Surgical Dilatation and Evacuation

What is dilation and evacuation (D&E)?

D&E is a surgical procedure where the pregnancy tissue is removed from the womb, through the vagina and cervix (neck of the womb) using special forceps and vacuum suction. This procedure is performed under regional anaesthesia (an injection to numb a part of the body, in this case, waist down with you being awake) or general anaesthesia (where you are asleep). An ultrasound scan is also performed during the procedure to reduce the risk of complications and make sure that all the pregnancy tissues are removed. This procedure is performed in pregnancy above 12 weeks gestation.

What are the advantages of D&E?

• Quick procedure as compared to medical management
• Quick recovery and early return to normal activity
• Highly effective with success rate >97-99%
• Can avoid pain during passing out of pregnancy tissue
• Will not see the pregnancy tissue unless you wish to do so
  
  

Who may not be suitable for D&E?

• If your pregnancy is complicated by a condition called the placenta accreta spectrum disorder (PAS), where the placenta is deeply attached to the wall of the uterus (womb) and may penetrate and invade the outer layer of the uterus, sometimes into the adjacent organs such as the bladder
• If the fetus needs a post-mortem evaluation
  

How do I prepare for the procedure?

Preparation of the cervix

This is an important step to soften the cervix and prepare it to make the procedure safer.

You will be given a tablet, called mifepristone, to swallow approximately 1-2 days before the procedure. About 1-2 hours before the surgery, you will also be given some tablets (misoprostol), either by placing them under your tongue or in the vagina.

For pregnancy above 18 weeks, some cervical dilators, called the Dilapan, will be inserted into the cervix on the morning of your surgery. These rods swell over time to gently open the cervix. Insertion only takes a few minutes. As the Dilapan expands, it can cause some cramping or vaginal spotting.

Feticide

This procedure is carried out in a scan room before the D&E procedure. Under ultrasound guidance, the doctor will administer an injection into the fetal heart to stop the heartbeat. This is only advised if you are at high risk of massive bleeding (e.g. placenta praevia, when the placenta attaches in the lower part of the womb) and above 20-22 weeks of gestation.

Fasting

On the day before your procedure, you will receive a phone call regarding the scheduled time of surgery and reporting details. You will also be advised on the time to stop eating and drinking. Eating and/or drinking after these specific times may result in the postponement of your procedure.

What to Expect During Surgical Dilation and Evacuation

What should you expect during surgical dilation and evacuation?

On arrival to the Day Surgery Unit

After checking in to the Day Surgery Unit, you will be asked to change into a hospital gown. Your anaesthetist will discuss with you the anaesthesia options: regional anaesthesia (injection to the lower back to provide anaesthesia from the waist down) or general anaesthesia (when you are asleep). The surgeon will also see you before the surgery and you can consult the surgeon if you have any questions.

What happens in the operating theatre (OT)?

This procedure is usually completed in less than half an hour.After administration of anaesthesia, the cervix is dilated (stretched) gradually, and the pregnancy tissues are removed in pieces using special forceps and vacuum suction. An ultrasound scan is also performed at the same time to reduce the risk of complications and make sure that all the pregnancy tissues are removed.If you are under regional anaesthesia, you may hear some sound because of the suction.If you have opted for an insertion of intrauterine contraceptive device (IUCD) or contraceptive implant, this can also be performed at the end of the procedure.

What should I expect after the procedure?

• You will be brought to the recovery area immediately after the procedure. You will stay there for about 1-2 hours and be given something to eat and drink. Once you feel well and have been reviewed by the doctor / nurse, you may go home.
• You will need someone to accompany you home. For 24 hours after general anaesthesia, you must not drive a vehicle, drink alcohol, make important decisions (e.g. sign any legal documents) or engage in strenuous exercise or heavy lifting.
• You may experience a period cramp-like pain and light vaginal bleeding. This should gradually reduce over the next two weeks. You will be given some painkiller tablets, to be taken at home as required over the next few days. You should continue to use sanitary pads (not tampons) until your next period. We also recommend that you avoid sexual intercourse until the bleeding stops.
• If you have a Rhesus negative blood group, you will also be given an anti-D immunoglobulin injection before you go home.
• You will be prescribed antibiotics to reduce your risk of getting infection. A dose of azithromycin tablet will be given to you before you go home, and a course of metronidazole tablets will be given to you for completion at home. It is advisable not to consume any alcohol with metronidazole tablets.
• If your pregnancy is more than 20 weeks gestation at the time of this procedure, you may be prescribed cabergoline tablets to stop breast milk production.
• If you are not ready for another pregnancy, we recommend using reliable contraception until you are keen to conceive again. You may refer to the contraceptive leaflet for more information. All contraceptive methods can be started immediately after a D&E procedure.
• Some women may experience long-term emotional problems after a pregnancy loss. You should talk to your doctor about these feelings.

When should I seek medical attention?

Some symptoms of the risks and complications of D&E procedure can present after you have been discharged from the hospital. If you experience any of the below symptoms, you should return to the hospital for medical assessment:

1. Excessive vaginal bleeding: If you experience heavy bleeding (TWO pads an hour for TWO consecutive hours)
2. Abdominal pain: If you experience severe lower abdominal pain not relieved by painkillers prescribed
3. Fever
   
4. Foul-smelling vaginal discharge
   
5. Feeling generally unwell

When do I return for a follow-up appointment?

You will be given a teleconsultation or a physical clinic appointment 4 to 6 weeks after your procedure.

Schedule

Surgical Dilatation and Evacuation (D&E)
(For gestation 12+0 to 17+6 weeks)

PART 1: To swallow a tablet called mifepristone.

PART 2: Surgery Day

Surgical Dilatation and Evacuation (D&E)
(For gestation 18+0 to 23+6 weeks)

PART 1: To swallow a tablet called mifepristone.

PART 2: To insert cervical dilator (DILAPAN)

Proceed to Day Surgery Unit after Dilapan insertion.

Treatment locations at SingHealth

• Urgent O&G Centre (UOGC)
  Basement 1, Women’s Tower, KKH
• Clinic C
  Level 1, Women’s Tower, KKH
• Day Surgery Unit
  Basement 1, Children’s Tower, KKH
  
  

The information above is also available for download in pdf format.