Recommended Procedure for 4-Month Pregnancy Termination
Dilation and evacuation (D&E) is the procedure of choice for pregnancy termination at 4 months (16 weeks) gestation, as it has dramatically lower complication rates compared to medical methods and should be performed in a hospital setting by an experienced provider. 1, 2
Why D&E is Preferred
The evidence strongly favors surgical over medical termination at this gestational age:
- D&E has a hemorrhage rate of 9.1% versus 28.3% with medical methods 1
- Infection risk is 1.3% with D&E versus 23.9% with medical methods 1
- Overall complication rate is 4% with D&E versus 29% with medical induction 2
- Hospital stay is significantly shorter with D&E compared to medical methods 3
Cervical Preparation Protocol
Osmotic dilators (such as Laminaria) should be placed prior to the procedure, as maximal use decreases complication rates. 4, 2
- Osmotic dilators provide superior cervical dilation compared to prostaglandins alone throughout the second trimester 4
- One-day cervical preparation is adequate below 19 weeks gestation; two-day preparation may be considered for more advanced gestations 4
- Pre-operative misoprostol can be added to reduce complications, though osmotic dilators alone are effective 4, 5
Anesthesia and Pain Management
Most D&E procedures are performed with sedation or general anesthesia for maternal comfort. 6, 1
- Fetal analgesia is NOT recommended and should not be administered, as fetal pain awareness is not developmentally plausible before 24-25 weeks gestation 6
- Direct fetal administration of analgesia is invasive, technically challenging, and offers no benefit while potentially causing maternal harm 6
Post-Procedure Care
Antibiotic prophylaxis must be administered to prevent post-abortal endometritis, which occurs in 5-20% of women without prophylaxis 1, 5
Rh-negative women must receive anti-D immunoglobulin to prevent alloimmunization 1, 7
Medical Method (Only When D&E Unavailable)
If a skilled surgical provider is not available or D&E cannot be performed:
- Prostaglandin E1 (misoprostol) or E2 can be used for medical termination 1, 7
- Avoid prostaglandin F compounds as they increase pulmonary arterial pressure and decrease coronary perfusion 1, 8
- Monitor oxygen saturation with pulse oximetry during prostaglandin administration 1
- Medical methods have significantly higher complication rates and should only be used when surgery is not feasible 2
Critical Considerations
Timing matters: Delaying the procedure increases complication risks and limits options 7
Provider expertise is essential: D&E requires technical skill, and the procedure should be performed by experienced providers in appropriate hospital settings 1, 9
Confirmation of diagnosis: D&E reliably allows confirmation of fetal abnormalities when that is the indication, contrary to historical concerns 9