Dilation and evacuation

Last updated
Dilation and evacuation
D&E
Background
Abortion typeSurgical
First use1970s
Gestation 13–24 weeks
Infobox references

Dilation and evacuation (D&E) or dilatation and evacuation (British English) is the dilation of the cervix and surgical evacuation of the uterus (potentially including the fetus, placenta and other tissue) after the first trimester of pregnancy. It is a method of abortion as well as a common procedure used after miscarriage to remove all pregnancy tissue. [1] [2]

Contents

In various health care centers it may be called by different names:

D&E normally refers to a specific second trimester procedure. [2] However, some sources use the term D&E to refer more generally to any procedure that involves the processes of dilation and evacuation, which includes the first trimester procedures of manual and electric vacuum aspiration. [1] Intact Dilation and Extraction (D&X) is a different procedural variation on D&E. [3]

Dilation and evacuation procedures have been increasingly banned in US states since the Dobbs v. Jackson Women's Health Organization decision overruled the right to an abortion. [4]

Indications for D&E

Dilation and evacuation (D&E) is one of the methods available to completely remove the fetus and all of the placental tissue in the uterus after the first trimester of pregnancy. [5] A D&E may be performed for a surgical abortion, or for surgical management of a miscarriage. [6]

Abortion

Induced abortion after the first trimester of pregnancy is rare. Approximately 930,000 abortions were documented in the US in 2020. Of these, 492,000 were medication abortions. [7] Fewer than 10% of all abortions in the United States are performed after 13 weeks of gestation, and just over 1% are performed after 21 weeks gestation. [8] In the United States, 95–99% of abortions after the first trimester of pregnancy are performed by surgical abortion via dilation and evacuation. [8]

People who do not have access to affordable abortion care in their area or who face legal restrictions to obtaining a wanted abortion may wait longer to get an abortion after they make the decision to terminate their pregnancy. When an abortion is delayed, a D&E may be necessary. [9] Other factors that often lead to an abortion in the second trimester are late testing for pregnancy, insurance or funding barriers, or delayed provider referral. [10]

Abortion can be considered in the case of congenital anomalies, including genetic aneuploidies and anatomic anomalies, especially since they may not be identified until the second trimester. [11] [10] Other medical indications for an abortion in the second trimester include preeclampsia with severe features or preterm premature rupture of membranes prior to a viable fetal age. [10]

Miscarriage

Dilation and evacuation can be offered for management of second trimester miscarriage if skilled providers are available. [6] Some women choose D&E over labor induction for a second trimester loss because it can be a scheduled surgical procedure, offering predictability over labor induction, or because they find it emotionally easier than undergoing labor and delivery. The risks of maternal morbidity during an induction of labor are higher compared to a dilation and evacuation. [12] Additionally, a subsequent dilation and curettage procedure for retained placental products may be required after an induction of labor for a miscarriage. [12] Both a labor induction and dilation and evacuation offer the option of fetal and placental testing. Although pregnancy loss is emotionally distressing, there are rarely medical complications associated with a short (<1 week) delay to management. [13]

Molar pregnancy

Dilation and evacuation is also a treatment option for a molar pregnancy, especially for those who wish to maintain fertility. The procedure is typically done under sonographic guidance as soon as a hydatidiform mole is suspected. [14] [15]

Description of procedure

Cervical preparation

Prior to the procedure, cervical preparation with osmotic dilators or medications is recommended in order to reduce risk of complications such as cervical laceration and to facilitate cervical dilation during the procedure. [16] [17] [10] Although there is no consensus as to which method of cervical preparation is superior in terms of safety and technical ease of the procedure, one particular concern is reducing the risk of preterm birth. Concerns within the medical community have advised against or at least asked for further research concerning the safety of performing the dilation of the cervix on the same day as the surgery for some or all second trimester pregnancies. The concern is that performing the dilation too soon before the surgery could increase the risk of preterm birth should the woman ever carry a subsequent pregnancy to term. [18] [19] However, for dilation and evacuation at greater than 20 weeks gestation, at least one day of cervical preparation is recommended, with the option of serial dilation for more than one day. [20] Dilation can be achieved with either osmotic dilation or misoprostol, although osmotic dilation with either laminaria or Dilapan is recommended. [20]

Anesthesia options

Most patients will be provided NSAIDs for pain management. Local anesthetics, such as lidocaine, are frequently injected by the cervix to reduce pain during the procedure. [21] [10] [22] IV sedation may also be used. [23] General anesthesia may be used depending on individual circumstances, however it is not preferred as it adds significant anesthesia risks to the procedure. [21] : 90–100 

