Dilation and Curettage or Vacuum Curettage (D&C)

What is Dilation and curettage or Vacuum Curettage (D&C)

• Dilation and curettage and vacuum curettage are minor procedures.
• A D&C involves stretching (dilation) the cervix and scraping (curettage) the inside lining of the uterus (endometrium).
• During a Dilation and curettage , tissue is gently scraped from the endometrium, starting from the top portion of the uterus down to the lowest part of the uterus (cervix).
• During a vacuum curettage, the lining and tissue in the uterus are removed with the use of gentle suction.
• Dilatation and curettage is one of the most well-known gynecological procedures.
• It serves main purposes, which could be therapeutic or diagnostic.
• The activity outlines indications, techniques, and contraindications.
• It elaborates the importance of the interprofessional team in handling the patient case.

Objectives:

Here are the objectives of the Dilation and Curettage

• Identify the indications of dilatation and curettage.
• Describe the technique in regards to dilatation and curettage.
• Review the clinical significance of dilatation and curettage.
• Discuss interprofessional team strategies for improving care coordination and communication.

Curettage may be performed to either diagnose or treat a problem. As a diagnostic procedure, curettage is performed to examine tissues from the uterus. A diagnostic curettage may be done if you have:

• Irregular bleeding in the uterus.
• Bleeding with the development of clots.
• Spotting between menstrual periods.
• Prolonged menstrual periods or other abnormal bleeding.
• Bleeding after menopause.
• No menstrual period (amenorrhea).
• A change in size and shape of the uterus.
• Abnormal endometrial cells discovered during a Pap test.

What are the indications of Dilation and Curettage?

Some common indications for Dilation and Curettage include:

1. Diagnostic Purposes:
   • Abnormal Uterine Bleeding: D&C may be used to investigate the cause of abnormal or heavy uterine bleeding that does not respond to conservative treatment.
   • Postmenopausal Bleeding: D&C is sometimes performed to evaluate the cause of bleeding in postmenopausal women, which could be due to various reasons, including uterine abnormalities or cancer.
   • Suspicion of Uterine Cancer: D&C may be done to obtain a tissue sample for pathological analysis when there is a suspicion of uterine cancer or other abnormal growths in the uterus.
   • Recurrent Miscarriages: In cases of recurrent miscarriages, D&C can be used to examine the fetal tissue and uterine lining to determine potential causes.
2. Therapeutic Purposes:
   • Incomplete Miscarriage or Abortion: D&C is commonly performed to remove retained tissue after an incomplete miscarriage or abortion to prevent infection and complications.
   • Management of Abnormal Uterine Conditions: D&C can be used to treat certain uterine conditions, such as endometrial polyps, small fibroids, or abnormal uterine lining thickening (endometrial hyperplasia).
   • Treatment of Excessive Bleeding: In some cases, D&C may be used to treat excessive or prolonged bleeding in the uterus that is not controlled by other means.
   • Uterine Septum Resection: D&C can be performed to correct a uterine septum, a congenital condition where the uterus is divided by a septum, which can lead to infertility or recurrent miscarriages.

• There are diagnostic indications as well as therapeutic indications for the Dilation and Curettage. Many diagnostic indications for the D&C have been replaced with office endometrial biopsy (EMB).
• Dilation and Curettage and EMB have been shown to reveal similar rates of cancer detection; however, there remain clinical scenarios where that is insufficient. Hysteroscopy (with directed sampling) followed by D&C is recommended but not required.

Contraindications

Here are a few contraindications for Dilation and Curettage:

1. Pregnancy: D&C is contraindicated in cases of confirmed or suspected pregnancy, especially in the first trimester. Performing D&C during early pregnancy can pose risks of miscarriage or harm to the developing fetus.
2. Uncontrolled Bleeding Disorders: Individuals with bleeding disorders or those taking anticoagulant medications that prevent blood clotting may not be suitable candidates for D&C due to the risk of excessive bleeding.
3. Uterine Perforation: If there is a risk of uterine perforation (tearing of the uterus) due to a history of previous uterine surgeries or other factors, D&C may not be advisable.
4. Active Pelvic Inflammatory Disease (PID): Performing D&C during an active infection, such as PID, can increase the risk of complications and the spread of infection.
5. Cervical Cancer or Severe Cervical Dysplasia: D&C is not recommended if there is a suspicion of cervical cancer or severe cervical dysplasia. Other diagnostic procedures or treatments are typically used in such cases.
6. Recent Cervical or Uterine Surgery: Patients who have undergone recent cervical or uterine surgery may need to avoid D&C to allow for proper healing.
7. Known Uterine or Cervical Cancer: D&C is not appropriate for diagnosing or treating known uterine or cervical cancer. Other procedures are used for staging and managing these conditions.
8. Severe Cervical Stenosis: In cases of severe cervical stenosis (narrowing of the cervix), it may be difficult or unsafe to perform a D&C.

