Dilation and curettage

Last updated
Dilation and curettage
D&C
Background
Abortion typeSurgical
First useLate 19th century
Gestation 4–12 weeks
Usage
WHO recommends only when manual vacuum aspiration is unavailable
United States1.7% (2003)
Medical notes
Undertaken under heavy sedation or general anesthesia. Risk of perforation. Day-case procedure
Infobox references

Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening or opening) 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 (early abortion before 13 weeks), 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. [1] [2] [3] [4]

Contents

D&C normally refers to a procedure involving a curette, also called sharp curettage. [2] However, some sources use the term D&C to refer to any procedure that involves the processes of dilation and removal of uterine contents, or life or former life inside which includes the more common suction curettage procedures of manual and electric vacuum aspiration. [5]

Clinical uses

D&Cs may be performed in pregnant and non-pregnant patients, for different clinical indications. Such examples are for Early Abortion, Removing the remains of a non-viable pregnancy or retention of placenta from a pregnancy loss/abortion. Treatment of menopause induced anomalies with menstrual cycle.g

During pregnancy or postpartum

A D&C may be performed early in pregnancy to remove pregnancy tissue, either in the case of a non-viable pregnancy, such as a missed or incomplete miscarriage, or an undesired pregnancy, as in a surgical abortion. [6] Medical management of miscarriage and medical abortion using drugs such as misoprostol and mifepristone are safe, non-invasive and potentially less expensive alternatives to D&C.

Because medication-based non-invasive methods of abortion now exist, dilation and curettage has been declining as a method of abortion, although suction curettage is still the most common and preferred method to ensure complete removal of remains as the method is a completed process used for termination of a First-Trimester Pregnancy. [7] [8] The World Health Organization recommends D&C with a Sharp Curette as a method of surgical abortion ONLY when manual vacuum aspiration with a suction curette is unavailable. [9]

For patients who have recently given birth, a D&C may be indicated to remove retained placental tissue that does not pass spontaneously or for postpartum hemorrhage. [10]

Non-pregnant patients

D&Cs for non-pregnant patients are commonly performed in tandem with Hysteroscopy another diagnostic procedure, for the diagnosis of gynecological conditions usually involving abnormal bleeding; during menopause or with various abnormal structures growing within the uterus [11] to remove the excess uterine lining in women who have conditions such as polycystic ovary syndrome; [12] to remove tissue in the uterus that may be causing abnormal uterine bleeding, such as endometrial polyps or uterine fibroids; [3] [2] or to diagnose the cause of post-menopausal bleeding, such as in the case of endometrial cancer.

Hysteroscopy is a valid alternative or addition to D&C for many surgical indications, from diagnosis of uterine pathology to the removal of fibroids and even retained tissue of Pregnancy . It allows direct visualization of the inside of the uterus and may allow targeted sampling and removal of tissue inside the uterus. [13]

Procedure

An illustration of a dilation and curettage Dilation & curettage.svg
An illustration of a dilation and curettage

Depending on the anticipated duration and difficulty expected with the procedure, as well as the clinical indication and patient preferences, a D&C may be performed with local anesthesia, moderate sedation, deep sedation, or general anesthesia. [14] The first step in a D&C is to place a speculum in the vagina so as to see the cervix. Often, a tenaculum is placed to steady the cervix. Next, the provider will dilate the cervix. This can be done with Hegar or similar dilators. [6] The amount of dilation depends on the amount of tissue to be removed as well as the size of the instruments to be used. After sufficient dilation, a curette, a metal rod with a handle on one end and a loop on the other, is then inserted into the uterus through the dilated cervix. The curette is used to gently scrape the lining of the uterus and remove the tissue in the uterus. If a suction curette is used, as in a vacuum aspiration, a plastic tubular curette will be introduced into the uterus and connected to suction to remove all tissue in the uterus. This tissue is examined for completeness (in the case of abortion or miscarriage treatment) or by pathology for abnormalities (in the case of treatment for abnormal bleeding). [2]

Complications

The most common complications associated with D&C are infection, bleeding, or damage to nearby organs, including through uterine perforation. [15] Aside from the surgery itself, complications related to anesthesia administration may also occur.

Infection is uncommon after D&C for a non-pregnant patient, and society practice guidelines do not recommend routine prophylactic antibiotics to patients. [16] However, for curettage of a pregnant patient, the risk of infection is higher, and patients should receive antibiotics that cover the bacteria commonly found in the vagina and gastrointestinal tract; doxycycline is a common recommendation, though azithromycin may also be used. [16]

Another risk of D&C is uterine perforation. The highest rate of uterine perforation appears to be in the setting of postpartum hemorrhage (5.1%) compared with a lower rate in diagnostic curettage in non-pregnant patients (0.3% in the premenopausal patient and 2.6% in the postmenopausal patient). [17] Perforation may cause excessive bleeding or damage to organs outside the uterus. If the provider is concerned about ongoing bleeding or the possibility of injury to organs outside the uterus, a laparoscopy may be done to verify that there has been no undiagnosed injury.

Another potential risk is Asherman’s syndrome, a condition where intrauterine adhesions lead to subfertility, amenorrhea, or recurrent pregnancy loss. Although older studies [18] [19] [20] described a high (25-30%) risk of developing this condition after dilation and curettage for treatment of miscarriage, these procedures were likely done using sharp curettage, which is no longer routinely performed in modern miscarriage and abortion care. Newer studies [21] [22] reflect the common technique of suction curettage and demonstrate a much lower risk of Asherman’s syndrome, with incidence in large prospective trials ranging from 0.7-1.6%. A history of multiple (>3) procedures [21] and sharp curettage [22] were identified as risk factors for developing clinical Asherman’s syndrome. A systematic review in 2013 concluded that recurrent miscarriage treated with D&C is the main risk factors for intrauterine adhesions. [23] There are currently no studies linking asymptomatic intrauterine adhesions and long-term reproductive outcomes, and similar pregnancy outcomes have been found after miscarriage regardless of whether surgical treatment, medication management, or conservative management (i.e. watchful waiting) was chosen. [23]

See also

Related Research Articles

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

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">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<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.

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

Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention.

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">Endometrial polyp</span> Medical condition

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

<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.

Dilation and evacuation (D&E) or dilatation and evacuation is the dilation of the cervix and surgical evacuation of the uterus 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.

<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">Endometrial biopsy</span> Diagnostic medical procedure

The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes a histologic evaluation which aids the physician in forming a diagnosis.

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

Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.

<span class="mw-page-title-main">Osmotic dilator</span> Medical device to dilate the uterine cervix

Osmotic 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. Synthetic osmotic dilators are commonly referred to by their brand names, such as Dilapan. Dilapan-S are composed of polyacrylonitrile, a plastic polymer. The hygroscopic nature of the polymer causes the dilator to absorb fluid and expand.

<span class="mw-page-title-main">Cervical pregnancy</span> Medical condition

A cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix. Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity – a so-called cervico-isthmic pregnancy – it may continue longer. Placental removal in a cervical pregnancy may result in major hemorrhage.

<span class="mw-page-title-main">Products of conception</span>

Products of conception, abbreviated POC, is a medical term used for the tissue derived from the union of an egg and a sperm. It encompasses anembryonic gestation which does not have a viable embryo.

Early pregnancy bleeding refers to 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.

Müllerian duct anomalies are those structural anomalies caused by errors in Müllerian duct development during embryonic morphogenesis. Factors that precipitate include genetics, and maternal exposure to teratogens.

