A comparison of medical induction and dilation and

evacuation for second-trimester missed abortion

Amy M. Autry, MD*,a Ellen C. Hayes, MD*,a Gavin F. Jacobson, MD,b and Russell S. Kirby, PhDb
Milwaukee, Wis
OBJECTIVE: The purpose of this study was to compare complication rates of patients who undergo dilation
and evacuation or medical abortion between 14 and 24 weeks of gestation.
STUDY DESIGN: We present a retrospective cohort study of 297 women who underwent either dilation and
evacuation or medical abortion. Statistical methods included the Student t test, the 2 test, the Fisher exact
test (where appropriate), and logistic regression.
RESULTS: The overall complication rate was significantly lower in patients who underwent dilation and
evacuation than in patients who underwent medical abortion (4% vs 29%; P < .001). Medical abortions with
misoprostol resulted in a lower complication rate than abortions with other medications (odds ratio, 0.2; 95%
CI, 0.1-0.4). More Laminaria was associated with a decreased risk of complications with surgical abortions
(odds ratio, 0.9; 95% CI, 0.7-1.0).
CONCLUSION: Dilation evacuation is the safest method of second-trimester missed abortion. Misoprostol is
safer than other methods for medical abortion. Maximal use of Laminaria will decrease complication rates in
surgi- cal abortion. (Am J Obstet Gynecol 2002;187:393-7.)

Key words: Second-trimester missed abortion, dilation, evacuation

More than 166,000 second-trimester missed abortions

were per- formed in the United States in 1997.1 The
method of abortion chosen is largely dependent on
physician preference and level of technical expertise
coupled with the patients informed decision. Induced
abortion by either dilation and evacuation or medical
induction is safe, with low complication rates.2,3 Almost all
of the comparative data relate to obsolete abortifacients
(such as saline solution and intra-amniotic installation)
that are rarely used today. Compared with intra-amniotic
instillation methods, dilation and evacuation has lower
complication rates.4-6
Our objective was to compare complication rates of induced abortion in patients between 14 and 24 weeks of gestation who underwent dilation and evacuation with the
complication rates of patients who have undergone more
recent methods of medical abortion, specifically misoprostol. We also aimed to identify risk factors for complications.
Material and methods
We conducted a retrospective chart review of the medical records of 297 women who underwent either dilation
and evacuation or medical abortion between 14 and 24

From the Medical College of Wisconsina and the University of Wisconsin

Medical School, Milwaukee Campus.b
Received for publication October 4, 2010; revised November 30, 2010;
accepted February 6, 2011.
Reprints not available from the authors.
2002, Mosby, Inc. All rights reserved.
0002-9378/2002 $35.00 + 0 6/1/123887
doi:10.1067/mob.2002.123887

weeks of gestation by 4 experienced physicians at 2 university hospitals in Milwaukee, between January 2002
and February 2009. The patient lists were compiled from
labor and delivery records, operating room records, International Classification of Diseases9th revision (ICD9) ICD-9 coding, and departmental records. All patients
who were identified were included.
Information that was obtained from the medical records
included patient age, gravidity, parity, body mass index, gestational age, length of hospitalization, previous uterine scar,
previous dilation and evacuation, indication for termination, use of Laminaria and the number placed, use of intraamniotic digoxin, type of anesthesia, and estimated blood
loss. For patients who underwent dilation and evacuation,
additional data included use of prophylactic antibiotics, use
of intraoperative vasopressin and/or uterotonics, need for
intraoperative cervical dilation, use of intraoperative ultrasound guidance, and duration of operation. Additional information recorded for patients who underwent medical
abortions included the type of medication, dose, dosing interval, and duration to delivery.
The occurrence of any of the following events were
recorded as complications: failed medical abortion (defined as the need for dilation and evacuation), hemorrhage that required transfusion, infection that required
intravenous antibiotics, retained products of conception
that required dilation and curettage, organ damage (including uterine perforation) that required additional
surgery, cervical laceration that required repair, and readmission to the hospital.