Infection prophylaxis

Immediately prior to the procedure, antibiotics of either doxycycline or azithromycin are usually administered to prevent infection. [10]

Thromboprophylaxis

Prophylaxis for venous thromboembolism is not typically required for this procedure. [24]

Surgical procedure

A speculum is placed in the vagina to allow visualization of the cervix. If osmotic dilators were placed prior to the procedure, these are removed. [25]

The cervix may be further dilated with rigid dilator instruments such as Hegar and Pratt dilators (as opposed to osmotic dilators). [10] Sufficient cervical dilation decreases the risk of morbidity, including cervical injury and uterine perforation. [19] [10] Uterine contents are removed using a cannula to apply aspiration, followed by forceps to remove fetal parts. [26] Tissue inspection ensures removal of the fetus in its entirety. The procedure may be performed under ultrasound guidance to aid in visualizing uterine anatomy and to assess if all tissue has been removed at the completion of the procedure. [21] Operative ultrasonography is beneficial because it can reduce the risk of uterine perforation. [27]

The procedure usually takes less than half an hour. [28]

Uterotonics

There is no consensus on the routine use of perioperative or postoperative uterotonic medications. While many providers use these agents, there is no definitive evidence to support a decreased risk for bleeding under 20 weeks gestation. [10]

Recovery

D&E is usually performed in the outpatient setting, and the patient can be safely sent home the same day after a period of observed recovery, ranging from 45 minutes to several hours. Generally, the woman may return to work the following day. [28] The type of anesthesia given also influences the appropriate amount of recovery time before discharge. There is rarely a need for narcotic pain medications afterwards, and NSAIDs are recommended for home pain management. Recovery from the procedure is typically fast and uncomplicated. [25] : 174 

Some women may experience lactation after a second-trimester loss or termination of pregnancy. Limited data exists for the efficacy of medications to suppress lactation. However, one randomized control trial found cabergoline to be effective in preventing breast symptoms of engorgement, leakage, and tenderness after a second-trimester loss or termination of pregnancy. [29]

Variations

If the fetus is removed intact, the procedure is referred to as intact dilation and extraction by the American Medical Association, [30] and referred to as "intact dilation and evacuation" by the American Congress of Obstetricians and Gynecologists (ACOG). [31]

Risks

D&E is a safe procedure when performed by experienced practitioners. [21] The rate of mortality for all types of legal abortion procedures in the US (not specifically D&E) is 0.43 abortion-related deaths per 100,000 reported legal abortions. [32] There were four identified deaths related to abortion in the US during 2019, out of 625,000 abortions. [32] The strongest risk factor for mortality following abortion is increasing gestational age. [33]

Risks of D&E include bleeding, infection, uterine perforation, retained products of conception, and cervical laceration. [17] Hemorrhage occurs following less than 1% of all surgical abortions. [10] Infection rates following second trimester abortion have been reported to be 0.1–4%. The risk of infection is decreased by the use of antibiotics. [10] The risk of retained products of conception and uterine perforation are both under 1%. [24] The risk of cervical laceration is up to 3%. [24] Even rarer, a hysterectomy or damage to surrounding organs or tissues (i.e. bowel or omentum) can occur during a D&E. [21] [17]

There is no evidence that surgical abortion causes an increase in infertility or adverse outcomes in subsequent pregnancies. [21] : 252–254 

Alternatives

Alternatives to D&E include labor induction abortion and medical abortion.

Complication rates after D&E are lower than those of labor induction (medical abortion) after 13 weeks, as has been established through multiple studies. [28] Additionally, in certain clinical scenarios—severe anemia, for example—D&E may be preferred over labor induction. [34]

Law

The laws in the United States surrounding dilation and evacuation have been rapidly evolving since the Dobbs v. Jackson decision of 2022. Proposals to limit abortion access sometimes target specific procedures such as D&E, though this also restricts access for non-abortion patients, such as those with pregnancy loss. [4] Kansas was the first state to ban D&E in 2015, later it was struck down in 2016. Currently, D&E  is specifically banned in thirty-four states, except when deemed necessary for the preservation of the patient's life. [4] Twenty-one states have banned a "partial-birth" abortion, referring to an intact dilation and extraction. [4] Three of the twenty-one states have a health exception, and seventeen states allow an exception for life endangerment. [4]

Abortion laws in Europe, including dilation and evacuation, vary by country.

