Dilation and Curettage (D&C)

Overview

A dilatation and curettage (D&C) is a surgical procedure used to remove the uterine (womb) lining of women. The cervix (neck) of the uterus (womb) is dilated with the use of a dilator. If necessary, the endometrium (uterine lining) or uterine contents are removed and submitted to a laboratory for analysis.

The technique can be used on either pregnant or non-pregnant women and can be diagnostic or therapeutic. Occasionally, circumstances cause the two to overlap, and the diagnostic method becomes therapeutic. This surgical technique or medical care would be administered to a pregnant patient desiring a first trimester (14 weeks) elective termination or management of a missed, incomplete, or unavoidable abortion.

What is dilation and curettage (D&C)?

A dilation and curettage (D&C) operation is used to remove tissue from the uterine lining (endometrium). The vagina is spread open during a D&C. The cervix is then gently opened so that tissue may be removed, which is commonly done with a scrape or suction instrument.

A D&C procedure can be performed in a hospital or clinic. The majority of ladies return home the same day. Your anesthetic provider will keep you comfortable and safe. You may be given medication that calms you or puts you to sleep. You may be given pain medication before to the surgery.

Anatomy and Physiology

The D&C procedure involves the removal of tissue from the uterine cavity. The endometrial lining of a non-pregnant female is sampled and sent for pathological examination. The standard of care suggests hysteroscopy with a directed uterine sample, but if resources are limited, do the D&C with tissue submission to pathology for diagnosis. The cervix is the anatomical entrance to the uterine cavity. It measures 3 to 4 centimeters in length. To acquire access to the uterine cavity, both the external os (visible in the vagina) and the internal os must be dilated.

The size of the uterine cavity will vary based on distorting characteristics such as fibroids and polyps, as well as how far along the fetus is in gestation. The non-pregnant uterine lining is divided into two layers: the stratum basalis and the stratum functionalis. The D&C is intended to remove the stratum functionalis, however, it has little effect on the hypothalamic-pituitary-ovarian axis in terms of ovulation or future menstruation.

The pregnancy or products of conception will be removed from the uterine cavity while attempting to avoid removing tissue beyond the decidua basalis layer. The decidua develops as a result of steroid hormone modification of the endometrial lining. The decidua is made up of three layers. The decidual basalis is where implantation occurs and the basal plate develops; it is also where the placenta detaches after delivery. To avoid the formation of adhesions, the surgeon will strive to avoid removing tissue beyond this layer during the pregnancy D&C.

Indications

For the D&C, there are both diagnostic and therapeutic indications. Many D&C diagnostic justifications have been replaced by office endometrial biopsy (EMB). D&C and EMB have been demonstrated to identify cancer at equal rates; nevertheless, there are clinical settings where this is inadequate. Although hysteroscopy (with guided sample) followed with D&C is desirable, it is not essential.

The surgeon would conduct a D&C if the patient was unable to tolerate the EMB or if the tissue sample recovered was inadequate for diagnosis. Cervical stenosis, as well as recurrent abnormal bleeding or postmenopausal hemorrhage following a benign office biopsy, necessitates a D&C.

Contraindications

The intention to sustain a viable intrauterine pregnancy is the sole absolute contraindication to a D&C. There are related contraindications to consider when deciding whether the operation should be conducted in an outpatient clinical environment or in the operating room. Depending on your institution, patients with bleeding diathesis or who use anticoagulant drugs may exacerbate an issue in the outpatient setting.

In general, first trimester abortions done on anticoagulated individuals are regarded as safe and result in comparable bleeding to those who are not on anticoagulants. The importance of keeping these drugs must be balanced against the severity of the patient's illness state and the reason she is on the prescription. Patients with clotting deficiencies should have their clotting factors restored before the surgery.

If the pregnancy is thought to be a molar pregnancy, the procedure should be conducted in the operating room to avoid anesthetic difficulties and the risk of serious bleeding. In a patient with a known active pelvic infection, a planned or elective D&C should be postponed. In the case of a septic abortion or endometritis with suspected retained products of conception, however, the surgeon should proceed with uterine evacuation.

Equipment used in D&C

Every provider requires dilators, curettes, and an aspiration tool, which might be manual or electric. Steel Pratt dilators, Hank dilators, and Hegar dilators are the three most frequent types of dilators. Pratt dilators are commonly used because they feature long tapered tips that allow for the least amount of effort. They are available in sizes 9-79 F. (French unit).

Hank dilators resemble Pratt dilators with a cuff on them. They are measured in French units, although their taper from tip to dilation is steeper than that of Pratt dilators. With this dilator set, there is an increased risk of perforation because many clinicians utilize the cuff as a stopping point because each cervix and even uterine cavity is unique.

Hegar dilators are short with a blunt tip. They grow fast in size, necessitating greater power to dilate, increasing the danger of perforation. This set of dilators may be difficult to use for overweight women or women with longer vaginal canals since it does not reach the full cervical canal. There have been no trials that compare the safety or efficacy of these various dilator sets.

