Dilation and evacuation (D&E) for abortion

Surgery Overview

Dilation and evacuation (D&E) is done in the second 12 weeks (second trimester) of pregnancy. It usually includes a combination of vacuum aspiration, dilation and curettage (D&C), and the use of surgical instruments (such as forceps).

An ultrasound is done before a D&E to determine the size of the uterus and the number of weeks of the pregnancy.

A device called a cervical (osmotic) dilator is often inserted in the cervix 24 hours before the procedure to help slowly open (dilate) the cervix. Dilating the cervix reduces the risk of any injury to the cervix during the procedure. Misoprostol may also be given several hours before surgery. This medicine can help soften the cervix.

D&E usually takes 30 minutes. It is usually done in a hospital but does not require an overnight stay. It can also be done at a clinic where health professionals are specially trained to perform abortion. During a D&E procedure, your health professional will:

• Give you a first dose of antibiotic to prevent infection.
• Position you on the exam table in the same position used for a pelvic exam, with your feet on stirrups while lying on your back.
• Insert a speculum into the vagina.
• Clean the vagina and cervix with an antiseptic solution.
• Give you a pain medicine injection in the cervical area (paracervical block) along with a sedative. If the procedure is done in an operating room, you could receive a spinal anesthesia injection into the fluid around the spinal cord, which numbs the area between your legs, or general anesthesia, which makes you unconscious.
• Grasp the cervix with an instrument to hold the uterus in place.
• Dilate the cervical canal with probes of increasing size. An abortion in the second 12 weeks will need the cervix to be dilated more than required for a vacuum aspiration or D&C.
• Pass a hollow tube (cannula) into the uterus. The cannula is attached by tubing to a bottle and a pump that provides a gentle vacuum to remove tissue in the uterus. Some cramping is felt during the rest of the procedure.
• Pass a grasping instrument (forceps) into the uterus to grasp larger pieces of tissue. This is more likely in pregnancies of 16 weeks or more and is done before the uterine lining is scraped with a curette.
• Use a curved instrument (curette) to gently scrape the lining of the uterus and remove tissue in the uterus.
• Use suction, which may be done as a final step to make sure the uterine contents are completely removed.
• Give you a medicine to reduce the amount of bleeding with the procedure.

The uterine tissue removed during the D&E is examined to make sure that all of the tissue was removed and the abortion is complete.

Health professionals may use ultrasound during the D&E procedure to confirm that all of the tissue has been removed and the pregnancy has ended.

What To Expect After Surgery

Dilation and evacuation (D&E) is a surgical procedure. A normal recovery includes:

• Irregular bleeding or spotting for the first 2 weeks. During the first week, avoid tampons and use only sanitary pads.
• Cramps similar to menstrual cramps, which may last from several hours to a few days, as the uterus shrinks back to its nonpregnant size.
• Emotional reactions for 2 to 3 weeks.

After the procedure:

• Antibiotics are given to prevent infection.
• Rest quietly that day. You can do normal activities the following day, based on how you feel.
• Acetaminophen (such as Tylenol) or ibuprofen (such as Advil) can help relieve cramping pain.
• Medicines may be given to help the uterus contract and return to its prepregnancy size.
• Do not have sexual intercourse for at least 1 week, or longer, as advised by your health professional.
• When you start having intercourse again, use birth control, and use condoms to prevent infection. For immediately effective birth control, you can use a barrier method (such as a diaphragm, cervical cap, or condom). An intrauterine device (IUD) is effective immediately after it is placed in the uterus. If you start hormone birth control pills, patches, or injections right after the procedure, be sure to use a backup method until the hormone medicine becomes effective. For more information, see the topic Birth Control.

Signs of complications

Less than 1% of all women who have an abortion have serious problems afterward.¹

Call your health professional immediately if you have any of these symptoms after an abortion:

• Severe bleeding. Both medical and surgical abortions usually cause bleeding that is different from a normal menstrual period. Severe bleeding can mean:
  • Passing clots that are bigger than a golf ball, lasting 2 or more hours.
  • Soaking more than 2 large sanitary pads in an hour, for 2 hours in a row.
  • Bleeding heavily for 12 hours in a row.
• Signs of infection in your whole body, such as headache, muscle aches, dizziness, or a general feeling of illness. Severe infection is possible without fever.
• Severe pain in the abdomen that is not relieved by pain medicine, rest, or heat
• Hot flushes or a fever of 100.4°F (38°C) or higher that lasts longer than 4 hours
• Vomiting lasting more than 4 to 6 hours
• Sudden abdominal swelling or rapid heart rate
• Vaginal discharge that has increased in amount or smells bad
• Pain, swelling, or redness in the genital area

Call your health professional for an appointment if you have had any of these symptoms after a recent abortion:

• Bleeding (not spotting) for longer than 2 weeks
• New, unexplained symptoms that may be caused by medicines used in your treatment
• No menstrual period within 6 weeks after the procedure
• Signs and symptoms of depression. Hormonal changes after a pregnancy can cause postpartum depression that requires treatment.