Physician training

A national survey of 190 US obstetrics and gynecology residency program directors in 2018 found that 22% considered their graduates to have had enough training in dilation and evacuation to be competent. After Dobbs v. Jackson, almost half of the US obstetrics and gynecology programs are located in states that have implemented abortion restrictions, which will further limit training in dilation and evacuation. [35] [36] The Accreditation Council for Graduate Medical Education states that these programs must either adapt by sending residents to legal jurisdictions where they are able to obtain this training or include uterine evacuation simulations in the educational curriculum. [37]

See also

Related Research Articles

Abortion is the termination of a pregnancy by removal or expulsion of an embryo or fetus. An abortion that occurs without intervention is known as a miscarriage or "spontaneous abortion"; these occur in approximately 30% to 40% of all pregnancies. When deliberate steps are taken to end a pregnancy, it is called an induced abortion, or less frequently "induced miscarriage". The unmodified word abortion generally refers to an induced abortion. The most common reasons given for having an abortion are for birth-timing and limiting family size. Other reasons reported include maternal health, an inability to afford a child, domestic violence, lack of support, feeling they are too young, wishing to complete education or advance a career, and not being able or willing to raise a child conceived as a result of rape or incest.

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of sections and/or layers of the lining of the uterus and or contents of the uterus such as an unwanted fetus, remains of a non-viable fetus, retained placenta after birth or abortion as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping (curettage). It is a gynecologic procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester abortion or miscarriage.

Intact dilation and extraction 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.

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

Late termination of pregnancy, also referred to politically as third trimester abortion, describes the termination of pregnancy by inducing labor during a late stage of gestation. In this context, late is not precisely defined, and different medical publications use varying gestational age thresholds. As of 2015, in the United States, more than 90% of abortions occur before the 13th week, 1.3% take place after the 21st week, and less than 1% occur after 24 weeks.

<span class="mw-page-title-main">Misoprostol</span> Medication to induce abortion and treat ulcers

Misoprostol is a synthetic prostaglandin medication used to prevent and treat stomach and duodenal ulcers, induce labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. It is taken by mouth when used to prevent gastric ulcers in people taking nonsteroidal anti-inflammatory drugs (NSAID). For abortions it is used by itself or in conjunction with mifepristone or methotrexate. By itself, effectiveness for abortion is between 66% and 90%. For labor induction or abortion, it is taken by mouth, dissolved in the mouth, or placed in the vagina. For postpartum bleeding it may also be used rectally.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.

<span class="mw-page-title-main">Vacuum aspiration</span> Gynaecological procedure

Vacuum or suction aspiration is a procedure that uses a vacuum source to remove an embryo or fetus through the cervix. The procedure is performed to induce abortion, as a treatment for incomplete spontaneous abortion or retained fetal and placental tissue, or to obtain a sample of uterine lining. It is generally safe, and serious complications rarely occur.

Hysterotomy abortion is a surgical procedure that removes an intact fetus from the uterus in a process similar to a cesarean section. The procedure is generally indicated after another method of termination has failed, or when such a procedure would be medically inadvisable, such as in the case of placenta accreta.

<span class="mw-page-title-main">Cervical effacement</span> Thinning and shortening of the cervix

Cervical effacement or cervical ripening refers to the thinning and shortening of the cervix. This process occurs during labor to prepare the cervix for dilation to allow the fetus to pass through the vagina. While this is a normal, physiological process that occurs at the later end of pregnancy, it can also be induced through medications and procedures.

Cervical weakness, also called cervical incompetence or cervical insufficiency, is a medical condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term. Definitions of cervical weakness vary, but one that is frequently used is the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester. Cervical weakness may cause miscarriage or preterm birth during the second and third trimesters. It has been estimated that cervical insufficiency complicates about 1% of pregnancies, and that it is a cause in about 8% of women with second trimester recurrent miscarriages.

<span class="mw-page-title-main">Endometrial ablation</span> Medical procedure

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.

<span class="mw-page-title-main">Placenta accreta spectrum</span> Medical condition

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:

  1. Accreta – chorionic villi attached to the myometrium, rather than being restricted within the decidua basalis.
  2. Increta – chorionic villi invaded into the myometrium.
  3. Percreta – chorionic villi invaded through the perimetrium.
<span class="mw-page-title-main">Osmotic dilator</span> Medical device to dilate the uterine cervix

Osmotic dilators, also known as hygroscopic dilators, are medical implements used to dilate the uterine cervix by swelling as they absorb fluid from surrounding tissue. They may be composed of natural or synthetic materials. A laminaria stick or tent is a thin rod made of the stems of dried Laminaria, a genus of kelp. Laminaria sticks can be generated from Laminaria japonica and Laminaria digitata. Second generation dilators such as Dilapan-S are composed of polyacrylonitrile, a plastic polymer. The hygroscopic nature of the polymer causes the dilator to absorb fluid and expand.