Curettes can be made of metal or plastic. The sharp metal curette is generally used in the diagnostic D&C. The handle is long and has an open teardrop form at the tip. They come in a range of sizes, which are determined by the maximum diameter at the tip. In the postmenopausal patient, a curette with teeth is occasionally utilized for forceful tissue samples of the endometrium.

In pregnant individuals, plastic curettes or cannulas are more routinely employed. These cannulas might be stiff or flexible, straight or curved. These cannulas are measured in millimeters, and in the first trimester, abortion diameters ranging from 7 to 12 mm are usually adequate.

Because stiff plastic cannulas are more difficult to install, if the provider is using a Pratt dilator, they will dilate just past the selected cannula size. In other words, if you're utilizing an 8 mm cannula, a 25-26 Pratt dilator will be enough for implantation.

Aspirators are classified as either electric or manual vacuum aspirators (MVA). Where this operation is conducted, as well as space availability, may influence which provider is chosen. The electric suction aspirator creates negative pressure in order to swiftly and efficiently empty the uterus and reduce bleeding.

This equipment is often noisy, which might heighten the patient's anxiety. The MVA is a portable device that creates negative pressure with a big connected syringe. These can be quite effective in the office, but they take longer because suction is gone when the syringe is loaded and must be emptied.

Preparation of the patient

Cervical preparation for the D&C is an option. In general, cervical preparation is needed for any second-trimester procedure, often known as the D&E or dilation and evacuation, but not always for the first trimester D&C. Traditionally, two approaches can be considered: osmotic dilators and chemical ripening agents.

Osmotic dilators, such as Laminaria, are well-established, safe, and successful methods of cervix dilation, but they must be placed overnight. These agents are inserted into the cervical os and absorb moisture from the cervix, gradually enlarging and dilating the os.

Prostaglandin analogs or progesterone antagonists are utilized as chemical agents to soften or prime the cervix. Misoprostol, a prostaglandin analog, is the most often used vaginally delivered medicine for cervical preparation. It is a safe and effective method of cervical preparation that may be given on the same day.

Mifepristone, a progesterone antagonist, is equally effective as misoprostol; however, its high cost and restricted availability prevent its widespread usage. The Society of Family Planning does not suggest cervical preparation for first-trimester abortions unless the woman is at high risk of complications, such as cervical lacerations, insufficient cervical dilatation, or uterine perforation.

Cervical priming is necessary, but it can have unfavorable side effects. Later first trimester abortions (12 to 14 weeks), adolescents, and women with difficult cervical dilation, such as those who have had a LEEP procedure, should consider a priming agent. The patient should be positioned for dorsal lithotomy. A bimanual exam is performed to determine the size and location of the uterus.

To limit the risk of post-abortion infection, vaginal pretreatment with an antiseptic solution is usually undertaken. There is some evidence that a preparation including chlorhexidine or providone-iodine is preferable to saline alone, although studies are insufficient. There is evidence that using a chlorohexidine solution reduces the vaginal bacterial burden, however, this study was not powered to look at clinical effects.

Preoperative antibiotics have been shown to reduce the likelihood of post-surgical abortion in pregnant patients but not in non-pregnant individuals. Routine procedures such as endometrial biopsies and hysteroscopy do not prescribe antibiotic prophylaxis; hence, the non-pregnant D&C is not advised. Preoperative doxycycline is a safe and efficient prophylactic for surgically induced abortions, whether given as a single dosage or over a short period of time.

Dilation and curettage procedure

In the vagina, a bivalve or weighted speculum is inserted. If local anesthetic is being utilized, the cervix and lower uterine section should be injected. Most of the time, 1% lidocaine is sufficient. The non-dominant hand grasps the anterior lip of the cervix and pulls it towards the introitus with a tenaculum.

The uterus will be stabilized and the cervicouterine angle will be reduced, lowering the risk of uterine perforation. The routine use of uterine sound for cavity length does not help the operation unless the uterus could not be palpated during the first exam.

If a diagnostic D&C is performed on a non-pregnant patient, an endocervical curettage is performed and delivered as a separate specimen prior to endometrial sample to avoid contaminating the cervical specimen with endometrial cells. Otherwise, in all D&Cs, begin dilatation of the cervix with the smallest dilator that will pass and increase dilator size gradually. The dilator must go through both the exterior and interior os.

Surgeons learn to recognize this landmark by observing a lack of slight resistance to gentle pressure. The dilator should be held with two fingers in the surgeon's dominant hand to avoid excessive pressure, which increases the risk of uterine perforation. The amount of tissue to be removed and the size of the curette will define the extent of dilatation. Inserts the metal or plastic curette after proper dilatation.

