second-trimester dilatation and evacuation de abortion

3. D&E technique Dilatation and Evacuation (D&E) � A surgical method of abortion using a combination of cervical dilatation, suction aspiration and specialized forceps to assist in tissue evacuation. D&E is often known as a surgical procedure, different from a medical induction, the other type of second-trimester abortion which just uses medications. D&E is often known as a surgical procedure, different from a medical induction, the other type of second-trimester abortion which just uses medications.

4. D&E Appropriate for second-trimester abortion when trained, experienced clinicians are available and when: Woman prefers a short process and/or an outpatient procedure Inpatient beds or facilities for overnight stay are limited or not available

5. Counseling andInformed consent The client must understand: Her clinical condition The risks/benefits of her clinical options Explain the abortion procedure What will happen, what she will feel Communicate effectively Use simple, clear language Consent should be voluntary and informed The voluntary aspect is important. The clinician should make sure the woman is not being pressured into her decision by others; ideally this must be checked in private, without her friends or relatives present. It is also important to understand the local law/context in which the procedure is taking place. There may be specific laws regarding minors - if they can consent for themselves or not, for example Also there may be local law or expectations around husband/partner involvementThe voluntary aspect is important. The clinician should make sure the woman is not being pressured into her decision by others; ideally this must be checked in private, without her friends or relatives present. It is also important to understand the local law/context in which the procedure is taking place. There may be specific laws regarding minors - if they can consent for themselves or not, for example Also there may be local law or expectations around husband/partner involvement

6. Special Cases Termination of a desired pregnancy More grief Sensitivity needed Fetal death in utero in the second-trimester Likely a desired pregnancy Causes of the loss? Increased risk of DIC if > 4 weeks after fetal death in utero Risk of DIC: This usually occurs after four weeks, and has been reported in 25 percent of women who retain a dead fetus for more than a month. Case reports of earlier occurances, but not as likely If > 4 weeks after intra-uterine fetal death, consider doing pre-procedure laboratory evaluations of coagulation factors (Maslow, AD, Breen, TW, Sarna, MC, et al. Prevalence of coagulation abnormalities associated with intrauterine fetal death. Can J Anaesth 1996; 43:1237. ) Risk of DIC: This usually occurs after four weeks, and has been reported in 25 percent of women who retain a dead fetus for more than a month. Case reports of earlier occurances, but not as likely If > 4 weeks after intra-uterine fetal death, consider doing pre-procedure laboratory evaluations of coagulation factors (Maslow, AD, Breen, TW, Sarna, MC, et al. Prevalence of coagulation abnormalities associated with intrauterine fetal death. Can J Anaesth 1996; 43:1237. )

7. Medical History Past pregnancy/menstrual history Length of amenorrhea Allergies Medications Contraceptive use Previous surgery, especially uterine surgery This is basically the same as for first-trimester procedures. -Service delivery issue: Who takes the medical history? Where and when does this occur?This is basically the same as for first-trimester procedures. -Service delivery issue: Who takes the medical history? Where and when does this occur?

8. Medical History Be aware of: Active asthma Uterine fibroids Hypertension Epilepsy Previous cesarean section, cervical conization, myomectomy Previous postpartum hemorrhage Bleeding disorder Pre-existing conditions that may affect provision of second-trimester abortion: Asthma- if postabortion atony, use some prostaglandins with caution (Hemabate, PGF 2-alpha) Fibroids and other uterine anomalies--only experienced providers should perform D&E, and with caution. Induction abortion may be better choice, depending on the anomaly. Hypertension- If postabortion atony, use methylergonovine (Methergine) with caution. Avoid use in women with bp >160/100 mmHg Epilepsy--procedure may require intensive medical support Previous uterine surgery--with induction procedures, consider lowering initial dose History of postpartum hemorrhage or bleeding disorder Pre-existing conditions that may affect provision of second-trimester abortion: Asthma- if postabortion atony, use some prostaglandins with caution (Hemabate, PGF 2-alpha) Fibroids and other uterine anomalies--only experienced providers should perform D&E, and with caution. Induction abortion may be better choice, depending on the anomaly. Hypertension- If postabortion atony, use methylergonovine (Methergine) with caution. Avoid use in women with bp >160/100 mmHg Epilepsy--procedure may require intensive medical support Previous uterine surgery--with induction procedures, consider lowering initial dose History of postpartum hemorrhage or bleeding disorder

9. Physical Exam Vital signs- blood pressure and pulse Abdomen Pelvic Cervical lesions Uterine size, position, masses Abdomen Approximate fundal height Unexplained scars Pelvic Bimanual exam important to assess uterine size, position (although in second trimester, uterus is often not greatly anteverted or retroverted anymore) Abdomen Approximate fundal height Unexplained scars Pelvic Bimanual exam important to assess uterine size, position (although in second trimester, uterus is often not greatly anteverted or retroverted anymore)

10. Confirming Length of Pregnancy Errors in estimating gestational age cause problems Inaccurate dating complications Menstrual history Abdominal exam and pelvic exam Ideally, ultrasound should be used (biparietal diameter and femur length) Ideally, use of biparietal diameter, femur length is used to confirm gestational age of pregnancy. Accurate dating is extremely important Inaccurate dating = cause of complications Important not to do a procedure beyond gestational age limit of one�s training and experience Better to assume the pregnancy is further along than earlier (better to assume it is bigger than smaller) Remember, ultrasound in the second trimester can be off by 1-2 weeks Ideally, use of biparietal diameter, femur length is used to confirm gestational age of pregnancy. Accurate dating is extremely important Inaccurate dating = cause of complications Important not to do a procedure beyond gestational age limit of one�s training and experience Better to assume the pregnancy is further along than earlier (better to assume it is bigger than smaller) Remember, ultrasound in the second trimester can be off by 1-2 weeks

11. Biparietal Diameter (BPD) Note: These next two slides are not meant to train clinicians in ultrasonography, but meant to remind clinicians about the most accurate measurements. If in a setting that uses ultrasound: The anatomical landmarks used to ensure the accuracy and reproducibility of the measurement include: 1) a midline falx, 2) the thalami symmetrically positioned on either side of the falx, 3) visualization of the Septum Pellucidum at one third the frontooccipital distance. A wrong measurment plane can produce errors up to 20mm A leading edge to leading edge measurement or a middle-to-middle measurement are both acceptable. The BPD should be measured as early as possible after 13 weeks for dating (before 13 weeks should use crown-rump length). Note: These next two slides are not meant to train clinicians in ultrasonography, but meant to remind clinicians about the most accurate measurements. If in a setting that uses ultrasound: The anatomical landmarks used to ensure the accuracy and reproducibility of the measurement include: 1) a midline falx, 2) the thalami symmetrically positioned on either side of the falx, 3) visualization of the Septum Pellucidum at one third the frontooccipital distance. A wrong measurment plane can produce errors up to 20mm A leading edge to leading edge measurement or a middle-to-middle measurement are both acceptable. The BPD should be measured as early as possible after 13 weeks for dating (before 13 weeks should use crown-rump length).

12. Femur Length (FL) By convention, measurement of the FL is considered accurate only when the image shows two blunted ends. In Appendix B of the Clinician�s Guide to Second-trimester Abortion Second Edition, there are fetal measurement tables to use for comparison and dating: biparietal diameter, and femur length.By convention, measurement of the FL is considered accurate only when the image shows two blunted ends. In Appendix B of the Clinician�s Guide to Second-trimester Abortion Second Edition, there are fetal measurement tables to use for comparison and dating: biparietal diameter, and femur length.

13. D&E - Ten Steps Prepare instruments Prepare the woman Cervical antiseptic prep Administer paracervical block Dilate cervix Insert cannula Empty uterus with suction and forceps Inspect tissue Perform any concurrent procedures Process instruments and dispose of waste Overview of the actual procedure � after the woman is deemed a good candidate and has consented to the procedure.Overview of the actual procedure � after the woman is deemed a good candidate and has consented to the procedure.

14. 1. Prepare Instruments Check that aspirator retains vacuum Prepare more than one aspirator Make sure large dilators and D&E forceps are sterile and available

15. 2. Prepare the Woman Prepare the cervix Administer 400 mcg misoprostol 3-4 hours before procedure Route Vaginal, placed high in posterior fornix, or Buccal, placed in cheek pouches (for 30 minutes and then swallowed) Monitor bleeding and pain Heavy vaginal bleeding and strong pain indicate she is ready for procedure (even if before 3-4 hrs) Ensure pain medicine has been given

16. If vaginal use, place misoprostol tablets deep into posterior fornix

17. Prepare the Woman Ask the woman to empty her bladder Help her onto the table Position drain bin or pan under table to catch all fluids Wash hands, put on gloves and personal barriers Ask if she is ready to start Perform bimanual examination Remove dirty gloves Put on sterile gloves

18. 3. Perform Cervical Antiseptic Prep Follow no-touch technique Insert speculum Wash upper vagina and cervix with antiseptic-soaked sponge

19. 4. Perform Paracervical Block This is covered in more detail in �Pain Management� PowerPoint. Anesthetic agent: Commonly 1 percent lidocaine, but can use 0.5% lidocaine or 0.25 percent bupivacaine The dose of 1 percent lidocaine (100 mg) [maximum dose 4.5 mg/kg body weight or 20 mL for a 50 kg woman] achieves a peak plasma level well below the toxic range and occurs 10 to 15 minutes following the injection. If the woman is <50 kg, use 0.5% lidocaine, or use less volume for paracervical block. (Blanco, LJ, Reid, PR, King, TM. Plasma lidocaine levels following paracervical infiltration for aspiration abortion. Obstet Gynecol 1982; 60:506.)This is covered in more detail in �Pain Management� PowerPoint. Anesthetic agent: Commonly 1 percent lidocaine, but can use 0.5% lidocaine or 0.25 percent bupivacaine The dose of 1 percent lidocaine (100 mg) [maximum dose 4.5 mg/kg body weight or 20 mL for a 50 kg woman] achieves a peak plasma level well below the toxic range and occurs 10 to 15 minutes following the injection. If the woman is <50 kg, use 0.5% lidocaine, or use less volume for paracervical block. (Blanco, LJ, Reid, PR, King, TM. Plasma lidocaine levels following paracervical infiltration for aspiration abortion. Obstet Gynecol 1982; 60:506.)

20. 5. Dilate Cervix, 6. Insert Cannula Pull outward with tenaculum to straighten cervical passage into the uterus Attempt insertion of 14 mm cannula through cervix If cannula passes with minimal force, continue with procedure If 14 mm cannula does not pass completely, but feels close to this, the clinician can try dilating up gently with dilators. It is optimal to use a 14 mm cannula for D&E�s, smaller cannula may result in longer and more problematic procedure. If gestational age is 12-13 weeks, a 12 cannula may then be fine. If 14 mm cannula does not pass completely, but feels close to this, the clinician can try dilating up gently with dilators. It is optimal to use a 14 mm cannula for D&E�s, smaller cannula may result in longer and more problematic procedure. If gestational age is 12-13 weeks, a 12 cannula may then be fine.

21. Difficult dilatation If dilators do not go in easily, if adequate dilatation not achieved, do not proceed with the procedure More Misoprostol (400-600 mcg) is needed and additional waiting period Gentle dilatation is critical Risk of perforation increases if more than moderate force is required

22. 7. Empty Uterus Attach aspirator to cannula and aspirate amniotic fluid Rotate cannula, and gently move in and out as needed Remove cannula, empty syringe, re-establish vacuum and reinsert as needed until fluid is evacuated Maintain no-touch technique

23. Aspirate the Amniotic Fluid

24. Evacuate Uterus: Use of Forceps Maintain traction on cervix Insert forceps in vertical position, so that jaws open up and down, not side to side Hold forceps with thumb against, but not through anterior ring As soon as forceps passes through internal os, open gently as wide as possible Close forceps to grasp tissue, rotate 90o and remove

25. Use of Forceps Note to Trainer: show this motion with a real instrument while describing it.Note to Trainer: show this motion with a real instrument while describing it.

26. Evacuation continued Be careful not to grasp myometrium During evacuation, re-grasp tissue as needed to reduce bulk Be sure to view cervix and not to tear it with forceps Most evacuations can be accomplished from the lower portion of the uterine cavity Be careful not to grasp myometrium This can be minimized by working low in uterus - use vacuum to pull tissue down to just above os, and grasp just above os, and try not to grasp high up in uterus Be cautious if woman experienced pain when grasping�may be the myometrium Be careful not to grasp myometrium This can be minimized by working low in uterus - use vacuum to pull tissue down to just above os, and grasp just above os, and try not to grasp high up in uterus Be cautious if woman experienced pain when grasping�may be the myometrium

27. Evacuation continued Use suction to bring tissue down from uterine fundus as needed, alternating with forceps Avoid probing deep into uterus in horizontal position

28. 8. Inspect Tissue Empty contents of aspirator into container Strain tissue as needed Examine fetal tissue to be sure evacuation is complete Identify 4 extremities, thorax, spine, calvarium and placenta Exam of tissue is essential! An incomplete procedure may lead to hemorrhage and infection For incomplete evacuation or difficult procedures- use ultrasound guidance.For incomplete evacuation or difficult procedures- use ultrasound guidance.

29. 9. Perform Concurrent Procedures After tissue inspection is complete, wipe cervix with swab and assess bleeding Perform bimanual exam Perform concurrent procedures, e.g.: Repair of any cervical tear IUD (intrauterine device) insertion Female sterilization 

30. 10. Process Instruments and Dispose of Waste Cover fetal tissue Put all instruments into soaking solution Dispose of all needles appropriately Remove gloves and place in soaking solution or discard Wash hands Properly dispose of fetal tissue After thorough examination to assure procedure is complete, fetal parts can be disposed of according to hospital/clinic regulations. After thorough examination to assure procedure is complete, fetal parts can be disposed of according to hospital/clinic regulations.