Dilatation and Curettage - Overview

Dilatation and curettage, also called as, D&C is a minor gynecological procedure, which involves dilating the cervix and curetting the uterine contents.

Dilatation and curettage, also called as D&C, is a common surgical procedure done on women to scrape and collect the tissue from inside the uterus. The cervical passage in a women leads to the uterus. 'Dilatation' is a widening of the cervical passage. This is done using smoothly conical and tapered, graduated metal rods of various sizes and these are appropriately called the dilators. The gradually large metal dilators lead to widening of the tight cervical passage slowly.

Curettage ("C") is the second part of the procedure and is done to scrape the inside contents of the uterus. For this, a sharp spoon-like instrument called curette is used. The procedure is usually performed under general or regional anaesthesia.

Normal Anatomy of the uterus

Dilatation and Curettage - Indications

Dilatation and curettage (D&C) may be done as a diagnostic or a therapeutic procedure.

Uterine scraping (D & C) may be done to:

Diagnose conditions by collecting tissue samples for biopsy.

 To treat irregular or heavy bleeding.

 Evacuation of retained products of conception (ERPOC) - removes any leftover tissue after a spontaneous abortion .

The other indications for D & C include:

 Treat intermenstrual bleeding.

 To investigate the causes of infertility.

 To remove polyps in the endometrial or inner lining of the uterus.

 To diagnose endometrial cancer.

 To remove an embedded intrauterine device (IUD) used for contraception.

 To perform abortion in the early stages of pregnancy.

 To evacuate spontaneous abortion products.

 To investigate the cause of abnormal bleeding in postmenopausal women taking hormone replacement therapy.

Dilatation and Curettage -Contraindications
There are very few contraindications to D&C. They are:

 If a patient is too ill to undergo surgery.

 If the patient is unable to move her legs apart, such as with severe arthritis in the hips.

 If the patient has problem with clotting mechanism of the body.

Dilatation and Curettage - Pre-Op Preparations

Pre-operative Preparations are done prior to a Dilatation and Curettage procedure to improve the out come of surgery.

These are preparations, which are done prior to surgery to improve the out come of surgery.

  It can be done as day-surgery or may require an overnight stay in the hospital.

 It is recommended that the patient take nothing by mouth (food, water, etc.) for at least 6 hours before the scheduled operation or after midnight, if the operation is planned in the morning.

 Painkillers and antibiotics may be prescribed before the procedure.

 A sedative maybe useful to relieve the anxiety of surgery.

 The genital area may be shaved and prepared for the surgery.

 Before surgery or during the previous night a bath maybe advisable. While bathing thorough cleaning of the genital area with soap and water a few times can help in lowering the bacterial count and lessen the chances of any infection from surgery.

 An enema maybe administered to the patient prior to performing the surgery. Sometimes a laxative maybe given to clear the bowels prior to the surgery.

Dilatation and Curettage - Anesthesia

Dilatation and Curettage can be done under general, spinal or local anesthesia.

The different types of anesthesias given to a patient prior to the procedure depend on both the choice of the anesthetist and the patient. It is best to discuss it with him or her when they visit you before surgery.

a. General Anesthesia

General anesthesia is a state of total unconsciousness resulting from anesthetic medicines. The medicines can be administered as an inhaled gas or as an injected liquid. Most D&Cs are done under general anesthesia. The procedure is normally very short and the general anesthetic can be quickly reversed, with the patient going home soon afterwards.


b. Spinal Anesthesia

Spinal anesthesia is induced by injecting small amounts of local anesthetic into the back of the spine in the middle section. The drug is injected using a very fine needle that is almost similar to the thickness of hair. The patient is put on the side in a crouching position to get the right space between the vertebrae. Once the injection pierces the tough fascia, the anaesthetic drug is injected into the cerebro-spinal fluid (CSF).

The advantage of spinal anesthesia is that the patient is awake but at the same time does not have any sensation below the waist. It avoids all the complications of general anesthesia. Another popular anesthesia is called Epidural anesthesia Here the injection is given in a slightly different space in the spinal region and this takes away the sensationof pain keeping intact the power in the lower limbs.

c. Local Anesthesia

Local anesthesia involves numbing a small area by injecting a local anesthetic medicine under the skin just where an incision is to be made. The medicine can be injected locally. Occasionally, in a very motivated patient, the D&C procedure can be done under a local anesthetic with or without intravenous pain medication.


Dilatation and Curettage - Procedure

Dilatation and Curettage (D&C) involves a gradual dilatation of the cervix to facilitate the curetting of the uterine cavity.

The actual procedure is done in a sterile environment such as an operating room, either in a hospital, a surgical center, or in a specially designated room in a physician's office.

 After adequate anesthesia has been administered, the patient’s legs are parted and flexed and comfortably put up on a stirrup in a position that is called the 'lithotomy' position. This ensures a good view of the genital area for the surgeon or gynecologist to operate.

 The vagina and cervix are scrubbed with an antibacterial solution that maybe iodine or alcohol based.

 The cervix is visualized using an instrument that is located in the vagina called the speculum. Lights are so adjusted to visualize the cervix so that its upper lip can be grasped with a special curved forceps called the ‘Vulsellum’. This helps both in stabilizing and bringing the cervix down towards the vaginal opening to ease with rest of the procedure.

