Second-trimester pregnancy termination: Dilation and evacuation
- Cassing Hammond, MD
Cassing Hammond, MD
- Associate Professor in Obstetrics & Gynecology
- Northwestern University
Second-trimester (14 to <28 weeks of gestation) pregnancy terminations comprise 10 to 15 percent of the approximately 42 million abortions performed annually worldwide [1,2]. The United States Centers for Disease Control and Prevention reported that 7.0 percent of abortions were performed between 14 to 20 weeks and 1.3 percent at or after 21 weeks .
The most common surgical technique for second-trimester termination in the United States is dilation and evacuation (D&E), and will be the focus of this topic [4,5]. Other surgical approaches include intact D&E, which is a variant of D&E, and hysterotomy . Hysterotomy is rarely used except when it is unsafe to dilate the cervix or induce labor, or when there is no trained D&E provider. Some patients with severe cervical stenosis or leiomyomas that completely obstruct the cervix and vagina may require hysterotomy.
Second-trimester surgical pregnancy termination is reviewed here. An overview of second-trimester pregnancy termination and the technique for induction abortion are discussed separately. (See "Overview of second-trimester pregnancy termination" and "Second trimester pregnancy termination: Induction (medication) termination".)
The dilation and evacuation procedure for second-trimester pregnancy termination consists of two components:
●Preparation and dilation of the cervix with osmotic, pharmacologic, and/or mechanical dilators
- ACOG Practice Bulletin No. 135: Second-trimester abortion. Obstet Gynecol 2013; 121:1394.
- Sedgh G, Henshaw S, Singh S, et al. Induced abortion: estimated rates and trends worldwide. Lancet 2007; 370:1338.
- Pazol K, Creanga AA, Zane SB, et al. Abortion surveillance--United States, 2009. MMWR Surveill Summ 2012; 61:1.
- Tietze C, Henshaw SK. Induced abortion: a world review, 3rd ed, Alan Guttmacher Institute, New York 1986.
- Stubblefield PG, Carr-Ellis S, Borgatta L. Methods for induced abortion. Obstet Gynecol 2004; 104:174.
- Prager SW, Oyer DJ. Second-trimester surgical abortion. Clin Obstet Gynecol 2009; 52:179.
- Johnstone FD, Beard RJ, Boyd IE, McCarthy TG. Cervical diameter after suction termination of pregnancy. Br Med J 1976; 1:68.
- Newmann SJ, Dalve-Endres A, Diedrich JT, et al. Cervical preparation for second trimester dilation and evacuation. Cochrane Database Syst Rev 2010; :CD007310.
- Newmann SJ, Sokoloff A, Tharyil M, et al. Same-day synthetic osmotic dilators compared with overnight laminaria before abortion at 14-18 weeks of gestation: a randomized controlled trial. Obstet Gynecol 2014; 123:271.
- Fox MC, Hayes JL, Society of Family Planning. Cervical preparation for second-trimester surgical abortion prior to 20 weeks of gestation. Contraception 2007; 76:486.
- Newmann S, Dalve-Endres A, Drey EA, Society of Family Planning. Clinical guidelines. Cervical preparation for surgical abortion from 20 to 24 weeks' gestation. Contraception 2008; 77:308.
- Edelman AB, Buckmaster JG, Goetsch MF, et al. Cervical preparation using laminaria with adjunctive buccal misoprostol before second-trimester dilation and evacuation procedures: a randomized clinical trial. Am J Obstet Gynecol 2006; 194:425.
- Drey EA, Benson LS, Sokoloff A, et al. Buccal misoprostol plus laminaria for cervical preparation before dilation and evacuation at 21-23 weeks of gestation: a randomized controlled trial. Contraception 2014; 89:307.
- Goldberg AB, Fortin JA, Drey EA, et al. Cervical Preparation Before Dilation and Evacuation Using Adjunctive Misoprostol or Mifepristone Compared With Overnight Osmotic Dilators Alone: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:599.
- Shaw KA, Shaw JG, Hugin M, et al. Adjunct mifepristone for cervical preparation prior to dilation and evacuation: a randomized trial. Contraception 2015; 91:313.
- Carbonell JL, Gallego FG, Llorente MP, et al. Vaginal vs. sublingual misoprostol with mifepristone for cervical priming in second-trimester abortion by dilation and evacuation: a randomized clinical trial. Contraception 2007; 75:230.
- Darney PD, Dorward K. Cervical dilation before first-trimester elective abortion: a controlled comparison of meteneprost, laminaria, and hypan. Obstet Gynecol 1987; 70:397.
- Chen JK, Elder MG. Preoperative cervical dilatation by vaginal pessaries containing prostaglandin E1 analogue. Obstet Gynecol 1983; 62:339.
- Lauersen NH, Den T, Iliescu C, et al. Cervical priming prior to dilatation and evacuation: a comparison of methods. Am J Obstet Gynecol 1982; 144:890.
- Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion: evidence and ethics. Contraception 2012; 85:140.
- Steward R, Melamed A, Kim R, et al. Infection and extramural delivery with use of digoxin as a feticidal agent. Contraception 2012; 85:150.
- Dean G, Colarossi L, Lunde B, et al. Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation. Contraception 2012; 85:144.
- Diedrich J, Drey E, Society of Family Planning. Induction of fetal demise before abortion. Contraception 2010; 81:462.
- ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009; 113:1180.