If suction is employed, perform manual or electronic suction after inserting the curette into the fundus of the uterus. The curette is placed against the uterine walls and dragged from the fundus to the cervix. To avoid cervical injury, remain inside the uterine cavity while suction is performed. Rotate the curette 360 degrees before repeating the vertical pass motion from the fundus to the level of the internal os, encompassing the whole uterine cavity.

A gritty texture suggests full pregnancy removal or, in non-pregnant treatments, sufficient endometrial sample. During the pregnancy D&C, there should be little to no bleeding from the os, as well as complete removal of the pregnancy, signifying completion.

If there is a gritty texture but no bleeding, consider bimanual massage to address suspected atony, product retention, or uterine or cervical damage. While doing the surgery, ultrasound can be utilized to directly see the uterus. The ultrasound may give a safety precaution to prevent damage in patients with an atypical uterine cavity or trouble dilating the cervix.

Complications of D&C

D&C is linked with a low overall mortality rate. The rate is 0.6 abortions for every 100,000 lawfully induced abortions. To put this in context, the chance of mortality during delivery is 14 times higher. With increasing gestational age, the risk of morbidity and death rises. Complications of D&C include infection, bleeding, cervical lacerations, uterine perforation, and post-op uterine adhesions in both pregnant and non-pregnant patients. Overall infection rates are minimal, ranging from 1% to 2%, and prophylactic antibiotic usage is advised in pregnant women.

Infection rates in non-pregnant individuals are significantly lower, and preventive antibiotics are not advised. The most common acute complication in pregnant or non-pregnant D&Cs is uterine perforation. Uterine perforation is more prevalent near the fundus, and risk factors include post-partum hemorrhage, post-menopausal state, nulliparity, and retroverted uterus.

With increasing gestational age, the risk of uterine perforation rises in pregnant individuals. The management of uterine perforation is determined by when it occurs during the surgery. If there was a bowel in the suction device and indications of intrauterine hemorrhage, the surgery may have to be completed with direct visibility via laparoscopy or ultrasound.

If there is a possibility of intestinal damage or considerable bleeding, as well as a lateral wall perforation, laparoscopy should be done. Cervical damage or lacerations to the cervix's lip are common when too much traction is given to the cervix during dilatation or manipulation. The majority of lacerations are treatable with pressure, silver nitrate, or ferric subsulfate.

Suture ligation is occasionally required. If the internal cervix canal is injured again, pressure or suture should be utilized initially. If there is no response, balloon tamponade or embolization should be considered, with additional examination for abdominal or retroperitoneal hemorrhage feasible.

Hemorrhage is relatively uncommon in non-obstetric patients undergoing D&C. In this case, the surgeon should consider uterine perforation or cervical damage as the most likely cause and treat it accordingly. Hemorrhage is more likely in pregnant patients undergoing D&C and rises with gestational age or being post-partum.

When assessing post-abortion bleeding, many etiologies must be examined. Retained products of conception, uterine atony, improper placentation, and cervix or uterus damage can all result in severe bleeding.

Management should be based on the etiology. Asherman syndrome, or post-operative uterine adhesions, is uncommon but more prevalent following a septic D&C. The patient may have infertility symptoms, abnormalities in her menstrual cycle, or menstrual discomfort, and a diagnostic hysteroscopy is done to visualize the adhesions. Depending on the degree of the adhesions, treatment might be tough.

Monitoring & Follow-up

The most frequent symptoms reported after a diagnostic dilation and curettage are cramps and light vaginal bleeding. The patient's expectations for these symptoms should be addressed to her before she is discharged from the office or outpatient surgical facility. In most cases, over-the-counter drugs are adequate for pain relief.

Heavy bleeding, fever, stomach discomfort or distention, nausea, and vomiting, or a foul vaginal odor should all be investigated to rule out infection, perforation, or retained tissue. Any postoperative symptoms that the patient develops should also be evaluated for worsening of previous comorbidities.

Two weeks after your procedure, or a few days after bleeding has stopped:

Shower instead of taking a bath
Avoid sexual intercourse
Use sanitary pads instead of tampons
Avoid going swimming
If you experience any signs of infection (such as fever, pain or discharge), see your doctor immediately.

Conclusion

Dilation and curettage is a surgical treatment that may be performed on both pregnant and non-pregnant people. If the pregnant woman wants to have an abortion, whether it is voluntary or not, she has both medicinal and surgical choices. The surgical approach with a D&C can more successfully manage bleeding and discomfort. It will be a more timely treatment than medical abortions. The outcomes are similar, but the risks and advantages are determined by the particular patient's risks and aspirations.

Non-pregnant patients can receive a D&C or an office endometrial biopsy with an ultrasound to analyze the uterine cavity and tissue. The latter can be deceptively comforting, hiding cancer until it becomes more aggressive or widespread while allowing the patient to avoid the operating room. The D&C is a frequent surgery that has been a part of the OBGYN's toolbox in the care of their patients for over 100 years. For years to come, this treatment will continue to deliver comparable answers and care to patients.