Dilation and Curettage

CHAPTER 141 Dilation and Curettage



Verneeta L. Williams, Sheila Thomas


Dilation and curettage (D&C) is a valuable diagnostic and therapeutic tool in the management of abnormal uterine bleeding (AUB) and pregnancy-related disorders. Endometrial biopsy techniques have replaced D&C in most diagnostic situations, and hysteroscopy (see Chapter 140, Hysteroscopy) is now often performed in place of the “blind” D&C when initial diagnostic and therapeutic interventions fail. When the operator is experienced and the proper ancillary personnel are available, the office D&C proves to be a very cost-effective and safe procedure for the patient. Otherwise, the procedure can be performed in the operating room. In many instances of abnormal bleeding, diagnosis is facilitated if the sampling is done just before an anticipated period (e.g., for anovulatory bleeding). Unless the procedure is pregnancy related, the clinician should ensure that the patient is not pregnant and should know the status of the Papanicolaou (Pap) smear before the surgery. In addition to this chapter, it would be helpful for the clinician to review Chapter 143, Endometrial Biopsy.


On reaching menopause all women should be informed about the risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physician.



Indications



Diagnostic



• To determine the cause of abnormal premenopausal bleeding that has not been corrected by medical management

• To determine the cause of abnormal premenopausal bleeding that occurs in women older than 40 years of age with inadequate endometrial biopsies

• To determine the cause of postmenopausal bleeding when endometrial aspiration is nondiagnostic

• To rule out cancer and adenomatous hyperplasia with atypia when complex hyperplasia (adenomatous hyperplasia) is found on endometrial biopsy

• When the endometrial lining (stripe) measures more than 5 mm on ultrasonography

• To determine the cause of significant uterine bleeding that is too excessive for an endometrial biopsy

• When a reliable pelvic examination is required but cannot be obtained to evaluate the internal organs before endometrial biopsy, and thus anesthesia would be helpful

• For a debilitated or apprehensive patient when endometrial biopsy cannot be performed

• When cervical stenosis cannot be resolved and prevents an office procedure

• When pregnancy-related causes are suspected for AUB

• When atypical glandular cells are reliably found and confirmed on Pap smear, but no cause is found in a less invasive work-up


Therapeutic



• For removal of suspected endometrial polyp

• For removal of retained products of conception associated with postpartum infection or hemorrhage

• For removal of retained products of conception after an incomplete abortion

• For therapy of excessive hemorrhaging

• For use in combination with hysteroscopy

NOTE: Performing a D&C to resolve hormonally related AUB has been found to be ineffective.



Other


Elective termination of pregnancy (see Chapter 127, Pregnancy Termination: First-Trimester Suction Aspiration) is another indication for D&C.



Contraindications



Absolute



• Existence of comorbid medical conditions that are unstable (e.g., renal failure, active cardiac compromise)

• Desired viable intrauterine pregnancy


Relative



• The presence of an active pelvic infection

• Signs of a systemic coagulopathy (i.e., diffuse intravascular coagulation or unknown anticoagulation status)

• Uncertainty concerning the viability of an intrauterine pregnancy

• Patient’s preference to defer procedure in anticipation of a spontaneous resolution of a miscarriage

• Prior history of uterine procedures and the development of Asherman’s syndrome (i.e., endometrial synechiae)

NOTE: A D&C should be performed in the office only with a cooperative patient who has no other significant health risk factors and only if adequate resuscitation equipment is available.



Equipment


See Figure 141-1.


• Sterile gowns (optional)

• Sterile gloves

• Sterile drapes

• Sterile sponge gauze

• Formalin bottles

• Lens paper or Telfa pads for endocervical curettage and uterine curettage tissue

• Antiseptic cleansing solution

• Sterile bowl

• Suction hosing and apparatus with pump (for some situations, especially if significant bleeding or pregnancy related)

• Ring forceps

• Uterine sound

• Graves or weighted (Auvard) speculum

• Polyp (Stone) forceps

• Cervical dilators

• Kevorkian endocervical curette for endocervical curettage

• Curved and straight suction catheters (size 8 to 12 mm) when applicable

• Sharp uterine curette

• Intravenous (IV) needle, catheter, and tubing

• IV fluids (optional)

• A 20-gauge spinal needle and syringe, dental anesthetizing gun, or needle extender when local anesthesia (submucosal block) will be used

• Lidocaine 5 mL (2%) with epinephrine for submucosal block or 10 mL of lidocaine without epinephrine for paracervical block or equivalent


image

image

Figure 141-1 A, Equipment used for dilation and curettage (left to right): sterile basin, 4 × 4 sterile sponge gauze, large obstetrics/gynecology applicators, weighted speculum, uterine sound, ring forceps, single-tooth tenaculum, curette, dental anesthetizing gun, 1.8 mL of 2% lidocaine with epinephrine, uterine dilators, leggings, and sterile covering. B, Suction device and tubing.


NOTE: Review Chapter 149, Loop Electrosurgical Excision Procedure for Treating Cervical Intraepithelial Neoplasia, for information regarding local anesthetic use (it is not needed if general anesthesia is given).



• Tenaculum

• Ultrasonography (optional)

• Pulse oximeter if IV sedation is given


Preprocedure Patient Education


Each patient should be comfortable with the decision to perform a D&C. All questions regarding the procedure, alternatives, and risks should be explained carefully so the patient can give informed consent (see the sample patient consent form online at www.expertconsult.com). If performed in the office with sedation, appropriate knowledge and equipment must be available for possible complications and resuscitation. A nurse should be available throughout the procedure to aid with preparing the patient for the procedure, injecting IV medications, and handling equipment, and to provide assistance during the postoperative and recovery periods. The patient’s vital signs must be stable for the clinician to perform an office D&C. If bleeding has been prolonged or heavy, a hemoglobin or hematocrit should be obtained. The ability to obtain IV access is also important should the need arise to correct hemodynamic instability.



Anesthesia and Analgesia


In the outpatient setting, anesthetic and analgesic choice is somewhat limited. For D&C procedures performed in the hospital, the choice of sedation is much wider. No matter which drug regimen is selected, it is important that personnel and equipment for resuscitation be available should anaphylaxis, bleeding, or oversedation occur.


When making anesthetic and analgesic choices for D&C, the clinician should consider the following:


• A paracervical block is useful before placement of a tenaculum onto the cervix and before cervical dilation, unless a general anesthetic is used (see Chapter 173, Paracervical Block).

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Electrical Cardioversion
  2. Removal of Perianal Skin Tags (External Hemorrhoidal Skin Tags)
  3. Knee Braces
  4. Compartment Syndrome Evaluation

Stay updated, free articles. Join our Telegram channel
Tags:
May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Dilation and Curettage

Full access? Get Clinical Tree
Get Clinical Tree app for offline access