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Dilation and evacuation

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Dilation and evacuation
D&E
Background
Abortion typeSurgical
First use1970s
Gestation13–24 weeks
Infobox references

Dilation and evacuation (D&E) or dilatation and evacuation (British English) is the dilation of the cervix and surgical evacuation of the uterus (potentially including the fetus, placenta and other tissue) after the first trimester of pregnancy. It is a method of abortion as well as a common procedure used after miscarriage to remove all pregnancy tissue.[1][2]

In various health care centers it may be called by different names:

  • D&E (Dilation and evacuation)
  • ERPOC (Evacuation of Retained Products of Conception)
  • TOP or STOP ((Surgical) Termination Of Pregnancy)

D&E normally refers to a specific second trimester procedure.[2] However, some sources use the term D&E to refer more generally to any procedure that involves the processes of dilation and evacuation, which includes the first trimester procedures of manual and electric vacuum aspiration.[1] Intact Dilation and Extraction (D&X) is a different procedural variation on D&E.[3]

Dilation and evacuation procedures have been increasingly banned in US states since the Dobbs v. Jackson Women's Health Organization decision overruled the right to an abortion.[4]

Indications for D&E

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Dilation and evacuation (D&E) is one of the methods available to completely remove the fetus and all of the placental tissue in the uterus after the first trimester of pregnancy.[5] A D&E may be performed for a surgical abortion, or for surgical management of a miscarriage.[6]

Abortion

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Induced abortion after the first trimester of pregnancy is rare. Approximately 930,000 abortions were documented in the US in 2020. Of these, 492,000 were medication abortions.[7] Fewer than 10% of all abortions in the United States are performed after 13 weeks of gestation, and just over 1% are performed after 21 weeks gestation.[8] In the United States, 95–99% of abortions after the first trimester of pregnancy are performed by surgical abortion via dilation and evacuation.[8]

People who do not have access to affordable abortion care in their area or who face legal restrictions to obtaining a wanted abortion may wait longer to get an abortion after they make the decision to terminate their pregnancy. When an abortion is delayed, a D&E may be necessary.[9] Other factors that often lead to an abortion in the second trimester are late testing for pregnancy, insurance or funding barriers, or delayed provider referral.[10]

Abortion can be considered in the case of congenital anomalies, including genetic aneuploidies and anatomic anomalies, especially since they may not be identified until the second trimester.[11][10] Other medical indications for an abortion in the second trimester include preeclampsia with severe features or preterm premature rupture of membranes prior to a viable fetal age.[10]

Miscarriage

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Dilation and evacuation can be offered for management of second trimester miscarriage if skilled providers are available.[6] Some women choose D&E over labor induction for a second trimester loss because it can be a scheduled surgical procedure, offering predictability over labor induction, or because they find it emotionally easier than undergoing labor and delivery. The risks of maternal morbidity during an induction of labor are higher compared to a dilation and evacuation.[12] Additionally, a subsequent dilation and curettage procedure for retained placental products may be required after an induction of labor for a miscarriage.[12] Both a labor induction and dilation and evacuation offer the option of fetal and placental testing. Although pregnancy loss is emotionally distressing, there are rarely medical complications associated with a short (<1 week) delay to management.[13]

Molar pregnancy

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Dilation and evacuation is also a treatment option for a molar pregnancy, especially for those who wish to maintain fertility. The procedure is typically done under sonographic guidance as soon as a hydatidiform mole is suspected.[14] [15]

Description of procedure

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Cervical preparation

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Prior to the procedure, cervical preparation with osmotic dilators or medications is recommended in order to reduce risk of complications such as cervical laceration and to facilitate cervical dilation during the procedure.[16][17][10] Although there is no consensus as to which method of cervical preparation is superior in terms of safety and technical ease of the procedure, one particular concern is reducing the risk of preterm birth. Concerns within the medical community have advised against or at least asked for further research concerning the safety of performing the dilation of the cervix on the same day as the surgery for some or all second trimester pregnancies. The concern is that performing the dilation too soon before the surgery could increase the risk of preterm birth should the woman ever carry a subsequent pregnancy to term.[18][19] However, for dilation and evacuation at greater than 20 weeks gestation, at least one day of cervical preparation is recommended, with the option of serial dilation for more than one day.[20] Dilation can be achieved with either osmotic dilation or misoprostol, although osmotic dilation with either laminaria or Dilapan is recommended.[20]