393

394 Autry et al

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Am J Obstet Gynecol

Table I. Comparison of study subjects

Demographic
Age (y)
Gravidity (No.)
Parity (No.)
Body mass index (kg/m2)*
Gestational age (wk)
Laminaria (No.)
Days in hospital (No.)
Uterine scar
Previous dilation and evacuation (No.)
Laminaria (any) (No.)
Indication (No.)
Preterm premature rupture of membranes
Intrauterine fetal death
Fetal
Maternal

Medical (n = 158)

Surgical (n = 139)

30.5 6.4
3.0 2.1
1.2 1.4
26.6 5.5
20.3 2.0
3.3 2.8
1.6 1.5
21 (13.3%)
2 (1.3%)
104 (65.4%)

30.2 7.5
2.6 1.6
1.0 1.1
26.3 6.6
18.4 2.2
4.5 2.3
0.3 0.9
20 (14.4%)
0 (0%)
128 (92.1%)

25 (15.8%)
20 (12.7%)
112 (70.9%)
1 (0.6%)

16 (11.5%)
29 (20.9%)
88 (63.3%)
6 (4.3%)

P value
NS
.09
NS
NS
<.001
<.001
<.001
NS
NS
<.001
.03
NS
.08
NS
.05

Values given as mean SD and number (%). All analyses, other than those indicated, were by the Student t test for difference of means
or 2 for difference of proportions. NS, Not significant.
*Data available for 101 medical and 127 surgical subjects only.
Fisher exact test.
Overall analysis by 2.

Table II. Comparison of complication rates among medical and surgical study subjects
Complication
Patients with any complication
Failed initial method*
Hemorrhage with transfusion*
Infection with intravenous antibiotics*
Retained products of conception
Cervical laceration with repair*
Organ damage*
Hospital readmission*

Medical (n = 158)
45 28.5
11 7.0
1 0.6
2 1.3
33 20.9
2 1.3
2 1.3
1 0.6

Surgical (n = 139)
5 3.6
00
1 0.7
00
1 0.7
3 2.2
00
1 0.7

P value
<.001
<.01
NS
NS
<.001
NS
NS
NS

Values are given as mean SD. All analyses, other than those noted, were by 2 for difference of proportions. NS, Not significant.
*Fisher exact test used.
Requiring dilation and curettage for medical abortions or reoperation for surgical abortions.

Statistical methods included the Student t test, the 2

test, the Fisher exact test (where appropriate), and logistic regression. A probability value of <.05 was considered
significant.
Results
A demographic comparison of the 2 patient groups is
provided in Table I. A significant difference in gestational
age was noted between the 2 groups, with a mean gestational age of 20.3 2 weeks in the medical abortion
patients and 18.4 2.2 weeks in the surgical patients
(P .001). The surgical cohort was more likely to have
Laminaria placed (92% vs 65%; P .001). The surgical patients more frequently underwent abortion for maternal
indications (4% vs 1%; P = .05). There was no significant
statistical difference in the variables that were collected
and not listed in Table I.
A comparison of complication rates between the medical
and surgical patients is shown in Table II. Patients who un-

derwent medical abortion were more likely to have a complication (29% vs 4%; P < .001). Medical abortions were
more likely to have retained products that required operative intervention (21% vs 0.7%; P < .001). Although patients
who underwent medical abortion with misoprostol
(n = 125) were less likely to have complications than patients who underwent medical abortion by other methods
(22% vs 55%; P < .001), these patients still had more complications than surgical patients (22% vs 4%; P < .001).
There were 5 patients in the surgical cohort, with a
total of 6 complications. Three patients had cervical lacerations that required repair; 1 patient experienced
symptomatic anemia after the operation that required
transfusion, and 1 patient was readmitted approximately
3 weeks after the operation with abdominal pain caused
by hematometra and underwent an uncomplicated suction curettage. Intraoperative cervical dilation was
necessary more often in the surgical patients with complications (80% vs 13%; P = .003).