A paracervical block is an anesthetic procedure used in obstetrics and gynecology, in which a local anesthetic is injected into between two and six sites at a depth of 3–7 mm alongside the vaginal portion of the cervix in the vaginal fornices. In the United States, the paracervical block is underutilized during insertion of intrauterine devices (IUDs). There is speculation that this is related to the disproportionate under-researching of women's health.

Early pregnancy bleeding is vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.

A medical abortion, also known as medication abortion or non-surgical abortion, occurs when drugs (medication) are used to bring about an abortion. Medical abortions are an alternative to surgical abortions such as vacuum aspiration or dilation and curettage. Medical abortions are more common than surgical abortions in most places around the world.

References

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  3. ↑ Haskell, Martin (1992-09-13). "Dilation and Extraction for Late Second Trimester Abortion". National Abortion Federation Risk Management Seminar. Dallas, Texas. Archived from the original on September 16, 2006. Retrieved 2007-05-05.
  4. 1 2 3 4 5 "Bans on Specific Abortion Methods Used After the First Trimester". Guttmacher Institute. 2016-08-16. Archived from the original on 2017-01-12. Retrieved 2021-03-02.
  5. ↑ Stubblefield, Phillip G.; Carr-Ellis, Sacheen; Borgatta, Lynn (July 2004). "Methods for Induced Abortion". Obstetrics & Gynecology. 104 (1): 174–185. doi:10.1097/01.aog.0000130842.21897.53. ISSN   0029-7844. PMID   15229018.
  6. 1 2 "ACOG Practice Bulletin No. 102: Management of Stillbirth". Obstetrics & Gynecology. 113 (3): 748–761. March 2009. doi: 10.1097/aog.0b013e31819e9ee2 . ISSN   0029-7844. PMID   19300347.
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  8. 1 2 Jatlaoui, Tara C.; Boutot, Maegan E.; Mandel, Michele G.; Whiteman, Maura K.; Ti, Angeline; Petersen, Emily; Pazol, Karen (2018-11-23). "Abortion Surveillance – United States, 2015". MMWR. Surveillance Summaries. 67 (13): 1–45. doi:10.15585/mmwr.ss6713a1. ISSN   1546-0738. PMC   6289084 . PMID   30462632.
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  12. 1 2 "Management of Stillbirth: Obstetric Care Consensus No, 10". Obstetrics & Gynecology. 135 (3): e110–e132. March 2020. doi:10.1097/AOG.0000000000003719. ISSN   0029-7844. PMID   32080052. S2CID   211230954.
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  14. ↑ Soper, John T. (February 2021). "Gestational Trophoblastic Disease: Current Evaluation and Management". Obstetrics & Gynecology. 137 (2): 355–370. doi:10.1097/AOG.0000000000004240. ISSN   0029-7844. PMC   7813445 . PMID   33416290.
  15. ↑ Bruce, Shaina; Sorosky, Joel (2023), "Gestational Trophoblastic Disease", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   29261918 , retrieved 2023-11-15
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  17. 1 2 3 Fox, Michelle C.; Krajewski, Colleen M. (February 2014). "Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013–4". Contraception. 89 (2): 75–84. doi: 10.1016/j.contraception.2013.11.001 . ISSN   1879-0518. PMID   24331860.
  18. ↑ Lyus, Richard (December 22, 2016). "Cervical preparation prior to second-trimester surgical abortion and risk of subsequent preterm birth". Journal of Family Planning and Reproductive Health Care. 43 (1): 70–71. doi: 10.1136/jfprhc-2016-101695 . PMID   28007822.
  19. 1 2 Newmann, Sara J.; Dalve-Endres, Andrea; Diedrich, Justin T.; Steinauer, Jody E.; Meckstroth, Karen; Drey, Eleanor A. (2010-08-04). "Cervical preparation for second trimester dilation and evacuation". The Cochrane Database of Systematic Reviews (8): CD007310. doi:10.1002/14651858.CD007310.pub2. ISSN   1469-493X. PMID   20687085.
  20. 1 2 Newmann, Sara; Dalve-Endres, Andrea; Drey, Eleanor A. (April 2008). "Cervical preparation for surgical abortion from 20 to 24 weeks' gestation". Contraception. 77 (4): 308–314. doi: 10.1016/j.contraception.2008.01.004 . PMID   18342657.
