Second-Trimester Abortion: Definition, Diagnosis, Options & Complete Management Guide

Comprehensive clinical guide to second-trimester abortion (13–26 weeks): definitions, diagnosis, medical & surgical options, step-by-step management, complications, post-care, legal and counselling considerations.

Introduction

Second-trimester abortion refers to termination of pregnancy performed after the first trimester. This article provides a clinician-oriented, step-by-step overview from definition through diagnosis, clinical options (medical and surgical), peri-procedural management, complication recognition and management, post-abortion care, counselling, documentation and medicolegal considerations.

Definition & Gestational Age

What is a second-trimester abortion?

• Second trimester: Commonly defined as pregnancies from 13+0 to 26+6 weeks' gestation. (Some jurisdictions use slightly different cutoffs; always confirm local definitions.)
• Second-trimester abortion: Any intentional termination of pregnancy occurring within this gestational window.

Indications for Second-Trimester Abortion

• Fetal: lethal or severe fetal anomaly incompatible with life (e.g., anencephaly, trisomy 13 with major malformations).
• Maternal: maternal medical conditions where continuation of pregnancy threatens health or life (e.g., severe cardiac disease, cancer requiring urgent treatment).
• Pregnancy complications: severe preeclampsia, uncontrollable hemorrhage, or infection.
• Social and personal reasons where pregnancy continuation is not feasible — subject to local laws and access.

Initial Assessment & Diagnosis

History & examination

• Confirm patient identity, obtain informed consent, explain options, risks and alternatives.
• Detailed obstetric and medical history (LMP, prior pregnancies, surgeries, allergies, current medications).
• Assess viability and gestational age — last menstrual period (LMP) and ultrasound correlation.
• Review contraception history and desire for future fertility.

Investigations

• Transabdominal or transvaginal ultrasound: confirm intrauterine pregnancy, gestational age, presentation (fetus, placenta), and any uterine abnormalities.
• Baseline bloods: full blood count, rhesus (Rh) typing and antibody screen, blood group, and other tests per local protocol (e.g., hemoglobin, platelets, coagulation if indicated).
• Infection screening: STI screening as appropriate; consider endometritis risk factors.
• Additional tests: if pregnancy termination is for fetal anomaly, offer targeted genetic testing and counseling results documentation.

Options: Medical vs Surgical

Choice of method depends on gestational age, local availability, provider skill, patient preference, clinical indications, and legal framework.

Overview table — common methods

Method	Typical gestational range	Pros	Cons / Considerations
Medical termination (mifepristone + misoprostol)	Generally used from ~13 to 24–26 weeks (protocols vary)	Non-surgical, avoids general anesthesia, can be performed in inpatient or monitored outpatient settings	Longer process, significant bleeding/cramping, requires access to follow-up and emergency care
Surgical — Dilation & Evacuation (D&E)	Usually 13–24 weeks	Definitive, shorter procedure time, controlled blood loss in experienced hands	Requires trained providers and appropriate equipment; risk of uterine perforation; anesthesia required
Induction of labour with prostaglandins +/- osmotic dilators	Often used later second trimester or when fetus is nonviable	Can be used when D&E not available or contraindicated	May require prolonged hospitalization and analgesia; psychological impact due to delivery-like process

Medical Termination — Protocol & Management

Typical regimen (general framework)

• Pre-treatment counseling: explain expected bleeding, pain, likely timing, need for repeat doses, and warning signs (heavy bleeding, fever, severe pain).
• Mifepristone (where available): given first to prime the uterus and sensitize to prostaglandins (dose regimens vary by protocol).
• Misoprostol: repeated doses vaginally/orally/sublingually every 3–6 hours until expulsion; total dose and interval depend on gestational age and protocol.
• Analgesia: multimodal pain control (NSAIDs ± opioids for severe pain) and antiemetics as needed.
• Anti-Rh (D) prophylaxis: for Rh-negative women per local protocol if fetus/placental tissue may enter maternal circulation.
• Monitoring: vital signs, bleeding, pain control; access to emergency care for hemorrhage or incomplete evacuation.

Surgical Termination — Dilation & Evacuation (D&E)

Preparation

• Cervical preparation: osmotic dilators (e.g., laminaria) inserted hours to a day prior OR use of misoprostol for cervical softening, depending on gestational age and protocol.
• Anesthesia: regional (paracervical block, spinal) or general anesthesia per setting and patient preference.
• Antibiotic prophylaxis: single-dose prophylaxis reduces infectious complications in many protocols.
• Blood availability: cross match or ensure availability if bleeding risk suspected.

Procedure steps (summary)

• Dilation of cervix (if not pre-dilated) followed by evacuation of uterine contents with suction and forceps under direct visualization where feasible.
• Inspect uterus and cervix; ensure complete evacuation clinically and by ultrasound if indicated.
• Post-procedure observation for bleeding, pain, vital sign stability.