Anesthesia options

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Most patients will be provided NSAIDs for pain management. Local anesthetics, such as lidocaine, are frequently injected by the cervix to reduce pain during the procedure.[21][10][22] IV sedation may also be used.[23] General anesthesia may be used depending on individual circumstances, however it is not preferred as it adds significant anesthesia risks to the procedure.[21]: 90–100 

Infection prophylaxis

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Immediately prior to the procedure, antibiotics of either doxycycline or azithromycin are usually administered to prevent infection.[10]

Thromboprophylaxis

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Prophylaxis for venous thromboembolism is not typically required for this procedure.[24]

Surgical procedure

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A speculum is placed in the vagina to allow visualization of the cervix. If osmotic dilators were placed prior to the procedure, these are removed.[25]

The cervix may be further dilated with rigid dilator instruments such as Hegar and Pratt dilators (as opposed to osmotic dilators).[10] Sufficient cervical dilation decreases the risk of morbidity, including cervical injury and uterine perforation.[19][10] Uterine contents are removed using a cannula to apply aspiration, followed by forceps to remove fetal parts.[26] Tissue inspection ensures removal of the fetus in its entirety. The procedure may be performed under ultrasound guidance to aid in visualizing uterine anatomy and to assess if all tissue has been removed at the completion of the procedure.[21] Operative ultrasonography is beneficial because it can reduce the risk of uterine perforation.[27]

The procedure usually takes less than half an hour.[28]

Uterotonics

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There is no consensus on the routine use of perioperative or postoperative uterotonic medications. While many providers use these agents, there is no definitive evidence to support a decreased risk for bleeding under 20 weeks gestation.[10]

Recovery

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D&E is usually performed in the outpatient setting, and the patient can be safely sent home the same day after a period of observed recovery, ranging from 45 minutes to several hours. Generally, the woman may return to work the following day.[28] The type of anesthesia given also influences the appropriate amount of recovery time before discharge. There is rarely a need for narcotic pain medications afterwards, and NSAIDs are recommended for home pain management. Recovery from the procedure is typically fast and uncomplicated.[25]: 174 

Some women may experience lactation after a second-trimester loss or termination of pregnancy. Limited data exists for the efficacy of medications to suppress lactation. However, one randomized control trial found cabergoline to be effective in preventing breast symptoms of engorgement, leakage, and tenderness after a second-trimester loss or termination of pregnancy.[29]

Variations

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If the fetus is removed intact, the procedure is referred to as intact dilation and extraction by the American Medical Association,[30] and referred to as "intact dilation and evacuation" by the American Congress of Obstetricians and Gynecologists (ACOG).[31]

Risks

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D&E is a safe procedure when performed by experienced practitioners.[21] The rate of mortality for all types of legal abortion procedures in the US (not specifically D&E) is 0.43 abortion-related deaths per 100,000 reported legal abortions.[32] There were four identified deaths related to abortion in the US during 2019, out of 625,000 abortions.[32] The strongest risk factor for mortality following abortion is increasing gestational age.[33]

Risks of D&E include bleeding, infection, uterine perforation, retained products of conception, and cervical laceration.[17] Hemorrhage occurs following less than 1% of all surgical abortions.[10] Infection rates following second trimester abortion have been reported to be 0.1–4%. The risk of infection is decreased by the use of antibiotics. [10] The risk of retained products of conception and uterine perforation are both under 1%.[24] The risk of cervical laceration is up to 3%.[24] Even rarer, a hysterectomy or damage to surrounding organs or tissues (i.e. bowel or omentum) can occur during a D&E. [21][17]

There is no evidence that surgical abortion causes an increase in infertility or adverse outcomes in subsequent pregnancies.[21]: 252–254 

Alternatives

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Alternatives to D&E include labor induction abortion and medical abortion.

