Dilation and Evacuation (D&E) for Pregnancy Termination
Dilation and evacuation (D&E) is the safest and preferred surgical method for second-trimester pregnancy termination, with significantly lower complication rates than medical methods, and should be performed in a hospital setting by experienced providers. 1, 2
Pre-Procedure Cervical Preparation
Cervical preparation is essential for D&E procedures, particularly beyond 14 weeks gestation. 3
Osmotic dilators are the superior method for cervical preparation:
- Provide better cervical dilation compared to prostaglandins alone throughout the second trimester 3
- Can be used alone or in combination with misoprostol 3
- Typically placed 12-24 hours before the procedure 3
Prostaglandin adjuncts (misoprostol):
- Adding prostaglandins to osmotic dilators increases cervical dilation only after 19 weeks gestation, without reducing procedure time 3
- Mifepristone plus misoprostol should be avoided as it causes high rates of pre-procedural expulsions 3
Timing considerations:
- Same-day procedures are safe and reasonable in the early second trimester 3
- Two-day cervical preparation produces greater dilation than one-day but doesn't reduce procedure time below 19 weeks 3
The D&E Procedure Itself
Surgical technique:
- The procedure involves mechanical dilation of the cervix followed by evacuation of uterine contents using suction and forceps 4, 5
- Performed as an outpatient or day-case procedure 6
- Typically completed in 10-30 minutes once adequate cervical preparation is achieved 5
Anesthesia requirements:
- Most D&E procedures are performed under sedation or general anesthesia 7, 1
- Fetal analgesia is NOT recommended, as there is no evidence of fetal pain awareness before 24-25 weeks gestation 7, 1
Safety Profile and Complications
D&E has dramatically lower complication rates compared to medical termination methods 1, 2:
- Hemorrhage: 9.1% (vs 28.3% with medical methods) 1, 2
- Infection: 1.3% (vs 23.9% with medical methods) 1, 2
- Retained tissue requiring additional procedure: 1.3% (vs 17.4% with medical methods) 1
Potential complications to monitor:
Post-Procedure Care
Mandatory prophylaxis:
- Antibiotic prophylaxis is required to prevent post-abortal endometritis, which occurs in 5-20% of women without antibiotics 1, 2
- Anti-D immunoglobulin (50 μg) must be given to all Rh-negative women to prevent alloimmunization 1, 2, 6
Monitoring requirements:
- Watch for signs of infection, retained products, and excessive bleeding 1
- Follow-up to confirm complete evacuation 6
Gestational Age Considerations
First trimester (up to 12-13 weeks):
- Manual vacuum aspiration (MVA) is preferred over D&E 6
- Medical abortion with mifepristone plus misoprostol is an alternative up to 9 weeks 6, 8
Second trimester (14-24 weeks):
- D&E is the method of choice throughout this period 1, 2, 4
- The procedure remains safe and effective even at later gestational ages (up to 22 weeks) 4, 5
Critical timing note: Chemotherapy should not be administered during the first trimester due to high risk (up to 20%) of fetal malformations; if chemotherapy is required, first-trimester termination is advised 7
Diagnostic Confirmation
Pathologic examination of D&E specimens:
- Can confirm prenatal diagnoses of fetal abnormalities in virtually all cases 4
- Identifies significant fetal and placental changes that explain intrauterine fetal demise 9
- Provides definitive diagnosis and may identify unexpected anomalies 9
Common Pitfalls to Avoid
- Do not delay treatment waiting for fever if infection is suspected—initiate broad-spectrum antibiotics immediately and proceed with urgent evacuation 6
- Do not use expectant management for confirmed intrauterine fetal demise, as infection risk increases with time 6
- Do not use prostaglandin F compounds in high-risk patients, as they increase pulmonary arterial pressure 2
- Avoid mifepristone plus misoprostol for cervical preparation before D&E due to high pre-procedural expulsion rates 3