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Abstract：
Although only 1.3% of abortions in the United States are between 20 and 24 weeks\' gestation, these procedures are associated with elevated risks of morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20-24 weeks\' gestation reduces procedural risk. For this gestational range, at least one day of cervical preparation with osmotic dilators is recommended before D&E. The use of overnight osmotic dilators alone is sufficient for most D&Es at 20-24 weeks\' gestation. Dilapan-S® dilators require a shorter time to achieve maximum dilation, may be more effective than laminaria and may increase the likelihood of success on the first D&E attempt. The use of adjunctive mifepristone administered one-day pre-operatively at the time of osmotic dilator placement, should be considered because evidence demonstrates that it makes D&E subjectively easier at 20-24 weeks without increasing side effects. While older studies suggest that two-days of serial osmotic dilators provide greater dilation than one day of dilators, adjunctive mifepristone may be comparable to a second day of dilators. Adjunctive misoprostol administered on the day of D&E does not appear to affect initial cervical dilation and procedure time and compared with mifepristone is associated with more side effects, such as pain and nausea. Using overnight mifepristone and same-day misoprostol without osmotic dilators at 20-24 weeks\' gestation lengthens D&E procedure time and appears to increase immediate complications, at least among less experienced providers. Some evidence shows the feasibility of same-day cervical preparation before D&E at 20-24 weeks using Dilapan-S® with adjunctive misoprostol or serial repeat dosing of misoprostol, but same-day preparation should be limited to providers with significant experience with these regimens. The Society of Family Planning recommends preoperative cervical preparation before D&E at 20-24 weeks\' gestation. Further studies are needed to clarify the best means of preparing the cervix in order to minimize abortion complications and improve outcomes in this gestational range.
摘要：
虽然在美国只有1.3%的堕胎是在妊娠20到24周之间，这些手术会增加发病率和死亡率.在妊娠20-24周时，在扩张和撤离（D＆E）之前进行充分的宫颈准备可降低手术风险。对于这个妊娠范围，建议在D＆E之前至少使用渗透性扩张剂进行宫颈准备一天对于妊娠20-24周的大多数D&Es,单独使用过夜渗透性扩张剂是足够的。Dilapan-S®扩张器需要更短的时间来实现最大扩张，可能比海带更有效，并且可能增加首次D＆E尝试成功的可能性。在放置渗透性扩张器时，术前一天使用辅助米非司酮，应该考虑，因为证据表明它使D＆E在20-24周时主观上更容易，而不会增加副作用。虽然较早的研究表明，两天的连续渗透扩张器比一天的扩张器提供更大的扩张，辅助米非司酮可能与第二天的扩张器相当。在D&E治疗当天服用米索前列醇似乎不会影响宫颈扩张和手术时间，与米非司酮相比，副作用更多。如疼痛和恶心。在妊娠20-24周时使用米非司酮和当日米索前列醇而不使用渗透性扩张剂会延长D＆E手术时间，并似乎会增加即时并发症。至少在经验不足的提供者中。一些证据表明，在20-24周使用Dilapan-S®联合米索前列醇或连续重复给药的米索前列醇，在D＆E之前进行当天宫颈准备的可行性，但当天的准备工作应仅限于对这些方案有丰富经验的提供者.计划生育协会建议在妊娠20-24周的D＆E之前进行术前宫颈准备。需要进一步的研究来阐明准备子宫颈的最佳方法，以最大程度地减少流产并发症并改善该妊娠范围内的结局。