Complication rates after D&E are lower than those of labor induction (medical abortion) after 13 weeks, as has been established through multiple studies.[28] Additionally, in certain clinical scenarios—severe anemia, for example—D&E may be preferred over labor induction.[34]

Law

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The laws in the United States surrounding dilation and evacuation have been rapidly evolving since the Dobbs v. Jackson decision of 2022. Proposals to limit abortion access sometimes target specific procedures such as D&E, though this also restricts access for non-abortion patients, such as those with pregnancy loss.[4] Kansas was the first state to ban D&E in 2015, later it was struck down in 2016. Currently, D&E  is specifically banned in thirty-four states, except when deemed necessary for the preservation of the patient's life.[4] Twenty-one states have banned a "partial-birth" abortion, referring to an intact dilation and extraction.[4] Three of the twenty-one states have a health exception, and seventeen states allow an exception for life endangerment.[4]

Abortion laws in Europe, including dilation and evacuation, vary by country.

Physician training

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A national survey of 190 US obstetrics and gynecology residency program directors in 2018 found that 22% considered their graduates to have had enough training in dilation and evacuation to be competent. After Dobbs v. Jackson, almost half of the US obstetrics and gynecology programs are located in states that have implemented abortion restrictions, which will further limit training in dilation and evacuation.[35][36] The Accreditation Council for Graduate Medical Education states that these programs must either adapt by sending residents to legal jurisdictions where they are able to obtain this training or include uterine evacuation simulations in the educational curriculum.[37]

See also

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References

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  1. ^ a b "Miscarriage". EBSCO Publishing Health Library. Brigham and Women's Hospital. January 2007. Archived from the original on 2007-09-27. Retrieved 2007-04-07.
  2. ^ a b "Dilation and evacuation (D&E) for abortion". Healthwise. WebMD. 2004-10-07. Archived from the original on 2007-05-02. Retrieved 2007-04-07.
  3. ^ Haskell, Martin (1992-09-13). "Dilation and Extraction for Late Second Trimester Abortion". National Abortion Federation Risk Management Seminar. Dallas, Texas. Archived from the original on September 16, 2006. Retrieved 2007-05-05.
  4. ^ a b c d e "Bans on Specific Abortion Methods Used After the First Trimester". Guttmacher Institute. 2016-08-16. Archived from the original on 2017-01-12. Retrieved 2021-03-02.
  5. ^ Stubblefield, Phillip G.; Carr-Ellis, Sacheen; Borgatta, Lynn (July 2004). "Methods for Induced Abortion". Obstetrics & Gynecology. 104 (1): 174–185. doi:10.1097/01.aog.0000130842.21897.53. ISSN 0029-7844. PMID 15229018.
  6. ^ a b "ACOG Practice Bulletin No. 102: Management of Stillbirth". Obstetrics & Gynecology. 113 (3): 748–761. March 2009. doi:10.1097/aog.0b013e31819e9ee2. ISSN 0029-7844. PMID 19300347.
  7. ^ Jones, Rachel K.; Kirstein, Marielle; Philbin, Jesse (2022-11-20). "Abortion incidence and service availability in the United States, 2020". Perspectives on Sexual and Reproductive Health (University of Ottawa). 54 (4): 128–141. doi:10.1363/psrh.12215. PMC 10099841. PMID 36404279. S2CID 203813573.
  8. ^ a b Jatlaoui, Tara C.; Boutot, Maegan E.; Mandel, Michele G.; Whiteman, Maura K.; Ti, Angeline; Petersen, Emily; Pazol, Karen (2018-11-23). "Abortion Surveillance – United States, 2015". MMWR. Surveillance Summaries. 67 (13): 1–45. doi:10.15585/mmwr.ss6713a1. ISSN 1546-0738. PMC 6289084. PMID 30462632.
  9. ^ "Later Abortion". Guttmacher Institute. 2016-10-13. Retrieved 2019-07-29.
  10. ^ a b c d e f g h i j k "Second-Trimester Abortion – ACOG". www.acog.org. Retrieved 2019-07-09.
  11. ^ "Screening for Fetal Chromosomal Abnormalities". www.acog.org. Retrieved 2023-10-30.
  12. ^ a b "Management of Stillbirth: Obstetric Care Consensus No, 10". Obstetrics & Gynecology. 135 (3): e110–e132. March 2020. doi:10.1097/AOG.0000000000003719. ISSN 0029-7844. PMID 32080052. S2CID 211230954.
  13. ^ "ACOG Practice Bulletin No. 102: Management of Stillbirth". Obstetrics & Gynecology. 113 (3): 748–761. March 2009. doi:10.1097/aog.0b013e31819e9ee2. ISSN 0029-7844. PMID 19300347.
  14. ^ Soper, John T. (February 2021). "Gestational Trophoblastic Disease: Current Evaluation and Management". Obstetrics & Gynecology. 137 (2): 355–370. doi:10.1097/AOG.0000000000004240. ISSN 0029-7844. PMC 7813445. PMID 33416290.
  15. ^ Bruce, Shaina; Sorosky, Joel (2023), "Gestational Trophoblastic Disease", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29261918, retrieved 2023-11-15
  16. ^ Organization, World Health (2014). Clinical practice handbook for safe abortion. World Health Organization. Reproductive Health and Research. Geneva, Switzerland. p. 37. ISBN 9789241548717. OCLC 879416856.{{cite book}}: CS1 maint: location missing publisher (link)
  17. ^ a b c Fox, Michelle C.; Krajewski, Colleen M. (February 2014). "Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013–4". Contraception. 89 (2): 75–84. doi:10.1016/j.contraception.2013.11.001. ISSN 1879-0518. PMID 24331860.
  18. ^ Lyus, Richard (December 22, 2016). "Cervical preparation prior to second-trimester surgical abortion and risk of subsequent preterm birth". Journal of Family Planning and Reproductive Health Care. 43 (1): 70–71. doi:10.1136/jfprhc-2016-101695. PMID 28007822.
  19. ^ a b Newmann, Sara J.; Dalve-Endres, Andrea; Diedrich, Justin T.; Steinauer, Jody E.; Meckstroth, Karen; Drey, Eleanor A. (2010-08-04). "Cervical preparation for second trimester dilation and evacuation". The Cochrane Database of Systematic Reviews (8): CD007310. doi:10.1002/14651858.CD007310.pub2. ISSN 1469-493X. PMID 20687085.
  20. ^ a b Newmann, Sara; Dalve-Endres, Andrea; Drey, Eleanor A. (April 2008). "Cervical preparation for surgical abortion from 20 to 24 weeks' gestation". Contraception. 77 (4): 308–314. doi:10.1016/j.contraception.2008.01.004. PMID 18342657.
