Second-Trimester Pregnancy Termination - Dilation and Evacuation - UpToDate

10/17/2016 Secondtrimester pregnancy termination: Dilation and evacuation UpToDate
Official reprint from UpToDate®
www.uptodate.com.scihub.cc ©2016 UpToDate®
Secondtrimester pregnancy termination: Dilation and evacuation
Author: Cassing Hammond, MD
Section Editor: Jody Steinauer, MD, MAS
Deputy Editor: Sandy J Falk, MD, FACOG поменять
прокси
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Nov 17, 2015.
INTRODUCTION — Secondtrimester (14 to <28 weeks of gestation) pregnancy terminations comprise 10 to
15 percent of the approximately 42 million abortions performed annually worldwide [1,2]. The United States
Centers for Disease Control and Prevention reported that 7.0 percent of abortions were performed between
14 to 20 weeks and 1.3 percent at or after 21 weeks [3].
The most common surgical technique for secondtrimester termination in the United States is dilation and
evacuation (D&E), and will be the focus of this topic [4,5]. Other surgical approaches include intact D&E,
which is a variant of D&E, and hysterotomy [6]. Hysterotomy is rarely used except when it is unsafe to dilate
the cervix or induce labor, or when there is no trained D&E provider. Some patients with severe cervical
stenosis or leiomyomas that completely obstruct the cervix and vagina may require hysterotomy.
Secondtrimester surgical pregnancy termination is reviewed here. An overview of secondtrimester
pregnancy termination and the technique for induction abortion are discussed separately. (See "Overview of
secondtrimester pregnancy termination" and "Second trimester pregnancy termination: Induction
(medication) termination".)
OVERVIEW — The dilation and evacuation procedure for secondtrimester pregnancy termination consists of
two components:
● Preparation and dilation of the cervix with osmotic, pharmacologic, and/or mechanical dilators
● Evacuation of the uterus with suction, extraction forceps, and curettage
Cervical preparation with osmotic and/or pharmacologic dilators is usually performed a day or two before the
procedure. On the day of the procedure, anesthesia and prophylactic antibiotics are administered. If further
cervical dilation is needed, this is performed with mechanical dilators (eg, Pratt, Hegar) just prior to the
procedure. Uterine evacuation is then performed. (See "Surgical instruments for gynecologic surgery", section
on 'Cervical dilators'.)
Indications and contraindications, counseling, and other issues related to the procedure are discussed
separately. (See "Overview of secondtrimester pregnancy termination".)
PREPROCEDURE PREPARATION
Cervical preparation — Cervical preparation is performed prior to secondtrimester dilation and evacuation
(D&E). This is a process of softening and dilating the cervix prior to the procedure to minimize cervical trauma
by avoiding the need for extensive mechanical dilation on the day of the procedure. Rapid mechanical dilation
is a risk factor for cervical insufficiency and may result in future secondtrimester pregnancy loss [7]. Osmotic
dilators (eg, laminaria) are the standard method of cervical preparation. In cases in which osmotic dilation
alone is not sufficient, dilators may be used in combination with a pharmacologic agent, typically misoprostol
and/or mifepristone. (See "Cervical insufficiency", section on 'Risk factors'.)
SciHub https://www.uptodate.com/contents/secondtrimesterpregnancyterminationdilationandevacuation
URL статьи или журнала, или DOI, или строка для поиска
http://www.uptodate.com.secure.scihub.cc/contents/secondtrimesterpregnancyterminationdilationandevacuation/print?source=search_result&searc… 1/21
Osmotic dilators — Osmotic dilators absorb moisture and thus gradually expand within the cervical canal
(table 1 and picture 1 and picture 2). They are placed one to two days prior to the procedure. In a twoday
dilation, on the second day, the dilators are removed and larger diameter or more numerous dilators are
placed on the second day. (See "Overview of pregnancy termination", section on 'Osmotic dilators'.)
In general, osmotic dilators are the mainstay of cervical preparation. Highquality evidence demonstrates that
when only one method of cervical preparation is used, osmotic dilators are the most effective method. The
efficacy of osmotic dilators compared with prostaglandins was illustrated in a metaanalysis of randomized
trials [8]. Based upon data from two trials, use of osmotic dilators compared with prostaglandins (usually
поменять
misoprostol) resulted in an average of 3.6 mm greater dilation and in a significantly decreased rate of a need
прокси
for further mechanical dilation (17 versus 85 percent; odds ratio [OR] 0.07, 95% CI 0.030.17) and of difficult
mechanical dilation (3 versus 23 percent; OR 0.17, 95% CI 0.060.47). This analysis was limited by the small
number of trials and number of participants in each trial. These studies were not large enough to detect
differences in infrequent complications, such as cervical laceration or uterine perforation.
The disadvantage of osmotic dilators is that they must be placed at least a day prior to the procedure and
often are placed over two days (with an additional visit to place a larger set of dilators on the second day) prior
to the procedure, although sameday options are available [9]. In contrast, misoprostol can be given the same
day as the procedure, allowing for the procedure to be completed in one day. This decreases the expense of
secondtrimester abortion and increases access for many patients.
Types of osmotic dilators (eg, laminaria) and the techniques for insertion are discussed in detail separately.
(See "Overview of pregnancy termination", section on 'Osmotic dilators'.)
Dilators with misoprostol or mifepristone — Osmotic dilators alone may not be sufficient at later
gestational ages or in women in whom dilation is not proceeding effectively or difficult dilation is anticipated. In
these patients, a combination of an osmotic dilator and a pharmacologic agent is the preferred approach.
Based on the available evidence reviewed below, our approach is:
● For women undergoing secondtrimester surgical abortion at >16 weeks of gestation, if a single method
of cervical preparation is used, we recommend osmotic dilators rather than a pharmacologic agent
(misoprostol or mifepristone).
However, for women in whom osmotic dilation alone is not sufficient, we suggest that osmotic dilators be
used with a pharmacologic agent rather than osmotic dilators alone. For use as an adjunct to osmotic
dilators, we suggest mifepristone rather than misoprostol. The need for mifepristone is determined by the
clinician at the time they are placed based on the difficulty of placing the dilators. Patients at risk for
difficult dilation include those with the following characteristics: prior cervical conization, lower segment
fibroids, prior cervical infection, or a known history of cervical stenosis.
In our practice, we use mifepristone as an adjunct to osmotic dilators for patients with the following
characteristics: (1) ≥20 weeks of gestation in whom we are unable to place 8 to 10 osmotic dilators during
the first dilator placement, or (2) any other patient at ≥20 weeks in whom we anticipate difficult dilation
based on the size of the gestation and the surgeon's subjective assessment of the cervix at time of dilator
placement. We administer mifepristone 200 mg orally 24 hours before dilation and evacuation (D&E).
Mifepristone often permits placement of fewer dilators without compromising cervical dilation. We had
previously used misoprostol as an adjunctive medication, but based upon data and our experience on
efficacy and tolerability, we now use mifepristone.
● For women undergoing secondtrimester surgical abortion at ≤16 weeks of gestation, cervical preparation
with misoprostol alone is a reasonable option, rather than either osmotic dilators alone or misoprostol or
