Dilation and evacuation

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 the most common method and procedure for abortions in the second trimester of pregnancy. The procedure can also be used to remove a miscarried fetus from the womb.

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. 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. Intact dilation and extraction (D&X) is a different procedural variation on D&E.

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. A D&E may be performed for a surgical abortion, or for surgical management of a miscarriage. 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 of gestation. In the United States, 95–99% of abortions after the first trimester of pregnancy are performed by surgical abortion via dilation and evacuation. 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. 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 dilation and evacuation. Additionally, a subsequent dilation and curettage procedure for retained placental products may be required after an induction of labor for a miscarriage.

Molar pregnancy

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.

Description of procedure

Cervical preparation

Prior to the procedure, cervical preparation with osmotic dilators or medications is recommended in order to reduce the risk of complications such as cervical laceration and to facilitate cervical dilation during the procedure. 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. 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. Dilation can be achieved with either osmotic dilation or misoprostol, although osmotic dilation with either laminaria or Dilapan is recommended. IV sedation may also be used. General anesthesia may be used depending on individual circumstances, however it is not preferred as it adds significant anesthesia risks to the procedure. 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.

The procedure usually takes less than half an hour. 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.

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.

Variations

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

Risks

D&E is a safe procedure when performed by experienced practitioners. There were four identified deaths related to abortion in the US during 2019, out of 625,000 abortions.

Risks of D&E include bleeding, infection, uterine perforation, retained products of conception, and cervical laceration. The risk of cervical laceration is up to 3%.

Law

The laws in the United States surrounding dilation and evacuation have been rapidly evolving since the Dobbs v. Jackson Women's Health Organization decision in 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. Twenty-one states have banned a "partial-birth" abortion, referring to an intact dilation and extraction. 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.