  21. ^ a b c d e f Paul, Maureen, Hrsg. Lichtenberg, Steve, Hrsg. Borgatta, Lynn, Hrsg. Grimes, David A., Hrsg. Stubblefield, Phillip G., Hrsg. Creinin, Mitchell D., Hrsg. (2011). Management of Unintended and Abnormal Pregnancy Comprehensive Abortion Care. John Wiley & Sons. ISBN 9781444358476. OCLC 899157428.{{cite book}}: CS1 maint: multiple names: authors list (link)
  22. ^ Allen, Rebecca H.; Singh, Rameet (June 2018). "Society of Family Planning clinical guidelines pain control in surgical abortion part 1 – local anesthesia and minimal sedation". Contraception. 97 (6): 471–477. doi:10.1016/j.contraception.2018.01.014. ISSN 0010-7824. PMID 29407363.
  23. ^ Cansino, Catherine; Denny, Colleen; Carlisle, A. Sue; Stubblefield, Phillip (2021-12-01). "Society of Family Planning clinical recommendations: Pain control in surgical abortion part 2 – Moderate sedation, deep sedation, and general anesthesia". Contraception. 104 (6): 583–592. doi:10.1016/j.contraception.2021.08.007. ISSN 0010-7824. PMID 34425082.
  24. ^ a b c Hammond, Casey; Steinauer, Jody; Chakrabarti, Alana (June 6, 2023). "Second-trimester pregnancy termination: Dilation and evacuation". UpToDate. Retrieved November 14, 2023.
  25. ^ a b Management of unintended and abnormal pregnancy : comprehensive abortion care. Paul, Maureen. Chichester, UK: Wiley-Blackwell. 2009. ISBN 978-1444312935. OCLC 424554827.{{cite book}}: CS1 maint: others (link)
  26. ^ Organization, World Health (2014). Clinical practice handbook for safe abortion. World Health Organization. Reproductive Health and Research. Geneva. p. 52. ISBN 9789241548717. OCLC 879416856.{{cite book}}: CS1 maint: location missing publisher (link)
  27. ^ Stubblefield, Phillip G.; Carr-Ellis, Sacheen; Borgatta, Lynn (July 2004). "Methods for Induced Abortion". Obstetrics & Gynecology. 104 (1): 174–185. doi:10.1097/01.AOG.0000130842.21897.53. ISSN 0029-7844. PMID 15229018.
  28. ^ a b c Hammond, C. (2009). "Recent advances in second-trimester abortion: an evidence-based review". Am J Obstet Gynecol. 200 (4): 347–356. doi:10.1016/j.ajog.2008.11.016. PMID 19318143.
  29. ^ Henkel, Andrea; Johnson, Sarah A.; Reeves, Matthew F.; Cahill, Erica P.; Blumenthal, Paul D.; Shaw, Kate A. (June 2023). "Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Pregnancy Loss: A Randomized Controlled Trial". Obstetrics & Gynecology. 141 (6): 1115–1123. doi:10.1097/AOG.0000000000005190. ISSN 0029-7844. PMID 37486652. S2CID 258767994.
  30. ^ Health and Ethics Policies of the AMA Archived 2020-04-26 at the Wayback Machine American Medical Association. H-5.982 Retrieved April 24, 2007.
  31. ^ ACOG Statement on the US Supreme Court Decision Upholding the Partial-Birth Abortion Ban Act of 2003 Archived 2007-06-11 at the Wayback Machine (April 18, 2007). Retrieved 2007-04-22.
  32. ^ a b Kortsmit, Katherine (2022). "Abortion Surveillance — United States, 2020". MMWR. Surveillance Summaries. 71 (10): 1–27. doi:10.15585/mmwr.ss7110a1. ISSN 1546-0738. PMC 9707346. PMID 36417304.
  33. ^ Jatlaoui, Tara C.; Boutot, Maegan E.; Mandel, Michele G.; Whiteman, Maura K.; Ti, Angeline; Petersen, Emily; Pazol, Karen (2018-11-23). "Abortion Surveillance – United States, 2015". MMWR. Surveillance Summaries. 67 (13): 1–45. doi:10.15585/mmwr.ss6713a1. ISSN 1546-0738. PMC 6289084. PMID 30462632.
  34. ^ Borgatta, Lynn; Kapp, Nathalie (2011). "Labor induction abortion in the second trimester". Contraception. 84 (1): 4–18. doi:10.1016/j.contraception.2011.02.005. PMID 21664506.
  35. ^ "The State Abortion Policy Landscape One Year Post-Roe". Guttmacher Institute. 2023-06-14. Retrieved 2023-11-13.
  36. ^ Vinekar, Kavita; Karlapudi, Aishwarya; Nathan, Lauren; Turk, Jema K.; Rible, Radhika; Steinauer, Jody (August 2022). "Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs". Obstetrics & Gynecology. 140 (2): 146–149. doi:10.1097/AOG.0000000000004832. ISSN 0029-7844. PMID 35852261. S2CID 250627945.
  37. ^ "ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology Summary and Impact of Interim Requirement Revisions" (PDF). Accreditation Council for Graduate Medical Education. June 24, 2022.
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