  21. 1 2 3 4 5 6 Paul, Maureen, Hrsg. Lichtenberg, Steve, Hrsg. Borgatta, Lynn, Hrsg. Grimes, David A., Hrsg. Stubblefield, Phillip G., Hrsg. Creinin, Mitchell D., Hrsg. (2011). Management of Unintended and Abnormal Pregnancy Comprehensive Abortion Care. John Wiley & Sons. ISBN   9781444358476. OCLC   899157428.{{cite book}}: CS1 maint: multiple names: authors list (link)
  22. ↑ Allen, Rebecca H.; Singh, Rameet (June 2018). "Society of Family Planning clinical guidelines pain control in surgical abortion part 1 – local anesthesia and minimal sedation". Contraception. 97 (6): 471–477. doi: 10.1016/j.contraception.2018.01.014 . ISSN   0010-7824. PMID   29407363.
  23. ↑ Cansino, Catherine; Denny, Colleen; Carlisle, A. Sue; Stubblefield, Phillip (2021-12-01). "Society of Family Planning clinical recommendations: Pain control in surgical abortion part 2 – Moderate sedation, deep sedation, and general anesthesia". Contraception. 104 (6): 583–592. doi: 10.1016/j.contraception.2021.08.007 . ISSN   0010-7824. PMID   34425082.
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  26. ↑ Organization, World Health (2014). Clinical practice handbook for safe abortion. World Health Organization. Reproductive Health and Research. Geneva. p. 52. ISBN   9789241548717. OCLC   879416856.{{cite book}}: CS1 maint: location missing publisher (link)
  27. ↑ Stubblefield, Phillip G.; Carr-Ellis, Sacheen; Borgatta, Lynn (July 2004). "Methods for Induced Abortion". Obstetrics & Gynecology. 104 (1): 174–185. doi:10.1097/01.AOG.0000130842.21897.53. ISSN   0029-7844. PMID   15229018.
  28. 1 2 3 Hammond, C. (2009). "Recent advances in second-trimester abortion: an evidence-based review". Am J Obstet Gynecol. 200 (4): 347–356. doi:10.1016/j.ajog.2008.11.016. PMID   19318143.
  29. ↑ Henkel, Andrea; Johnson, Sarah A.; Reeves, Matthew F.; Cahill, Erica P.; Blumenthal, Paul D.; Shaw, Kate A. (June 2023). "Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Pregnancy Loss: A Randomized Controlled Trial". Obstetrics & Gynecology. 141 (6): 1115–1123. doi:10.1097/AOG.0000000000005190. ISSN   0029-7844. PMID   37486652. S2CID   258767994.
  30. ↑ Health and Ethics Policies of the AMA Archived 2020-04-26 at the Wayback Machine American Medical Association. H-5.982 Retrieved April 24, 2007.
  31. ↑ ACOG Statement on the US Supreme Court Decision Upholding the Partial-Birth Abortion Ban Act of 2003 Archived 2007-06-11 at the Wayback Machine (April 18, 2007). Retrieved 2007-04-22.
  32. 1 2 Kortsmit, Katherine (2022). "Abortion Surveillance — United States, 2020". MMWR. Surveillance Summaries. 71 (10): 1–27. doi:10.15585/mmwr.ss7110a1. ISSN   1546-0738. PMC   9707346 . PMID   36417304.
  33. ↑ Jatlaoui, Tara C.; Boutot, Maegan E.; Mandel, Michele G.; Whiteman, Maura K.; Ti, Angeline; Petersen, Emily; Pazol, Karen (2018-11-23). "Abortion Surveillance – United States, 2015". MMWR. Surveillance Summaries. 67 (13): 1–45. doi:10.15585/mmwr.ss6713a1. ISSN   1546-0738. PMC   6289084 . PMID   30462632.
  34. ↑ Borgatta, Lynn; Kapp, Nathalie (2011). "Labor induction abortion in the second trimester". Contraception. 84 (1): 4–18. doi: 10.1016/j.contraception.2011.02.005 . PMID   21664506.
  35. ↑ "The State Abortion Policy Landscape One Year Post-Roe". Guttmacher Institute. 2023-06-14. Retrieved 2023-11-13.
  36. ↑ Vinekar, Kavita; Karlapudi, Aishwarya; Nathan, Lauren; Turk, Jema K.; Rible, Radhika; Steinauer, Jody (August 2022). "Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs". Obstetrics & Gynecology. 140 (2): 146–149. doi: 10.1097/AOG.0000000000004832 . ISSN   0029-7844. PMID   35852261. S2CID   250627945.
  37. ↑ "ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology Summary and Impact of Interim Requirement Revisions" (PDF). Accreditation Council for Graduate Medical Education. June 24, 2022.
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