Dilation-and-Evacuation WITHOUT Additional Curettage
At 13 weeks gestation, dilation-and-evacuation (D&E) should be performed WITHOUT routine additional curettage, as surgical aspiration alone is the preferred technique for second-trimester uterine evacuation.
Rationale Based on Current Evidence
The most relevant guideline evidence addresses surgical abortion techniques in the second trimester. Dilatation and evacuation is identified as the safest procedure in both the first and second trimesters 1. The key distinction is that modern D&E technique utilizes surgical aspiration rather than sharp curettage.
Why Aspiration Over Curettage
Research evidence directly comparing these techniques demonstrates that surgical aspiration should be favored over curettage because it is quicker, less painful, and leads to less bleeding 2. This finding comes from studies of first-trimester procedures but the principle applies to second-trimester evacuations as well—sharp curettage adds unnecessary trauma to the uterine lining without improving evacuation rates.
The Modern D&E Technique
At 13 weeks gestation, the standard D&E procedure involves:
- Cervical preparation (osmotic dilators or pharmacologic agents placed hours to overnight before the procedure)
- Mechanical evacuation using suction aspiration and forceps to remove fetal tissue
- Confirmation of completion through ultrasound visualization or careful inspection of evacuated tissue
The term "curettage" historically referred to sharp scraping of the uterine cavity, which is not routinely necessary when proper aspiration technique is employed. The aspiration cannula effectively evacuates tissue without the additional trauma of sharp curettage.
Clinical Pitfalls to Avoid
Do not confuse "D&E" with "D&C": While these terms are sometimes used interchangeably in older literature, modern D&E at 13 weeks relies primarily on aspiration and forceps extraction, not sharp curettage. Adding routine sharp curettage increases bleeding risk and procedural time without improving outcomes 2.
Exception—Incomplete evacuation: If ultrasound or tissue examination suggests retained products after initial aspiration, gentle additional aspiration (not sharp curettage) may be indicated. However, this should be based on objective findings, not performed routinely.
Fibroids can complicate the procedure: In rare cases where large fibroids prevent adequate visualization or access to the uterine cavity, standard D&E may be unsuccessful 3. This represents a technical limitation requiring alternative approaches, not an indication for more aggressive curettage.
Evidence Quality Considerations
The 2011 ESC cardiovascular guideline 1 provides the clearest statement that "dilatation and evacuation is the safest procedure" for second-trimester termination, though it doesn't specifically address the curettage question. The 2014 French research 2 directly compares aspiration versus curettage techniques, showing aspiration's superiority in terms of speed, pain, and bleeding—this represents the best available evidence on the specific technical question.
The 2025 Society of Family Planning guidelines 4 focus on medication abortion protocols rather than surgical technique details, but notably recommend against routine additional interventions (like osmotic dilators with certain medication regimens) when they don't improve outcomes 4.
The consistent message across guidelines is that less invasive approaches with proven efficacy should be preferred over more aggressive techniques that add risk without benefit.