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Review
. 2025 Jul 8;7(7):CD006714.
doi: 10.1002/14651858.CD006714.pub3.

Surgical versus medical methods for second-trimester induced abortion

Jessica M Atrio  1 , Sarita Sonalkar  2 , Helena Kopp Kallner  3   4 , Rachel B Rapkin  5   6 , Kristina Gemzell-Danielsson  7   8 , Patricia A Lohr  9
Affiliations
Review

Surgical versus medical methods for second-trimester induced abortion

Jessica M Atrio et al. Cochrane Database Syst Rev. .

Abstract

Background: Understanding the relative benefits and harms of surgical versus medical methods for second-trimester abortion is essential for guiding clinical practice across diverse settings and patient populations. This review evaluates differences in outcomes and patient experiences to support informed counseling and care. It updates a previous version published in 2008.

Objectives: To compare the benefits and harms of surgical and medical methods of induced abortion in the second trimester (i.e. at or after 13 weeks' gestation).

Search methods: We identified trials using CENTRAL (Ovid EBM Reviews), MEDLINE ALL (Ovid), Embase.com, LILACS, Scopus, and Google Scholar on 29 November 2023. We also searched the reference lists of identified studies, relevant review articles, book chapters, and conference proceedings for additional, previously unidentified studies. We contacted experts in the field for information on other published or unpublished research.

Selection criteria: Randomized trials comparing surgical abortion by vacuum aspiration or dilation and evacuation (D&E) to medical abortion with mifepristone and misoprostol in the second trimester of pregnancy.

Data collection and analysis: We assessed the validity of each study using Cochrane methods. We contacted investigators for additional information regarding trial conduct or outcomes as required. Some outcomes were consistently reported across multiple studies and could be combined for meta-analysis. The primary outcome of interest was abortion completed with the intended method (defined as fetal expulsion).

Main results: We included three studies (281 participants). The studies were conducted in Nepal (n randomized = 141), England (n randomized = 122), and the United States (n randomized = 18) and included participants with pregnancy durations ranging from 12 weeks to 19 weeks and 6 days. We used GRADE to assess the certainty of evidence. Abortion completed with the intended method (defined as fetal expulsion) occurred for nearly all trial participants. There may be no difference between surgical and medical methods, although the evidence for this outcome is very uncertain (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.02; 3 trials; 269 participants). Incomplete abortion requiring an additional procedure or intervention (immediate or delayed) may occur less often with surgical abortion (RR 0.19, 95% CI 0.07 to 0.53; 3 trials; 269 participants), but the evidence is very uncertain. Hemorrhage requiring blood transfusion may occur less often with surgical abortion, but the evidence is very uncertain as the outcome occurred infrequently (RR 0.29, 95% CI 0.07 to 1.12; 3 trials; 269 participants). There may be less bleeding with surgical abortion than with medical abortion based on a measure of total blood loss (difference in mean estimated blood loss (mL) -59.80, 95% CI -65.21 to -54.39; 1 trial; 141 participants; low certainty evidence). At two weeks post-abortion, medical abortion may be associated with more bleeding reported by participants as heavier than a menstrual period than surgical abortion (RR 0.10, 95% CI 0.01 to 0.76; 1 trial; 56 participants), but the evidence is very uncertain. One cervical laceration was reported in the surgical abortion group across the three studies, therefore the evidence for the effect of surgical versus medical abortion on the risk of injury to the cervix, vagina, or uterus is very uncertain. Patient-reported pain scores may be lower with surgical abortion compared with medical abortion, but the evidence is very uncertain (mean difference in pain score on visual analogue scale -2.20, 95% CI -3.81 to -0.59; 1 trial; 56 participants). Patient satisfaction (overall) with the assigned method appeared similar (2 trials; 83 participants), but the evidence is very uncertain, and the data could not be pooled due to inconsistent outcome measures.

Authors' conclusions: Comparative evidence on second-trimester surgical abortion (vacuum aspiration or D&E) versus medical abortion (mifepristone and misoprostol) was limited, drawn from three studies with varying practices and reported outcomes. While allocation to interventions was robust, none of the studies were blinded. Additionally, concerns about enrollment and incomplete outcome reporting may have influenced the results. While both methods resulted in expulsion of the fetus in nearly all cases, there is very low certainty evidence that medical abortion may increase the risk of incomplete abortion and interventions to remove the placenta. The uncertainty was due to variations in clinical protocols and interventions conducted during the abortion process for placental removal with medical abortion. Low certainty evidence suggests that medical abortion results in a slightly increased risk of bleeding, defined as mean estimated blood loss (mL). Serious hemorrhage that required transfusion was rare, and differences between groups may have little to no effect on the outcome, but the evidence is very uncertain. More studies using consistent protocols and measures (such as the STAR and MARE guidelines) are needed. Additionally, research that focuses on the patient's experience and to inform counseling should be considered.

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Conflict of interest statement

All authors provide medical and surgical abortions in clinical practice.

Jessica Atrio is an Independent Contractor on the Advisory Board for ViiV Healthcare Company, providing advice on the latest data presented or published on antiretroviral therapy to assess any data gaps and/or changes or updates to our current strategy (HIV prevention and treatment). Dr Atrio is employed as obstetrician and gynecologist at Montefiore Medical Center in New York.

Sarita Sonalkar is an Independent Contractor for Sumitomo Dainippon Pharma Co., Ltd., and an Independent Contractor for the World Health Organization. Dr Sonalkar has received personal funds for intellectual property for educational content, and works as a health professional for Penn Medicine.

Helena Kallner has a social media (Instagram) account that publishes opinions on abortion matters and is a member of a professional organization that does advocacy work. Dr Kallner is a senior consultant in obstetrics and gynecology at Dandery Hospital Sweden and president of the European Society of Contraception and Reproductive Health.

Rachel Rapkin is an Independent Contractor receiving personal funds from Organon & Co. for Nexaplanon training, has published opinions on abortion online, is Clinical Lead, Te Mahoe Unit (abortion unit) Te Whatu Ora Health New Zealand, September 2023 to present; Planned Parenthood Southwest and Central Florida, 2017 to 2023; OB/Gyn USF Obstetrics and Gynecology Tampa, Florida, August 2013 to February 2023; and is Member: American College of Obstetricians and Gynecologists (ACOG), Society of Family Planning (SFP), Abortion Providers Group Aotearoa New Zealand (APGANZ), and New Zealand College of Sexual and Reproductive Health (NZCSRH).

Kristina Gemzell‐Danielsson has received personal fees from Line Pharma for speaking engagements, works as a Senior Consultant in Obstetrics and Gynecology at the Karolinska University Hospital, and is the Director of the WHO Collaborating Centre for Research in Human Reproduction.

Patricia Lohr is the Director of Research and Innovation for the British Pregnancy Advisory Service, an organization that provides abortion care and undertakes advocacy on issues related to reproductive autonomy. She is Co‐Chair of the British Society of Abortion Care Providers, an Advisor for the charity Abortion Talk, a member of Doctors for Choice UK, and has received funds from DKT International for travel and conference registration to give talks on manual vacuum aspiration.

Update of

References

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Lohr 2008b
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