 Dilatation is next done using sequential metal round tapered dilators and the opening to the uterus is gradually widened to about the size of a large pencil.

 Once this dilatation has been completed, the spoon like curette is inserted into the uterine cavity and is used to gently scrape the lining of the uterus.

 When the surgeon feels the gritty layer of cells just above the muscle of the uterus, then he/she knows that the scraping has gone deep enough to sample the tissue adequately.

  This scraping is done throughout the uterus and the tissue that is removed is then sent to a pathologist for microscopic examination.

 Depending on the indication for the procedure the surgeon terminates the procedure once he feels that enough tissue has been obtained, or that the entire cavity has been sampled or scrapped.

Dilatation and Curettage - Complications
Complications are usually rare. Complications due to Anesthesia include:

 Reactions to Anesthetic medications

  Breathing difficulties

Complications of Surgery include:

 Bleeding

  Infection

  Puncture (perforation) of the uterus

 Laceration (tear) of the cervix

  Scarring of the uterine lining (endometrium)

Dilatation and Curettage - Post Operative Care

Postoperative care involves the precautions that we need to follow after a Dilatation and Curettage (D&C) procedure.

The precautions that need to followed after the surgery are:

  Some cramping or mild abdominal discomfort is considered usual after a D&C, consult the doctor if the pain is severe.

  Medications should be taken as per the prescription of the doctor.

  Ensure to take the entire course of antibiotic.

  Refrain from the use of internal tampons and sexual intercourse for about a week or as advised by your doctor.

 Use sanitary napkins during this time period.

  If there are any signs of infection such as fever, pain or discharge consult the doctor immediately.

Dilatation and Curettage - D&C and Beyond

Dilatation and Curettage (D&C) is a life saving procedure to control the abnormal bleeding after a spontaneous or incomplete abortion.

In general, the number of D&Cs being performed has declined over the years. This procedure is no longer done to regulate abnormal bleeding patterns in women. Most of these problems are now managed with hormone-based medications. Ultrasound is, likewise, playing a greater role in helping to evaluate the uterus without surgery.

Procedures, such as endometrial pipelle biopsy, that remove a deeper layer of the womb lining, seem to be more effective and are often used as an alternative to D&C, particularly with women who have suspected endometrial cancer. But where indicated, like for example, after an incomplete abortion, it is definitely life saving.

Dilatation and Curettage - FAQ's
1.Who performs a D&C?
A Gynaecologist performs a D&C.

2.How long will a patient have to stay in the hospital for a D&C?
It is usually a day care procedure and the patient can get admitted and discharged on the same day or sometimes the next day.

3.After a D&C when can the patient start her routine activities?
She can carry on her routine activities after 24 hrs and not before, as she is likely to feel drowsy due to anaesthesia.

4.When can she return to work?
Most women can return to work within 3 days if the occupation does not involve heavy physical work, in which case she will need to consult with her doctor.

5.What will happen if a woman has repeated D&C's?
She is likely to develop infections and may also have infertility due to scar tissue sealing the uterus shut known as Asherman's Syndrome.

6.Will there be bleeding after the procedure?
Expect slight bleeding and staining for about 5 to 14 days after the procedure. But if the bleeding is heavy, or if it is prolonged, you will need to consult the doctor.

7.Will there be pain after the surgery?
Expect cramping after the surgery, for which pain medications are usually prescribed. The pain disappears after 24 to 48 hrs.

8.What are the abnormal symptoms, which we need to report to the doctor?
If there is heavy bleeding with clots, or if there is foul smelling vaginal discharge, or if there is intense abdominal pain with fever, then you will have to report to the doctor immediately.

Dilatation and Curettage - Glossary
Spontaneous Abortion- It is the spontaneous loss of a fetus before the 20th week of pregnancy.

Intermenstrual Bleeding- is bleeding from the uterus that occurs between menstrual periods.

Infertility- is the inability to achieve a pregnancy after 12 months of unprotected intercourse.

Endometrial Polyps- are out growths from the endometrium, which is the lining of the uterus.

Endometrial Cancer- is cancer that starts in the endometrium, the lining of the uterus.

IUD- is Intra Uterine Device, which is a small plastic or copper device, placed inside the woman's uterus to prevent conception.

Therapeutic Abortion- is the deliberate termination of a pregnancy.

Hormone Replacement Therapy (HRT)- It is the administration of medication containing the hormones estrogen and progesterone, which is given to post menopausal women.

Cerebrospinal Fluid (CSF)-It is a clear, colorless liquid that bathes the central nervous system. It cushions the brain and provides nutrients to the brain.

Ultrasound Test- It is a radiology technique, which uses high- frequency sound waves to produce images of the organs and structures of the body.

Lithotomy Position- Position in which the patient is on their back with the hips and knees flexed and the thighs apart. The position is often used for vaginal examinations and childbirth

Dilatation and Curettage - References
1. http://www.medicinenet.com/
dilatation_and_curettage/page4.htm

2. http://www.nhsdirect.nhs.uk/articles/
article.aspx?132sectionid=27794

3. http://www.nlm.nih.gov/medlineplus/
ency/imagepages/17047.htm

Compiled by : Dr.Paderla Anitha
Reviewed by: Dr.Shroff, Dr.Reeja Tharu