mifepristone combined with osmotic dilators. Misoprostol alone is appropriate for women who do not have
SciHub
risk factors for cervical stenosis, and it offers that advantage of completing the procedure in one day.
https://www.uptodate.com/contents/secondtrimesterpregnancyterminationdilationandevacuation
We use the gestational age threshold of 16 weeks because there are few data for use of misoprostol
alone for cervical preparation at later gestational ages [8].
The United States Society of Family Planning (SFP) guidelines are consistent with our recommendations. The
SFP advises the following [10,11]:
● Routine use of misoprostol as an alternative to osmotic dilation prior to secondtrimester D&E after 16
weeks of gestation is not recommended due to increased risk of inadequate cervical dilation.
● Routine use of adjunctive buccal misoprostol in addition to osmotic dilators for preoperative cervical
поменять
прокси
preparation is not recommended in the early second trimester (before 16 weeks), but may be considered
at later gestational ages.
● Buccal or vaginal misoprostol use may be considered by experienced clinicians in lieu of osmotic dilation
early in the second trimester (before 16 weeks) in women at low risk for cervical or uterine injury.
Randomized trial data shows that the combination of dilators with misoprostol or mifepristone improves
outcomes compared with dilators alone:
● Misoprostol with laminaria resulted in greater dilation in women at later gestational ages in one
randomized trial [12]. Women at 13 to 21 weeks (n = 125) underwent D&E with placement of laminaria
the day before the procedure. Participants were assigned to receive a buccal 400 mcg misoprostol or
placebo at 90 minutes before the procedure. Misoprostol increased the initial mean dilation only in
gestations ≥19 weeks (53.6 versus 48.5 French), but not at earlier gestational ages. Women receiving
buccal misoprostol reported more cramping.
● Misoprostol combined with laminaria compared with laminaria plus placebo was evaluated in a
randomized trial of women at 21 to 23 weeks [13]. Mean D&E duration was 1.7 minutes shorter with
misoprostol. Cervical dilation was minimally greater with misoprostol (median 75 mm versus 73 mm);
however, clinicians did not find the misoprostol D&Es easier to complete. Severe pain was reported in
significantly more women treated with misoprostol (50 versus 11 percent).
● Use of either misoprostol or mifepristone with osmotic dilators resulted in better outcomes than osmotic
dilators alone in another randomized trial (n = 300), including use of additional mechanical dilation and
operative duration [14]. Efficacy was highest and adverse effects were lowest with mifepristone rather
than misoprostol. This trial is described in detail below.
Misoprostol had been the medication most commonly used as an adjunct to osmotic dilators. Adjunctive
misoprostol has been shown to increase cervical dilation at later gestational ages, though women experience
more side effects related to misoprostol. Adjunctive mifepristone improves cervical dilation and might
decrease the need for multiple sets of osmotic dilators without increasing side effects commonly seen with
misoprostol [15,16].
Use of misoprostol combined with mifepristone has been evaluated in two randomized trials:
● A randomized trial found that use of mifepristone can shorten the duration of osmotic dilator use. This trial
included women from 19 to 23 6/7 weeks (n = 50); all patients received misoprostol (400 mcg, buccal),
and women were assigned to mifepristone (200 mg) plus osmotic dilators for one day (one set of dilators
was used) versus osmotic dilators for two days (two sets were used; dilators were changed after one day)
without mifepristone [15]. There was no significant difference in procedure duration (approximately 11
minutes in both groups) or ease of procedure between the two groups. Mifepristone resulted in higher
preoperative and postoperative pain scores, but both groups reported that the experience was "better
than expected."
● Another randomized trial found that combined use of misoprostol and mifepristone was more effective
than misoprostol alone. This trial included women from 12 to 20 weeks (n = 877) and assigned women to
mifepristone (200 mg) with misoprostol (600 mcg; women were assigned to either sublingual or vaginal
administration) or misoprostol alone (600 mcg; either sublingual or vaginal administration) [16]. Dilapan
tents were used in significantly fewer women in the mifepristone group than in the misoprostol alone
group (30 versus 54 percent). Average cervical dilation was significantly more in the mifepristone group
(12.5 versus 8.5 mm). Procedure duration was approximately one minute shorter with use of
mifepristone.
Use of misoprostol versus mifepristone as an adjunct to osmotic dilators has been evaluated in only one
randomized trial: поменять
прокси
● A randomized trial evaluated adjunctive misoprostol or mifepristone in two gestational age cohorts, and
found that both agents resulted in a lower use of mechanical dilation and less surgical difficulty, but
mifepristone also resulted in a decrease in total procedure duration and had fewer adverse effects [14].
Women (n = 300) were enrolled in two groups, 16 to 186/7 weeks of gestation and 19 to 236/7 weeks, and
assigned to one of three interventions: overnight osmotic dilators alone, dilators plus misoprostol (400
mcg, buccal) three hours preoperatively, or dilators plus mifepristone (200 mg) during mechanical dilator
placement at time of D&E. Findings included:
• D&E operative time was not significantly decreased across groups, but total procedure time was
significantly higher with dilators alone compared with mifepristone, particularly in the late cohort
(dilators versus mifepristone: early cohort, 8 versus 7 minutes; late cohort, 13 versus 9 minutes).
• Use of additional mechanical dilation at surgery was significantly higher with dilators alone compared
with a pharmacologic adjunct (total cohort: dilators alone [27 percent] versus misoprostol [9 percent]
versus mifepristone [16 percent]).
• Surgical difficulty (by surgeon report) was significantly decreased with a pharmacologic adjunct,
particularly with mifepristone (early cohort: dilators alone [12 percent] versus misoprostol [4 percent]
versus mifepristone [2 percent]; late cohort: dilators alone [19 percent] versus misoprostol [19
percent] versus mifepristone [4 percent]).
• Adverse effects were highest with misoprostol, including an unacceptable level of pain (37 percent
versus 8 to 9 percent in other groups) and fever (8 percent versus 0 percent in other groups).
• Complications were lower with use of a pharmacologic adjunct, but the study was inadequately
powered to detect a significant difference (dilators [10 percent] versus misoprostol [2 percent] versus
mifepristone [2 percent]).
Investigators have evaluated several other pharmacologic agents as primary or adjunctive ripening agents,
including gemeprost, meteneprost, prostaglandin (PG) F2a, and PG E2 vaginal suppositories, but none of
these has been found to be preferable to misoprostol or mifepristone [1719].
Injection to induce fetal demise — Injection of a substance to cause fetal demise prior to secondtrimester
surgical abortion is controversial. The advantages of this practice are that feticidal injection precludes the
possibility of live birth, thereby potentially reducing emotional stress on the patient, and also allowing the
surgeon to minimize concerns regarding compliance with legislation that penalizes uterine evacuation in which
portions of the fetus are removed prior to demise [20]. In addition, it has been proposed that fetal demise
makes the procedure technically easier by inducing fetal maceration and cervical priming, but this has not
been demonstrated. Many clinicians use such injections before all secondtrimester surgical abortions, while
