Dilation and curettage

INTRODUCTION The gynecologist has a variety of tools available for evaluation and
treatment of women with abnormal uterine bleeding. Dilation and curettage (D&C) will be
reviewed here. Office procedures for endometrial sampling and an overview of diagnostic
approaches to endometrial evaluation, including both noninvasive and invasive assessment, are
discussed separately. (See "Endometrial sampling procedures" and "Evaluation of the
endometrium for malignant or premalignant disease" .)
INDICATIONS D&C has both diagnostic and therapeutic indications.
Diagnostic indications The development of equipment and techniques for office based
endometrial sampling has obviated the need for diagnostic D&C in most patients. Numerous
studies have shown that the endometrium is adequately evaluated with sampling techniques. (See
"Endometrial sampling procedures" .)
However, there are still some indications for diagnostic D&C, such as in women:

With a nondiagnostic office biopsy who are at high risk of endometrial carcinoma. (See
"Endometrial carcinoma: Epidemiology and risk factors", section on 'Risk factors' .)

With endometrial hyperplasia, and in whom endometrial cancer needs to be excluded.

(See "Classification and diagnosis of endometrial hyperplasia" .)

With insufficient tissue for analysis on office biopsy.

In whom cervical stenosis prevents the completion of an office biopsy.

For whom another operative procedure, such as hysteroscopy or laparoscopy, is deemed

necessary.

Diagnostic D&C should be done with hysteroscopy to obtain a visual image of the endometrial
cavity and to exclude focal disease. Hysteroscopy thus turns a "blind" procedure into one
allowing directed curettage. This helps to prevent missing unsuspected polyps and insures that
the most visibly abnormal areas are sampled. (See "Overview of hysteroscopy" .)
Therapeutic indications Dilation and evacuation/curettage (D&EC) is used as a therapeutic
modality in the following clinical settings:

Treatment of incomplete, inevitable, missed, septic, and induced abortions. (See

"Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic
evaluation" and "Surgical termination of pregnancy: First trimester" .)

Initial treatment of molar pregnancies. (See "Gestational trophoblastic neoplasia: Staging

and treatment" .)

Temporary management of women with prolonged or excessive vaginal bleeding

unresponsive to hormonal therapy. (See "Managing an episode of severe or prolonged
uterine bleeding", section on 'Uterine curettage' .)

Suction curettage (without dilation) may be used to manage postpartum hemorrhage due
to retained products of conception. (See "Overview of postpartum hemorrhage" .)

CONTRAINDICATIONS The only major contraindication to D&C is viable and desired

intrauterine pregnancy. Bleeding diathesis is a relative contraindication since bleeding may be
excessive in such patients. The management of these patients, including possibly temporarily
withholding anticoagulants, needs to be decided on a case by case basis in consultation with the
patient's other physicians. In the presence of acute vaginal, cervical, or pelvic infection, the
procedure should be deferred, if possible, until the infection has been treated. One exception is
therapeutic D&C to remove infected products of conception. Cervical cancer, if obstructing the
endocervical canal, also represents a contraindication as heavy bleeding or perforation may
occur. In these patients cervical biopsy would be diagnostic and D&C would be unnecessary.
PREOPERATIVE PREPARATION D&C is generally performed under general or regional
anesthesia; therefore, the patient should limit oral intake prior to the procedure. The American
Society of Anesthesiologists recommends no intake of clear liquids in the two hours before and
no solid food in the six hours before procedures involving anesthesia (eight hours in pregnant
women) [ 1 ]. An empty stomach is also desirable for patients who plan paracervical block
anesthesia in case the block is inadequate and another anesthetic or sedative needs to be
administered.
Prophylactic antibiotics are not necessary.
Preoperative laboratory tests are generally not necessary, except as indicated by the patient's age
and medical condition. (See "Preoperative medical evaluation of the healthy patient", section on
'Laboratory evaluation' .)
ANESTHESIA General, regional, or paracervical block anesthesia can be used. The type of
anesthesia chosen depends upon the indication for the procedure, as well as the medical history
of the woman. General anesthesia provides complete muscular relaxation, which is important
when examination under anesthesia is a critical element of the procedure. Regional anesthesia
provides adequate muscular blockade without the pulmonary and gastrointestinal risks of general
anesthesia.

