Beloved Holistics Radio Episode 81 - Second Trimester Abortion
“At the deepest level a woman yearns for you not to take her way of expressing herself personally. She wants to be fierce, full of loving-rage, as soft as a feather in the wind, and as sad as an ocean in a tropical thunderstorm, whenever the fuck she wants. If you don't react, and love her through her expressions, the core of her essence, then your kingdom allows her to bloom like a wildflower, to spread her wings and fly, to be the woman she always longed to be. This is all she wants and asks from you." - Lorin Krenn
PB#135 - Published June 2013 (Reaffirmed 2017)
It's none of your damn business why a woman desires a 2nd trimester abortion. There are also a lot of scenarios in which 2nd trimester abortion skills are necessary but that have nothing to what many perceive to be a seemingly easy decision to terminate a pregnancy.
If you don't feel confident in your skills as a provider to perform 2nd trimester abortions, do your patients the service of developing a referral relationship with another provider who does.
Inducing fetal demise prior to 2nd-trimester abortion does not improve safety or decrease procedure time in case of D&E, but he it does shorten induction time for medical abortion.
Misoprostol + mifepristone = the most effective protocol of medical options
All methods of contraception are effective on the day of 2nd-trimester abortion apart from cervical cap, diaphragm, or hysteroscopic sterilization (including IUD)
First...a short lesson on legality
- the U.S. Supreme Court has determined that it's unconstitutional for individual states to ban abortion (Roe versus Wade, 1973)
- many states have passed laws, however, that limit access to abortion services
- Partial-Birth Abortion Ban Act, 2003 --> dilation and evacuation (D&E) banned unless fetal demise occurs before surgery
- by 2011, six states had banned abortion >20 wga due to concerns around the fetus feeling pain
- only 65% of providers offer abortion services at >12 wga (only 25% at >20 wga)
Why did you wait until the 2nd trimester to get an abortion?!
- "I didn't have health insurance when I first found out that I was pregnant"
- "I had no idea I was pregnant"
- "I couldn't find a doctor to refer me to an abortion clinic until now"
- "I wasn't able to get off time from work...I need the money so badly"
- "I just found out from my second trimester formal anatomy ultrasound and subsequent diagnostic testing that my fetus has anencephaly"
- "There's only one abortion center in my state, and I rely on public transportation"
- "It's none of your goddamn business, Senator McConnell. Maybe you should instead focus on improving access to women's health and contraception in your great state if you feel so 'invested' in this conversation, you unbelievably arrogant, son-of-a-bitch, typical old white fart"
Note: This PB also covers management of pregnancy failure (<20 wga) and fetal demise in the 2nd trimester
How is 2nd trimester abortion performed?
- D&E (95%...though medical abortion may be underreported in the 2nd trimester)
- more cost effective and (usually) faster than medical methods; also more predictable! (one and done --> perhaps less emotionally challenging for the patient)
- lower risk of complications (4% versus 29% with medical methods), esp retained POC but also pain and GI side effects, compared to misoprostol alone
- the procedure is pretty straightforward: grab and pull to dismember the fetus; yes...that's it
- an alternative is to dilation the cervix sufficiently to extract the fetus intact (i.e. intact D&E), which carries lower risk of uterine perforation or infection
- before the procedure, the cervix is softened and dilated with the placement of osmotic dilators
- procedure can be performed without ultrasound guidance (not sure why you wouldn't use it if accessible, though)
- many residency training programs also do a poor job of teaching D&E skills
- hysterectomy or hysterotomy may also be required, but only indicated if all other methods have failed
- may be preferable in the presence of fetal anomalies, fetal genetic disorders, or maternal health issues (i.e. when intact fetal anatomy is preferred for autopsy purposes)
- medications, mechanical dilators, or osmotic dilators are all options --> multiple factors at play in choosing the best route
- misoprostol alone OR mifepristone followed by misoprostol OR oxytocin
- in comparison medications, misoprostol is the preferred method given its high efficacy, low cost, and ease of use
- no added benefit if osmotic dilator is used in conjunction with misoprostol
- administering mifepristone 24-48 hrs before misoprostol is the most effective regimen (90% efficacy if miso started 24 hrs after) --> shorter induction interval and fewer adverse effects than miso alone (e.g. lower risk of retained POC or need for hospitalization)
- mifepristone is sometimes hard to come by, unfortunately
Are there ways to ensure fetal demise before the procedure?
