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خرید پکیج
تعداد ایتم قابل مشاهده باقیمانده : 4 مورد

Second-trimester pregnancy termination: Induction (medication) termination

Second-trimester pregnancy termination: Induction (medication) termination
Author:
Cassing Hammond, MD
Section Editor:
Jody Steinauer, MD, MAS
Deputy Editor:
Alana Chakrabarti, MD
Literature review current through: May 2021. | This topic last updated: May 07, 2021.

INTRODUCTION — Second-trimester pregnancy termination may be performed with medication or surgery. Surgical termination, or dilation and evacuation (D&E), requires dilating the cervix followed by surgical extraction of products of conception. Medication termination, or induction abortion, involves the administration of medication through one of a variety of routes to induce labor and deliver the fetus. Both methods are safe and effective, and each offers different advantages and disadvantages.

Women may choose medication abortion if they prefer more awareness of the termination process, if they prefer an intact fetus, or if they want to avoid surgery. An intact fetus may be desirable if the patient desires to hold the fetus or, in cases of fetal anomalies, if an intact fetus is beneficial for a morphologic evaluation. In some health care settings, there is more access to second-trimester induction abortion than surgical abortion.

Second-trimester induction termination is reviewed here. An overview of second-trimester pregnancy termination and the technique for surgical abortion are discussed separately. First-trimester medication abortion is also discussed separately. (See "Overview of second-trimester pregnancy termination" and "First-trimester pregnancy termination: Medication abortion".)

PREPROCEDURE PREPARATION — Women who desire second-trimester induction termination require preoperative evaluation to establish gestational age, assess general medical status, and identify any medical factors that may impact the choice of induction versus surgical termination. Many of the medical factors favoring medical abortion are "provider-dependent," in that they derive from a specific provider's skill in a particular situation.

Choice of procedure is discussed in detail separately. (See "Overview of second-trimester pregnancy termination", section on 'Choosing dilation and evacuation versus induction termination'.)

Laws regarding abortion vary by country and by state in the United States. Most states restrict abortion after viability, although the definition of viability varies by state and maternal-fetal exemptions that countermand the viability statute vary by state. Clinicians offering abortion must be familiar with restrictions in their own locality.

Prophylactic antibiotics — Prophylactic antibiotics are not typically advised for second-trimester medication abortion. The Society of Family Planning (SFP) advises that prophylactic antibiotics may lower the risk of serious infection but advises against universal use [1]. (See 'Infection' below.)

The issue of antibiotic prophylaxis is similar for first-trimester medication abortion, which is discussed in detail separately. (See "First-trimester pregnancy termination: Medication abortion", section on 'Prophylactic antibiotics'.)

Cervical preparation — There is no evidence that osmotic cervical dilation facilitates induction when using modern prostaglandin (PG) analogs [2,3]. Special "precervical ripening" is no longer indicated during the second trimester prior to induction abortion.

Induced fetal demise — Clinicians may induce demise prior to abortion either to facilitate the abortion procedure or to prevent live birth. SFP 2010 guidelines advise that induction of fetal demise prior to medical abortion might shorten induction-to-abortion interval, particularly if potassium chloride (KCl) is utilized, though this is based on one small retrospective study using a PGE2 regimen [4]. More information is needed regarding the impact of different feticidal regimens on induction-to-abortion intervals among women undergoing misoprostol termination.

To induce fetal demise, there are several options, including intracardiac KCl or intrafetal and intraamniotic digoxin.

Induced fetal demise is discussed in detail separately. (See "Induced fetal demise".)

Anesthesia — Women undergoing medical induction can receive analgesia or anesthesia similar to that used for obstetric labor induction. Intermittent narcotic administration suffices for some patients, while others desire epidural anesthesia since this completely eliminates pain during more prolonged inductions. (See "Pharmacologic management of pain during labor and delivery".)

PROTOCOL — Current protocols for second-trimester induction abortion typically include a prostaglandin (PG), usually misoprostol, and may utilize mifepristone or oxytocin.

Type of prostaglandin — Instillation abortion with saline or urea has now been largely abandoned due to risks such as hypernatremia, coagulopathy, and hemorrhage [5,6]. In comparison with current methods of labor induction abortion (typically with misoprostol), randomized trial data show that instillation abortion results in longer induction times and higher rates of both blood transfusion and retained placenta [6].

