User:Squirreltime/Dilation and evacuation

Dilation and evacuation (D&E) 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. It is a method of abortion as well as a common procedure used after miscarriage to empty the uterus of any remaining tissue.

D&E typically refers to the above specific second trimester procedure. However, confusion often arises over the acronyms and 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 (correctly abbreviated D&C). Dilation and Extraction (D&X) is a different procedural variation on D&E.

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 *  Medical uses / indications 
 * Contra-indications
 * Risks/Complications
 * Technique (avoid step-by-step instructions)
 * Recovery or Rehabilitation
 * History (e.g., when it was invented)
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Indications for D&E
Dilation and evacuation (D&E) is a method to completely remove a pregnancy from the uterus in the second trimester of pregnancy. The alternative to D&E in the second trimester is a labor induction. A D&E may be performed for a surgical abortion, or for surgical management of a miscarriage, pregnancy loss or stillbirth.

Abortion
Induced abortion after the first trimester of pregnancy is rare. Approximately 630,000 abortions were performed in the US in 2015, the most recent year for which data are available. 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 gestation. In the United States, 95-99% of abortions after the first trimester of pregnancy are performed by surgical abortion via dilation and evacuation.

People who do not have access to affordable abortion care in their area or who face legal restrictions to obtaining a wanted abortion may be forced to wait longer to get an abortion after they make the decision to terminate their pregnancy. When an abortion is delayed from the first trimester into the second trimester, a D&E may be necessary.

Miscarriage
Dilation and evacuation can be offered for 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. Both methods 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.

Description
D&E can be performed in an outpatient or inpatient setting, with out without varying degrees of anesthesia. All of these variables are dependent on patient situation, cost, medical resources and political environment.

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is performed under anesthesia, most commonly sedation with light general anesthesia, although local paracervical block or regional anesthesia may be used. It may be performed with or without ultrasound guidance. Performance under ultrasound guidance has greatly improved our understanding about what actually occurs during a D&E. Prior to the procedure, the cervix is usually softened and passively dilated using osmotic dilators and/or misoprostol. This facilitates cervical dilation during the procedure without injury to the cervix.

The first step in the procedure itself is dilation of the cervix. The second step is insertion of a vacuum curette through the cervix. Under ultrasound, the tip of that curette is placed up against the fetal chest or abdomen. The suction is turned on. Amniotic fluid is removed and the fetus dies instantly due to removal of the fetal heart, lungs, and abdominal contents.

This leaves the fetal cranium and skeleton with soft tissue to be removed. The thorax, pelvis, cranium, and each arm and leg are removed separately using surgical instruments. The fetal cranium will usually have to be crushed in order to be extracted. Use of ultrasound greatly facilitates this part of the procedure although it may be done safely without ultrasound guidance. In the absence of ultrasound, the tissue will be carefully inspected to ensure all fetal tissue is removed. It is important to recognize that this is the removal of dead tissue to protect the patient from bleeding and infection well after the fetus died instantly. The fetus is almost never dismembered alive.

After removal of all fetal tissue, the uterine cavity is thoroughly curetted to ensure that all placental tissue, blood, and membranes are removed. The uterus will then be massaged to ensure it is firmly contracted to minimize post operative bleeding. The entire procedure usually takes less than 30 minutes and is well tolerated.

Recovery
Most D&E's are performed in the outpatient setting, and can be safely sent home same day after a period of observed recovery, ranging from 45 minutes to several hours. The type of anesthesia given also influences the appropriate amount of recovery time before discharge. There is rarely a need for narcotic pain medications afterwards, and NSAIDs are recommended for home pain management. Recovery from the procedure is typically fast and uncomplicated.

Some women may experience lactation after a second-trimester loss or termination of pregnancy. At this time, medications to suppress lactation are not proven to be effective.