• The only absolute contraindication to a D&C is the desire to maintain a viable intrauterine pregnancy. There are relative contraindications that should be contemplated to determine if the procedure should be performed in the outpatient clinical setting or the operating room. Patients with bleeding diathesis or that take anticoagulant medications could potentiate a problem in the outpatient setting, depending on your facility. 
• In general first trimester abortions performed on patients who are anticoagulated are considered safe and incur similar amounts of bleeding vs. patients not on anticoagulants.  Holding these medications must be weighed with the severity of the patient’s disease state and why she is on the medication. Patients who have a clotting deficiency should have their clotting factors replaced prior to the procedure. 
• If the pregnancy is a suspected molar pregnancy, this should be performed in the operating room in order to control anesthesia complications and the potential for severe hemorrhage. A scheduled or elective D&C should be delayed in a patient with a known active pelvic infection.  However, in the circumstance of a septic abortion or endometritis with possible retained products of conception, the surgeon should proceed with uterine evacuation.

Tell a health care provider about:

• Any allergies you have, including allergies to prescribed medicine or latex.
• All medicines you are taking, including vitamins, herbs, eye drops, creams, and over-the-counter medicines. This is especially important if you take any blood-thinning medicine. Bring a list of all of your medicines to your appointment.
• Any problems you or family members have had with anesthetic medicines.
• Any blood disorders you have.
• Any surgeries you have had.
• Your medical history and any medical conditions you have.
• Whether you are pregnant or may be pregnant.
• Recent vaginal infections you have had.
• Recent menstrual periods, bleeding problems you have had, and what form of birth control (contraception) you use.

What are the risks of Dilation and curettage?

Generally, Dilation and Curettage is a safe procedure. However, problems may occur, including:

• Infection.
• Heavy vaginal bleeding.
• Allergic reactions to medicines.
• Damage to the cervix or other structures or organs.
• Development of scar tissue (adhesions) inside the uterus, which can cause abnormal amounts of menstrual bleeding. This may make it harder to get pregnant in the future.
• A hole (perforation) or puncture in the uterine wall. This is rare.

What happens before the Dilation and Curettage procedure?

Staying hydrated

Follow instructions from your health care provider about hydration, which may include:

• Up to 2 hours before the procedure – you may continue to drink clear liquids, such as water, clear fruit juice, black coffee, and plain tea.

Eating and drinking restrictions

Follow instructions from your health care provider about eating and drinking after Dilation and Curettage, which may include:

• 8 hours before the procedure – stop eating heavy meals or foods such as meat, fried foods, or fatty foods.
• 6 hours before the procedure – stop eating light meals or foods, such as toast or cereal.
• 6 hours before the procedure – stop drinking milk or drinks that contain milk.
• 2 hours before the procedure – stop drinking clear liquids. If your health care provider told you to take your medicine(s) on the day of your procedure, take them with only a sip of water.

Medicines

• Ask your health care provider about:
  • Changing or stopping your regular medicines. This is especially important if you are taking diabetes medicines or blood thinners.
  • Taking medicines such as aspirin and ibuprofen. These medicines can thin your blood.Do nottake these medicines before your procedure if your health care provider instructs you not to.
• You may be given antibiotic medicine to help prevent infection.

General instructions

• For 24 hours before your Dilation and Curettage, do not:
  • Douche.
  • Use tampons.
  • Use medicines, creams, or suppositories in the vagina.
  • Have sexual intercourse.
• You may be given a pregnancy test on the day of the procedure.
• Plan to have someone take you home from the hospital or clinic.
• You may have a blood or urine sample taken.
• If you will be going home right after the procedure, plan to have someone with you for 24 hours.

What happens during the Dilation and Curettage procedure?

• To reduce your risk of infection:
  • Your health care team will wash or sanitize their hands.
  • Your skin will be washed with soap.
• An IV tube will be inserted into one of your veins.
• You will be given one of the following:
  • A medicine that numbs the area in and around the cervix (local anesthetic).
  • A medicine to make you fall asleep (general anesthetic).
• You will lie down on your back, with your feet in foot rests (stirrups).
• The size and position of your uterus will be checked.
• A lubricated instrument (speculumor Sims retractor) will be inserted into the back side of your vagina. The speculum will be used to hold apart the walls of your vagina so your health care provider can see your cervix.
• A tool (tenaculum) will be attached to the lip of the cervix to stabilize it.
• Your cervix will be softened and dilated. This may be done by:
  • Taking a medicine.
  • Having tapered dilators or thin rods (laminaria) or gradual widening instruments (tapered dilators) inserted into your cervix.
• A small, sharp, curved instrument (curette) will be used to scrape a small amount of tissue or cells from the endometrium or cervical canal. In some cases, gentle suction is applied with the curette. The curette will then be removed. The cells will be taken to a lab for testing.

The Dilation and Curettage procedure may vary among health care providers and hospitals.

What happens after the procedure?

• You may have mild cramping, backache, pain, and light bleeding or spotting. You may pass small blood clots from your vagina.
• You may have to wear compression stockings. These stockings help to prevent blood clots and reduce swelling in your legs.
• Your blood pressure, heart rate, breathing rate, and blood oxygen level will be monitored until the medicines you were given have worn off.

Care Instructions After Dilation and Curettage or Vacuum Curettage

Here is the information about how to care for yourself after your Dilation and Curettage. Your health care provider may also give you more specific instructions. If you have problems or questions, contact your health care provider.

What can I expect after the procedure?

After your procedure, it is common to have:

• Mild pain or cramping.
• Some vaginal bleeding or spotting.

These may last for up to 2 weeks after your procedure.

Follow these instructions at home:

Activity

• Do not drive or use heavy machinery while taking prescription pain medicine.
• Avoid driving for the first 24 hours after your procedure.
• Take frequent, short walks, followed by rest periods, throughout the day. Ask your health care provider what activities are safe for you. After 1–2 days, you may be able to return to your normal activities.
• Do not lift anything heavier than 10 lb (4.5 kg) until your health care provider approves.
• For at least 2 weeks, or as long as told by your health care provider, do not:
  • Douche.
  • Use tampons.
  • Have sexual intercourse.

General instructions

• Take over-the-counter and prescription medicines only as told by your health care provider. This is especially important if you take blood thinning medicine.
• Do not take baths, swim, or use a hot tub until your health care provider approves. Take showers instead of baths.
• Wear compression stockings as told by your health care provider. These stockings help to prevent blood clots and reduce swelling in your legs.
• It is your responsibility to get the results of your procedure. Ask your health care provider, or the department performing the procedure, when your results will be ready.
• Keep all follow-up visits as told by your health care provider. This is important.

Contact a health care provider if:

• You have severe cramps that get worse or that do not get better with medicine.
• You have severe abdominal pain.
• You cannot drink fluids without vomiting.
• You develop pain in a different area of your pelvis.
• You have bad-smelling vaginal discharge.
• You have a rash.

It’s important to note that D&C is a surgical procedure that carries potential risks and complications. Therefore, it should only be performed when medically necessary and after considering other available diagnostic or therapeutic options. The specific indication for D&C will depend on the patient’s individual medical history, symptoms, and the assessment of their healthcare provider.

Summary

• Dilation and curettage (also referred to as a D&C) is one of the most common procedures performed.
• The Dilation and Curettage procedure can be applied to a pregnant or non-pregnant female and be either diagnostic or therapeutic.
• Sometimes the circumstances lead to the two overlapping, and the diagnostic procedure becomes therapeutic.
• The pregnant patient seeking a first trimester (< 14 weeks) elective termination or management of a missed, incomplete or inevitable abortion would be offered this surgical procedure or medical management.
• D&E (dilation and evacuation) refers to the procedure performed on a second-trimester pregnancy (>14 weeks) and is outside of the scope of this article.
• Three out of ten women will have an abortion by age 45, with the majority of these in an outpatient setting.