Oxytocin, the most commonly used induction agent at later gestational ages, fails to induce labor as effectively as other single-agent therapies at midtrimester because the uterus has relatively fewer oxytocin receptors at less than 20 weeks of gestation. Oxytocin is associated with longer induction-abortion intervals than newer methods, as well as higher risks of side effects such as postpartum hemorrhage and even water intoxication [7,8]. Patients desiring medical abortion in the second trimester now have safer, more effective options, utilizing PG agents either alone or in combination with progesterone antagonists.

Several PG agents have been used to induce abortion:

Misoprostol and gemeprost, both PGE1 analogs, are the most common medications used for induction abortion.

Comparative studies have found that both misoprostol and gemeprost induce labor more effectively and with fewer side effects than other PGs (eg, carboprost, sulprostone) and single-agent oxytocin or oxytocin in combination with other types of PGs [9-13]. Both misoprostol and gemeprost induce labor at a variety of gestational ages [14]. The dose decreases as pregnancy advances because the uterus becomes more sensitive to PG with decreasing dose requirements as pregnancy advances.

Misoprostol is typically the preferred agent due to lower rates of certain adverse effects and complications and based on practical considerations. Gemeprost and misoprostol have been found to have similar efficacy in randomized trials [15-19]. As an example, in one trial of 81 women between 12 to 25 weeks of gestation, pregnancy termination with misoprostol (200 mcg every 12 hours) compared with gemeprost (1 mg every three hours) resulted in a significantly higher rate of complete abortion (61 versus 32 percent) but a longer induction-to-abortion interval (27.8 versus 14.5 hours). The mean blood loss was significantly lower in the misoprostol group. Women treated with misoprostol had fewer adverse effects (eg, nausea, vomiting).

The advantages of misoprostol in comparison with gemeprost are reduced need for narcotic analgesia, less frequent need for surgical evacuation of the uterus, more routes of administration, is less expensive, and does not require refrigeration [14].

Carboprost, a PGF2alpha analog, results in more systemic side effects than PGE analogs [20].

Sulprostone, a PGE2 analog, has fallen out of favor because it has been associated with myocardial infarction [9].

Route and regimen — The route of administration, dose, and dosing interval of misoprostol vary across protocols. There are limited high-quality data to establish the optimal protocol. In general, misoprostol administered by the buccal route has been found to have higher bioavailability than oral and with fewer adverse effects. Sublingual administration has similar efficacy to vaginal dosing. However, for first-trimester medication abortion, many experts advise avoiding vaginal administration due to concerns regarding infection. A systematic review of randomized trials found that the vaginal route was preferable although, among multiparous women, sublingual administration appeared equally effective [19]. A subsequent randomized trial found that vaginal or sublingual dosing was associated with a shorter time to pregnancy completion than oral dosing [21].

General principles of the dose, route of administration, and timing of misoprostol are discussed in detail separately. (See "Misoprostol as a single agent for medical termination of pregnancy", section on 'Data on drug administration' and "First-trimester pregnancy termination: Medication abortion", section on 'Misoprostol'.)

For the second trimester, the dose of misoprostol ranges from 200 to 800 mcg. In regimens using misoprostol or gemeprost alone, median induction-to-abortion intervals are approximately 12 to 16 hours [22]. The abortion time interval is decreased with more frequent dosing. Two randomized trials demonstrated a significantly shorter induction time with vaginal administration of misoprostol 400 mcg every three hours compared with every six hours, without a significant increase in side effects [23,24].

Use of mifepristone — Mifepristone is an antiprogestin that competitively blocks both progesterone and glucocorticoid receptors. By opposing the activity of progesterone, mifepristone elicits a variety of effects that make the uterus more susceptible to abortion. These effects include cervical dilation, decidual necrosis, increased endogenous PG production, and increasing uterine sensitivity to exogenously administered PG. Mifepristone administration gradually elicits a fivefold increase in sensitivity to PG 24 to 48 hours after its administration [25]. The synergy between mifepristone and PG permits greater efficacy of PG at lower doses, potentially minimizing side effects [26].

Mifepristone and misoprostol have been consistently found to be safe and effective in second-trimester induction abortion [10,22,27]. Mifepristone used in combination with misoprostol is the most effective method of inducing delivery in the second trimester [28]. Many different regimens utilizing mifepristone and misoprostol, alone or in combination, result in fetal expulsion within 24 hours during more than 90 percent of inductions [29,30].