- http://prochoice.org/wp-content/uploads/2015_NAF_CPGs.pdf (Accessed on October 15, 2015).
- Peterson WF, Berry FN, Grace MR, Gulbranson CL. Second-trimester abortion by dilatation and evacuation: an analysis of 11,747 cases. Obstet Gynecol 1983; 62:185.
- Grimes DA, Schulz KF, Cates WJ Jr. Prevention of uterine perforation during curettage abortion. JAMA 1984; 251:2108.
- Schulz KF, Grimes DA, Cates W Jr. Measures to prevent cervical injury during suction curettage abortion. Lancet 1983; 1:1182.
- Darney PD, Sweet RL. Routine intraoperative ultrasonography for second trimester abortion reduces incidence of uterine perforation. J Ultrasound Med 1989; 8:71.
- Lederle L, Steinauer JE, Montgomery A, et al. Obesity as a Risk Factor for Complications After Second-Trimester Abortion by Dilation and Evacuation. Obstet Gynecol 2015; 126:585.
- Hammond C, Chasen S. Dilation and evacuation. In: Management of unintended and abnormal pregnancy: Comprehensive abortion care, Paul M, Lichtenberg S, Borgatta L, et al (Eds), Wiley-Blackwell, Oxford 2003. p.167.
- Forna F, Gülmezoglu AM. Surgical procedures to evacuate incomplete abortion. Cochrane Database Syst Rev 2001; :CD001993.
- Lindell G, Flam F. Management of uterine perforations in connection with legal abortions. Acta Obstet Gynecol Scand 1995; 74:373.
- McMahon JT. Intact D&E. The first decade. Presented at the National Abortion Federation conference. April, 1995.
- Haskell M. Dilation and extraction for late second trimester abortion. Presented at the National Abortion Federation Risk Management Seminar. September 1992.
- Gawron LM, Hammond C, Ernst LM. Perinatal pathologic examination of nonintact, second-trimester fetal demise specimens: the value of standardization. Arch Pathol Lab Med 2013; 137:1083.
- Chasen ST, Kalish RB, Gupta M, et al. Dilation and evacuation at >or=20 weeks: comparison of operative techniques. Am J Obstet Gynecol 2004; 190:1180.
- Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP Guideline #20131. Contraception 2013; 87:331.
- O'Connell K, Jones HE, Lichtenberg ES, Paul M. Second-trimester surgical abortion practices: a survey of National Abortion Federation members. Contraception 2008; 78:492.
- Schulz KF, Grimes DA, Christensen DD. Vasopressin reduces blood loss from second-trimester dilatation and evacuation abortion. Lancet 1985; 2:353.
- Glick E. Surgical abortion, West End Women's Medical Group, 1998.
- Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011; 117:788.
- Whitley KA, Trinchere K, Prutsman W, et al. Midtrimester dilation and evacuation versus prostaglandin induction: a comparison of composite outcomes. Am J Obstet Gynecol 2011; 205:386.e1.
- Jacot FR, Poulin C, Bilodeau AP, et al. A five-year experience with second-trimester induced abortions: no increase in complication rate as compared to the first trimester. Am J Obstet Gynecol 1993; 168:633.
- Pridmore BR, Chambers DG. Uterine perforation during surgical abortion: a review of diagnosis, management and prevention. Aust N Z J Obstet Gynaecol 1999; 39:349.
- Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for second-trimester abortion. Am J Obstet Gynecol 2002; 187:393.
- Kauff ND, Chelmow D, Kawada CY. Intractable bleeding managed with Foley catheter tamponade after dilation and evacuation. Am J Obstet Gynecol 1995; 173:957.
- Altman AM, Stubblefield PG, Schlam JF, et al. Midtrimester abortion with Laminaria and vacuum evacuation on a teaching service. J Reprod Med 1985; 30:601.
- Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysis. Obstet Gynecol 1996; 87:884.
- Niinimäki M, Suhonen S, Mentula M, et al. Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: population register based study. BMJ 2011; 342:d2111.
- Thonneau P, Poirel H, Fougeyrollas B, et al. A comparative analysis of fall in haemoglobin following abortions conducted by mifepristone (600 mg) and vacuum aspiration. Hum Reprod 1995; 10:1512.
- Frick AC, Drey EA, Diedrich JT, Steinauer JE. Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications. Obstet Gynecol 2010; 115:760.
- Bartlett LA, Berg CJ, Shulman HB, et al. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol 2004; 103:729.
- Kalish RB, Chasen ST, Rosenzweig LB, et al. Impact of midtrimester dilation and evacuation on subsequent pregnancy outcome. Am J Obstet Gynecol 2002; 187:882.
- Jackson JE, Grobman WA, Haney E, Casele H. Mid-trimester dilation and evacuation with laminaria does not increase the risk for severe subsequent pregnancy complications. Int J Gynaecol Obstet 2007; 96:12.
- PREPROCEDURE PREPARATION
- Cervical preparation
- - Osmotic dilators
- - Dilators with misoprostol or mifepristone
- Injection to induce fetal demise
- Prophylactic antibiotics
- Cervical dilation
- Uterine evacuation
- - Intact dilation and evacuation
- Use of uterotonics
- Assessment for retained products of conception
- OUTCOME AND COMPLICATIONS
- Retained products of conception
- Uterine perforation
- Cervical laceration
- FUTURE OBSTETRIC OUTCOMES
- SPECIAL CIRCUMSTANCES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS