Last reviewed: January 6, 2020
- Dilatation and evacuation (D&E) and medical abortion with mifepristone and misoprostol or misoprostol only are safe and effective methods of abortion.
- Women should be offered a choice of methods when both D&E and medical abortion are available.
- Medical abortion has a higher rate of retained products of conception, failed abortion and minor adverse events.
- D&E requires a trained, experienced provider and specialized equipment.
Quality of evidence: Moderate
Comparison of methods
In retrospective cohort studies, women with gestations 13-24 weeks who had medical abortions had an increased rate of failed abortion and retained products of conception with a need for further intervention compared to women who had D&E (Autry, Hayes, Jacobson, & Kirby, 2002; Bryant, Grimes, Garrett, & Stuart, 2011; Sonalkar, Ogden, Tran, & Chen, 2017). However, the rate of major adverse events including infection, transfusion, hysterectomy and death does not differ between the two methods.
The largest trial comparing methods randomized 122 women with gestations between 13-20 weeks to D&E or medical abortion with mifepristone and misoprostol (Kelly, Suddes, Howel, Hewison, & Robson, 2010). Overall rates of complications were similar in the two groups, although the types of complications differed. Five women in the medical arm required uterine evacuation for retained products of conception and one suffered bleeding requiring transfusion; only one woman in the surgical arm required repeat uterine evacuation, one suffered a cervical laceration, and five had hemorrhage that did not require transfusion. A statistically significant proportion of women randomized to medical abortion had more bleeding and pain and found the abortion process less acceptable than women who had D&E. A pilot randomized trial of 18 women with gestations between 14-19 weeks comparing D&E and medical abortion with mifepristone and misoprostol found a higher rate of adverse events, specifically retained placenta and fever, in women undergoing medical abortion, although none were serious (Grimes, Smith, & Witham, 2004).
In published studies of medical abortion compared to D&E, rates of intervention for medical abortion may be artificially high because failure was defined as no expulsion within 24 hours (Bryant et al., 2011) and retained placenta was diagnosed after two hours (Grimes et al., 2004). In practice, more time may be allowed for successful medical abortion to occur.
The importance of choice
In settings where both D&E and medical abortion are available, if a woman is a candidate for either procedure, she should be offered a choice. Both randomized trials referenced above (Kelly et al., 2010; Grimes, et al., 2004) had difficulty with recruitment due to women’s strong preferences for one method-generally D&E-over the other. For women, the choice of abortion procedure is an intensely personal one (Kerns et al., 2018)—some women prefer the speed and predictability of D&E, while others prefer a more “labor-like” process with an intact fetus (Kelly et al., 2010; Kerns et al., 2012). To choose the abortion procedure that best facilitates their coping, women need adequate information regarding the two abortion methods and the ability to make their decision autonomously (Kerns et al., 2018).
Autry, A. M., Hayes, E. C., Jacobson, G. F., & Kirby, R. S. (2002). A comparison of medical induction and dilation and evacuation for second-trimester abortion. American Journal of Obstetrics & Gynecology, 187(2), 393-397.
Bryant, A. G., Grimes, D. A., Garrett, J. M., & Stuart, G. S. (2011). Second-trimester abortion for fetal anomalies or fetal death: Labor induction compared with dilation and evacuation. Obstetrics & Gynecology, 117(4), 788-792.
Grimes, D. A., Smith, M. S., & Witham, A. D. (2004). Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: A pilot randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 111(2), 148-153.
Kelly, T., Suddes, J., Howel, D., Hewison, J., & Robson, S. (2010). Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: A randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 117(12), 1512-1520.
Kerns, J. L., Light, A., Dalton, V., McNamara, B., Steinauer, J., & Kuppermann, M. (2018). Decision satisfaction among women choosing a method of pregnancy termination in the setting of fetal anomalies and other pregnancy complications: A qualitative study. Patient Education and Counseling, 101(10), 1859-1864.
Kerns, J., Vanjani, R., Freedman, L., Meckstroth, K., Drey, E. A., & Steinauer, J. (2012). Women’s decision making regarding choice of second trimester termination method for pregnancy complications. International Journal of Gynecology & Obstetrics, 116(3), 244-248.
Sonalkar, S., Ogden, S. N., Tran, L. K., & Chen, A. Y. (2017). Comparison of complications associated with induction by misoprostol versus dilation and evacuation for second-trimester abortion. International Journal of Gynecology & Obstetrics, 138, 272-275.