Paracervical block with intravenous conscious sedation is a convenient, inexpensive, and

effective technique amenable to the outpatient setting ( picture 1 ). The block anesthetizes uterine
nerves as they pass through Frankenhauser's plexus in the cervix. Chloroprocaine 1 percent
(Nesacaine) provides an improved margin of safety over lidocaine because it is rapidly
metabolized and theoretically has a lower risk of toxicity if an inadvertent intravascular injection
occurs. (See "Overview of pregnancy termination", section on 'Paracervical block' .)
There have been a number of randomized controlled trials comparing the analgesic effects of
intrauterine instillation of anesthetics (eg, 3 to 5 mL of 2 percent lidocaine or 2 percent
mepivacaine ) versus placebo. Although about half of the trials showed that topical anesthesia
significantly reduced the patient's perception of pain during an intrauterine procedure [ 2-7 ], the
other half did not [ 8-12 ].
PROCEDURE
General issues A D&C is performed with the woman in the dorsal lithotomy position. Care
must be taken to avoid over-abduction of the hip joint when placing her in stirrups. Furthermore,
the lateral aspect of the legs should not rest against the stirrups as this can cause peroneal nerve
injury with subsequent foot-drop. (See "Nerve injury associated with pelvic surgery" .)
An examination under anesthesia is performed first. (See "Pelvic examination under anesthesia"
.) The size, shape, and position of the uterus are noted, with particular attention to the axis of the
cervix and flexion of the fundus. Appreciation of the latter is critical to reduce the incidence of
uterine perforation. The size, shape, and consistency of the adnexa are determined next.
After the examination, the perineum, vagina, and cervix are cleansed with an aseptic solution and
drapes are placed; it is not necessary to shave vulvar hair.
Exposure Vaginal retractors or a speculum is inserted into the vagina to provide exposure.
The type of vaginal retraction required for adequate exposure depends upon the woman's body
habitus and the procedure being performed. The Graves speculum provides adequate exposure of
the cervix and is well-suited for women undergoing a therapeutic D&EC.
When a hysteroscopy is being performed in conjunction with the D&C, a side-open Graves
speculum provides a maximum range of motion to the hysteroscope during the examination and
is easily removed. Alternatively, a Sims retractor or an Auvard weighted speculum ( figure 1 )
can be used in conjunction with Schieden vaginal side wall retractors ( picture 2 ). (See "Surgical
instruments for gynecologic surgery" .)
Tenaculum A tenaculum is generally used to grasp the anterior lip of the cervix ( picture 3 ).
The single tooth tenaculum is useful in women with a small amount of cervical tissue (eg,
postmenopausal women, women who have undergone previous cone biopsy); however, this
instrument is more likely to cause a laceration of the cervix. We prefer the Bierer (multi-toothed)
tenaculum because it is less traumatic. Ring forceps may also be used to grasp the cervix,
particularly in the pregnant patient in whom the soft, engorged cervix is prone to laceration and

