Dilation and Evacuation (D&E): A Comprehensive Overview
Dilation and evacuation (D&E) or dilatation and evacuation (British English) is a gynecological procedure. It 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. 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.
Background and Overview of D&E
D&E is a surgical abortion type and was first used in the 1970s. 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 healthcare 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)
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.
Indications for D&E
Dilation and evacuation (D&E) is one of the methods available to completely remove the fetus and all of the placental tissue in the uterus after the first trimester of pregnancy. A D&E may be performed for a surgical abortion or for surgical management of a miscarriage.
Abortion
Induced abortion after the first trimester of pregnancy is rare. 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.
When an abortion is delayed, a D&E may be necessary. 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. Abortion can be considered in the case of congenital anomalies, including genetic aneuploidies and anatomic anomalies, especially since they may not be identified until the second trimester. Other medical indications for an abortion in the second trimester include preeclampsia with severe features or preterm premature rupture of membranes prior to a viable fetal age.
Abortion Statistics (US, 2020)
| Total Documented Abortions | Medication Abortions |
|---|---|
| Approximately 930,000 | 492,000 |
Miscarriage
Dilation and evacuation can be offered for the management of second trimester miscarriage if skilled providers are available. 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. Both a labor induction and dilation and evacuation offer the option of fetal and placental testing. Although pregnancy loss is emotionally distressing, there are rarely medical complications associated with a short (<1 week) delay to management.
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.
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.