Late Second Trimester Abortion (17 to 24 weeks)
In-Clinic Late Abortion can be divided into one of two categories:
- Late Second Trimester Abortions (16.5 to 28 weeks)
- Late Term Abortions (21.3 weeks or further to include Third Trimester Abortions)
The second trimester of pregnancy is from 14.1 to 28 weeks from the woman’s Last Menstrual Period. Early Second Trimester Abortions occur between 14.1 to 16.4 weeks.
The division between Early Second and Late Second Trimester Abortions is that surgical procedures in Early Second Trimester Abortions do not necessarily need cervical preparation (opening and softening of the cervix) or surgical forceps required in order to remove the pregnancy tissue.
Cervical preparation is required to surgically remove the pregnancy tissue in late second trimester and late term abortions from the intrauterine cavity because the pregnancy tissue is too large to be removed with the surgical sterile suction curette alone.
Surgical forceps are required to insert inside the Uterine cavity and gently remove the pregnancy with minimal complications or side effects.
What Are Late Term Abortions?
There is no medical term that defines what a late term abortion is. Only 1.3% of abortions are performed at 21.3 weeks or further. This happens to be just below the lower edge of fetal viability.
Fetal Viability (fetus able to live outside the womb) is not defined by a specific number of weeks. Viability must be evaluated on a i individual basis. The range may be 22 to 28 weeks. It must be understood that infants at 30 to 40 weeks may not be viable.
Abortions being performed from 22 weeks or further should assure fetal demise prior to beginning the abortion procedure whether the surgical or a medical abortion pill procedure.
For our definition of late term abortion, we are using the arbitrary number of 21.3 weeks pregnant because of the lower edge of fetal viability.
Late Term Abortion Methods
There are two methods of how Late Term Abortions can be performed:
- Medical Abortion using the Late Term Abortion Pill
- Surgical Dilation and Evacuation (D&E)
Late Term Abortion Pills:
The Late Term Medication Abortion Method uses the combination of two pills.
The first pill is Mifepristone (RU 486, Mifegyne, Mifeprex, Early Options, French Pill). The second pill is Misoprostol (Cytotec).
The Late Term Medications have been used to perform second trimester and late term abortions since the late 80’s in several European Countries (Sweden and other Norwegian Countries, France). It quickly spread to China, India and other Asian Countries.
The procedure was found to be highly efficient, safe with minimal complications and side effects.
How Far Can Abortions Be Performed Utilizing The Medical Abortion Pill Process?
The Late Term Medication can be used throughout the second trimester (14.1 to 28 weeks) and the third trimester of pregnancy 28.1 weeks or further.
There are several Late Term Abortion Pill Clinics that perform abortions up to 24, 26, 28, 30 weeks or further if there are maternal or fetal medical indications.
How Does Late Term Abortion Work?
Mifepristone works by blocking the hormone Progesterone from binding to its receptors on the Uterus. This causes the following to occur:
- Increase of pressure inside the Uterine (womb) cavity
- Breakdown of the lining of the Uterus which leads to increased production of Prostaglandins
- Softening and opening of the Cervix (opening at the lower portion of the Uterus
The combination of above leads to Uterine contractions, internal production of prostaglandins and Vaginal bleeding.
Approximately 0.5 to 1% of women may go in active labor and delivery of the fetus with within 24 hours taking Mifepristone alone.
Misoprostol is a Prostaglandin E1 tablet. It binds to the Prostaglandin receptors on the Uterus and leads to Uterine contractions and vaginal bleeding. This leads to the pregnancy tissue being expelled.
Performing Late Term Abortions Utilizing Surgical Dilation and Evacuation Procedure:
Second Trimester Surgical abortions are responsible for ⅔ of the maternal morbidity and mortality around the World.
Late Term Abortion Clinics use the most advanced abortion surgical instruments, medications and techniques have reduced the maternal morbidity and death rate to less than 0.05%.
Cervical Preparation (Ripening, Priming) For In-Clinic Second Trimester And Late Term Abortion:
The most important step to be performed when undergoing the in-clinic second trimester and late term abortion surgical procedure is assuring the Cervix is adequately primed. If not, there is the increased risk of a Incompetent Cervix.
An incompetent cervix is due to using abortion instruments to force open the firm and closed cervix.
A incompetent cervix is where the cervical tissue becomes weak and may lead to problems with future pregnancies. This may include:
- Spontaneous abortions between 15 to 22 weeks
- Premature births
- Low birth weight
Priming of the Cervix is the use of medications that adequately soften and dilate (open) the cervix in order to safely remove the fetus and placenta (after birth) with minimal complications or side effects. The side effects associated with the surgical abortion procedure are the following:
- Cervical tears and lacerations
- Damage to the bowel or bladder
- Uterine perforation (puncture of the wall)
- Heavy vaginal bleeding
- Retained pregnancy tissue
- Uterine Infection
- Pelvic Inflammatory Disease
- Severe Sepsis (Bacteria in the blood)
- Maternal Death
The medications used for Cervical Priming are 1) Laminaria and 2) Misoprostol.