hemorrhage. In some patients, such as women with a lacerated or torn anterior lip, it will be
necessary to attach the tenaculum to the posterior cervical lip.
Endocervical curettage If indicated, an endocervical curettage (ECC) is performed before
dilation of the cervix to avoid contamination of the histologic specimen with endometrial cells. A
Kevorkian-Younge curette is introduced into the cervical canal up to the internal os ( picture 4 ).
This instrument is slightly curved and narrow to accommodate the small endocervical canal. All
four quadrants of the canal are scraped and the specimen placed on a pad (eg, Telfa).
The ECC is performed to detect the presence of endometrial carcinoma extending into the
cervical canal or the presence of endocervical pathology. The clinical usefulness of the ECC has
been questioned. It is predictive of cervical involvement of endometrial carcinoma when the
histology demonstrates stromal involvement. However, numerous investigators have
demonstrated a false-positive rate of 80 percent when tumor is detected on ECC alone [ 13 ].
Since surgical staging of endometrial carcinoma does not require a separate ECC, the need for an
ECC is only relevant for patients who cannot undergo a full staging procedure. If there is a
clinical indication for D&C at the time of a cervical conization, the conization should be
performed prior to the D&C to preserve cervical architecture. (See "Endometrial carcinoma:
Epidemiology and risk factors" .)
Sounding Traction is applied to the tenaculum to align the axis of the cervix and the uterine
canal. The uterus is sounded to document the size and confirm the position. The sound is held
between the thumb and the index finger to avoid application of excessive pressure. In some
cases, dilation of the cervix may be required before sounding the uterus. A normal uterus sounds
to 8 to 9 cm.
The pregnant uterus, however, should never be sounded because there is a high risk of uterine
perforation. (See "Uterine perforation during gynecologic procedures" .)
Cervical dilation After sounding the uterus, the cervix is dilated. The most common dilators
are the Pratt and Hegar ( picture 5 ). The Pratt dilator comes in sizes ranging from 13 to 43
French; each French unit is equivalent to 0.33 mm in diameter. It is characterized by a gradual
taper at the end of the instrument. By comparison, Hegar dilators have a blunt end and come in
sizes ranging from 1 to 26 mm in diameter. We prefer the tapered end of the Pratt dilator to the
Hegar dilator. The former has been shown to require less force for dilation and is less likely to
cause a perforation of the uterus [ 14 ].
The dilator is grasped in the middle of the instrument with the thumb and index finger ( figure 2
). The cervix is gradually dilated beginning with the #13 French Pratt dilator. The dilator should
be inserted through the internal os, without entering the uterine cavity excessively. This is helpful
in preventing uterine perforation and avoids damage to the endometrium, which obscures
optimal visualization if hysteroscopic examination is also planned.
The degree of cervical dilation is dependent upon the indication for the procedure. When
diagnostic hysteroscopy and D&C are performed, the dilation is conducted to a point at which

the hysteroscope may be comfortably inserted. The #17 French Pratt dilator will easily
accommodate a 5 mm hysteroscope or a #3 sharp curette.
When products of conception are to be removed, the cervix is generally dilated to a diameter in
millimeters equal to the gestational age of the uterus. Dilation is easily accomplished up to 9
mm, at which time the cervix may become difficult to dilate [ 15 ]. When cervical dilation
beyond 9.0 mm is required (eg, second trimester pregnancy termination or operative
hysteroscopy), osmotic dilators should be placed preoperatively to allow gradual, atraumatic
cervical dilation. (See "Overview of pregnancy termination", section on 'Osmotic dilators' .)
Cervical ripening agents (prostaglandins) may facilitate dilation. (See "Overview of
hysteroscopy", section on 'Cervical preparation and dilation' .)
Complicated cases A stenotic cervical os if often present in postmenopausal patients and
sometimes in women who have had previous cervical surgery. Stenosis increases the risk of
cervical laceration and uterine perforation; therefore, these women are best dilated beginning
with a series of small (1 to 4 mm) Hegar dilators.
Having multiple types of cervical dilators available will enable the surgeon to find the optimal
instrument to approach each specific clinical scenario. Tiny metal lacrimal duct probes are useful
for identifying the cervical canal in women with severe stenosis. Also, if the os is tightly scarred,
penetration of the external dimple with a number 11 scalpel blade facilitates much easier passage
of dilators without undue force. Care must be taken to excise on the external dimple and not
incise further into cervical tissue. Tapered Teflon dilators permit gradual and gentle dilation of a
stenotic canal. The instrument should be inserted far enough to reach the full diameter at the
internal os, but no further. Deep insertion of dilators presents a significant risk for perforation at
the fundus, especially in a patient who is pregnant, postpartum, or breastfeeding patient. If
dilators do not pass with gentle pressure, the surgeon should stop and reassess the uterine
position, the amount of cervical traction, and the direction of insertion.
Transabdominal ultrasound can be useful in guiding a difficult dilation and may be prudent in
women with a previous perforation of the uterus [ 16 ]. This technique is especially useful in
completing a D&C if a perforation is suspected or if there is a question as to the adequacy of the
evacuation. Rarely it may be necessary to perform a conization to open the cervical canal.
Curettage
Curettes Metal curettes are available in blunt and sharp styles, ranging in size from #1 to #6,
with 1 being the smallest ( picture 6 ). The curette is malleable, which allows the instrument to
be bent slightly to conform to the ante- or retro-flexed uterus.
Sharp curettes are typically used for gynecologic procedures, including first trimester pregnancy
termination. The blunt curette is best suited for the removal of small fragments of retained
products of conception in the second trimester and postpartum uterus, and is often used after
suction curettage. The blunt edge prevents excessive removal of the basalis layer of the