others use them only in those cases in which they consider this to have a benefit for the patient.
The benefits of feticidal injection to the patient remain unproven. Two randomized trials arrived at conflicting
results regarding whether injection of digoxin prior to D&E resulted in an increased rate of extramural birth
SciHub
(spontaneous delivery of the fetus prior to the procedure) or an increased risk of infection [21,22]. Extramural
birth sometimes occurs prior to demise, and this, along with the unplanned nature of this event, may
potentially cause distress to the patient. In addition, feticidal injection has been associated with an increased
rate of nausea or pelvic pain [20]. A report by the Society of Family Planning found insufficient evidence to
support preD&E feticidal injection [23]. Some experts have questioned the ethics of adding this invasive
procedure with potential risks and unproven benefits, particularly if performed principally to fulfill a legal
requirement.
Given the available data and other considerations, for most women undergoing secondtrimester D&E, we
suggest not using feticidal injection. Use of feticidal injection is a reasonable option for women who place a
high value on preprocedure feticidal injection and who are willing to accept a potential increased risk ofпоменять
extramural birth, infection, and other adverse effects (nausea or pelvic pain). прокси
The technique and choice of agents used for induced fetal demise are discussed in detail separately. (See
"Induced fetal demise".)
Anesthesia — Secondtrimester D&E is typically performed using a paracervical block and intravenous
conscious sedation. Anesthesia for D&E is discussed separately. (See "Overview of pregnancy termination",
section on 'Anesthesia'.)
Prophylactic antibiotics — The American College of Obstetricians and Gynecologists advises a single dose
of antibiotics just prior to induced abortion for prevention of surgical site infection (table 2) [24]. This is
consistent with guidelines from the National Abortion Federation, which recommends antibiotic prophylaxis for
all first and secondtrimester surgical abortions [25].
Pregnancy termination procedures do not require antibiotic prophylaxis for bacterial endocarditis, in the
absence of highrisk conditions. (See "Antimicrobial prophylaxis for bacterial endocarditis", section on 'Clinical
approach'.)
Thromboprophylaxis — Thromboprophylaxis is not typically required for secondtrimester D&E. Indications
for thromboprophylaxis for surgical procedures are discussed separately. (See "Prevention of venous
thromboembolic disease in surgical patients".)
PROCEDURE
Speculum — A Graves or Pederson speculum is typically used, but in some cases, these speculums make
the dilation and evacuation (D&E) procedure challenging to accomplish because they prevent introduction of
extraction forceps beyond the hub of the speculum. Alternatives include doing the procedure without a
speculum (using care to visualize the cervix with each pass of the forceps) or using a shortbladed speculum
(eg, Klopfer speculum). We routinely use a Klopfer speculum because a long speculum (Pederson, Graves)
limits the degree of freedom in the arc of movement of long instruments.
Cervical dilation — Based upon the diameter of most forceps used for D&E, the minimum dilation required
ranges from 14 to 19 mm (42 to 57 French) [10]. Sufficient cervical dilation decreases the risk of morbidity,
including cervical injury and uterine perforation [2628].
Cervical preparation with osmotic dilators and/or prostaglandins accomplishes some of this dilation. Additional
dilation may be required in some cases. In general, the extraction forceps should easily traverse the cervix
without resistance. In our practice, we use Sopher forceps (picture 3) for pregnancies through 16 to 18 weeks
gestational size. After 18 weeks of gestation, we prefer the larger Bierer forceps (picture 4).
The procedure and instrumentation for mechanical cervical dilation is described separately. (See "Dilation and
curettage", section on 'Cervical dilation' and "Surgical instruments for gynecologic surgery", section on
'Cervical dilators'.)
Uterine evacuation — The D&E procedure for evacuation of the fetus and placenta is performed using a
combination of suction, extraction with forceps, and curettage.
After adequate cervical dilation is achieved, suction curettage is performed. Suction cannulae up to 16 mm
permit evacuation of gestations through approximately 16 to 18 weeks. The procedure for suction curettage is
described separately. (See "Surgical termination of pregnancy: First trimester", section on 'Curettage'.)
If a cannula smaller than 16 mm is used or the gestational age is greater than 16 to 18 weeks, suction
curettage is followed by use of fetal extractor forceps (eg, Hern, Van Lith, Sopher, or Bierer forceps) to
remove fetal parts (picture 3 and picture 4). Procedures that require use of large forceps should be performed
by an experienced surgeon.
поменять
Techniques that facilitate the procedure and help to avoid complications include: прокси
● Ultrasound guidance can provide information about the uterine anatomy and the location of fetal parts.
This may facilitate technically challenging extractions and may decrease the risk of uterine perforation
[29]. Providers should consider using ultrasound in obese patients, patients with uterine anomalies, and in
any case in which the provider experiences difficulty with extraction. One study of over 4500 second
trimester surgical abortions found no increased risk of complications in obese patients [30].
● Digital examination of the uterine cavity can help to locate fetal parts, which helps to correctly place the
extraction forceps.
● Most surgeons find they have to open the extraction forceps wider than anticipated, particularly to encircle
the calvaria of a later gestation.
● The pregnant uterus curves somewhat anteriorly. Some forceps, such as the Hern, angle the jaws of the
instrument anteriorly to help correct for the natural location of fetal parts.
● Surgeons must be very careful to avoid pushing fetal parts with the forceps since this may push them
deeper into the fundus and even through the uterine wall, causing uterine perforation.
● The fetal parts should be brought down to the lower uterine segment for disarticulation. This prevents
operating in close proximity to the thinner and more easily perforated uterine fundus. Caution should be
employed since bony spicules exposed during fetal disarticulation can perforate the uterine walls and
abrade the cervix.
● The optimal approach is to operate in the midline. More lateral placement of forceps may result in a
lateral uterine perforation with potential involvement of the uterine vessels.
● Surgeons should attempt to reduce the number of passes of extraction forceps since this reduces the
opportunity to perforate the uterus or abrade the cervix. When possible, the fetus should be removed as
intact as possible, which minimizes the number of passes and provides greater assurance of complete
extraction.
● Surgeons may utilize the Hanson maneuver to improve fetal localization [31]. With the extraction forceps
placed in the lower uterine cavity, the surgeon places his or her other hand on the patient's abdominal
wall to localize the forceps in relation to fetal parts and to help prevent uterine perforation.
Both the fetus and placenta must be entirely removed. Some surgeons prefer to remove the placenta after the
fetus to avoid disruption of the placental bed, but this is not always possible. The placenta has a characteristic
soft consistency that experienced surgeons can discern with extractors.
Following extraction of fetal and placental tissue, most surgeons finish the D&E by curetting the uterine lining
with a suction cannula. This permits removal of most of any remaining placental fragments. Some surgeons
