Dilatation and evacuation procedures and second-trimester abortions. The role of physician skill and hospital setting

Abstract

Some clinicians have hesitated to perform dilatation and evacuation (D & E) procedures at 13 weeks' gestation or later because D & Es are more difficult to perform safely than suction-curettage procedures. Moreover, many clinicians still believe all second-trimester abortion procedures should be performed in a hospital. To evaluate these concerns, we analyzed 24,664 abortion performed between 1973 and 1978 by four physicians associated with a large outpatient abortion facility; 3,711 (15%) of the abortions were second-trimester procedures. Dilatation and evacuation was associated with a lower rate of serious complications per 100 procedures (0.23) than instillation of either dinoprost (prostaglandin F2 alpha) (1.28) or hypertonic saline (2.26). In addition, D & E had lower rates for most other specific complications. We conclude that D & E, while requiring more operator skill than earlier suction-curettage procedures, can be learned by gynecologists familiar with suction-curettage, can be performed more safely than the alternative instillation procedures, and can be safely practiced in selected ambulatory settings.

PIP: Continuing controversies have surrounded the emergence of dilatation and evacuation procedures as a method of performing 2nd trimester abortions. To evaluate concerns relating to 2nd trimester abortions, the 6 year experience between 1973-1978 of a labor abortion facility in the midwest, staffed by 4 physicians, was analyzed. Due to the fact that focus was on 1 specific practice, the situation of comparing different case series results among different institutions was avoided. Additionally, the facility served women from the same locality and socioeconomic stratum throughout the study interval. By restricting analysis to 1 group of physicians, variations in operator technique were controlled for, thus reducing the potential biases resulting from clinicians with different levels of training, experience, and innate skill. Excluding abortions performed concurrnetly with sterilization, the Meadowbrook Women's Clinic (MWC) in Minneapolis performed 24,664 abortion procedures during the 6-year study interval. At 12 week's gestation or earlier, 20,953 (84% of the total) were performed by suction curettage. At 13 weeks' gestation or later, 2204 (9%) were by dilatation and evacuation, 884 (4%) by saline instillation, and 623 (3%) by dinoprost instillation accounted for almost all abortions at 13 week's gestation or later. The overall serious complication rate for procedures at MWC was low. Approximately 1 in 400 dilatation and evacuation procedures, 1 in 80 dinoprost instillation procedures, and 1 in 40 saline instillation procedures led to temperature greater than 38 degrees Centigrade for more than 3 days, hemorrhage requiring transfusion, or unintended abdominal surgery. Fewer than 1 in 1000 women undergoing a suction curettage procedure suffered serious complications. Of those procedures available at 13 weeks' gestation or later, dilatation and evacuation was the safest. Compared with dinoprost instillation, dilatation and evacuation was associated with significantly lower rates of serious complications, hemorrhage, retained products of conception, re-evacuation, endometritis, and febrile morbidity. Even when performed at 17 weeks' gestation or later, dilatation and evacuation had a lower rate of serious complications than either dinoprost or saline instillation, although only significantly so for the latter. Dilatation and evacuation had a slightly higher rate of cervical injury, although this was not statistically significant. At MWC, neither gestational age, the physician, nor the type of facility had a great effect on the relatively low risks of dilatation and evacuation.