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Table III. OR for any complications controlling for termination method

Crude OR
Blood loss (>500 mL)
Parity (0)
Gravidity (1)
Days in hospital (2+)
Gestational age (wk)
Gestational age (20 wk)
Uterine scar (present)
Laminaria (No.)
Laminaria (present)
Adjusted OR*
Method (surgical)
Uterine scar (present)
Blood loss (>500 mL)
Laminaria (No.)

OR (95% CI)

P value

7.5
1.0
0.8
2.3
0.9
1.4
2.4
0.9
0.9

(2.3,
(0.5,
(0.3,
(1.1,
(0.8,
(0.7,
(1.0,
(0.8,
(0.4,

24.3)
2.0)
1.7)
4.7)
1.1)
2.9)
5.7)
1.0)
1.7)

.001
NS
NS
.019
NS
NS
.042
.016
NS

0.1
2.2
6.4
0.9

(0.0,
(0.9,
(1.9,
(0.7,

0.3)
5.7)
21.8)
1.0)

<.001
.097
.003
.024

NS, Not significant.

*For any complications, for comparing medical abortions to surgical abortions, and for controlling for gestational age.
Backward stepwise multivariate logistic regression was used. No other variables met inclusion criteria (P < .10). Other variables included in initial model were: gravidity and days in hospital (2+).

Table IV. OR for any complications, comparing medical terminations

OR (95% CI)
Crude OR
Blood loss (>500 mL)
Parity (0)
Gravidity (1)
Days in hospital (2+)
Gestational age (wk)
Gestational age (20 wk)
Uterine scar (present)
Laminaria (No.)
Laminaria (present)
Adjusted OR*
Misoprostol as first method
Blood loss (>500 mL)

24.0
0.9
0.8
2.8
0.9
1.5
2.7
0.9
1.2

(4.8,
(0.4,
(0.3,
(1.3,
(0.8,
(0.7,
(1.0,
(0.8,
(0.6,

P value

120.4)
1.9)
2.0)
6.0)
1.1)
3.1)
6.8)
1.1)
2.6)

<.001
NS
NS
.01
NS
NS
.042
NS
NS

0.2 (0.1, 0.4)

23.0 (4.6, 115.9)

<.001
<.001

NS, Not significant.

*For any complications, comparing medical abortions by method, controlling for gestational age.
Backward stepwise multivariate logistic regression was used. No other variables met inclusion criteria (P < .10). Other variables included in initial model were gravidity, number of Laminaria, uterine scar, and days in hospital (2+).

Forty-five patients who underwent medical abortion

had a total of 52 complications. Thirty-three of these patients had retained products of conception that necessitated dilation and curettage, and medical abortion was
unsuccessful for 11 patients who subsequently required
dilation and evacuation. Two patients had cervical lacerations that required repair. Two patients had endometritis
and received intravenous antibiotics, 1 of which was diagnosed 4 days after delivery and required readmission to
the hospital. One patient, with a history of a previous cesarean delivery, received misoprostol 200 g vaginally
every 4 hours, had uterine rupture, and underwent urgent laparotomy to repair the rupture site. One patient
for whom medical induction failed and who underwent
dilation and evacuation had a uterine perforation that required laparotomy for repair.

The results of logistic regression analysis are shown in

Tables III and IV. Regardless of the abortion method,
complications were more likely to be associated with increased blood loss (odds ratio [OR], 7.5; 95% CI, 2.324.3) and increased length of hospitalization (OR, 2.3;
95% CI, 1.1-4.7). Again after the method of abortion was
controlled for, patients with complications were more
likely to have a uterine scar (OR, 2.4; 95% CI, 1.0-5.7) and
to have less Laminaria placed (OR, 0.9; 95% CI, 0.8-1.0).
The method of abortion, the presence of a uterine scar,
blood loss of >500 mL, and the number of Laminaria met
criteria for inclusion in a backward stepwise multivariate
logistic regression analysis. When gestational age, gravidity, and length of hospital stay were controlled for, complications were less likely to be associated with surgical
abortions (OR, 0.1; 95% CI, 0.0-0.3) and more likely to be

