With second-trimester procedures, complication rates gradually increase with EGA, (NASEM 2018, Kapp 2020, Grimes 1984), while overall rates of serious complications remain low. At this EGA, most complications are similar to those at <13 weeks (See Ch 6: Managing Complications), with the following nuances:

Hemorrhage due to Atony  • EBL > 500 ml = hemorrhage

• Review risk stratification and etiologies (4Ts) 

• Ensure good uterine tone without suspicious flow prior to removing instruments.

• If visualized LUS suggests atony, immediately provide vigorous bi-directional bimanual massage with ball of gauze in ring forceps in posterior fornix and low abdominal compression by free hand or US probe.

• Watch until the tone returns.

Review 6T treatment steps and uterotonics

0.07 – 0.4 %

NASEM 2018, Upadhyay 2015, Weitz 2013

Hemorrhage due to Arteriovenous malformation (AVM) • Rare, life-threatening source of profuse bleeding uncontrolled despite usual measures • If standard 6T bleeding management steps don’t resolve, apply tamponade with foley, Bakri, or vaginal pack and transport for embolization/cautery Rare; case reports

Hashim 2013

Cervical laceration/trauma Low/Ant/endocerv tear:

• Vaginal bleeding in the setting of a well contracted uterus. May see cervical laceration or visualize bleeding from external os.

High cervical tear:

• Hemodynamic instability in absence of external hemorrhage and in setting of a well contracted uterus suggestive and/or

• Abdominal US showing free fluid behind posterior uterus or in cul de sac.

• Prevention: large grasp of cervix with tenaculum, use of  atraumatic tenaculum, adequate cervical prep, decrease passes through cervix.

• Low or anterior cx: apply direct pressure and/or silver nitrate or Monsel’s solution.

• Endocervical tears caused by a bony fetal part, can lead to lacerations into body of the cervix; may require suturing. If extends up behind bladder and may require OR repair.

• High cervical tears caused by forceful mechanical dilation can result in uterine artery laceration. May require balloon tamponade or surgical management.

0.8% early 2nd trimester with lams + dilation

Grossman 2008

Peterson 1983

Uterine perforation • Instruments pass deeper than expected by EGA and pelvic exam
Patient may feel sudden sharp pain; may be painless

Risk factors:

• Inadequate dilation

• Increased gestational age

• Uterine flexion

• Previous c-section

• Operator inexperience

• Uterine anomaly

Stop procedure:
• Turn off suction

• Assess patient: VS, pain,bleeding, abdominal exam

• Check contents of aspirate for omentum or bowel, and for POC If stable:

• Evaluate with US

• Experienced providers have safely explored uterus and completed procedure under US guidance

• Observe for 1.5-2 hours

• Consider uterotonics to contractuterus and control bleeding

• Consider antibiotics If unstable or perforation occurred with suction, transfer

0.02 – 0.07%

NASEM 2018 Upadhyay 2015 Weitz 2013

Partial or Complete  Placenta Previa Patients > 14 weeks with history of c-section and complete previa at high risk for PAS (see below) • See US and Doppler screening criteria

• If no PAS, consider outpatient mgmt with the following expert guidance:

• Anticipate scant to moderate bleeding with cervical prep and dilation.

• Keep the patient in clinic and monitor bleeding during cervical prep.

• Consider using synthetic osmotic dilators (Dilapan-S®) in addition to misoprostol to expedite dilation.

• Initiate procedure if bleeding increases prior to full cervical prep “wait time”.

• Under US guidance, remove placenta with forceps prior to initiating aspiration or D&E.

0.05% of pregnancies

1-5 x higher with increasing # c-sections

Janiaux 2019

Placenta Accreta Spectrum (PAS) • See PAS risk factors

• With concurrent low lying or anterior placenta (<2 cm above os) or placenta previa

• At risk for severe hemorrhage

• See US and Doppler screening criteria

• Refer PAS to multi-disciplinary center, for scheduled procedure with transfusion services and surgical management to mitigate bleeding risk


0.07-0.2% of pregnancies

0.3% if previous c-section

Janiaux 2019

Silver 2018

Matsuzaki 2021

Figure 7. Possible sites of uterine perforation: fundal (lateral regions are more vascular than midline), at internal os (often due to overstretching junction of cervix and lower uterine segment, injuring ascending branches of uterine artery), and low cervical perforation (can injure descending branches of uterine artery). 


As inequity and injustice in abortion access spread across the U.S., providers have an opportunity to consider non-traditional methods of expanding access to care.  While in-person training with an experienced provider remains the gold standard for expanding D&E skills, alternate methods of increasing provision may include simulation models and incremental increases in gestational age using a gradual stepwise approach. Incremental expansion in gestational age by you as a provider and by clinics and organizations can improve patient access, travel, and stress, while minimizing fragmentation of care. Patients with higher-risk pregnancies can be managed or referred to a higher level of care depending on provider skills and regional resources. Depending on your legal constraints, providers may use formal or informal referral networks, with warm hand-off using pager or cell phone, or warm lines for second opinions.  As a provider, you play an instrumental role in setting the tone at your clinic, helping staff with later abortion values exploration, normalizing the possibility of seeing more complex patients, and expanding the services offered.

Appendix A: Instruments and Supplies for Abortion > 14 weeks

(Beyond standard equipment for aspiration < 14 weeks)

  • Advanced dilators (up to #49/51 Fr. Pratt (see Fig. 1)
  • Forceps (See Appendix B and Procedural Steps for forceps recommendations by EGA)
  • Rigid curved cannulas up to size 16 (Optional)
  • Large bore tubing to accommodate larger cannulas (see Fig. 2)
  • EVA machine suction container lids to fit  large tubing (see Fig. 2)
  • An array of speculums to include short bivalve (see Fig 3)

  • Cervical ripening agents:
    • misoprostol 200 mcg tabs,
    • mifepristone 200mg tabs,
    • osmotic dilators (synthetic (Dilapan-S) and/or laminaria),
    • and/or foley bulbs with stat lock cath stabilizers
  • Table basin or emesis-type basin
  • Medications and IV supplies, including:
    • conscious sedation medications and reversals
    • hemorrhage medications
    • IV fluids: 500-1000mL bags of isotonic solution for fluid resuscitation
    • Medications for paracervical block (+/- vasopressin, bicarbonate)
  • Sample tray (See Fig. 3 & 4)

Appendix B: Forceps


Forceps Body


Hern Van Lyth Evacuation Forceps 9½” (241mm) 9mm Jaws
Hern Van Lyth Evacuation Forceps 10″ (254mm) 11mm Jaws

Small Finks Forceps 10½” (267mm) 13mm Jaws – smaller teeth
Fink Ovum Forceps 10½” (267mm) 13mm Jaws – larger teeth
Sopher Ovum Forceps 11-13″ (279-330mm) 12-14mm Jaws
Bierer Ovum Forceps 11-13″(279-330mm) 16-19mm Jaws – larger teeth


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