Laminaria is sterile seaweed that is shaped in the form and length of a matchstick. When inserted inside the cervix, it absorbs water similar to a sponge. The Laminaria slowly enlarges symmetrically. This slowly softens and opens the Cervix.
Cervical priming with Laminaria may take 2 to 4 days to accomplish adequate opening of the cervix in order for the surgical procedure to be carried out in a safe manner.
The patients will need to return to the office every day and at times twice daily in order to remove and reinsert new Laminaria until sufficient dilation of the Cervix is accomplished.
Misoprostol tablets can be inserted vaginally or placed between the cheek and gum (buccally) or underneath the tongue (sublingually).
Misoprostol causes Uterine contractions with softening and opening of the Cervix.
Inducing Fetal Demise In Late Term Abortions:
Women over 21.3 weeks should be offered to undergo a fetal demise procedure prior to starting the abortion process for two reasons:
- It prevents the possibility of delivery of a fetus that shows any signs of life-
- Palpable pulsation in the umbilical
If anyone of those events are found by medical examination, aggressive measures must be initiated to save the child; with or without the Woman’s consent.
- Reports show that following fetal demise, the fetal tissue becomes macerated (softer). This allows the manual removal of the pregnancy tissue easier and lowers the risk of cervical tears, uterine perforation or retained pregnancy tissue being left behind.
How Is Fetal Demise Assured With A Late Term Abortion?
Fetal Demise is carried out by giving Women IV sedation prior to starting the procedure for comfort. The procedure is performed under direct sonographic (Ultrasound) guidance.
Digoxin, Potassium Chloride (KCL), 1% Lidocaine and Air (creating air embolism) can be injected into the fetal heart (intracardiac). These methods stop the fetal heartbeat immediately.
Digoxin may also be injected into any part of the fetal body (buttocks, shoulder, thigh) or into the intra-amniotic cavity (water that surrounds the fetus). This allows the fetus to succumb in 24 hours or less nearly 100% of the time.
What To Expect On Arrival At Abortion Clinics That Perform Late Term Procedures?
Second Trimester and Late Term Abortion patients receive medical forms to fill out that includes history, consent forms to review for the abortion procedure and birth control.
Lab work is obtained (urine and blood) to confirm pregnancy, blood count and Rh testing.
An Ultrasound (Sonogram) screening exam is performed. This evaluation includes but not limited to the estimation of fetal age. This is made by taking measurement of the fetus; such as head size, femur length and abdominal circumference.
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. This evaluation may aid in the determination of fetal viability.
An extensive counseling session takes place. It includes the benefits and risks of continuing the pregnancy and the complications and side effects associated with the abortion procedure.
The Physician goes over the Patients history, performs a physical exam and discusses the benefits and risks of the abortion procedure.
How Is A Late Term Abortion Performed?
Women who are 21.3 weeks or further undergo the procedure to initiate fetal demise. The use of Digoxin injection is the most common medication used to induce fetal demise.
Women who are undergoing the Late Term Abortion Medication Procedure are given Mifepristone to take in the office.
The fastest induction (onset of labor) to delivery that occurs is if the second medication (Misoprostol) is not taken until 36 to 48 hours after taking Mifepristone. The onset to delivery time is approximately 6 to 8 hours.
Most women choose to complete the abortion process within 24 hours of the initial clinic visit. This means taking the first set of Misoprostol tablets at the same time as Mifepristone.
The average time from start to finish is 8 to 18 hour when medication are taken simultaneously or Misoprostol alone.
Misoprostol may be inserted vaginally, orally, between the cheek and gum (buccal) or underneath the tongue (sublingual).
The dosage, frequency and route of administration of Misoprostol is determined by the Physician’s preference and patient history.
Common Side Effects Of Misoprostol
- Headaches and Dizziness
- Skin rash
- Itchy palms
- Nausea and Vomiting
- Abdominal Pain
- Vaginal Bleeding
What Should Be Expected During A Second Trimester and Late Term Abortion?
- cramps and mild bleeding
- Over 80% of women do not require any pain medication throughout the entire process.
- 15% of women may require OTC medications such as Tylenol or Advil to control pain
- 4 to 5% of women require narcotics for pain control
How Long Does It Normally Take For The Premature Labor Induction Procedure For Second Trimester Or Late Term Abortion To Complete?
The average start to completion is 6 to 18 hours. It may be completed as early as 4 hours or as late as 48 hours.
The heaviest bleeding and discomfort occurs just prior to passage of the pregnancy tissue.
What Happens To Patients Who Do Not Deliver By The Abortion Pill Procedure?
If the fetus does not deliver spontaneously after given a trial of multiple insertions of Misoprostol and no significant change in the cervix, rupturing of the membranes (amniotic sac) may be 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.
Amniotic fluid with fetal cells that enters the woman’s blood stream may cause severe shortness of breath and lack of oxygen circulating throughout the body.