then perform a "curette check," using a sharp curette to gently feel for any retained parts and confirm the
texture of an empty uterus. In our experience, this maneuver is not necessary and has the potential to
SciHub
needlessly increase pain, as well as the risk of uterine perforation [32,33].
Intact dilation and evacuation — A variant of D&E is intact D&E. With this technique, the fetus is
removed intact or nearly intact through the cervix [34,35]. After achieving sufficient cervical dilation with
osmotic dilators, surgeons use extraction forceps to deliver a breech fetus until the calvaria is lodged above
the internal os. The remainder of the fetus is delivered intact following decompression of the calvaria, often by
suctioning intracranial contents. If the fetus is in vertex presentation, the surgeon can make an incision in the
calvaria, suction intracranial contents, and collapse the calvaria with extraction forceps. The remainder of the
fetus will subsequently deliver intact.
The potential advantages of intact D&E compared with standard D&E include: поменять
прокси
● The likelihood of uterine perforation and cervical abrasion may be decreased because the technique
minimizes the number of instrumental passes and permits direct visualization within the vagina.
● Because the fetus is removed intact, it might also permit superior morphologic evaluation to further clarify
prenatal diagnosis, although pathologic evaluation can also be performed on nonintact specimens [36].
The only study comparing intact D&E with standard D&E was a retrospective study of 383 women who
underwent surgical abortion at ≥20 weeks of gestation [37]. There was no difference in estimated blood loss or
operative duration between the intact extraction and disarticulation groups. The overall rate of complications
was 5 percent in both groups. Three patients in the D&E group required admission to a surgical intensive care
unit (complications included amniotic fluid embolus, sepsis, pulmonary embolus, perforation of hysterotomy
scar); however, there were insufficient data to detect a difference in the risk of major complications.
In the United States, the PartialBirth Abortion Act of 2003 criminalizes some variants of D&E and provides no
legal exception for cases performed to protect maternal health. Clinicians should consult the provisions of the
law if they intend to perform an intact extraction, and some experts advise use of preoperative feticidal
injection.
Use of uterotonics — The routine use of perioperative or postoperative uterotonic agents (eg, oxytocin,
vasopressin) is a subject of debate. Although many providers routinely use uterotonics, Society of Family
Planning guidelines advised that there is no compelling evidence justifying their routine use [38,39]. The risk of
perioperative hemorrhage increases with advancing gestational age and is most commonly the result of
uterine atony. The uterus becomes increasingly responsive to oxytocin after 20 weeks of gestation, increasing
its efficacy in treating hemorrhage.
Options for use of uterotonic agents include:
● Paracervical injection of a uterotonic agent at the time the paracervical block is administered. Dilute
oxytocin or dilute vasopressin injected during deep paracervical injection may help control blood loss
[40,41]. Paracervical injection of vasopressin was found to significantly reduce blood loss in a randomized
trial [40]. In our practice, we use a solution of vasopressin 5 units in 20 mL of 1 percent lidocaine and
administer 10 mL of the solution on each side of the cervix.
● Intravenous oxytocin or vasopressin after evacuation. Some surgeons initiate uterotonics only after
evacuation based on a concern of entrapping fetal material as the uterus contracts.
Assessment for retained products of conception — At the end of the procedure, the surgeon should
inventory evacuated contents and account for the major fetal parts (calvaria, thorax, pelvis, four extremities).
The most important measure of complete evacuation is the clinical assessment of an experienced surgeon
who has inspected evacuated products.
Pelvic ultrasound may also be helpful. This is particularly the case when clinicians evacuate anomalous
pregnancies or pregnancies in which fetal demise results in substantial maceration of fetal anatomy.
SciHub
Unfortunately, small blood clots rapidly accumulate immediately after D&E, which may obscure some fetal
parts or mimic the appearance of a retained placenta.
OUTCOME AND COMPLICATIONS — Secondtrimester surgical abortion is a safe and effective procedure.
Uterine evacuation is completed in a single procedure in most women. In general, less than 5 percent of
women have retained products of conception or a complication. Complications of dilation and evacuation
(D&E), in addition to retained products of conception, include cervical laceration, uterine perforation, infection,
and hemorrhage [10].
Retained products of conception — Retained products of conception are found following less than 1
percent of secondtrimester D&E procedures [42,43]. The evaluation and management of retained products of
conception is discussed separately. (See "Retained products of conception".) поменять
прокси
Uterine perforation — Uterine perforation is potentially one of the most serious complications of surgical
abortion and occurs in less than 1 percent of secondtrimester D&E procedures [26,44]. In some cases, a
perforation results in hemorrhage or damage to the bowel or bladder or to large vessels. Factors that increase
the risk of uterine perforation include increasing gestational age, cervical abnormalities, multiparity, and an
inexperienced provider. Perforations in the second trimester are more likely to involve injury to bowel or other
structures than those occurring in the first trimester [27,45]. The evaluation and management of uterine
perforation is discussed separately. (See "Uterine perforation during gynecologic procedures".)
Cervical laceration — A cervical laceration occurs in up to 3 percent of secondtrimester abortions, whether
performed by D&E or medical abortion [46]. Surgeons can reduce the frequency of cervical laceration by
using cervical preparation and by appropriate technique with mechanical dilators.
Most cervical lacerations are small and require no intervention, provided they remain hemostatic. Treatment
options for bleeding lacerations include clamp compression for several minutes, application of ferric subsulfate
solution (Monsel solution) or suturing. Cervical lacerations of the internal os, also known as "cervical
fractures," can dissect laterally into the paracervical space, causing severe hemorrhage or hematoma
formation. Surgeons should suspect high cervical injury when bleeding continues postoperatively despite
preservation of normal uterine tone. Application of pressure and ferric subsulfate solution controls many of
these injuries. Balloon tamponade and angiographic embolization might also help control bleeding from
severe high cervical tears [47]. (See 'Cervical preparation' above.)
Infection — Infection rates following secondtrimester abortion vary up to as high as 4 percent. Definitions of
postabortion infection vary, as do diagnostic criteria for postabortal endometritis [26,44,48]. Use of
prophylactic antibiotics, as recommended above, reduces rates of infection to less than 1 percent [49]. There
are no data regarding the rates of infection in surgical compared with induction termination. (See 'Prophylactic
antibiotics' above.)
The management of postabortal endometritis is similar to that for postpartum endometritis. (See "Postpartum
endometritis".)
Hemorrhage — Definitions of postabortion hemorrhage vary. Although many investigators have previously
defined hemorrhage as an estimated blood loss of ≥200 mL, the Society of Family Planning definition is either
≥500 mL or a surrogate marker (eg, need for transfusion) [38]. Estimates of the incidence of postabortion