Induction of Labour for Fetal Demise or Later Second Trimester

• Used when D&E not available, or in cases of intact delivery preference (e.g., some fetal anomalies).
• Prostaglandin regimens (misoprostol or dino prostone) are commonly used; oxytocin may follow for uterine contractions.
• Requires psychological preparation and pain management; more time in hospital may be necessary.

Complications — Recognition & Management

Major complications to watch for

• Hemorrhage: heavy bleeding needing uterotonics, uterine massage, transexamic acid, uterine aspiration, surgical repair, or transfusion in severe cases.
• Infection: fever, foul lochia; treat with broad-spectrum antibiotics and consider evacuation if retained tissue.
• Injury: cervical trauma, uterine perforation—recognize by severe pain, hemodynamic instability; may require surgical repair.
• Incomplete abortion: ongoing bleeding and pain; ultrasound and possible repeat evacuation.
• Emotional/psychological distress: provide counselling and referral as needed.

Post-Abortion Care & Follow-Up

• Observe until hemodynamically stable; provide analgesia and antiemetics as needed.
• Offer contraception counseling and immediate initiation of chosen method if desired (IUD insertion may be considered post-procedure per local protocols).
• Provide written discharge instructions: red flags (fever, heavy bleeding, severe pain), contact numbers, follow-up appointment.
• Arrange follow-up visit: clinical assessment and urine or serum pregnancy test or ultrasound if indicated to confirm completeness.
• Offer psychosocial support and referral to counseling if needed.

Counselling, Consent & Legal Considerations

• Obtain informed consent after discussing risks, benefits, alternatives, and expected course.
• Respect patient autonomy, confidentiality, and cultural sensitivity.
• Document indication, method chosen, counseling details, consent, Rh status and prophylaxis (if given), medications, and follow-up plan.
• Be aware of local legal frameworks and mandatory reporting laws; if uncertain, consult legal or institutional policies before proceeding.

Prevention & Public Health Considerations

• Access to early pregnancy care reduces need for later abortions; ensure family planning services and contraceptive access.
• Quality antenatal screening for fetal anomalies and timely counseling may reduce late decisions.
• Training and resources for safe second-trimester services improve outcomes and lower complications.

Practical Checklists (Clinician Use)

Pre-procedure checklist

• Confirm identity, gestational age and informed consent.
• Baseline vitals and hemoglobin; Rh typing & antibody screen.
• Antibiotic prophylaxis per protocol; analgesia plan.
• Arrange cervical preparation if surgical method planned.
• Plan for contraception counseling and post-procedure follow-up.

Emergency/complication checklist

• Resuscitation equipment ready, IV access, cross matched blood available if needed.
• Uterotonics and transexamic acid accessible for hemorrhage.
• Escalation pathway to operating theatre or higher centre if perforation or uncontrolled bleeding.

Frequently Asked Questions (FAQs)

Q: What gestational ages are considered 'second trimester'?

A: Generally 13+0 to 26+6 weeks' gestation; local definitions vary. Always use ultrasound dating when possible.

Q: Is a second-trimester abortion more risky than a first-trimester one?

A: Risks (bleeding, infection, procedural complications) generally increase with gestational age; however, when performed by trained providers in appropriate settings, both medical and surgical second-trimester abortions can be safe. Risk mitigation includes proper counselling, cervical preparation, antibiotics, and access to emergency care.

Q: How long does medical termination take in the second trimester?

A: It varies — often several hours to days depending on gestational age and regimen. Patients should be counselled on expected timing and provided access to care for complications.

Q: Can I have children after a second-trimester abortion?

A: Most people retain fertility after a medically or surgically uncomplicated second-trimester abortion. Significant complications (rare) such as severe infection or uterine damage can affect future fertility — appropriate technique and infection prevention reduce these risks.

Clinical Resources & Suggested Guidelines

Note: Evidence-based protocols and exact medication dosing vary by country, institution and timeframe. Consult your local clinical guidelines (national obstetric societies, WHO, ACOG, NICE) for precise regimens, legal restrictions and recommended prophylaxis. Always verify up-to-date dosing and recommendations before applying clinically.

Clinical & Legal Disclaimer

This article provides general clinical information and is not a substitute for formal clinical guidelines or individualized medical advice. Local laws, institutional policies, and up-to-date clinical guidelines determine permissible practices and exact medication dosing. Clinicians should consult official guidelines (e.g., WHO, ACOG, national obstetric societies) and institutional protocols before management. Patients should seek individualized care from qualified health professionals.

Author: Dr. Humaira Latif — Clinical overview for educational purposes.

Last updated: August 8, 2025 (editor: verify local guidelines for any changes after this date).