| D&C | |
| Background | |
|---|---|
| Abortion type | Surgical |
| First use | Late 19th century |
| Gestation | 4–12 weeks |
| Usage | |
| WHO recommends only when manual vacuum aspiration is unavailable | |
| United States | 1.7% (2003) |
| Medical notes | |
| Undertaken under heavy sedation or general anesthesia. Risk of perforation. Day-case procedure | |
| Infobox references | |
Dilation (ordilatation)and curettage (D&C) is a medical procedure thatdilates (widens or opens) thecervix and surgically removes tissue from the lining of theuterus by scraping or scooping (curettage). The D&Cgynecologic procedure is used for treatment, diagnostic and therapeutic purposes.
D&C can be used to end an unwanted pregnancy or to remove the remains of a non-viable fetus. It can also be used to remove the placenta after childbirth, abortion, or miscarriage. D&C is a commonly used method for first trimesterabortion ormiscarriage.[1][2][3][4] D&C can also be used to remove tissue from theuterus for diagnostic purposes.
D&C normally refers to a procedure involving acurette, also calledsharp curettage.[2] However, some sources use the termD&C to refer to any procedure that involves the processes of dilation and removal of uterine contents which includes the more commonsuction curettage procedures of manual and electricvacuum aspiration.[5]
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.
A D&C may be performed early in pregnancy to remove pregnancy tissue, either in the case of a non-viable pregnancy, such as amissed orincomplete miscarriage, or anundesired pregnancy, as in asurgical abortion.[6]
Dilation and curettage has been declining as a method of abortion, due to medication-based non-invasive methods of abortion, such asmisoprostol andmifepristone. 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] TheWorld Health Organization recommends D&C with a sharp curette as a method of surgical abortion only when manualvacuum 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]
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 aspolycystic ovary syndrome;[12] to remove tissue in the uterus that may be causing abnormal uterine bleeding, such as endometrialpolyps oruterine fibroids;[3][2] or to diagnose the cause ofpost-menopausal bleeding, such as in the case ofendometrial 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]
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 withlocal anesthesia,moderate sedation, deep sedation, orgeneral anesthesia.[14] The first step in a D&C is to place aspeculum in the vagina so as to see the cervix. Often, atenaculum is placed to steady the cervix. Next, the provider will dilate thecervix. This can be done withHegar 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 asuction curette is used, as in avacuum 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 bypathology for abnormalities (in the case of treatment forabnormal bleeding).[2]
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 toanesthesia 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 isuterine 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, alaparoscopy may be done to verify that there has been no undiagnosed injury.
Another potential risk isAsherman's syndrome, a condition where intrauterine adhesions lead tosubfertility,amenorrhea, orrecurrent 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 to 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]