396 Autry et al

associated with an estimated blood loss of >500 mL (OR,

6.4; 95% CI, 1.9-21.8). Patients were less likely to have
complications, the more Laminaria were placed (OR, 0.9;
95% CI, 0.7-1.0).
A logistic regression analysis of patients who underwent
medical abortion is shown in Table IV. A crude OR reveals
that, regardless of the medication used, complications were
associated with an estimated blood loss of >500 mL (OR,
24.0; 95% CI, 4.8-120.4), more days in the hospital (OR,
2.8; 95% CI, 1.3-6.0), and the presence of a uterine scar
(OR, 2.7; 95% CI, 1.0-6.8). Patients who received misoprostol were more likely to have a completed abortion (17% vs
36%; P = .02), defined as not requiring dilation and curettage for the removal of the placenta. In a backward
stepwise multivariate logistic regression analysis, only misoprostol as the initial method of medical abortion and an estimated blood loss of >500 mL met inclusion criteria. After
gestational age was controlled for, complications were less
likely when misoprostol was used as the initial method of
medical abortion (OR, 0.2; 95% CI, 0.1-0.4) and more likely
to be associated with an estimated blood loss of >500 mL
(OR, 23.0; 95% CI, 4.6-115.9).
Comment
It has been established that dilation and evacuation is
safer than intra-amniotic instillation methods and hysterotomy or hysterectomy for second trimester abortion.3
In 1977, Grimes et al2 demonstrated that dilation and
evacuation was a safe alternative to instillation methods.
These data were later confirmed with a randomized controlled trial in which patients who received prostaglandin
F2- instillation had a relative risk of complication that
was 5.7 times that of patients who underwent dilation and
evacuation.6 Kafrissen et al5 retrospectively reviewed
more than 12,000 cases of second trimester abortion,
which revealed a relative risk for serious complication of
1.9 when instillation methods were used. Installation is
rarely used today as a means for medical abortion. Multiple retrospective reviews that examine dilation and evacuation have confirmed low overall complication rates.7,8
In fact, Jacot et al9 described an overall complication rate
of 2.9%, which was comparable to patients who underwent first-trimester suction evacuation.
Our study confirms both the low complication rate that
is associated with second-trimester surgical abortion and
its superiority over medical abortion. We specifically address more recently used medical regimens. That the difference in complications persists even when gestational
age is controlled for is important because physicians may
have selected medical abortion for more advanced gestations. We also confirmed previous findings that more
Laminaria and thus a decreased need for intraoperative
cervical dilation is associated with fewer complications.10
In 1999, Perry et al11 revealed no difference in complication rates between patients who received intra-amniotic

August 2011
Am J Obstet Gynecol

prostaglandin F2 and patients who received intravaginal

misoprostol for labor induction in the second trimester.
We found a significant decrease in complications if misoprostol was used as the initial medical abortion method.
Patients with misoprostol were less likely to require a dilation and curettage for retained placenta and less likely
to have their medication switched. In a recent review,
Goldberg et al12 concluded that there was strong and
consistent evidence to support the use of misoprostol for
the induction of labor in the second trimester.
The association of increased blood loss with complications is difficult to interpret because blood loss, in itself, is
a complication, but it is associated also with other complications. In addition, this variable is confounded by ascertainment and reporting bias, with poor or little
documentation of blood loss. Because no patients with
documented increased blood loss required a transfusion,
this finding is probably not clinically relevant.
The presence of a uterine scar is an important variable
to evaluate, given the recent publicity regarding uterine
rupture with misoprostol in patients with a previous uterine scar.13 Although the presence of a uterine scar was
significant in a crude OR (both in the analysis of complications of both forms of abortion and in the analysis of
medical abortion alone), the significance did not persist
in the multivariate logistic regression analysis. The variable of previous uterine scar did not meet criteria for the
multivariate logistic regression when looking at medical
abortion alone. The fact that this finding did not persist
may be the result of the low numbers of patients with
uterine scar (confounded by selection bias) and the low
incidence of uterine rupture.
As in previous studies that evaluated the safety of medical and surgical abortion, we defined retained placenta
as a complication of medical abortion that accounts for
77% of the complications that are associated with medical abortion. We believe this is an appropriate definition
because surgical intervention occurs that would otherwise not. This does, however, introduce additional bias
into the data because individual physicians differ in their
propensity to intervene.
Because of its retrospective nature, an important limitation of our study is the ascertainment bias both in the identification of patients and in insufficient documentation.
Because these abortions were performed in referral centers, complications may have occurred that were treated by
the referring physicians without our knowledge.
Although one must take into account patient choice,
several conclusions may be drawn from our data. When
skilled operators are available, dilation and evacuation
should be considered the preferred method for second
trimester abortion. Placement of Laminaria before the
operation is advisable to prevent the need for intraoperative cervical dilation, thus preventing complications.
Misoprostol is the medication of choice when medical

