Second-Trimester Dilation and Evacuation

Module

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Objectives

By the end of this unit, the learner should be able to do the following:

• List the equipment and supplies needed for second-trimester surgical abortion
• Summarize the steps of second-trimester uterine evacuation (or dilation and evacuation [D&E])
• Explain the possible complications of D&E

Abortion

Preprocedure Visit

• Patient counseling and informed consent*
• Obstetric history (e.g., prior cesarean, midline episiotomy)
• Medical history (transfer to appropriate setting/health care provider if needed)
• Labs: Complete blood count or hemoglobin, rhesus factor status, sexually-transmitted infection testing (risk based)
• Ultrasound for dating
• Antibiotic prophylaxis
• Cervical preparation
• Contraceptive counseling and plan

*As of February 2018, in 27 states there is a mandatory waiting period (24-72 hours) between the time consent is given and the time cervical preparation and abortion are performed.

Cervical Preparation

• Decreases risk of complications including:
  • Hemorrhage
  • Cervical laceration
  • Uterine perforation
• Options (alone or in combination):
  • Pharmacologic (misoprostol, mifepristone)
  • Osmotic dilators (Dilapan-S®, laminaria)
• Less than 16 weeks of gestation
  • Same-day preparation 3-6 hours before procedure
• More than 16 weeks of gestation
  • Overnight preparation 12-24 hours before procedure

Day of Procedure

• Establish intravenous access
• Confirm
  • Consent
  • Contraceptive plan
  • That patient has a ride home
  • Sedation plan
  • Medications and instruments available
• Premedication: Antibiotics more than 30 minutes before procedure

Medications

• Preprocedure misoprostol
  • Option for cervical preparation (2–3 hours preprocedure)
• 1% lidocaine with vasopressin
  • 20 units vasopressin in 50 mL 1% lidocaine
  • 10 mL = 4 units of vasopressin
• Uterotonics available
  • Misoprostol, oxytocin, Methergine®, Hemabate®
• Uterine tamponade balloon available
  • Foley balloon with 30 mL capacity
  • Bakri® balloon

Instruments

• Speculum
  • Klopfer®

  

  • Collins®
• 
  • Weighted
• Atraumatic grasper (Vulsellum® or ring forceps)

• Dilators (e.g., Pratt®, including large)

• Tissue extraction forceps
  • Bierer®

• Blumenthal®

• Hern®

• Sopher®

• Sponges and second ring forceps
• Vacuum aspirator
• Large cannula (12 mm or larger)
• Abdominal ultrasonography

Procedure

1. Position patient in dorsal lithotomy
2. Perform a timeout
3. Administer sedation
4. Remove and count cervical preparation materials if in place
5. Perform bimanual pelvic examination to assess dilation
6. Place speculum and grasper on anterior or posterior lip of cervix
7. Administer lidocaine with vasopressin paracervically
8. Pass tapered dilators if additional dilation needed
9. Perform amniotomy using forceps or suction cannula and drain amniotic fluid
10. With ultrasound guidance use extraction forceps to gently remove fetal parts and placenta
11. Perform suction curettage to confirm that all products of conception are extracted

Postprocedure

12. Tissue examination to ensure completion
    1. Identify and keep track of parts as removed: Skull, arms, legs, spine
    2. Use a pouch or surgical pan at edge of table to collect parts
    3. Identify all parts: Calvarium, pelvis, spine, extremities, volume of placental tissue
13. Place intrauterine device (IUD) or implant after tissue confirmed
14. Monitor bleeding and recovery from sedation for a minimum of 30 minutes depending on sedation type
15. If rhesus factor negative, administer 300 mcg RhoGAM® IM prior to discharge

Postabortion Contraception

Depending on patient preference:

• Consider initiating IUD after evacuation is complete
• Initiate contraceptive implant or injection before discharge
• Dispense or provide prescription for hormonal contraception (oral, transdermal, or vaginal) to be initiated within 10 days of procedure

Complications

Overall, second trimester abortion is very safe.

Risks include the following:

• Cervical laceration: Approximately 3%
• Retained placental tissue, fetal tissue, or both: 1%
• Infection: Approximately 1%
• Hemorrhage: Less than 1%
• Uterine perforation: 0.2–0.5%

Infection

• Infection: Approximately 1%
• Decrease risk with antibiotic prophylaxis: Doxycycline 100 mg 1 hour before procedure PLUS 200 mg postprocedure
• Timing: Administration of antibiotics with dinner the night before decreases nausea and does not compromise nil per os status preprocedure

Hemorrhage

Hemorrhage is defined as greater than 500 mL blood loss with clinical response (admission or transfusion).

• Perform bimanual examination and pelvic ultrasonography
• Uterine atony: Most common cause (2.6% of D&Es)
  • If atony present, administer uterotonics
    • Methergine® 0.2 mg IM
    • Misoprostol 600 mcg SL
    • Hemabate® 250 mcg IM, repeat PRN q15-90min; no more than 2000 mcg or 8 doses
  • Not all have clinically significant hemorrhage with atony
• Ensure that procedure is complete (no retained placental tissue or fetal tissue)
• Assess for cervical laceration
• If bleeding persists:
  • Monitor for development of disseminated intravascular coagulation
  • Consider risk factors for abnormal placentation
  • Consider uterine tamponade with balloon and transfer if in outpatient setting
  • Consider intravenous fluid administration: 500-1000 mL bolus

Follow Up

• Routine postabortion follow-up is not required
• If IUD is placed
  • Provide education to recognize expulsion
  • Schedule follow-up to confirm IUD in place in 2-6 weeks

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Author

• Kate A. Shaw, MD, MS Clinical Associate Professor Stanford University School of Medicine

Version 1.0, posted February 2018