What are the major risks of dilatation and evacuation (D&E)?

Major Risks of Dilatation and Evacuation (D&E)

The principal complications of dilatation and evacuation (D&E) include perforation, hemorrhage, and infection, with uterine perforation being the most serious risk occurring in approximately 1-3% of cases.

Primary Risks

1. Uterine Perforation

• Occurs in approximately 1-3% of D&E procedures 1
• More likely to occur:
  • During cervical dilation phase
  • With less experienced operators
  • In complex cases (e.g., advanced gestations)
• May require laparotomy to repair the defect and evaluate for injury to adjacent organs 2
• Can lead to damage to surrounding structures including bowel, bladder, or blood vessels
• Signs of perforation include:
  • Pain
  • Bleeding
  • Visualization of omentum or bowel in the suction curette 2

2. Hemorrhage

• Risk increases with:
  • Advanced gestational age
  • Uterine anomalies
  • Previous uterine surgery
  • Placenta previa or accreta
• May require blood transfusion in severe cases
• Can be immediate or delayed

3. Infection

• Post-procedure infection rates of approximately 1-3% in uncomplicated cases 1
• Significantly lower infection rates compared to other pregnancy termination methods (1.3% after D&E vs. 23.9% with induction of labor) 1
• Risk factors include:
  • Pre-existing genital tract infections
  • Retained products of conception
  • Inadequate sterile technique

Secondary Risks

1. Cervical Trauma/Laceration

• More common with:
  • Inadequate cervical preparation
  • Rapid dilation
  • Advanced gestational age

2. Retained Products of Conception

• Can lead to:
  • Delayed bleeding
  • Infection
  • Need for repeat procedure

3. Anesthesia-Related Complications

• Risks associated with sedation or general anesthesia
• Includes respiratory depression, aspiration, and allergic reactions

Risk Reduction Strategies

1. Adequate Cervical Preparation

• For procedures at 20-24 weeks, at least one day of cervical preparation with osmotic dilators is recommended 3
• Adjunctive medications can be considered:
  • Mifepristone administered one day pre-operatively makes D&E subjectively easier at 20-24 weeks without increasing side effects 3
  • Misoprostol can be used but may cause more side effects like pain and nausea compared to mifepristone 3

2. Provider Experience

• Risk of complications is lower with experienced providers
• Training and adequate case volume are important factors in reducing complications

3. Infection Prevention

• Proper sterile technique during the procedure
• Screening and treatment of pre-existing infections before the procedure
• Consideration of prophylactic antibiotics in high-risk cases 1
• Complete evacuation of uterine contents to prevent retained tissue 1

4. Procedural Setting

• High-risk patients should be managed in an experienced center with on-site surgical support 4
• Procedures should be performed in a facility with emergency support services available

Patient Monitoring and Follow-up

• Patients should be closely monitored post-procedure for:

  • Vital signs
  • Bleeding
  • Pain
  • Signs of infection

• Patient education should include warning signs requiring immediate medical attention:

  • Fever
  • Increasing abdominal pain or tenderness
  • Foul-smelling vaginal discharge
  • Prolonged or heavy bleeding
  • Malaise or flu-like symptoms 1

Despite these risks, when performed by experienced providers with appropriate techniques, D&E has been shown to have lower overall complication rates compared to other second-trimester abortion methods such as induction with saline or prostaglandins 5.