Second Trimester Abortion at 16 Weeks
Dilation and evacuation (D&E) is the recommended procedure for second trimester abortion at 16 weeks of gestation, as it has significantly lower complication rates compared to medical methods and should be performed in a hospital setting by an experienced provider. 1, 2, 3, 4
Why D&E is Preferred at 16 Weeks
Superior Safety Profile:
- D&E demonstrates hemorrhage rates of only 9.1% compared to 28.3% with medical methods 1, 2, 3
- Infection occurs in 1.3% of D&E cases versus 23.9% with medical induction 1, 2, 3, 4
- Retained tissue requiring additional procedures occurs in 1.3% of D&E cases compared to 17.4% with medical methods 1, 2, 3
Procedural Considerations:
- D&E is the safest and most effective method for second trimester termination from 14 to 24 weeks gestation 2, 3, 5
- The procedure must be performed in a hospital setting by experienced providers 2, 3
- Most D&E procedures are performed with sedation or general anesthesia 2
Cervical Preparation (Critical Step)
Optimal Regimen:
- Use misoprostol 400 mcg buccally plus osmotic dilators, which increases pre-procedure cervical dilation and reduces need for additional dilation compared to osmotic dilators alone 6
- Alternatively, mifepristone plus osmotic dilators reduces procedure time and increases dilation achieved 6
Osmotic Dilator Options:
- Overnight laminaria placement reduces procedure time and increases pre-procedure dilation compared to same-day synthetic dilators 6
Medical Method (Alternative When D&E Unavailable)
If surgical abortion is not accessible, medical induction can be used but carries higher risks:
Preferred Medical Regimen:
- Mifepristone 200 mg orally followed 24-48 hours later by misoprostol 400 mcg every 3 hours (vaginal, buccal, or sublingual) 7, 8
- This combination achieves 95% completion within 24 hours of misoprostol administration 7
- The combined regimen reduces abortion time by 40-50% compared to misoprostol alone 7
Misoprostol-Only Regimen (when mifepristone unavailable):
- Misoprostol 400 mcg vaginally or sublingually every 3 hours 7
- Achieves approximately 80-85% abortion rate at 24 hours 7
- Higher doses (600-800 mcg) can be given at longer intervals (up to 12 hours) 7
Essential Supportive Care
Antibiotic Prophylaxis:
- Administer prophylactic antibiotics to prevent post-abortal endometritis, which occurs in 5-20% of women without prophylaxis 2
Rh Immunoprophylaxis:
- All Rh-negative women must receive 50 mcg anti-D immunoglobulin to prevent alloimmunization 1, 2
- Fetomaternal hemorrhage occurs in 32% of spontaneous abortions 1
Pain Management:
- Provide adequate analgesia during and after the procedure 2
- Fetal analgesia is not indicated, as there is no evidence of fetal pain awareness before 24-25 weeks gestation 2
Critical Pitfalls to Avoid
Do Not Use Expectant Management:
- Expectant management is absolutely contraindicated at 16 weeks with confirmed fetal demise due to increased risk of intrauterine infection, coagulopathy, and maternal sepsis 1
- Expectant management carries 60.2% maternal morbidity versus 33.0% with active abortion care 1
- Intraamniotic infection occurs in 38.0% with expectant management versus 13.0% with abortion care 1
Recognize Infection Early:
- Do not wait for fever to diagnose infection 1
- Look for maternal tachycardia, purulent cervical discharge, uterine tenderness, and fetal tachycardia 1
- If infection suspected, initiate broad-spectrum antibiotics immediately and proceed with urgent surgical evacuation 1
Avoid Prostaglandin F Compounds:
- These agents significantly increase pulmonary arterial pressure and may decrease coronary perfusion 2
Post-Procedure Contraceptive Counseling
Immediate Contraception: