Dilation and evacuation

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Dilation and evacuation
(D&E)
Background
Abortion type Surgical
First use 1970s
Gestation 13-24 weeks
Usage
UK: Eng. & Wales 45% (2005)
Infobox references

In methods of abortion, dilation and evacuation (D&E also sometimes called dilation and extraction) is the dilation of the cervix and surgical evacuation of the contents of the uterus. It is a method of abortion as well as a therapeutic procedure used after miscarriage to prevent infection by ensuring that the uterus is fully evacuated.[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]

Reasons to use D&E[edit]

Dilation and evacuation (D&E) is one of the methods available for a second-trimester abortion. A D&E is done to completely remove all of the tissue in the uterus for an abortion in the second trimester of pregnancy. The reason for D&E rather than the simpler DVC, Dilation and Vacuum Curettage, is that the fetal skeleton begins to calcify at 14 weeks and the fetus can not be removed by suction alone.

A D&E is recommended[citation needed] for women diagnosed in the second trimester with a fetus that has severe medical problems or abnormalities. Abnormalities such as severe neural tube defects or congenital heart anomalies are typically diagnosed by ultrasound during weeks 18-23, because detailed anatomy cannot be fully evaluated before that time due to requirements for fetal size.[3]

When an abortion is delayed, a D&E may be necessary.[4]

Approximately 11% of induced abortions are performed in the second trimester. In 2002, there were an estimated 142,000 second-trimester abortions in the United States.[5] The second trimester of pregnancy begins at 13 weeks gestation. For first-trimester and early second-trimester abortions, the pregnancy may be ended by vacuum aspiration alone. Sometimes in the second trimester, however, it becomes necessary to use instruments to remove the fetus. This instrumental procedure is normally what is meant when the term dilation and evacuation is used.

Description[edit]

D&E is performed under anesthesia, most commonly sedation with light general anesthesia, although local paracervical block or regional anesthesia may be used. It may be performed with or without ultrasound guidance. Performance under ultrasound guidance has greatly improved our understanding about what actually occurs during a D&E. Prior to the procedure, the cervix is usually softened and passively dilated using osmotic dilators and/or misoprostol. This facilitates cervical dilation during the procedure without injury to the cervix.

The first step in the procedure itself is dilation of the cervix. The second step is insertion of a vacuum curette through the cervix. Under ultrasound, the tip of that curette is placed up against the fetal chest or abdomen. The suction is turned on. Amniotic fluid is removed and the fetus dies instantly due to removal of the fetal heart, lungs, and abdominal contents. In the absence of ultrasound guidance, the surgeon will carefully observe the tissue extracted by the vacuum curette to insure the fetal liver, which has a characteristic black appearance, has been removed as confirmation that the fetus has died.[citation needed]

This leaves the fetal cranium and skeleton with soft tissue to be removed. The thorax, pelvis, cranium, and each arm and leg are removed separately using surgical instruments. The fetal cranium will usually have to be crushed in order to be extracted. Use of ultrasound greatly facilitates this part of the procedure although it may be done safely without ultrasound guidance. In the absence of ultrasound, the tissue will be carefully inspected to insure all fetal tissue is removed. It is important to recognize that this is the removal of dead tissue to protect the patient from bleeding and infection well after the fetus died instantly. Under no circumstances is the fetus being dismembered alive. In some countries where ultrasound guidance is not used, the prior step of removal of internal organs is not performed and the dismemberment occurs while the fetus is alive.[citation needed]

After removal of all fetal tissue, the uterine cavity is thoroughly curetted to insure that all placental tissue, blood, and membranes are removed. The uterus will then be massaged to insure it is firmly contracted to minimize post operative bleeding. The entire procedure usually takes less than 30 minutes and is well tolerated.

Variations[edit]

The standard D&E procedure is difficult after 20 weeks gestational age due to the toughness of the fetal tissues.[6]

If the fetus is removed intact, the procedure is referred to as intact dilation and extraction by the American Medical Association,[7] and referred to as "intact dilation and evacuation" by the American Congress of Obstetricians and Gynecologists (ACOG).[8]

Law[edit]

In 2015 Kansas became the first US state to ban the dilation and evacuation procedure for abortions.[9] The law was struck down in January 2016 without ever having gone into effect.[10]

See also[edit]

References[edit]

  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. ^ https://fetalmedicine.org/var/uploads/18-23_Weeks_Scan.pdf
  4. ^ "Surgical Abortion Procedures". webmd.com. 
  5. ^ Guttmacher Institute: "Facts On Induced Abortion in the United States" Archived 2007-10-13 at the Wayback Machine., May 2006. Accessed May 2006.
  6. ^ 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. 
  7. ^ Health and Ethics Policies of the AMA American Medical Association. H-5.982 Retrieved April 24, 2007.
  8. ^ 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.
  9. ^ Kansas governor signs nation's 1st ban on abortion procedure - Yahoo News. News.yahoo.com (2015-04-07). Retrieved on 2015-04-12.
  10. ^ Alter, Charlotte. "Kansas Court Strikes Down Second-Trimester Abortion Ban". TIME.com. Retrieved 2016-10-20.