This may lead to Disseminated Intravascular Coagulation (DIC) where the blood is not able to clot and cause failure of the liver, kidneys, and other vital organs. This can lead to maternal death.
A high dose oxytocin regimen may be started after initiating an intravenous (IV) infusion if rupturing the amniotic fluid does not initiate labor. Pain medication may be given for discomfort after Physician evaluation.
Surgical Dilation and Evacuation procedure for Late Second Trimester and Late Term Abortion Procedures:
After the Cervical Preparation occurs over a 2 to 4 day period of time, the Surgical Procedure May Proceed.
IV sedation is given to reduce anxiety and pain discomfort after placing Patients in the same position on the examination table as undergoing a Pap Exam.
A Vaginal Speculum (instrument used to keep the vaginal walls open so the cervix may be seen) is placed.
A Sonogram (Ultrasound) is used through the surgical procedure to visualize the pregnancy test inside the Uterus while removing helps. This helps to reduce potential damage to the wall of the Uterus.
The Cervix is anesthetized (numbed) with 1% Lidocaine to help alleviate any discomfort.
Serial Dilators are inserted through the Cervix to stretch the opening if required. This should not be necessary if adequate Cervical Priming occurred before beginning the surgical procedure.
Surgical Specialized Forceps are placed inside the Uterus and the fetus and placenta (afterbirth) is removed in a gentle fashion. A sterile suction curette is placed inside the Uterus and attached to an election machine that allows removal of all remaining products in the Uterine cavity.
Women are escorted to the recovery room where vital signs are monitored and the amount of vaginal bleeding is accessed for an hour.
If there is no evidence of complications and the patient has no issues with standing, pain or vaginal bleeding and vital signs are stable, the patient is discharged.
She is given antibiotics and an instruction sheet with a 24 hour emergency number when to call.
The bleeding and cramps normally lasts from 5 days to 14 days. Approximately 8% of women may experience vaginal bleeding up to 30 days and 1% do so up to 60 days.
What Are The Complications That May Occur During A Second Trimester or Late Term Abortion?
- Heavy Bleeding
- Incomplete Abortion
- Uterine and Pelvic Infection
- Severe pain due to a pelvic injury such as Uterine Rupture or other bowel or bladder injury
What Symptoms Should Alert Patients To Call The Office Immediately?
- Severe pain when doing normal routine activities not alleviated with taking pain medications
- Temperature greater than 100.4 for 24 hours or greater than 101.4 anytime after discharge
- Heavy bleeding- bleeding more than 2 pads an hour for 2 hours in a roe
- Foul vaginal discharge
When Can A Woman Become Pregnant After Having An Abortion?
Ovulation normally does not happen until 20 days after an abortion procedure. It may happen as early as 5 days after the procedure.
Sperm are able to live up to 5 five days.
Emergency Contraception (Morning After Pill) should be offered to all patients prior to discharge or Birth Control Pills may be started the first Sunday after the abortion procedure is complete.
Do Surgical Or Medical Abortions Prevent Breastfeeding?
Surgical or Medical Abortions are not a contraindication to breastfeeding.
What Are Long Term Effects Of Having A Surgical Or Medical Abortion?
There should be no long term complications with an abortion unless it is associated with a severe pelvic infection that goes untreated with antibiotics. It may lead to:
- Severe pelvic and lower abdominal pain
- Painful intercourse
Abortions are not associated with Breast Cancer, Preterm Births, Low Birth Weight Infants or Premature Deliveries.
There is no increase in depression, anxiety or other Psychological issues after abortion except for women who 1) have a previous Psychological history or do not have family support.
Women should return to the Abortion Facility in 3 to 4 weeks to assure the Patient is having no side effects or complications related to the abortion procedure.
Long acting (IUD, Depo Provera Injections, Progesterone Pellets) reversible birth control may discussed.
Pregnancy prevention reduces the incidence of maternal morbidity and mortality. It can save hundreds of thousands of lives.
What Is The Cost Of A Late Second Trimester Abortion Or Late Term Abortion?
The price of the procedure may range in price from $0.0 to $35,000. This cost range depends on the following:
- Geographic location
- VIP or Exclusive Service for women who need the ultimate in privacy
- The further along the number of weeks, the higher the price
- Private donors and non-profit organizations may be able to help cover the cost of the abortion procedure, travel expenses and room and board
Abortion Clinic Late Term facilities in the US are able to perform in-clinic and outpatient Second Trimester and Late Term Abortions using the Abortion Pill or Surgical Methods.
The Medical Abortion Procedure Utilizing the combined regimen of Mifepristone and Misoprostol or Misoprostol alone, can be started and completed in 24 hours or less in 99% of patients with less than 1% chance of complications or side effects.
There is no upper limitation on the number of weeks pregnant that a medical abortion cannot be performed. They may be performed at 15, 16, 20, 23, 24, 26, 28 weeks or further.
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