The World Health Organization (WHO), American College of Obstetricians and Gynecologists (ACOG), Society of Family Planning (SFP), and Royal College of Obstetricians and Gynaecologists (RCOG) recommend regimens in which mifepristone precedes use of either misoprostol or gemeprost [29,31-33].

Use of mifepristone followed by oxytocin compared with mifepristone followed by misoprostol was compared in one randomized trial that found no significant difference in success rate (100 versus 96 percent). Time to fetal expulsion was longer in the oxytocin group (11.3 versus 7.0 hours), but the rate of fever and shivers was lower [7].

A systematic review analyzed results from 20 randomized trials and nine observational studies [34]. Pooled data demonstrated that administration of misoprostol 12 to 24 hours after mifepristone modestly increased induction-abortion intervals by one to two hours. The overall abortion times, the time from administration of mifepristone to delivery, were substantially lower, though primarily because practitioners started inductions earlier. Another study compared a regimen that initiated mifepristone at the same time as misoprostol with a regimen in which misoprostol began 24 hours later. Although taking both medicines simultaneously decreased efficacy at 24 hours and resulted in increased total use of misoprostol, the overall time of the abortion process and the number of clinic visits were reduced [35]. In our practice, we begin inductions 36 hours after mifepristone administration, but we advise practitioners that beginning inductions as soon as 12 to 24 hours is safe and effective. Certainly, providers have considerable latitude to accommodate patients' personal needs and the availability of induction services without fear of compromising safety.

Medical society protocols — ACOG recommends the following protocols for second-trimester induction abortion [31]:

Mifepristone 200 mg, administered orally, followed by:

Misoprostol 800 mcg, administered vaginally, followed by 400 mcg, administered vaginally or sublingually every three hours for up to a maximum of five doses.

or

Misoprostol 400 mcg, administered buccally every three hours for up to a maximum of five doses also may be used.

If mifepristone is not available:

Misoprostol 400 mcg, administered vaginally or sublingually every three hours for up to five doses. Vaginal dose is superior to sublingual dose for nulliparous women.

or

A vaginal loading dose of 600 to 800 mcg of misoprostol, followed by 400 mcg administered vaginally or sublingually every three hours may be more effective.

If misoprostol is not available:

Oxytocin 20 to 100 units, infused intravenously over three hours, followed by one hour without oxytocin to allow diuresis. Oxytocin dose may be slowly increased to a maximum of 300 units over three hours.

RCOG recommends 400 mcg of vaginal misoprostol every three hours, up to five doses, in pregnancies between 13 and 22 weeks [20].

Our practice — In our practice, we prefer to administer mifepristone before induction with misoprostol or other agents. We aim to administer mifepristone at least 24 hours prior to induction; shorter intervals are acceptable in some situations (eg, patient preference).

If cervical dilation occurs but the patient does not deliver after five doses of misoprostol, we continue with additional doses of misoprostol until the fetus delivers. While the medical society protocols do not provide specific instruction on how to proceed in this situation, our practice is based on a retrospective study in which 17 percent of patients undergoing medical induction between 14 and 24 weeks required more than five doses of misoprostol; 60 percent of those women (47 women) required one or two additional doses prior to delivery of the fetus, and the maximum dose required was 12 [36]. Complication rates (eg, chorioamnionitis, postpartum hemorrhage, retained placenta) were similar among those who received ≤5 versus ≥6 misoprostol tablets.

However, if cervical dilation does not occur after five doses of misoprostol, options include:

Discontinue induction and restart the process with misoprostol after 12 to 24 hours.

Proceed with cervical preparation (eg, osmotic dilators, intracervical Foley balloon) followed by either administration of misoprostol or oxytocin. (See "Induction of labor: Techniques for preinduction cervical ripening", section on 'Balloon catheter' and "Induction of labor: Techniques for preinduction cervical ripening", section on 'Hygroscopic dilators'.)

Administer a higher dose of misoprostol (up to 800 mcg vaginally) followed by lower doses. (See 'Medical society protocols' above.)

Switch induction agents and try oxytocin. (See 'Medical society protocols' above.)

Convert to a surgical abortion if cervical dilation is adequate and a skilled provider is available.

We do not change our practice for patients with a prior hysterotomy (eg, cesarean delivery, myomectomy). While these patients are at risk of uterine scar dehiscence, there is no evidence to support deviating from the ACOG/RCOG protocols. There is no evidence justifying alteration of medical induction regimens among women with scarred uteri.

