Late Second Trimester Abortion or Late Term Surgical Abortion (17 to 24 weeks)
Second Trimester (17 to 21.5 weeks) Second trimester patients receive a pre-operative evaluation similar to first trimester patients. However, due to the greater length of pregnancy, second trimester patients receive a more extensive ultrasound screening exam at the beginning of their appointment at the Women’s Centers. Those features of the pregnancy that are evaluated at this time include the diagnosis of fetal age, which is made by taking measurement of the fetus; such as head size, femur length and abdominal circumference. These measurements provide a determination of fetal age, although not precise. Other evaluations include position of the placenta, the presence, absence, or unusual quantity of amniotic fluid; the presence of visible fetal anomalies and pathology such as fibroids in the uterine wall, all aid in the determination of fetal viability.
Aside from variations in informed consent materials, the second trimester patient experiences the same pre-operative procedures as the first trimester patient. Misoprostol and Laminaria, if indicated, are inserted on the first day. Misoprostol is given orally and or vaginally depending on Physician preference and patient history. The Physician also determines when Laminaria are removed and whether any need to be added after removal of the first set. If there has been no significant change in the cervix, the amniotic sac (membranes) are ruptured. The primary purpose of this technique is to increase the natural Prostaglandins near and around the cervix which creates stronger uterine contractions, initiates labor, and expedites the delivery process. The second purpose of releasing all the amniotic fluid from within the intrauterine cavity is to decrease the incidence of an amniotic fluid embolism, whereby the amniotic fluid could enter the patient’s bloodstream and cause severe shortness of breath, lack of oxygen circulating throughout the body, Disseminated Intravascular Coagulation (DIC) where the blood is not able to clot leading to failure of liver, kidneys, and other vital organs and other serious complications including maternal death. A high dose oxytocin regimen may be started after initiating an intravenous (IV) infusion. This is only started when the patient does not experience adequate uterine contractions, or if her cervix fails to dilate using the Misoprostol tablets alone. Medication may be given for discomfort after Physician evaluation.
Following the injection into the fetus, Misoprostol and possibly Laminaria are placed into the posterior vaginal vault, and into the cervix respectively. The remainder of the procedure is similar to that of one for 17 to 22 weeks. If the fetus that is between 17 to 24 weeks does not deliver spontaneously after given a trial of multiple insertions of Misoprostol & Laminaria, rupturing of the membranes, and a high dose oxytocin protocol, it may require that the physician perform a surgical evacuation of the uterus (dilation and evacuation i.e., D&E) using instruments such as forceps to remove the fetus and placenta. All the other steps taken up to this point serve to enhance the safety of the late second trimester abortion procedure. The choice of procedural technique is dictated by the patient’s health and safety and individual Physician preference.
It is rare that the cervical preparation described above does not allow the cervix to open and soften enough for the abortion procedure to not take place over a 2 day period of time. Instead of being completed in one or two days, it may require an additional set of Laminaria be placed inside the cervix and the patient may be sent home overnight while the cervix is allowed to dilate further and become softer. Upon returning the following day, the Laminaria are removed and more medication is given to allow the uterus to contract. Once the cervix has opened adequately, the patient is taken to the exam room where the tissue is removed as described in Early Second Trimester Abortion.
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