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

Dilation and evacuation (D&E) 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]

Indications for D&E[edit]

Dilation and evacuation (D&E) is one of the methods available to completely remove all of the pregnancy tissue in the uterus after the first trimester of pregnancy.[3] A D&E may be performed for a surgical abortion, or for surgical management of a miscarriage.[4]

Abortion[edit]

Induced abortion after the first trimester of pregnancy is rare. Approximately 630,000 abortions were performed in the US in 2015, the most recent year for which data are available. 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.[5] In the United States, 95-99% of abortions after the first trimester of pregnancy are performed by surgical abortion via dilation and evacuation.[5]

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 the make the decision to terminate their pregnancy. When an abortion is delayed, a D&E may be necessary.[6]

Miscarriage[edit]

Dilation and evacuation can be offered for management of second trimester miscarriage if skilled providers are available.[4]

Description of procedure[edit]

Cervical preparation[edit]

Prior to D&E, the cervix must be dilated sufficiently to allow the surgeon to pass surgical instruments through the cervix without causing injury to the cervix. At later gestational ages, patients may require a two day procedure with cervical preparation occurring the day prior to the D&E. Adequate dilation of the cervix is important prior to surgical abortions because it helps to prevent complications of D&E, such as laceration of the cervix.[7][8] Dilation of the cervix can be accomplished with osmotic dilators, with adjunctive medications such as misoprostol or mifepristone, or a combination of these methods. There is no consensus as to which cervical preparation method is superior in terms of safety and technical ease of the procedure.[9]

Anesthesia options[edit]

Local anesthetics, such as lidocaine, are frequently injected near the cervix to reduce pain during the procedure. [10][8][11] IV sedation may also be used. General anesthesia is usually not necessary.

Infection prophylaxis[edit]

Immediately prior to the procedure, antibiotics are usually administered to prevent infection. [8]

Surgical Procedure[edit]

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.

The cervix may be further dilated with dilators. Sufficient cervical dilation decreases the risk of morbidity, including cervical injury and uterine perforation [9][8]. The procedure may be performed under ultrasound guidance to aid in visualizing uterine anatomy and ensuring that all tissue has been removed at the completion of the procedure[10]. The pregnancy tissue including all fetal parts and placental tissue is removed using a combination suction curettage and surgical instruments called forceps.

Recovery[edit]

Most patients return to home the same day as the procedure.

Variations[edit]

If the fetus is removed intact, the procedure is referred to as intact dilation and extraction by the American Medical Association,[12] and referred to as "intact dilation and evacuation" by the American Congress of Obstetricians and Gynecologists (ACOG).[13]

Risks of D&E[edit]

D&E is a safe procedure when performed by experienced practitioners.[14] The rate of mortality following legal in the US is 0.62 legal induced abortion-related deaths per 100,000 reported legal abortions. The strongest risk factor for mortality following abortion is increasing gestational age. [15]

Risks of D&E include bleeding, infection, uterine perforation, and damage to surrounding organs or tissues . Hemorrhage occurs following less than 1% of all surgical abortions.[16] Infection rates following second trimester abortion have been reported to be 0.1-4%.[16] The risk of infection is decreased by the use of antibiotics. Rare risks of D&E include uterine perforation, retained products of conception, and rare risk of hysterectomy.

There is no evidence that surgical abortion causes in increase in infertility or adverse outcomes in subsequent pregnancies.

Alternatives to D&E[edit]

Law[edit]

In 2015 Kansas became the first US state to ban the dilation and evacuation procedure for abortions.[17] The law was struck down in January 2016 without ever having gone into effect.[18]

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. ^ 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.
  4. ^ 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.
  5. ^ 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.
  6. ^ "Later Abortion". Guttmacher Institute. 2016-10-13. Retrieved 2019-07-29.
  7. ^ Fox, Michelle C.; Krajewski, Colleen M. (2014-2). "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. Check date values in: |date= (help)
  8. ^ a b c d "Second-Trimester Abortion - ACOG". www.acog.org. Retrieved 2019-07-09.
  9. ^ 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.
  10. ^ a b 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.CS1 maint: Multiple names: authors list (link)
  11. ^ Allen, Rebecca H.; Singh, Rameet (2018-06). "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. Check date values in: |date= (help)
  12. ^ Health and Ethics Policies of the AMA American Medical Association. H-5.982 Retrieved April 24, 2007.
  13. ^ 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.
  14. ^ 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.CS1 maint: Multiple names: authors list (link)
  15. ^ 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.
  16. ^ a b "Second-Trimester Abortion - ACOG". www.acog.org. Retrieved 2019-07-09.
  17. ^ Kansas governor signs nation's 1st ban on abortion procedure - Yahoo News. News.yahoo.com (2015-04-07). Retrieved on 2015-04-12.
  18. ^ Alter, Charlotte. "Kansas Court Strikes Down Second-Trimester Abortion Ban". TIME.com. Retrieved 2016-10-20.