References

  1. ↑ Pazol, Karen; Creanga, Andreea A.; Burley, Kim D.; et al. (November 29, 2013). "Abortion Surveillance – United States, 2010". Surveillance Summaries. 62 (ss08). Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control: 1–44. PMID   24280963 . Retrieved 14 January 2014– via CDC.gov.
  2. 1 2 3 4 "Dilation and sharp curettage (D&C) for abortion". WebMD. 2004-10-07. Retrieved 2007-04-29.
  3. 1 2 Hayden, Merrill (2006-02-22). "Dilation and curettage (D&C) for dysfunctional uterine bleeding". WebMD.com. Archived from not due to hormone invalance or retained pregnancy fragments the original on 2007-10-21. Retrieved 2007-04-29.{{cite web}}: Check |url= value (help)
  4. ↑ Nissl, Jan (2005-01-18). "Dilation and curettage (D&C) for bleeding during menopause". WebMD.com. Retrieved 2007-04-29.
  5. ↑ "What Every Pregnant Woman Need to Know About Pregnancy Loss and Neonatal Death". The Unofficial Guide to Having a Baby. WebMD. 2004-10-07. Archived from the original on 28 May 2008. Retrieved 2007-04-29.
  6. 1 2 "ACOG: FAQ: Dilation and Curettage". American College of Obstetricians and Gynecologists . Retrieved 10 January 2020.
  7. ↑ "Minor surgical procedure common in O&G associated with increased risk of preterm delivery". EurekAlert!. European Society of Human Reproduction and Embryology. 16 June 2015. Retrieved 2018-10-17.
  8. ↑ "INDUCED ABORTION in The United States". guttmacher.org. Guttmacher Institute. September 2019. Retrieved 11 October 2019.
  9. ↑ Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Do ctors. World Health Organization, UNICEF, United Nations Population Fund. 2017. p. P-71. ISBN   9789241565493.
  10. ↑ Wolman I, Altman E, Fait G, et al. (2009). "Evacuating Retained Products of Conception in the setting of an ultrasound unit". Fertil. Steril. 91 (4 Suppl): 1586–1588. doi: 10.1016/j.fertnstert.2008.10.032 . PMID   19064261.
  11. ↑ Anastasiadis PG, Koutlaki NG, Skaphida PG, Galazios GC, Tsikouras PN, Liberis VA (2000). "Endometrial polyps: prevalence, detection, and malignant potential in women with abnormal uterine bleeding". Eur J Gynaecol Oncol. 21 (2): 180–183. PMID   10843481.
  12. ↑ "Dilation and Curettage (D&C)". www.phyllisgeemd.com. Practice Builders & Health Central Women's Care, PA. 2016. Archived from the original on 2009-04-25. Retrieved 2018-10-17.
  13. ↑ "Hysteroscopy". Cleveland Clinic. Retrieved 11 October 2019.
  14. ↑ Allen, Rebecca H.; Singh, Rameet (2018-06-01). "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.
  15. ↑ "Dilation and curettage (D&C)". Mayo Clinic. Retrieved 24 October 2020.
  16. 1 2 "ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures". Obstetrics & Gynecology. 131 (6). American College of Obstetricians Gynecologists' Committee on Practice Bulletins – Gynecology: e172–e189. June 2018. doi:10.1097/AOG.0000000000002670. ISSN   0029-7844. PMID   29794678. S2CID   44097972.
  17. ↑ Hefler, Lukas; Lemach, Andrea; Seebacher, Veronika; et al. (June 2009). "The Intraoperative Complication Rate of Nonobstetric Dilation and Curettage". Obstetrics & Gynecology. 113 (6): 1268–1271. doi: 10.1097/AOG.0b013e3181a66f91 . ISSN   0029-7844. PMID   19461421. S2CID   205471595.
  18. ↑ Friedler S, Margalioth EJ, Kafka I, et al. (1993). "Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy – a prospective study". Hum. Reprod. 8 (3): 442–444. doi:10.1093/oxfordjournals.humrep.a138068. PMID   8473464.
  19. ↑ Schenker JG, Margalioth EJ (1982). "Intra-uterine adhesions: an updated appraisal". Fertility and Sterility. 37 (5): 593–610. doi: 10.1016/S0015-0282(16)46268-0 . PMID   6281085.
  20. ↑ Kodaman PH, Arici A (2007). "Intrauterine adhesions and fertility outcome:how to optimize success?". Current Opinion in Obstetrics and Gynecology. 19 (3): 207–214. doi:10.1097/GCO.0b013e32814a6473. PMID   17495635. S2CID   3082867.
  21. 1 2 Sevinç, Fahrünnisa; Oskovi-Kaplan, Z. Asli; Çelen, Şevki; Ozturk Atan, Deniz; Topçu, Hasan Onur (2021). "Identifying the risk factors and incidence of Asherman Syndrome in women with p ost-abortion uterine curettage". Journal of Obstetrics and Gynaecology Research. 47 (4): 1549–1555. doi:10.1111/jog.14667. ISSN   1341-8076. PMID   33462894. S2CID   231642553.
  22. 1 2 Gilman Barber, Ashley R.; Rhone, Stephanie A.; Fluker, Margo R. (2014). "Curettage and Asherman's Syndrome—Lessons to (Re-) Learn?". Journal of Obstetrics and Gynaecology Canada. 36 (11): 997–1001. doi: 10.1016/s1701-2163(15)30413-8 . ISSN   1701-2163. PMID   25574677.
  23. 1 2 Hooker AB, Lemmers M, Thurkow AL, et al. (2013). "Systematic review and meta-analysis of intrauterine adhesions after miscarriage: Prevalence, risk factors and long-term reproductive outcome" (PDF). Human Reproduction Update. 20 (2): 262–278. doi: 10.1093/humupd/dmt045 . PMID   24082042.
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