hemorrhage vary. Rates reported in published series range from 0 to 3 cases/1000 firsttrimester procedures
versus 0.9 to 10/1000 cases of secondtrimester abortion [38]. There are no data regarding the rates of
hemorrhage in surgical compared with induction termination. However, blood loss is higher in induction
procedures [38,50,51].
Hemorrhage can result from a variety of causes, including uterine atony, retained products of conception,
coagulopathy, abnormal placentation, and uterine or cervical injury. Uterine atony is the most common cause
of hemorrhage following D&E and complicates approximately 2 percent of D&E procedures [52].
Prior cesarean section is also associated with an increased risk of postabortion hemorrhage. This increase in
risk is seen after one cesarean (1.8 times higher in one study [30]), and notably was 7.4 times higher after two
or more cesarean deliveries in another study [52]. Operators confronting patients with a history of prior
cesarean should consider taking perioperative measures to reduce the likelihood of hemorrhage, including
use of vasopressin in the paracervical block and utilization of preoperative cervical ripening agents. They
should also anticipate hemorrhage by assuring the presence of pharmacologic and other agents necessary to
treat postabortion hemorrhage when it arises. (See "Overview of postpartum hemorrhage".)
Mortality — From 2004 to 2008, the United States Centers for Disease Control and Prevention reported a
mortality rate of 0.64 per 100,000 legal induced abortions; these data are for first and secondtrimester
abortions, and the majority of abortions were D&E procedures [3]. The strongest risk factor for surgical
abortionrelated mortality is increasing gestational age. The risk of death from surgical abortion increases
поменять
roughly 38 percent per week of gestation after eight weeks [53]. прокси
FOLLOWUP — Followup for secondtrimester induction abortion is the same as for surgical abortion. This is
discussed in detail separately. (See "Overview of secondtrimester pregnancy termination", section on 'Follow
up'.)
FUTURE OBSTETRIC OUTCOMES — Study results vary regarding dilation and evacuation (D&E) and risks
to subsequent pregnancy. Some studies have found an increased risk of cervical insufficiency with rapid
mechanical dilation or an increasing number of abortion procedures [7]. (See "Cervical insufficiency", section
on 'Risk factors'.)
However, in a retrospective review of 600 patients undergoing D&E between 14 and 24 weeks, the overall
rate of preterm birth in subsequent pregnancies was less than the overall rate of preterm birth for the general
United States population (6.5 versus 12.5 percent) [54]. Similarly, a study that compared subsequent
pregnancy outcomes among 317 women undergoing secondtrimester D&E with 170 matched controls found
that women with a history of prior D&E delivered slightly earlier in gestation than controls (38.9 versus 39.5
weeks of gestation); this was statistically significant, but clinical significance is uncertain. There was no
statistically significant difference in birth weight, spontaneous preterm delivery, abnormal placentation, and
overall rates of perinatal complications [55].
SPECIAL CIRCUMSTANCES — Management of patients with special issues of concern (eg, uterine
anomalies, lowlying placenta, multiple gestation) is discussed separately. (See "Overview of secondtrimester
pregnancy termination", section on 'Special circumstances'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics"
and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easytoread
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12th grade reading level and are best for patients who want indepth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Abortion (The Basics)")
● Beyond the Basics topic (see "Patient education: Abortion (pregnancy termination) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● The most common surgical technique for secondtrimester termination in the United States is dilation and
evacuation (D&E). Other surgical approaches include intact D&E, which is a variant of D&E, and
SciHub
hysterotomy. Hysterotomy is rarely used except when it is unsafe to dilate the cervix or induce labor. (See
'Introduction' above.)
● The D&E procedure consists of two components: (1) preparation and dilation of the cervix with osmotic,
pharmacologic, and/or mechanical dilators, and (2) evacuation of the uterus with suction, extraction
forceps, and curettage. (See 'Overview' above.)
● The approach to cervical preparation prior to secondtrimester termination depends upon the gestation
age. For women undergoing secondtrimester surgical abortion at >16 weeks of gestation, osmotic
dilators are the most effective method. As a single method of cervical preparation, we recommend
osmotic dilators rather than a pharmacologic agent (misoprostol or mifepristone) (Grade 1B). However,
for women in whom osmotic dilation alone is not effective or who have risk factors for difficult dilation, we
поменять
suggest that osmotic dilators be used with a pharmacologic agent rather than osmotic dilators alone прокси
(Grade 2B). For use as an adjunct to osmotic dilators, we suggest mifepristone rather than misoprostol
(Grade 2B).
● For women undergoing secondtrimester surgical abortion at ≤16 weeks of gestation, cervical
preparation with misoprostol alone is a reasonable option, rather than with either osmotic dilators alone or
misoprostol combined with osmotic dilators. This approach is appropriate for women who do not have risk
factors for cervical stenosis, and it offers that advantage of completing the procedure in one day. (See
'Cervical preparation' above.)
● For most women undergoing secondtrimester D&E, we suggest not using preprocedure feticidal injection
(Grade 2B). Use of feticidal injection is a reasonable option for women who place a high value on
preprocedure feticidal injection and who are willing to accept a potential increased risk of extramural birth,
infection, and other adverse effects (nausea or pelvic pain). (See 'Injection to induce fetal demise' above.)
● Surgeons must document completion of D&E by inspecting the products of conception for the four
extremities and calvaria. Intraoperative pelvic ultrasound can assist surgeons performing D&E,
particularly in a teaching setting. (See 'Assessment for retained products of conception' above.)
● In general, fewer than 5 percent of women who undergo secondtrimester D&E have retained products of
conception or a complication. Potential complications of secondtrimester D&E include retained products
of conception, uterine perforation, cervical laceration, infection, and hemorrhage. (See 'Outcome and
complications' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. ACOG Practice Bulletin No. 135: Secondtrimester abortion. Obstet Gynecol 2013; 121:1394.
2. Sedgh G, Henshaw S, Singh S, et al. Induced abortion: estimated rates and trends worldwide. Lancet
2007; 370:1338.
3. Pazol K, Creanga AA, Zane SB, et al. Abortion surveillanceUnited States, 2009. MMWR Surveill
Summ 2012; 61:1.
4. Tietze C, Henshaw SK. Induced abortion: a world review, 3rd ed, Alan Guttmacher Institute, New York
1986.
5. Stubblefield PG, CarrEllis S, Borgatta L. Methods for induced abortion. Obstet Gynecol 2004; 104:174.
6. Prager SW, Oyer DJ. Secondtrimester surgical abortion. Clin Obstet Gynecol 2009; 52:179.
7. Johnstone FD, Beard RJ, Boyd IE, McCarthy TG. Cervical diameter after suction termination of
pregnancy. Br Med J 1976; 1:68.
SciHub
8. Newmann SJ, DalveEndres A, Diedrich JT, et al. Cervical preparation for second trimester dilation and
evacuation. Cochrane Database Syst Rev 2010; :CD007310.
http://www.uptodate.com.secure.scihub.cc/contents/secondtrimesterpregnancyterminationdilationandevacuation/print?source=search_result&sear… 10/21
9. Newmann SJ, Sokoloff A, Tharyil M, et al. Sameday synthetic osmotic dilators compared with overnight
