feel cramping as the cervix stretches, but the procedure is not usually painful. Some physicians use laminaria even for first-trimester abortions. Synthetic agents, like Lamisil and Dilapan, can also soften the cervix and help it dilate.

After the cervix has dilated, the D&E takes place in much the same sequence as a first-trimester D&C. Usually a D&E involves anesthesia, either a local injection of something like Novocain to numb the cervix, or regional anesthesia injected into the spinal column to deaden feeling from the waist down. Some physicians also supplement local or regional anesthesia with intravenous sedation, which causes grogginess and eases anxiety. Many women prefer general anesthesia, during which they are entirely unconscious, but it does relax the uterus and make it slightly more susceptible to perforation. Once the cervix has been dilated, the surgeon uses vacuum suction and/or curettage to remove the contents of the uterus.

How long does a second-trimester D&E take?

The operation itself usually requires between fifteen and forty-five minutes, but counting the time for preoperative testing and cervical dilation with laminaria, which are often done the day before, the procedure lasts more than twenty-four hours.

What happens if the surgeon perforates the uterus during an abortion?

Usually the hole heals by itself, but occasionally a second operation is needed to sew it up. Very rarely, the injury is severe enough that a hysterectomy is required. When abortions were illegal and therefore performed by less competently trained people or people who did not do the procedure frequently (and were therefore less skillful), perforation and infection were much more common than they are today. Still, even in the most skilled hands, a perforation can happen.

Induced Labor

A medical abortion during the second trimester makes use of prostaglandins or other drugs to cause the uterus to contract. The usual agent is a prostaglandin, though sometimes saline (a salt solution) or urea is used. Prostaglandins work more quickly than saline or urea, but also have some side effects, including nausea, vomiting, and diarrhea, which can usually be controlled with medication. The agent that will start contractions can either be injected directly into the uterus or be given as a vaginal suppository every three hours.

Which is preferable, a medical or a surgical abortion?

Although the time frame or the availability of specific procedures at certain clinics or from certain physicians may determine which kind of abortion is possible at a given time and place, the answer to this question varies from woman to woman.

Some women dislike the invasiveness of a surgical abortion. They would much rather have a drug-induced miscarriage, which proceeds naturally once the process has been set in motion by drugs. Some women who have labor induced for second-trimester abortions want the sense of closure we have mentioned.

Medical abortions, even those undertaken early in pregnancy, involve spending a certain amount of time at the doctor’s office: for the initial visit, for tests, for follow-up visits. Surgical abortions are quick. Some women do not want to wait for a drug to take its course, not knowing when or if the abortion will happen. They wish to get the abortion over with and put it behind them.

After an Abortion

Some physicians routinely give methergine or another medication to help the uterus return to its normal size; others give it if the occasion seems to demand it, or send it home for the patient to have in case bleeding starts in the next twenty-four hours. If the patient has had gonorrhea or chlamydia, her caregiver will give antibiotics. If she is Rh negative, she will get Rhogam, an agent that will prevent her being a candidate for Rh disease in future pregnancies.

After an abortion the patient should rest that day, resuming most normal activities the following day. She should avoid rigorous aerobic exercise, heavy lifting, and sexual intercourse for at least a week. Some physicians suggest waiting two weeks before intercourse or strenuous activity. For at least the first few days after the procedure, she should use pads, not tampons, for bleeding; the cervix is still somewhat open and the uterus is vulnerable to bacteria climbing up through the open cervix. Spotting or bleeding may continue, either continuously or intermittently, for two or three weeks, though some women do not have bleeding after the first day or so. You can take a shower immediately, but because of the possibility of infection it is better not to take a tub bath (or go swimming) for the first several days.

Motrin or another over-the-counter painkiller can help with the cramping, which may go on for several days. If the cramps get severe, call your caregiver, as they could be a sign of infection.

When will the signs of pregnancy go away?

Usually breast tenderness will disappear after two or three days, as will any discharge.

What are the signs of complication after an abortion’?

The complications of abortion include incomplete abortion, in which some of the fetal or placental tissue is retained. This happens especially often in abortions performed very early in pregnancy, before six weeks of gestation. Fever over 100 degrees Fahrenheit, heavy bleeding (soaking a pad every hour or two), bleeding that gets heavier for two successive days, foul vaginal discharge, persistent and severe abdominal pain, swollen tender abdomen, and vomiting are all signs of complication. Call your physician if you have any of these symptoms or if you continue to have symptoms of pregnancy more than a week after the abortion.

What happens at thepostabortion checkup?

Usually your caregiver will schedule a checkup about two weeks after an abortion to be certain that the uterus has returned to its normal size, to make sure there are no complications, and to discuss contraception.

Is there a “safe”period after an abortion when contraception is not necessary?

No, there is no safe period. If you have used a diaphragm or a cervical cap, you need to have it refitted, though the size will probably not have changed. If you take birth control pills, you should start taking them right away; use condoms and a spermicide or some other backup measure for the first month, until a full cycle has occurred.

How long after an abortion do menstrual periods resume?

A normal menstrual period generally occurs within four to eight weeks after the abortion. If you have not had one by six weeks, call your doctor.

What emotions do women feel after an abortion?

At the very beginning, almost everyone feels relief that the procedure is finished and the pregnancy is over. After that, feelings vary. Women who terminated planned pregnancies because of fetal abnormalities often feel the same grief and loss as women who have lost pregnancies through natural causes. Women who terminated unintended pregnancies may feel guilt and/or loss even though they chose not to continue the pregnancy.

 

 

Selections from the book: “The Yale Guide to Women`s Reproductive Health: From Menarche to Menopause”, 2003.

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