- sure: snip the umbilical cord, inject digoxin into the fetus, or inject KCl into the fetal heart
- doesn't increase safety, decrease procedure time, or decrease difficulty prior to D&E
- may shorten induction time in medical abortion
- abortion carries overall super low risk of maternal mortality (<<<0.1%); 14x higher likelihood of dying through childbirth than with abortion
- abortion-related mortality increases at higher gestational ages: 0.1:100,000 at 8 wga, 9:100,000 at 21 wga
- we're talking about bleeds that sufficiently excessive to require transfusion or hospital admission or quantifiably >500 mL
- occurs in around 0.6% of 2nd-trimester abortions
- higher risk if:
inadequate cervical ripening
history of >1 c-section
- may be due to retained POC, cervical laceration, uterine atony, uterine perforation, abnormal placentation, or DIC
- <1% of D&E cases
- occurs in ~8% of 2nd-trimester abortions in which mifepristone is used
- more likely after medical versus surgical abortion
- 2.6% of D&E cases (more likely in older patients and history of prior c-section
- 3.3% of 2nd-trimester abortions (including both D&E and medical)
- risk factors include: use of mechanical dilation, nulliparity, higher GA, and provider inexperience
- can often be managed through topical silver nitrate (superficial) or suturing (deep)
- suturing the cervix itself will generally be sufficient, but be prepared to suture the cervical artery at 3 or 9 o'clock, as needed (if this doesn't work, then you have to consider other etiologies, like uterine artery transection)
- 0.2-0.5% of D&E cases
- risk factors include: higher GA, nulliparity, and provider inexperience
- less likely with adequate cervical ripening
- exploratory surgery needed if patient becomes hemodynamically unstable (can complete the procedure under direct visualization in that case)
- if not unstable, you may consider completing it under ultrasound guidance (or waiting until later)
- 0.3% risk if misoprostol used in a patient with prior CS (versus 0.04% without history of prior CS); risk presume to be higher with multiple prior c-sections
- still reasonable to use misoprostol if no more than one prior c-section
Disseminate intravascular coagulation (DIC)
- super heavy persistent hemorrhage? collect stat H/H, INR/PT, and coags (i.e. aPTT, fibrinogen)
- 0.1-4% of 2nd-trimester abortions (probably on the lower end given poor definition of "infection" in most studies)
- prophylactic antibiotics are recommended before D&E (not for medical abortions)
- doxycycline or cefazolin are reasonable (doxy 100 mg 1 hour before and 200 mg 2 hour after is a great regimen)
- super freaking rare (10-20 per 100,000)
- 80% mortality rate: watch out!
Oh no! Postabortion hemorrhage!
- visually inspect cervix, bimanually assess uterine tone, and perform transabdominal ultrasound to evaluate for retained POC
- if atony suspected, prompt bimanual fundal massage
- rectal or buccal administration of 800-1000 mcg of misoprostol (oxytocin unlikely to be effective due to the paucity of oxytocin receptors in the 2nd trimester)
- if bleeding persists, extra IV fluids or blood products may be necessary; stat H/H, INR/PT, and coag studies is helpful
- transfuse if indicated
- if uterotonics aren't sufficient, intrauterine balloon tamponade --> umbilical artery embolization if bleeding persists (UAE can control bleeding in atony, cervical laceration, or DIC)
- also remember the possibility of bleeding related to undiagnosed uterine perforation
- hysterectomy is last resort (but don't be afraid to use it!) --> open hyst most likely
What can I do to prevent postabortion hemorrhage?
- be patient with pre-procedure cervical ripening
- vasopressin has been found to reduce postpartum bleeding if used in paracervical block
What if abnormal placentation is suspected pre-op?
- D&E is recommended (over medication)
- prepare ahead of time for hemorrhage (i.e. make sure you have access to uterotonics and blood products!)
- also ask yourself: "am i cool with open hysterectomy especially in the setting of pregnancy?"
- pre-op UAE is not helpful
- predictive value of ultrasound for placenta accreta is only 65%; MRI is better
- if patient is experiencing postabortion hemorrhage presumably due to placenta accreta, UAE will be effective 43% of the time
- all methods are fair game (including IUD) on the same day as 2nd-trimester abortion apart from cervical cap, diaphragm, or hysteroscopic sterilization