Cervical preparation before second-trimester dilatation and evacuation — DFSRH MCQ

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EasySecond TrimesterCervical preparation before second-trimester dilatation and evacuationDFSRH

A 28-year-old nulliparous woman is undergoing dilatation and evacuation at 20+4 weeks’ gestation. The procedure is scheduled for the following afternoon. She has no uterine anomaly, previous cervical surgery or contraindication to mifepristone. Which cervical preparation regimen is most appropriate?

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Reveal the answer and explanation

Correct answer: A — Administer oral mifepristone 200 mg and insert osmotic dilators at the same visit the day before

Explanation lettering: B = shown as A · C = shown as B · E = shown as C · A = shown as D · D = shown as E

At 20+4 weeks, the gestation lies within the 19+1-to-23+6-week category in NICE guidance. Osmotic dilators should therefore be offered. NICE additionally recommends considering oral mifepristone 200 mg on the day before the abortion, with the dilators inserted at the same visit. This makes B the regimen that most closely follows current UK guidance. Osmotic dilators progressively expand and promote endogenous prostaglandin release; adjunctive mifepristone softens the cervix and can reduce procedural difficulty at later gestations. A omits the required osmotic dilators; mifepristone alone is an option at 14+0 to 16+0 weeks, but not at 20+4 weeks. C is plausible because misoprostol can be used without dilators at earlier second-trimester gestations, but NICE identifies no pharmacological alternative to osmotic dilators after 19+0 weeks. D combines two pharmacological agents but still omits mechanical dilatation. E includes the essential dilators, but NICE advises against adding misoprostol when osmotic dilators were inserted the previous day because additional benefit has not been demonstrated and adverse effects may increase. Therefore, overnight osmotic dilators with simultaneous mifepristone is the single best answer.

Reference: NICE NG140: Abortion care — Recommendations (Published 25 September 2019; last updated 27 May 2025) — https://www.nice.org.uk/guidance/NG140/chapter/recommendations RCOG: Surgical abortion from 14 weeks of pregnancy — Summary sheet (Publication or update date not stated on the current resource; checked 19 August 2026) — https://www.rcog.org.uk/media/5imndcjp/4580-rcog-summary-sheet_surgical-abortion-from-14-weeks-summary-sheet-v2.pdf