This document discusses medical abortion in the second trimester using mifepristone and misoprostol. It provides details on the medications, administration routes, success rates, and considerations for pain management. Mifepristone antagonizes the effects of progesterone to induce cervical softening and dilation. Misoprostol, a prostaglandin analogue, is commonly used in combination with mifepristone or alone to induce contractions. Success rates of over 90% have been reported in the second trimester when using these medications.

1. Medical Abortion in Second
Trimester
Polyphile Ntihinyurwa, MD,MMED
Family Planning & Reproductive health Fellow
St Paul’s Hospital Millennium Medical College

2. Contents
• Introduction
• Choice of medication
• Feticidal
• Special considerations
• Conclusions
• References

3. Introduction
• The second trimester marks the end of organogenesis
• The placenta assumes the full responsibility of progesterone production
over corpus luteum
• High cervical integrity
• Highly bond decidual interface to facilitate gradient of nutrients
• Shallow concentration of PGE2 at the cervix, repressed by 15-HPGD
• The uterus has grown in size and has more receptors for CAP
• The woman has started feeling the quickening

4. Mifepristone
• A competitive progesterone receptor antagonist (relative binding affinity
>2x of progesterone)
• Antagonizes the endometrial and myometrial effects of progesterone
• Causes endometrial decidual degeneration,
• Cervical softening and dilatation,
• Release of endogenous PG, and an increase in the sensitivity of the
myometrium to the contractile effects of prostaglandins
• Alone can also reach successful abortion in 54-90% within 1-2 weeks
• Evidence suggest its combination with PGE1 analogue as the most
effective of pregnancy termination.

5. Misoprostol
• PGE1 analogue
• Most preferred
• Fewer or no side effects
• Cost-effective
• Availability
• Several routes of administration with one formulation
• Its ability to treat haemorrhage
• Can be used alone or following mifepristone

6. Misoprostol
With Mifepristone 200mg
• 200mcg-400mcg depending on GA
• Given 24-48 hours after
mifepristone
• Sublingual route is more effective
• Given every 3 hours
Alone
• 200-400mcg depending on GA
• Can be used alone if mifepristone is
not available
• As effective (>90%) but longer
induction to expulsion period
• Given every 3 hours

7. Misoprostol
Mean plasma concentrations of misoprostol acid over time
(arrow bars = 1 SD) Source: Rebecca Allen, 2009
Routes:
• Sublingual
• Buccal
• Oral
• Vaginal
• buccal has higher bioavailability
and fewer adverse effects than
oral.
• Sublingual administration has
similar efficacy to vaginal dosing.

8. • 298 patients from 2009-2018
• 94 (31.5%) received same-day mifepristone.
• Expulsion within 24 hours:
• 93.6% of the mifepristone-plus-misoprostol group
• 79.9% of the misoprostol-only group (RR 1.17,
95%CI 1.07−1.28).
• Expulsion within 12 hours:
• 56.4% of the mifepristone-plus-misoprostol group
• 34.0% of the misoprostol-only group (RR 1.66,
95%CI 1.28−2.16).
• After adjusting for demographic and clinical
characteristics:
• Expulsion within 24 hours: similar (RR 1.07,
95%CI 0.92−1.26),
• Expulsion within 12 hours remained different
(RR 1.69, 95%CI 1.01−2.83).
• Median time to expulsion was shorter in the
mifepristone-plus-misoprostol group (689
minutes vs 901 minutes, p < 0.001).
Published: September 13, 2021 DOI: https://doi.org/10.1016/j.contraception.2021.09.006

9. Oxytocin
• Mifepristone 200mg 24 hours prior
• 1 hour of no oxytocin after each 500ml of
oxytocin-containing N9 to allow diuresis
• Success rate is 100% but no significant
difference relative with misoprostol (96%)
• fever and shivers was lower with Oxytocin
regimen
• Time to expulsion
• Oxytocin: 13.3 hours
• Misoprostol: 7 hours
Williams Obstetrics, v24

10. The use of foley catheter
• No sufficient literature on the use of foley catheter for abortion
• In Egypt: A comparison of 100 women (16±3W) on misoprostol 400μg q4hours PV
and 100 women (17±3W) with combined foley bulb inflated with 50mml saline
• Induction to abortion: 12.76 ± 1.63 vs 8.16 ± 1.52 hours
• No significant difference in complications and acceptability
• The combined group were more likely to recommend the method
• Higher satisfaction in the combined group
Mohamed R. et. al, 2015

11. Pregnancy above 20 weeks
• Considered in much literature as preterm delivery
• The term abortion remains used if the intention is to terminate
the progression to a live birth
• 35% of neonates born 20-23Weeks present signs of survival for a
few hours

12. Survival rates
Among 106 neonates born 22-23 weeks in Germany (Katrin M. et al, 2016)
• 86 infants (81%) received active care.
• 22 (26%) survived without severe complications
In USA, data from 2013-2018 among 10 877 infants born at 22-28
weeks: (Bell, E. F., et al, 2022)
• 78.3% survived to discharge
• 10.9% at 22 weeks
• 94.2% at 28 weeks

13. Combinations of signs of life in the first hour after delivery at
20–23 weeks gestation (CESDI data only).
P I Macfarlane et al. Arch Dis Child Fetal Neonatal Ed
2003;88:F199-F202
Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.
Data in UK 1995-200 on deliveries
between 20-23W
• 869 fetuses were recorded
• 65% (565) died before delivery
• 35% Were live births
• 8% survived the first year of life
• Survival time at 20W: 80min median
• Survival time at 23W: 6hrs median,
Observed signs of life

14. Preventing transient survival
• Evidence demonstrates that digoxin, KCL, and lidocaine are all effective in inducing fetal
demise. Intra-fetal administration of digoxin is superior to intra-amniotic digoxin
administration.
• Administration of feticide using intracardiac KCL may shorten the abortion experience.
• Limited data from observational studies also supports an increase in maternal side
effects and/or complications related to the administration of digoxin.
Tesfaye H. Tufa. et. al. 2020

15. Incomplete abortion
• Clinical evaluation for the
need to give mifepristone
• If bleeding, surgical is
best recommended to
evacuate the uterus and
control the bleeding
WHO, Abortion care guidelines, 2022

16. Missed abortion
WHO, Abortion care guidelines, 2022

17. Pain management
• Analgesia or anesthesia similar to other laboring clients
• Intermittent narcotic administration
• Tramadol
• Pethidine
• Some clients may prefer epidural analgesia
• NSAID
• Ibuprofen
• Diclofenac

18. Advantages of 2nd Term Medical Abortion
• Allows morphologic evaluation in case of malformation
• Gives a chance to the mother to hold the fetus if desired
• Offers awareness of the abortion process to the mother as
the essential of labor and delivery experience

19. References
• Mehler K, Oberthuer A, Keller T, et al. Survival Among Infants Born at 22 or 23
Weeks’ Gestation Following Active Prenatal and Postnatal Care. JAMA
Pediatr. 2016;170(7):671–677. doi:10.1001/jamapediatrics.2016.0207
• Bell EF, Hintz SR, Hansen NI, et al. Mortality, In-Hospital Morbidity, Care
Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-
2018 [published correction appears in JAMA. 2022 Jun 7;327(21):2151]. JAMA.
2022;327(3):248-263. doi:10.1001/jama.2021.23580
• Shay RL, Benson LS, Lokken EM, Micks EA. Same-day mifepristone prior to
second-trimester induction termination with misoprostol: A retrospective cohort
study. Contraception. 2022;107:29-35. doi:10.1016/j.contraception.2021.09.006