Fewer studies have evaluated mifepristone for cervical ripening. In one, mifepristone alone provided less dilation than hydroscopic dilators (BO'gatta, 2012). In another trial, mifepristone added 48 hours before misoprostol created greater cervical dilation compared with misoprostol alone (Carbonell, 2007). Last, Goldberg and associates (2015) compared hygroscopic dilation with or without added mifepristone. They found no diferences for gestations < 19 weeks, but the combination aided procedures for later ages.
In sum, hygroscopic dilators are consistently efective for cervical preparation before D & E. For those desiring same-day procedures, Dilapan-S alone or misoprostol alone may ofer advantages. Layering agents may be most helpful for later gestations or for an inadequate response from initial hygroscopic dilators alone. Yet, layering adds cost and potential side efects (Shaw, 2016).
With elective abortion, some choose to induce fetal demise prior to D & E to avert a live birth or to avoid violating the Partial Birth Abortion Ban Act, cited later (Diedrich, 2010). For this, an intracardiac potassium chloride injection or a 1-mg intraamnionic or intrafetal digoxin injection is frequently used prior to cervical ripening (Sfakianaki, 2014; White, 2016).
During D & E, sonography can be used as an adjunct in all cases or selectively in more challenging ones. Perioperative antibiotic prophylaxis mirrors that for first-trimester procedures (p. 359). To reduce postprocedure bleeding, vasopressin, 2 to 4 units in 20 mL of saline or anesthetic, can be injected intracervically or as part of a paracervical block (Kerns, 2013; Schulz, 1985). Once adequate cervical dilation is achieved, the initial surgical step drains amnionic fluid with an 11-to 16-mm suction cannula or with amniotomy and gravity. his reduces the risk of amnionic fluid embolism and brings the fetus into the lower uterine segment for removal (Owen, 2017; Prager, 2009).
For pregnancies beyond 16 weeks, the fetus is extracted, usually in parts, using Sopher forceps or other destructive instruments. With complete removal of the fetus, a large-bore vacuum curette is used to remove the placenta and remaining tissue.
Major complications are infrequent with D & E, and rates range from 0.2 to 2 percent in large series (Cates, 1982; Lederie, 2015; Peterson, 1983). These include uterine perforation, cervical laceration, uterine bleeding, and postabortal infection. Rare complications include disseminated intravascular coagulopathy or amnionic luid embolism (Ray, 2004; York,i2012).
Placenta previa or the accrete syndromes can raise D & E risks.
Once diagnosed, placenta accreta typically prompts hysterec tomy (Matsuzaki, 2015). For placenta previa, D & E is preferred to quickly evacuate the placenta, but the ability to transfuse present (American College of Obstetricians and Gynecologists, 2017h; Perriera, 2017). Medical induction may be elected, but the risk for transfusion is greater than with D & E (Nakayama, 2007; Ruano, 2004). Data are few, but predelivery uterine artery embolization may lower bleeding risks (Pei, 2017).