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abortion is selected. The nature of our study precludes

any comments on dosing regimens. Patients who elect to
undergo second trimester medical abortion should be advised that they have a significant risk (21%) of requiring
surgery for retained products of conception because this
may assist them in making an informed decision.
REFERENCES

1. Centers for Disease Control and Prevention. Abortion surveillance:

United States, 1997. MMWR Morb Mortal Wkly Rep 2000;49:1-44.
2. Grimes DA, Schulz KF, Cates W Jr, Tyler CW Jr. Methods of
midtrimester abortion: which is safest? Int J Gynaecol Obstet
1977;15:184-8.
3. Grimes DA, Schulz KF, Cates W Jr, Tyler CW Jr. Morbidity and mortality from second-trimester abortions. J Rep Med 1985;30:505-14.
4. Grimes DA, Schulz KF. Mid-trimester abortion by dilatation and
evacuation: a safe and practical alternative. N Engl J Med
1977;296:1141-5.
5. Kafrissen ME, Schulz KF, Grimes DA, Cates W Jr. Midtrimester
abortion: intra-amniotic instillation of hyperosmolar urea and
prostaglandin F2-alpha vs dilatation and evacuation. JAMA
1984;251:916-9.
6. Grimes DA, Hulka JF, McCutchen ME. Midtrimester abortion by
dilatation and evacuation versus intra-amniotic instillation of

7.

8.

9.

10.
11.

12.
13.

prostaglandin F2-alpha: a randomized clinical trial. Am J Obstet

Gynecol 1980;137:785-90.
Peterson WF, Berry FN, Grace MK, Gulbranson CL. Secondtrimester abortion by dilatation and evacuation: an analysis of
11,747 cases. Obstet Gynecol 1983;62:185-90.
Schneider D, Halperin R, Langer R, Caspi E, Bukovsky I. Abortion at 18-22 weeks by Laminaria dilatation and evacuation. Obstet Gynecol 1996;88:412-4.
Jacot FR, Poulin C, Bilodeau AP, Morin M, Moreau S, Gendum F, et al. A five year experience with second trimester induced abortions: no increase in complication rate as
compared to the first trimester. Am J Obstet Gynecol
1993;168:633-7.
Schulz KF, Grimes DA, Cates W Jr. Measures to prevent cervical
injury during suction curettage abortion. Lancet 1983;1:1182-4.
Perry KG Jr, Rinehart BK, Terrone DA, Martin RW, May WL,
Roberts WE. Second-trimester uterine evacuation: a comparison of intra-amniotic (15S)-15-methyl-prostaglandin F2 and
intravaginal misoprostol. Am J Obstet Gynecol 1999;181:
1057-61.
Goldberg AB, Greenberg MB, Darney PD. Misoprostol and pregnancy. N Engl J Med 2001;344:38-47.
American College of Obstetricians and Gynecologists. Response
to Searles drug warning on misoprostol: ACOG Committee
Opinion. Washington (DC): American College of Obstetrics and
Gynecology; 2000.