Termination after 23 weeks is not common in the United States, and an optimal regimen has not been established. When pregnancy termination is performed at ≥24 weeks, the indication is generally a fetal anomaly. For gestational ages 24 to 28 weeks, the SFP has published a systematic review and guidelines for pregnancy termination from 24 to 28 weeks; these include data and recommendations for pregnancy termination and labor induction for fetal demise [37]. For mifepristone-misoprostol regimens, seven observational studies were included and showed that a dosing regimen of misoprostol 200 mcg or 400 mcg every four hours is associated with 24-hour expulsion rates of 80 to 97 percent, with mean expulsion times ranging from 8.5 to 13.6 hours. The SFP advised that mifepristone 200 mg or 600 mg be followed by misoprostol 36 to 48 hours later. Misoprostol-only regimens for this gestational age range are discussed separately. (See "Misoprostol as a single agent for medical termination of pregnancy", section on 'Clinical regimen'.)

Use of other medications — There is variation in the approach to second-trimester abortion across medical settings. In China, approximately 7.63 million abortions were performed in 2007 [38]. The most common method of second-trimester abortion in China has been intraamniotic injection of ethacridine lactate, a dye with antiseptic properties. A systematic review of 15 randomized trials conducted in China evaluated mifepristone combined with misoprostol versus intraamniotic injection of ethacridine lactate and found that mifepristone/misoprostol has lower failures rates (2 to 6 percent versus 7 to 21 percent, risk ratio 0.37, 95% CI 0.17-0.80) and shorter time of labor (an average of 1.9 hours shorter). More gastrointestinal side effects occurred in the mifepristone/misoprostol group, but cervical injury was more frequent in the ethacridine lactate group.

OUTCOME AND COMPLICATIONS — Second-trimester surgical abortion is a safe and effective procedure. Most terminations are completed as inductions, but some women require a surgical procedure for a retained placenta. In addition to retained products of conception, potential complications include uterine rupture, cervical laceration, hemorrhage, and infection.

Incomplete abortion — Incomplete abortion is more common in second-trimester induction abortion than in surgical abortion (1 to 7 versus 0 percent) [31,39,40].

Retained placenta — In induction procedures with mifepristone and misoprostol, 2 to 10 percent of women have a retained placenta [22,41,42]. Induction protocols that include misoprostol inductions less commonly require surgical intervention for delivery of the placenta than induction with other agents, though rates of retained placenta are higher for all medical methods compared with dilation and evacuation (D&E) [39,40,43].

Traditionally, in an induction abortion, clinicians have performed curettage if the placenta remained undelivered 30 to 120 minutes following delivery of the fetus. This is based upon reports regarding a technique that is now used infrequently, hyperosmolar saline and prostaglandin E2 (PGE2), which was associated with higher rates of complications with an increasing interval from the delivery of the fetus to the placenta [44,45]. With misoprostol inductions, some data suggest that waiting for up to four hours is acceptable. As an example, in one retrospective study of 233 women who underwent second-trimester induction with misoprostol, 59 percent of placentas delivered within one hour of fetal expulsion. The overall rate of surgical intervention for retained placenta was 6 percent, and 11 of 14 surgical procedures were performed to expedite hospital discharge [46]. An interval of four or more hours for the delivery of the placenta was not associated with increased morbidity.

As a result of this study for hemodynamically stable patients, we manage delivery of the placenta expectantly for four hours after delivery of the fetus before intervening to remove the placenta.

Uterine rupture — Uterine rupture can occur in women with a scarred or unscarred uterus [47]. In a systematic review of second-trimester abortion with misoprostol, the risk of uterine rupture among women with prior cesarean delivery was 0.28 percent, whereas the risk in women without prior cesarean was 0.04 percent [48]. The Society for Family Planning (SFP) in the United States supports second-trimester induction abortion in women with prior cesarean delivery [29]. No studies have evaluated the safety of medical abortion among women with uterine scarring secondary to prior myomectomy or surgery for correction of müllerian uterine anomalies.

Cervical laceration — Cervical laceration may occur in either induction or surgical abortion. (See "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Cervical laceration'.)

Infection — The medications used for induction abortion, particularly misoprostol, often result in pyrexia, which makes it difficult to evaluate the rate of infection. A literature review by the SFP reported a 1 to 3 percent incidence of infection, not solely pyrexia, following second-trimester medication abortion [1].