Why It Is Done

Dilation and evacuation (D&E) is one of the methods available for a second-trimester abortion. A D&E is done to completely remove all of the tissue in the uterus for an abortion in the second trimester of pregnancy.

• A D&E is sometimes recommended for women diagnosed in the second trimester with a fetus that has severe medical problems or abnormalities.
• A woman who is pregnant as a result of rape or incest may not confirm the pregnancy until the second trimester because of her emotional reaction to the traumatic cause of the pregnancy.
• A woman who doesn't have access to an affordable abortion specialist in her area or whose access is slowed by legal restrictions may take several weeks to have a planned abortion. When an abortion is delayed, a D&E may be necessary.¹

How Well It Works

Dilation and evacuation is a safe and effective method. It has become the standard treatment of care in the United States for an abortion in the second trimester of pregnancy.

Risks

The risks of dilation and evacuation (D&E) include:

• Injury to the uterine lining or cervix.
• A hole in the wall of the uterus (uterine perforation, rare), which most commonly happens during cervical dilation. Bleeding is usually minimal, and no repair is necessary. If bleeding is a concern, a laparoscopy (a procedure that uses a lighted viewing instrument) can be used to see whether it has stopped.
• Infection. Bacteria can enter the uterus during the procedure and cause an infection. This is more likely if an untreated disease, such as a sexually transmitted disease (STD), is present before the procedure. Antibiotics given during and after the D&E procedure will reduce this risk.
• Moderate to severe bleeding (hemorrhage), which is sometimes caused by:
  • Injury to the uterine lining or cervix.
  • Uterine perforation.
  • Uterine rupture. In rare cases, an upper uterine incision scar tears open when a medicine is used to induce contractions. (The lower uterus, where most cesarean scars are, is thicker and has much less risk for rupture.)
  • Tissue remaining in the uterus (retained products of conception). This usually causes recurring cramping abdominal pain and bleeding within a week of the procedure. However, prolonged bleeding sometimes does not occur until several weeks later.

Risks are higher for surgical abortions done in the second trimester of pregnancy than for those done in the first trimester, particularly if they are done after 16 weeks of pregnancy.

Other rare complications include:

• Tissue remaining in the uterus (retained products of conception). Cramping abdominal pain and bleeding recur within a week of the procedure. However, prolonged bleeding sometimes does not develop until several weeks later.
• Blood clots. If the uterus doesn't contract to pass all the tissue, the cervical opening can become blocked, preventing blood from leaving the uterus. The uterus becomes enlarged and tender, often with abdominal pain, cramping, and nausea.

A repeat vacuum aspiration and medicine to stop bleeding are used to treat retained products of conception or blood clots.

What To Think About

An abortion is unlikely to affect your fertility, so it is possible to become pregnant in the weeks right after the procedure. Avoid sexual intercourse until your body has fully recovered, for at least 1 week, or as advised by your health professional. When you do start having intercourse again, use birth control, and use condoms to prevent infection.

Counseling for a second-trimester abortion may be more involved than for an early abortion because of the length of the pregnancy and the reason for the abortion.

Should you have continuing emotional reactions after an abortion, seek counseling from a grief counselor or other licensed mental health professional.

Postpartum depression can be triggered by changing pregnancy hormones after an abortion. If you have more than 2 weeks of symptoms of postpartum depression, such as fatigue, sleep or appetite change, or feelings of sadness, emptiness, anxiety, or irritability, see your health professional about treatment. Keep track of your symptoms with a postpartum depression checklist(What is a PDF document?).

The hospital or surgery center may send you instructions on how to get ready for your surgery or a nurse may call you with instructions before your surgery.

Right after surgery, you will be taken to a recovery area where nurses will care for and observe you. You will probably stay in the recovery area for 1 to 4 hours. You will then be moved to a hospital room or you will go home. In addition to any special instructions from your doctor, your nurse will explain information to help you in your recovery. You will go home with a page of care instructions including who to contact if a problem arises.

Complete the surgery information form (PDF)(What is a PDF document?) to help you prepare for this surgery.

Author:	Healthwise Medical Writer	Last Updated: October 6, 2006
Medical Review:	Joy Melnikow, MD, MPH - Family Medicine Lori A. Boardman, MD, ScM - Obstetrics and Gynecology
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