Heavy or prolonged bleeding is the principal complication, with up to 8% of women experiencing some bleeding for as long as 30 days. Need for surgical curettage is predicted by the gestational age when the mifepristone is administered. Two percent of women treated at 49 days or less, 3% of those treated at 50 to 56 days, and 5% of those treated at 57 to 63 days needed curettage for bleeding or failed abortion in a large study with 200 mg of mifepristone and 800 μg of vaginal misoprostol (342). Late bleeding, at 3 to 5 weeks after expulsion of the pregnancy, accounted for more than half of the curettages. The complications reported to the manufacturer of mifepristone from the first 80,000 patients treated were published (343). One woman died of ectopic pregnancy after refusing care. Another patient survived severe sepsis, and another, a 21-year-old woman with no risk factors, survived an acute myocardial infarction. Other severe sepsis cases have since occurred. A 27-year-old woman participating in a clinical trial in Canada died of multiple organ system failure from Clostridium sordelli sepsis after complete expulsion of a 5.5-week pregnancy despite receiving excellent care (344). Five other similar sepsis deaths were reported in the popular press. The five deaths in the United States occurred among approximately 500,000 women treated with mifepristone/misoprostol, allowing estimation of a case fatality rate of 1 per 100,000, comparable to the rate of death with surgical abortion and much less than the risk of childbirth (345). There were no further cases of clostridial sepsis among the large number of women treated in the Planned Parenthood clinics when the new protocol of buccal misoprostol plus routine antibiotic prophylaxis was followed (337).
Abortions performed after 13 weeks include those done because of fetal defects, medical illness, or psychiatric problems that had not manifested earlier in pregnancy, and changed social circumstances, such as abandonment by the father. Young maternal age is the single greatest factor determining the need for late abortion (317).
Dilation and Evacuation D&E is the most commonly used method of midtrimester abortion in the United States. Typically, the cervix is prepared by insertion of hygroscopic dilators, stems of the seaweed Laminaria japonicum (laminaria), or Dilapan-S hydrophilic polymer rods. Placed in the cervical canal as small sticks, these devices take up water from the cervix and swell, triggering dilation. Laminaria, in addition, induces endogenous prostaglandin synthesis, which aids in cervical softening. When the dilators are removed the following day, sufficient cervical dilation is accomplished to allow insertion of strong forceps and a large-bore vacuum cannula to extract the fetus and placenta (346,348). Ultrasound guidance during the procedure is helpful (348). For more advanced procedures, dilators are inserted sequentially over 2 or more days to achieve a greater degree of cervical dilation (349). At the end of the midtrimester, procedures that combine serial cervical dilation with feticidal injections, induction of labor, and assisted expulsion of the fetus are used (350). Pretreatment for a few hours with buccal or vaginal misoprostol provides sufficient cervical softening and dilatation for early midtrimester D&E, and there is considerable interest in using this as an alternative to overnight laminaria further into the midtrimester (351).
Intact D&E is another modification useful for procedures at the end of the midtrimester. After wide cervical dilatation is achieved with serial placement of cervical dilators, the membranes are ruptured and an assisted breech delivery is performed, with decompression of the after-coming fetal head to allow delivery of the fetus intact (352).