Hemorrhage — Hemorrhage resulting in transfusion complicates less than 1 percent of induction terminations. The risk of hemorrhage increases with gestational age and duration of induction. Common causes include retained products of conception, uterine atony, and trauma to the lower genital tract [49]. Although clinicians often treat postabortal atony similar to postpartum atony, the second-trimester uterus has fewer oxytocin receptors, limiting response to high-dose oxytocin. Carboprost 250 mcg intramuscularly every 15 minutes up to eight doses and low-dose cervical vasopressin have both been described in the setting of postabortal hemorrhage [50]. Balloon tamponade with intrauterine balloon catheters, uterine compression sutures, and angiographic embolization might become necessary in more severe cases of hemorrhage [51-53]. Intractable hemorrhage refractory to other therapy can require hysterectomy.

Other complications — Meaningful mortality data, stratified according to induction regimen used, are unavailable. Given a very low number of deaths reported annually for all second-trimester abortions, it is unlikely that any commonly used medical regimen confers a significant risk of maternal death.

FOLLOW-UP — Follow-up for second-trimester induction abortion is the same as for surgical abortion. This is discussed in detail separately. (See "Overview of second-trimester pregnancy termination", section on 'Follow-up'.)

SPECIAL CIRCUMSTANCES — Management of patients with special issues of concern (eg, uterine anomalies, low-lying placenta, multiple gestation) is discussed separately. (See "Overview of second-trimester pregnancy termination", section on 'Special circumstances'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pregnancy termination".)

SUMMARY AND RECOMMENDATIONS

Second-trimester induction abortion (also referred to as medication or medical abortion) is performed using solely medications. One advantage of this approach compared with surgical abortion is that it results in an intact fetus, which may be preferable for a patient in certain circumstances. (See 'Introduction' above.)

Prophylactic antibiotics are not typically advised for second-trimester medication abortion. (See 'Prophylactic antibiotics' above.)

Osmotic dilators do not facilitate second-trimester medical abortion. Some clinicians use osmotic dilators if there is a high likelihood of conversion of the procedure to a surgical uterine evacuation. (See 'Cervical preparation' above.)

Feticidal injections are often given to prevent live birth. Another potential goal of induced fetal demise is to facilitate labor induction. (See 'Induced fetal demise' above.)

Women undergoing induction termination can receive analgesia or anesthesia similar to that used for obstetric labor induction. Intermittent narcotic administration suffices for some patients, while others desire epidural anesthesia. (See 'Anesthesia' above.)

Current protocols for second-trimester induction abortion typically include a prostaglandin (PG), usually misoprostol, and may utilize mifepristone or oxytocin. Prior protocols that used hypertonic saline have been largely abandoned due to risks such as hypernatremia, coagulopathy, and hemorrhage. (See 'Protocol' above.)

For women undergoing second-trimester induction abortion, we suggest use of misoprostol combined with mifepristone rather than misoprostol alone (Grade 2B). (See 'Protocol' above.)

Protocols for induction abortion vary (see 'Protocol' above). An example of a protocol is mifepristone 200 mg, administered orally, followed by either:

Misoprostol 800 mcg, administered vaginally, followed by 400 mcg, administered vaginally or sublingually every three hours for up to a maximum of five doses.

or

Misoprostol 400 mcg, administered buccally every three hours for up to a maximum of five doses also may be used.

Potential complications of induction abortion include: retained placenta, uterine rupture, cervical laceration, infection, or hemorrhage. (See 'Outcome and complications' above.)

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  50. Lichtenberg ES, Grimest DA. Surgical complications: Prevention and Management. In: Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care, Paul M, Lichtenberg ES, Borgatta L, et al (Eds), Wiley-Blackwell, Hoboken 2009. p.232.
  51. Baskett TF. Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy. Obstet Gynecol 2007; 110:68.
  52. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynaecol Obstet 2001; 74:139.
  53. Steinauer JE, Diedrich JT, Wilson MW, et al. Uterine artery embolization in postabortion hemorrhage. Obstet Gynecol 2008; 111:881.
Topic 90163 Version 15.0

References

1 : Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102.

2 : A randomized clinical trial of the addition of laminaria to misoprostol and hypertonic saline for second-trimester induction abortion.

3 : A comparison of misoprostol with and without laminaria tents for induction of second-trimester abortion.

4 : Effect of causing fetal cardiac asystole on second-trimester abortion.

5 : Coagulopathy and induced abortion methods: rates and relative risks.

6 : A randomized comparison of misoprostol to intrauterine instillation of hypertonic saline plus a prostaglandin F2alpha analogue for second-trimester induction termination in Uzbekistan.

