What is the recommended procedure for medical termination of pregnancy (MTP) at 4 months?

Medical Termination of Pregnancy at 4 Months

For medical termination of pregnancy at 4 months (second trimester), dilation and evacuation (D&E) is the safest and most recommended procedure, though labor induction with prostaglandins is an alternative when surgical expertise is unavailable.

Surgical Method (Preferred)

• Dilation and evacuation (D&E) is the safest procedure for second-trimester termination of pregnancy, with lower rates of complications compared to medical methods 1
• D&E should be performed in a hospital setting rather than an outpatient facility to ensure all emergency support services are available 1
• The procedure should be performed by experienced providers to minimize complications 1
• Benefits of D&E compared to medical termination include:
  • Lower risk of hemorrhage (9.1% vs 28.3% with medical methods) 2
  • Lower risk of infection (1.3% vs 23.9% with medical methods) 2
  • Lower rate of retained tissue requiring additional procedures (1.3% vs 17.4% with medical methods) 2

Medical Method (Alternative)

If surgical evacuation is not feasible or a skilled provider is unavailable:

• Prostaglandin regimen can be administered to evacuate the uterus 1
• Options include:
  • Prostaglandin E1 (misoprostol) 1, 3
  • Prostaglandin E2 1
• For second trimester termination without mifepristone, misoprostol 800 mcg administered intravaginally is the initial dose 3
  • If no contractions occur, additional doses of 400 mcg orally every 3 hours (up to 3 times) may be needed 3
  • Average time to expulsion is approximately 12.7 hours 3
• When available, mifepristone followed by misoprostol provides higher success rates 4

Monitoring and Considerations

• During prostaglandin administration, systemic arterial oxygen saturation should be monitored with transcutaneous pulse oximetry 1
• Prostaglandin F compounds should be avoided as they can significantly increase pulmonary arterial pressure and may decrease coronary perfusion 1
• Saline abortion methods should be avoided due to risks of intravascular volume expansion, heart failure, and clotting abnormalities 1

Anesthesia and Pain Management

• Most D&E procedures are performed with sedation or general anesthesia 1
• Fetal analgesia is not recommended during pregnancy termination procedures as:
  • There is no evidence of fetal pain awareness before 24-25 weeks gestation 1
  • Administration of additional analgesics for potential fetal benefit could cause maternal harm 1
  • Direct fetal administration of analgesia is invasive and technically challenging 1

Post-Procedure Care

• Antibiotic prophylaxis is recommended to prevent post-abortal endometritis, which occurs in 5-20% of women not given antibiotics 1
• Rh-negative women should receive anti-D immunoglobulin to prevent alloimmunization 2
• Monitoring for complications including hemorrhage, infection, and retained tissue is essential 2

Important Considerations

• The method chosen should be based on gestational age, provider expertise, and facility capabilities 1, 2
• High-risk patients (e.g., those with cardiac disease) should be managed in experienced centers with on-site cardiac surgery capabilities 1
• Counseling regarding contraception should be provided following the procedure 2