Intact dilation and extraction (D&X, IDX, or intact D&E) is a surgical procedure that terminates and removes an intact fetus from the uterus. The procedure is used both after miscarriages and for abortions in the second and third trimesters of pregnancy. When used to perform an abortion, an intact D&E can occur after feticide or on a live fetus.
In the United States, where federal law describes an intact D&E on a live fetus as a partial-birth abortion, the procedure is uncommon. The 2003 federal Partial-Birth Abortion Ban Act, which was upheld by the Supreme Court of the United States in the case of Gonzales v. Carhart, outlaws an intact D&E of a fetus with a heartbeat under most, though not all, circumstances.
Indications As with non-intact D&E or labor induction in the second trimester, the purpose of D&E is to end a pregnancy by removing the fetus and placenta. Patients who have a fetus diagnosed with severe congenital anomalies may prefer an intact procedure to allow for viewing of the remains, grieving, and achieving closure. In cases where an autopsy has been requested, an intact procedure allows for a more complete examination of the body. An intact D&E is also used in abortions to minimize the passage of instruments into the uterus, reducing the risk of trauma. It also reduces the risk of cervical lacerations that may be caused by the removal of bony parts from the uterus and the risk of retention of fetal parts in the uterus such as brain matter and tissue.
Procedure As with non-intact D&E, intact D&E may be performed in freestanding clinics, ambulatory surgical centers, and in hospitals. Intra-operative pain control is usually dependent on the setting and patient characteristics but commonly involves local analgesia with either IV sedation or general anesthesia. Preoperative antibiotics are administered to reduce the risk of infection. In cases where the woman is Rh-negative, Rho(D) immunoglobulin (RhoGam) is administered to prevent the risk of developing erythroblastosis fetalis (hemolytic disease of the newborn) in subsequent pregnancies. Intact D&E is more feasible among women with higher parity, at higher gestational ages, and when cervical dilation is greater. There are no absolute contraindications.
Cervical preparation The surgery is preceded by cervical preparation, which may take several days. Osmotic dilators, natural or synthetic rods that absorb moisture from the cervix, are placed in the cervix and mechanically dilate the cervix over the course of hours to days. Misoprostol can be used to soften the cervix further. Intact D&E can only be performed with 2–5 centimeters of cervical dilation.
Fetal termination Fetal injection of digoxin or potassium chloride may be administered at the beginning of the procedure to allow for softening of the fetal bones or to comply with relevant laws in the physician's jurisdiction and the U.S. federal Partial-Birth Abortion Ban Act. Umbilical cord transection can also be used to induce fetal demise prior to removal.
Removal of fetus and placenta During the surgery, the fetus is removed from the uterus in the breech position. If the fetal presentation is not breech, forceps or manual manipulation can be used to turn it to a breech presentation while in the uterus (internal version). The fetal skull is usually the largest part of the fetal body and its removal may require mechanical collapse if it is too large to fit through the cervical canal. Decompression of the skull can be accomplished by incision and suction of the brain or by using forceps to collapse the skull.
Recovery Recovery from an intact D&E is similar to recovery from a non-intact D&E. Postoperative pain is usually minimal and managed with NSAIDs. In cases of uterine atony and corresponding blood loss, methergine or misoprostol can be given to encourage uterine contraction and achieve hemostasis. Patients who have recently undergone an intact D&E are monitored for signs of coagulopathy, uterine perforation, uterine atony, retained tissue, or hemorrhage.
Complications The risks of intact D&E are similar to the risks of non-intact D&E and include postoperative infection, hemorrhage, or uterine injury. Overall, the complication rate is low, with rates of serious complications (those requiring blood transfusion, surgery, or hospital treatment) ranging from 0 per 1,000 cases to 2.94 per 1,000 cases. The rate of minor complications is approximately 50 in 1,000 (5%), the same as the minor complication rate for non-intact D&E; the rate of serious complications is higher in non-intact D&E. Data directly comparing the safety of non-intact to intact D&E are limited. There is no difference in postoperative blood loss or major complications when compared to non-intact D&E. There is no difference in risk of subsequent preterm delivery. The risk of retained tissue is lower since the fetus is removed intact. In some cases, the physician may not be able to remove the fetus intact due to anatomical limitations. This may present a psychological problem for the patient who wishes to view the remains, or make a comprehensive autopsy impossible, precluding an accurate postmortem diagnosis of fetal anomalies.
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