Dilation and evacuation

1. Transcervical dilation and evacuation of the uterus (D&E) is the method most commonly used for mid-trimester abortions before 21 menstrual weeks. In the one-stage technique, forcible dilation is performed slowly and carefully to sufficient diameter to allow insertion of large, strong ovum forceps for evacuation. The better approach is a two-stage procedure in which multiple Laminaria are used to achieve gradual dilatation over several hours before extraction. Uterine evacuation is accomplished with long, heavy forceps, using the vacuum cannula to rupture the fetal membranes, drain amniotic fluid, and ensure complete evacuation.

2. Preoperative ultrasonography is necessary for all cases 14 weeks and beyond. Intraoperative real-time ultrasonography helps to locate fetal parts within the uterus.

3. Dilation and evacuation becomes progressively more difficult as gestational age advances, and instillation techniques are often used after 21 weeks. Dilation and evacuation can be offered in the late mid-trimester, but two sets of Laminaria tents for a total of 36-48 hours is recommended. After multistage Laminaria treatment, urea is injected into the amniotic sac. Extraction is then accomplished after labor begins and after fetal maceration has occurred.

References: See page 184.

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