Dilation and evacuation


By Dr R Meenakshi
Consultant Gynecologist & Obstetrician

Article Context

  1. Overview
  2. Procedure
  3. Risks
  4. Care at Medicover
  5. Frequently Asked Questions

Overview

The World Health Organisation (WHO) has recommended certain safe methods to cease an unwanted pregnancy. These methods are considered safe when they are performed keeping in consideration the safety requirements of the woman’s health and privacy. Abortion is the process of ending a pregnancy voluntarily because of certain medical or non-medical circumstances. These can include undesired pregnancy, underage sex, poor health of mother and child and so on.

There are generally two methods of abortion namely; medical and surgical, each having their own advantages and disadvantages. Dilation and evacuation (D&E) is a procedure of surgical abortion performed during the second trimester of the pregnancy. It typically includes vacuum aspiration, dilation and curettage. In this method, the doctors also use surgical instruments such as forceps.


When is a D&E recommended?

D&E is recommended during the late first trimester and second trimester of pregnancy. It is also recommended when:

  • The mother is in the second trimester and is diagnosed with the foetus having severe developmental abnormalities.
  • There is an incomplete medical abortion.
  • There is fatality of the embryo (spontaneous abortion) due to any reason.
  • A woman doesn't realise that she is pregnant until the second trimester and needs termination.

Procedure

Before the procedure

  • The doctor takes medical and obstetrical history, as well as a list of all current medications and allergies of the patient.
  • The uterus is examined and ultrasound is performed to determine the period of gestation, number of foetuses, confirm intrauterine location of the pregnancy or status of the pregnancy as viable.
  • The patient is educated about the abortion process, side effects, and clear instructions for assessing emergency services. Further, antibiotics are also prescribed to prevent infection.
  • Laboratory tests including comblete blood count for anemia and viral tests for sexually transmitted diseases are performed.
  • The cervix which is an opening to the uterus will be opened (dilated) by the doctor. This can be accomplished in two ways and usually takes several hours. Your doctor may decide to use medication to soften the cervix prior to the procedure. Misoprostol may be administered several hours prior to the surgery. Alternatively, the cervix can be opened by inserting one or more small metal sticks called dilators into the opening of the cervix.
  • Dilating the cervix lowers the risk of injury during the procedure.
  • D&E usually takes 30 minutes. It is typically performed in a hospital under mild sedation or anaesthesia but does not necessitate an overnight stay.

During the procedure

During D & E procedure,

  • Your doctor will give antibiotics to prevent infection.
  • Position you on the examination table with your feet on stirrups while lying on your back.
  • The vagina and cervix are cleaned with an antiseptic solution.
  • A speculum is inserted into the vagina.
  • A sedative and a pain reliever injection is given in the cervical area. If the procedure is performed in a hospital operating room, a spinal anaesthesia injection might also be given into the fluid surrounding the spinal cord. This numbs the area between the legs. The doctor might also use general anaesthesia to induce unconsciousness.
  • Your Gynecologist may also choose to open the cervix right before the abortion by inserting and removing smooth metal rods that increase in size until the cervix is opened.
  • An abortion in the second trimester will need the cervix to be dilated more than required for a vacuum aspiration.
  • A cannula (a hollow tube) is inserted into the uterus. The cannula is connected to a bottle and a pump by a tube which creates a gentle suction to remove tissue from the uterus.
  • Then, to grasp larger pieces of tissue, a forcep (grasping instrument) is passed into the uterus. This is more likely in pregnancies of at least 16 weeks.
  • After that a curette (curved instrument) is used to gently scrape the lining of the uterus and to remove tissues in the uterus.
  • The doctor then uses suction as a final step to make sure the uterine contents are completely removed.
  • The uterine tissue that has been removed is examined to ensure that all of the tissue has been removed and that the procedure has been completed.
  • Doctors may use ultrasound to confirm that all of the tissue has been removed and the pregnancy has ended and give you medicine to reduce the amount of bleeding from the procedure.

After the procedure

  • You must stay for about 30 minutes after the procedure to ensure that there is no excess bleeding and you are doing well. You may have to stay longer if anaesthesia was used for the procedure.
  • You can do normal activities when you feel alright.
  • Pain killers can help relieve cramping pain. Be safe with medicines.
  • Medication may be given to help the uterus contract and return to its pre pregnancy size.
  • A normal recovery includes spotting and cramps.
  • Irregular bleeding or spotting can be present for the first 2 weeks. Use sanitary pads until you stop bleeding. It is easier to monitor your bleeding if you use pads.
  • Cramps may last from several hours to a few days, as the uterus shrinks back to its non-pregnancy size.

Risks

The risks of D&E include the following:

  • Injury to the uterine lining or cervix.
  • A hole in the uterine wall (uterine perforation). This is most common during cervical dilation. Bleeding is more likely in the second trimester, and a repair may be required. If bleeding is a concern, a laparoscopy can be performed to determine whether it has stopped or not.
  • There can be mild chances of infection. During the procedure, bacteria can enter the uterus and cause an infection. This is more likely if the patient has an untreated infection, such as a sexually transmitted infection, prior to the procedure. Antibiotics administered during and after the D&E procedure will reduce surisks.
  • Moderate to severe bleeding (haemorrhage).
  • Left over tissue in the uterus.

Care at Medicover

Medicover hospital is a fast growing chain of hospitals known for its pioneering and advanced healthcare services across multiple specialties, including clinical gynaecology. We have radically catalysed the healthcare revolution with many more innovative initiatives across India. We have the top Obstetrics & Gynaecology department which hosts a team of experienced and highly accomplished doctors providing quality healthcare services with high degrees of precision and successful treatment outcomes.



Frequently Asked Questions:

D&E is a surgical method of abortion done in the second trimester (12 weeks) of the pregnancy.

A Gynaecologist or an obstetrician can perform D & E procedure.

D & E is a day care procedure and patients can be discharged the same day after observation.

There can be mild discomfort following the procedure. The pain disappears after 24-48hours. Pain relief medications are usually prescribed to ease any irritation.

In almost all cases, surgical abortion is completely effective. Few cases may require re-evacuation if unusual bleeding occurs or if there is any retained tissue.

Citations:

  • https://www.michigan.gov/mdhhs/adult-child-serv/informedconsent/michigans-informed-consent-for-abortion-law/procedures/dilation-and-evacuation-de
  • https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=tw2462
  • https://www.uclahealth.org/obgyn/surgical-abortion-second-trimester
  • https://www.sciencedirect.com/science/article/abs/pii/S0002937803001078