7 : Mifepristone followed by misoprostol or oxytocin for second-trimester abortion: a randomized controlled trial.

8 : High-dose vaginal misoprostol versus concentrated oxytocin plus low-dose vaginal misoprostol for midtrimester labor induction: a randomized trial.

9 : Vaginal misoprostol vs. concentrated oxytocin plus low-dose prostaglandin E2 for second trimester pregnancy termination.

10 : Mifepristone in combination with prostaglandins for termination of 10-16 weeks' gestation: a systematic review.

11 : Termination of second trimester pregnancy with gemeprost vaginal pessaries and intra-amniotic PGF2 alpha. A comparative study.

12 : The use of 16,16-dimethyl-trans delta 2 prostaglandin E1 methyl ester (gemeprost) vaginal pessaries for the termination of pregnancy in the early second trimester. A comparison with extra-amniotic prostaglandin E2.

13 : A prospective, randomized comparison of vaginal misoprostol versus intra-amniotic prostaglandins for midtrimester termination of pregnancy.

14 : Misoprostol for women's health: a review.

15 : Misoprostol (alone) in second trimester terminations of pregnancy: as effective as Gemeprost?

16 : A comparison between two doses of intravaginal misoprostol and gemeprost for induction of second-trimester abortion.

17 : Vaginal misoprostol compared with vaginal gemeprost in termination of second trimester pregnancy. A randomized trial.

18 : Misoprostol versus cervagem for the induction of labour to terminate pregnancy in the second and third trimester: a systematic review.

19 : Medical methods for mid-trimester termination of pregnancy.

20 : Recent advances in second-trimester abortion: an evidence-based review.

21 : Mifepristone and oral, vaginal, or sublingual misoprostol for second-trimester abortion: a randomized controlled trial.

22 : Midtrimester medical termination of pregnancy: a review of 1002 consecutive cases.

23 : A comparison of two regimens of intravaginal misoprostol for termination of second trimester pregnancy: a randomized comparative trial.

24 : Intravaginal misoprostol for pregnancy termination.

25 : Progesterone receptor blockage. Effect on uterine contractility and early pregnancy.

26 : A prospective randomized comparison of sublingual and oral misoprostol when combined with mifepristone for medical abortion at 12-20 weeks gestation.

27 : Mifepristone- and misoprostol-induced mid-trimester termination of pregnancy: a review of 272 cases.

28 : Pretreatment With Mifepristone Compared With Misoprostol Alone for Delivery After Fetal Death Between 14 and 28 Weeks of Gestation: A Randomized Controlled Trial.

29 : Clinical guidelines. Labor induction abortion in the second trimester.

30 : Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion: a randomized controlled trial.

31 : ACOG Practice Bulletin No. 135: Second-trimester abortion.

32 : ACOG Practice Bulletin No. 135: Second-trimester abortion.

33 : ACOG Practice Bulletin No. 135: Second-trimester abortion.

34 : Mifepristone-misoprostol dosing interval and effect on induction abortion times: a systematic review.

35 : Medical abortion with mifepristone and misoprostol at 13–22 weeks: how long between the mifepristone and the misoprostol?

36 : Complications associated with second trimester inductions of labor requiring greater than five doses of misoprostol.

37 : Interruption of nonviable pregnancies of 24-28 weeks' gestation using medical methods: release date June 2013 SFP guideline #20133.

38 : Termination of second-trimester pregnancy by mifepristone combined with misoprostol versus intra-amniotic injection of ethacridine lactate (Rivanol®): a systematic review of Chinese trials.

39 : A comparison of medical induction and dilation and evacuation for second-trimester abortion.

40 : Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation.

41 : Adequacy and safety of buccal misoprostol for cervical preparation prior to termination of second-trimester pregnancy.

42 : Introduction of the dilation and evacuation procedure for second-trimester abortion in Vietnam using manual vacuum aspiration and buccal misoprostol.

43 : Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes.

44 : Analysis of retained placenta associated with saline abortion: clinical considerations.

45 : Management of the third stage of labor in pregnancies terminated by prostaglandin E2.

46 : Intervention rates for placental removal following induction abortion with misoprostol.

47 : Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review.

48 : Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery: a systematic review.

49 : Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery: a systematic review.

50 : Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery: a systematic review.

51 : Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy.

52 : Tamponade-balloon for obstetrical bleeding.

53 : Uterine artery embolization in postabortion hemorrhage.