laminaria before abortion at 1418 weeks of gestation: a randomized controlled trial. Obstet Gynecol
2014; 123:271.
10. Fox MC, Hayes JL, Society of Family Planning. Cervical preparation for secondtrimester surgical
abortion prior to 20 weeks of gestation. Contraception 2007; 76:486.
11. Newmann S, DalveEndres A, Drey EA, Society of Family Planning. Clinical guidelines. Cervical
preparation for surgical abortion from 20 to 24 weeks' gestation. Contraception 2008; 77:308.
12. Edelman AB, Buckmaster JG, Goetsch MF, et al. Cervical preparation using laminaria with adjunctive
поменять
прокси
buccal misoprostol before secondtrimester dilation and evacuation procedures: a randomized clinical
trial. Am J Obstet Gynecol 2006; 194:425.
13. Drey EA, Benson LS, Sokoloff A, et al. Buccal misoprostol plus laminaria for cervical preparation before
dilation and evacuation at 2123 weeks of gestation: a randomized controlled trial. Contraception 2014;
89:307.
14. Goldberg AB, Fortin JA, Drey EA, et al. Cervical Preparation Before Dilation and Evacuation Using
Adjunctive Misoprostol or Mifepristone Compared With Overnight Osmotic Dilators Alone: A Randomized
Controlled Trial. Obstet Gynecol 2015; 126:599.
15. Shaw KA, Shaw JG, Hugin M, et al. Adjunct mifepristone for cervical preparation prior to dilation and
evacuation: a randomized trial. Contraception 2015; 91:313.
16. Carbonell JL, Gallego FG, Llorente MP, et al. Vaginal vs. sublingual misoprostol with mifepristone for
cervical priming in secondtrimester abortion by dilation and evacuation: a randomized clinical trial.
Contraception 2007; 75:230.
17. Darney PD, Dorward K. Cervical dilation before firsttrimester elective abortion: a controlled comparison
of meteneprost, laminaria, and hypan. Obstet Gynecol 1987; 70:397.
18. Chen JK, Elder MG. Preoperative cervical dilatation by vaginal pessaries containing prostaglandin E1
analogue. Obstet Gynecol 1983; 62:339.
19. Lauersen NH, Den T, Iliescu C, et al. Cervical priming prior to dilatation and evacuation: a comparison of
methods. Am J Obstet Gynecol 1982; 144:890.
20. Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion:
evidence and ethics. Contraception 2012; 85:140.
21. Steward R, Melamed A, Kim R, et al. Infection and extramural delivery with use of digoxin as a feticidal
agent. Contraception 2012; 85:150.
22. Dean G, Colarossi L, Lunde B, et al. Safety of digoxin for fetal demise before secondtrimester abortion
by dilation and evacuation. Contraception 2012; 85:144.
23. Diedrich J, Drey E, Society of Family Planning. Induction of fetal demise before abortion. Contraception
2010; 81:462.
24. ACOG Committee on Practice BulletinsGynecology. ACOG practice bulletin No. 104: antibiotic
prophylaxis for gynecologic procedures. Obstet Gynecol 2009; 113:1180.
25. http://prochoice.org/wpcontent/uploads/2015_NAF_CPGs.pdf (Accessed on October 15, 2015).
26. Peterson WF, Berry FN, Grace MR, Gulbranson CL. Secondtrimester abortion by dilatation and
evacuation: an analysis of 11,747 cases. Obstet Gynecol 1983; 62:185.
27. Grimes DA, Schulz KF, Cates WJ Jr. Prevention of uterine perforation during curettage abortion. JAMA
1984; 251:2108.
28. Schulz KF, Grimes DA, Cates W Jr. Measures to prevent cervical injury during suction curettage
abortion. Lancet 1983; 1:1182.
29. Darney PD, Sweet RL. Routine intraoperative ultrasonography for second trimester abortion reduces
incidence of uterine perforation. J Ultrasound Med 1989; 8:71.
30. Lederle L, Steinauer JE, Montgomery A, et al. Obesity as a Risk Factor for Complications After Second
Trimester Abortion by Dilation and Evacuation. Obstet Gynecol 2015; 126:585.
31. Hammond C, Chasen S. Dilation and evacuation. In: Management of unintended and abnormal
pregnancy: Comprehensive abortion care, Paul M, Lichtenberg S, Borgatta L, et al (Eds), Wiley
Blackwell, Oxford 2003. p.167.
32. Forna F, Gülmezoglu AM. Surgical procedures to evacuate incomplete abortion. Cochrane Database
Syst Rev 2001; :CD001993.
33. Lindell G, Flam F. Management of uterine perforations in connection with legal abortions. Acta Obstet
поменять
прокси
Gynecol Scand 1995; 74:373.
34. McMahon JT. Intact D&E. The first decade. Presented at the National Abortion Federation conference.
April, 1995.
35. Haskell M. Dilation and extraction for late second trimester abortion. Presented at the National Abortion
Federation Risk Management Seminar. September 1992.
36. Gawron LM, Hammond C, Ernst LM. Perinatal pathologic examination of nonintact, secondtrimester
fetal demise specimens: the value of standardization. Arch Pathol Lab Med 2013; 137:1083.
37. Chasen ST, Kalish RB, Gupta M, et al. Dilation and evacuation at >or=20 weeks: comparison of
operative techniques. Am J Obstet Gynecol 2004; 190:1180.
38. Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP
Guideline #20131. Contraception 2013; 87:331.
39. O'Connell K, Jones HE, Lichtenberg ES, Paul M. Secondtrimester surgical abortion practices: a survey
of National Abortion Federation members. Contraception 2008; 78:492.
40. Schulz KF, Grimes DA, Christensen DD. Vasopressin reduces blood loss from secondtrimester
dilatation and evacuation abortion. Lancet 1985; 2:353.
41. Glick E. Surgical abortion, West End Women's Medical Group, 1998.
42. Bryant AG, Grimes DA, Garrett JM, Stuart GS. Secondtrimester abortion for fetal anomalies or fetal
death: labor induction compared with dilation and evacuation. Obstet Gynecol 2011; 117:788.
43. Whitley KA, Trinchere K, Prutsman W, et al. Midtrimester dilation and evacuation versus prostaglandin
induction: a comparison of composite outcomes. Am J Obstet Gynecol 2011; 205:386.e1.
44. Jacot FR, Poulin C, Bilodeau AP, et al. A fiveyear experience with secondtrimester induced abortions:
no increase in complication rate as compared to the first trimester. Am J Obstet Gynecol 1993; 168:633.
45. Pridmore BR, Chambers DG. Uterine perforation during surgical abortion: a review of diagnosis,
management and prevention. Aust N Z J Obstet Gynaecol 1999; 39:349.
46. Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and
evacuation for secondtrimester abortion. Am J Obstet Gynecol 2002; 187:393.
47. Kauff ND, Chelmow D, Kawada CY. Intractable bleeding managed with Foley catheter tamponade after
dilation and evacuation. Am J Obstet Gynecol 1995; 173:957.
48. Altman AM, Stubblefield PG, Schlam JF, et al. Midtrimester abortion with Laminaria and vacuum
evacuation on a teaching service. J Reprod Med 1985; 30:601.
49. Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case
for universal prophylaxis based on a metaanalysis. Obstet Gynecol 1996; 87:884.
50. Niinimäki M, Suhonen S, Mentula M, et al. Comparison of rates of adverse events in adolescent and
adult women undergoing medical abortion: population register based study. BMJ 2011; 342:d2111.
51. Thonneau P, Poirel H, Fougeyrollas B, et al. A comparative analysis of fall in haemoglobin following
SciHub
abortions conducted by mifepristone (600 mg) and vacuum aspiration. Hum Reprod 1995; 10:1512.
52. Frick AC, Drey EA, Diedrich JT, Steinauer JE. Effect of prior cesarean delivery on risk of second
trimester surgical abortion complications. Obstet Gynecol 2010; 115:760.
53. Bartlett LA, Berg CJ, Shulman HB, et al. Risk factors for legal induced abortionrelated mortality in the
United States. Obstet Gynecol 2004; 103:729.
54. Kalish RB, Chasen ST, Rosenzweig LB, et al. Impact of midtrimester dilation and evacuation on
subsequent pregnancy outcome. Am J Obstet Gynecol 2002; 187:882.
55. Jackson JE, Grobman WA, Haney E, Casele H. Midtrimester dilation and evacuation with laminaria
does not increase the risk for severe subsequent pregnancy complications. Int J Gynaecol Obstet 2007;
поменять
прокси
96:12.
Topic 104595 Version 2.0
GRAPHICS
Osmotic cervical dilators
Size (dry
diameter
Name Material Dilation Comments
x length)
(mm)
поменять
Natural прокси
Laminaria Dried 2 to 10 x 4 hours: 25 Multiple laminaria are generally used.

(Laminaria compressed 60 to 85 percent
japonica, seaweed increase in
Laminaria stalk diameter
digitata) Overnight: 90
percent
increase in
diameter [1]
Synthetic
DilapanS Polyacrylate 3 x 55 4 hours: A previous version, Dilapan, had a tendency to

based 4 x 55 3 mm size:
break under high mechanical force; there have
hydrogel dilates to 8 been no reports of breakage with DilapanS. [3]
4 x 65
rod mm
4 mm size:
dilates to 8.5
mm
16 to 20
hours:
3 mm size:
dilates to 10
mm
4 mm size:
dilates to
11.3 mm [2]
The manufacture of lamicel, a polyvinyl alcohol polymer sponge soaked in 500 mg magnesium sulfate, was discontinued
in 2008.
Data from:
1. Krammer J, O'Brien WF. Mechanical methods of cervical ripening. Clin Obstet Gynecol 1995; 38:280.
2. Bokstrom H, Wiqvist N. Preoperative dilatation of the cervix at legal abortion with a synthetic, fastswelling
hygroscopic tent. Acta Obstet Gynecol Scand 1989; 68:313.
3. Allen RH, Goldberg AB. Cervical dilation before firsttrimester surgical abortion (<14 weeks' gestation). SFP Guideline
20071. Contraception 2007; 76:139.
4. Nicolaides KH, Welch CC, Koullapis EN, Filshie GM. Cervical dilatation by Lamicelstudies on the mechanism of action.
Br J Obstet and Gynaecol 1983; 90:1060.
5. Nicolaides KH, Welch MacPherson MB, Johnson IR, et al. Br J Obstet Gynaecol 1983; 90:475.
Graphic 69543 Version 2.0
Laminaria
поменять
прокси
Seaweed Laminaria japonica. Used for cervical dilation.
Reproduced with permission. Copyright © 2014 MedGyn Products, Inc. All rights reserved.
Osmotic cervical dilator
поменять
прокси
DilapanS.
Reproduced with permission. Copyright © 2014 MEDICEM.
Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults*
Preferred Alternative
Procedure Dose Dose
regimen ¶ regimens Δ
Hysterectomy Cefazolin, cefoxitin Cefazolin: Regimen:

(abdominal, vaginal, or cefotetan <120 kg: 2 g IV Ampicillin 3 g IV
laparoscopic, or
≥120 kg: 3 g IV sulbactam
robotic)
Regimen: поменять
Urogynecology
Cefoxitin or прокси
procedures including Clindamycin OR 600 to 900 mg IV
cefotetan:
those involving mesh
Vancomycin ¶ 15 mg/kg IV (not to
2 g IV
exceed 2 g per dose)
PLUS one of the following:
Gentamicin OR 5 mg/kg IV (if
overweight or obese,
based on dosing
weight) §
Aztreonam OR 2 g IV
Fluoroquinolone ¶◊
Regimen:
Metronidazole 500 mg IV
based on dosing
weight) §
Fluoroquinolone ¶◊
Cesarean section Cefazolin <120 kg: 2 g IV Regimen:

≥120 kg: 3 g IV Ampicillin 3 g IV
sulbactam
Regimen:
Clindamycin OR 600 to 900 mg IV
Vancomycin ¶ 15 mg/kg IV (not to
exceed 2 g per dose)
based on dosing
weight) §
Aztreonam 2 g IV
Regimen:
Metronidazole 500 mg IV
PLUS
Gentamicin 5 mg/kg IV (if
based on dosing
weight) §
Abortion, surgical Doxycycline 100 mg orally one Metronidazole 500 mg orally twice

hour before daily for five days
procedure and 200
SciHub
mg orally after Azithromycin 1 g orally one hour
before procedure
procedure
Hysterosalpingogram URL статьи или журнала, или DOI, или строка для поиска
Doxycycline ￥ 100 mg orally twice
or chromotubation daily for five days
Laparoscopy None
(diagnostic, tubal
sterilization,
operative except for
hysterectomy)
Other transcervical
procedures:
Hysteroscopy
(diagnostic or поменять
operative, прокси
including
hysteroscopic
sterilization)
Intrauterine device
insertion
Endometrial
biopsy
IV: intravenous.
* Common pathogens: enteric gramnegative bacilli, anaerobes, group B Streptococcus, enterococci.
¶ Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure.
If vancomycin or a fluoroquinolone is used, the infusion should be given over 60 to 90 minutes and started within 60 to
120 minutes before the initial incision.
Δ An alternative regimen should be used in women with history of immediate hypersensitivity to betalactam agents. Due
to increasing resistance of Escherichia coli to ampicillinsulbactam and fluoroquinolones, local sensitivity profiles should
be reviewed prior to use.
◊ Ciprofloxacin 400 mg IV OR levofloxacin 500 mg IV OR moxifloxacin 400 mg IV. Fluoroquinolones are contraindicated
in pregnancy and in women who are breastfeeding.
§ Gentamicin use for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Based on
evidence from colorectal procedures, a single dose of approximately 5 mg/kg gentamicin appears more effective for the
prevention of surgical site infection than multiple doses of gentamicin 1.5 mg/kg every eight hours [1]. For overweight
and obese patients (ie, actual weight is greater than 125 percent of ideal body weight), a dosing weight should be used.
A calculator to determine ideal body weight and dosing weight is available in UpToDate.
￥ Prophylaxis is warranted for patients with history of pelvic inflammatory disease or if the procedure demonstrates
dilated fallopian tubes. No prophylaxis is indicated for patients without dilated tubes.
Reference:
1. Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, doubleblind study of single
high dose versus multiple standard dose gentamicin both in combination with metronidazole for colorectal
surgical prophylaxis. J Hosp Infect 2000; 46:135.
Adapted from:
1. Treatment Guidelines from The Medical Letter, October 2012; Vol. 10 (122):73. www.medicalletter.org.
2. ACOG Committee on Practice BulletinsGynecology. ACOG practice bulletin No. 104: antibiotic prophylaxis for
gynecologic procedures. Obstet Gynecol 2009; 113:1180.
3. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
Sopher uterine forceps
поменять
прокси
Bierer uterine forceps
поменять
прокси
Contributor Disclosures
Cassing Hammond, MD Nothing to disclose Jody Steinauer, MD, MAS Nothing to disclose Sandy J Falk,
MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multilevel review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence. поменять
прокси
Conflict of interest policy

Second-Trimester Pregnancy Termination - Dilation and Evacuation - UpToDate

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Second-Trimester Pregnancy Termination - Dilation and Evacuation - UpToDate

Uploaded by

Copyright:

Available Formats

10/17/2016 Secondtrimester pregnancy termination: Dilation and evacuation UpToDate

Laminaria Dried 2 to 10 x 4 hours: 25 Multiple laminaria are generally used.

DilapanS Polyacrylate 3 x 55 4 hours: A previous version, Dilapan, had a tendency to

Hysterectomy Cefazolin, cefoxitin Cefazolin: Regimen:

Cesarean section Cefazolin <120 kg: 2 g IV Regimen:

Abortion, surgical Doxycycline 100 mg orally one Metronidazole 500 mg orally twice

You might also like

Second-Trimester Pregnancy Termination - Dilation and Evacuation - UpToDate

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Second-Trimester Pregnancy Termination - Dilation and Evacuation - UpToDate

Uploaded by

Copyright:

Available Formats

10/17/2016 Second­trimester pregnancy termination: Dilation and evacuation ­ UpToDate

Laminaria Dried 2 to 10 x 4 hours: 25 Multiple laminaria are generally used.

Dilapan­S Polyacrylate­ 3 x 55 4 hours: A previous version, Dilapan, had a tendency to

Hysterectomy Cefazolin, cefoxitin Cefazolin: Regimen:

Cesarean section Cefazolin <120 kg: 2 g IV Regimen:

Abortion, surgical Doxycycline 100 mg orally one Metronidazole 500 mg orally twice

You might also like

10/17/2016 Secondtrimester pregnancy termination: Dilation and evacuation UpToDate

DilapanS Polyacrylate 3 x 55 4 hours: A previous version, Dilapan, had a tendency to