A nurse is preparing a patient for a medical abortion. What information should the nurse include in the education regarding what to expect? Select all that apply.

Dilation and Evacuation (D&E) is a surgical technique used for second-trimester pregnancy termination. It involves cervical dilation, evacuation of uterine contents, and use of suction and forceps. It is preferred between 14 to 24 weeks due to fetal size and ossification. Risks include hemorrhage, uterine perforation, and infection. Cervical preparation with osmotic dilators or misoprostol is essential to reduce trauma. D&E is contraindicated in viable pregnancies and requires ultrasound guidance for safety.

Rationale for correct answer

3. D&E is the standard method for termination between 14 to 24 weeks gestation due to increased fetal size and calcification. At this stage, suction curettage alone is insufficient, and forceps are needed for complete evacuation. The question asks for the gestational age range where D&E is typically used, which aligns precisely with this window.

Rationale for incorrect answers

1. D&E is not used for pregnancies less than 6 weeks. At this early stage, the gestational sac is small and easily removed by manual vacuum aspiration or medical abortion using mifepristone and misoprostol. Surgical instrumentation is unnecessary and increases risk without benefit.

2. Between 6 to 10 weeks, suction curettage or medical abortion is preferred. The uterine contents are soft and easily evacuated without the need for forceps. D&E is excessive and not standard practice in this gestational range.

4. Beyond 28 weeks, termination is legally and ethically complex and typically involves induction abortion or cesarean delivery. D&E is contraindicated due to fetal viability and increased risk of uterine rupture and maternal morbidity. Surgical evacuation at this stage is rarely performed and not considered standard.

Take home points

• D&E is preferred for pregnancy termination between 14 to 24 weeks.
• Earlier gestations use suction curettage or medical abortion.
• Beyond 28 weeks, induction or cesarean is used due to fetal viability.
• Cervical preparation is essential before D&E to prevent trauma.

Medical abortion involves pharmacologic termination of pregnancy using agents that induce uterine contractions and cervical dilation. The standard regimen includes mifepristone, a progesterone antagonist, followed by misoprostol, a prostaglandin E1 analog. Misoprostol causes uterine cramping, bleeding, and gastrointestinal effects. Expulsion typically occurs within 24 to 48 hours. Follow-up is essential to confirm complete evacuation and rule out retained products. Pain intensity varies, and analgesics are often required. Hemoglobin should be monitored if bleeding exceeds 500 mL.

Rationale for correct answers

1. Severe cramping and heavy bleeding are expected due to uterine contractions induced by misoprostol and decidual shedding. These mimic labor-like symptoms and are necessary for complete expulsion of the gestational sac. The question stem asks what to expect, and this is a physiologic response to the medication.

3. Follow-up is essential to confirm complete abortion and exclude retained products of conception, which can lead to infection or hemorrhage. Ultrasound or serial β-hCG levels are used. The question tests knowledge of post-abortion care, and this is a standard protocol.

4. Misoprostol commonly causes nausea and diarrhea due to its prostaglandin activity on smooth muscle. These side effects are dose-dependent and transient. The question asks about expected effects, and these are well-documented.

Rationale for incorrect answers

2. Expulsion is rarely immediate and never painless. Misoprostol induces strong uterine contractions and cervical dilation, which cause significant discomfort. Expulsion typically occurs within 24 to 48 hours, not instantly. The claim of painless and immediate expulsion contradicts the pharmacologic mechanism.

5. Pain medication is often required due to cramping and uterine contractions. NSAIDs like ibuprofen are commonly prescribed. The statement that no pain medication is needed is inaccurate and disregards patient comfort and standard practice.

Take home points

• Misoprostol causes cramping, bleeding, and gastrointestinal side effects during medical abortion.
• Follow-up is mandatory to confirm complete uterine evacuation.
• Pain management is essential; NSAIDs are commonly used.
• Medical abortion differs from surgical abortion in timing, symptoms, and monitoring.