endometrium, which can occur in the soft postpartum uterus and lead to formation of intrauterine
adhesions (see 'Intrauterine adhesions' below).
Plastic suction curettes are used for initial removal of products of conception from the uterus.
Some surgeons also prefer the suction curette for diagnostic curettage [ 17 ]. Suction curettes
range in size from 2 to 16 mm in diameter. Curettes 6 mm are flexible while the larger curettes
are rigid ( picture 7 ). We prefer 6 to 8 mm curettes when performing suction curettage in a small
uterus (less than 8 week size). When a larger rigid suction curette is used, the curved instrument
provides better tactile sensation compared to the straight curette.
Sharp curettage Curettage is performed systematically beginning at the fundus. Even pressure
is applied to the endometrial surface along the entire length of the uterus from the fundus to the
internal cervical os ( figure 3 ). The endometrial tissue is deposited on a Telfa pad, which should
be placed in the vagina to catch any spillage. The entire surface of the endometrium is sampled
by moving around the uterus in a consistent and systematic fashion.
The curettage procedure is completed when the "uterine cry" (grittiness to palpation) is
appreciated on all surfaces of the uterus. The size and shape of any submucous fibroids detected
by tactile sensation should be noted as part of the operative note. Curettage followed by blind
extraction with Randall polyp forceps ( picture 4 ) improves the rate of detection of polyps over
curettage alone [ 18 ].
A study evaluating the surface area sampled in 50 patients undergoing prehysterectomy D&C
found that less than one-fourth of the cavity had been curetted in 16 percent of specimens; less
than one-half of the cavity had been curetted in 60 percent; and less than three-quarters of the
cavity had been effectively curetted in 84 percent [ 19 ]. Despite these limitations, D&C provides
adequate sensitivity for detecting endometrial pathology because pathologic conditions usually
cover a large proportion of the surface area of the endometrial cavity and are therefore detectable
by sampling techniques. Focal pathologic processes may, however, go undetected by any blind
procedure. (See "Evaluation of the endometrium for malignant or premalignant disease" .)
Suction curettage

Diagnostic Suction curettage may be used for diagnostic purposes. The preferred
method uses the Pipelle device and is performed as an office procedure, usually without
anesthesia or cervical dilation. (See "Endometrial sampling procedures" .)

The external cervical os is then checked for any evidence for excessive bleeding. The tenaculum
is removed and the cervix is examined for any trauma. Bleeding from the tenaculum site
generally responds to direct pressure or the application of ferric subsulfate solution (Monsel's
solution). Occasionally a suture or cautery is required.

Pregnant uterus Suction curettage is typically used for the evacuation of products of
conception, such as for incomplete or missed spontaneous abortion or for early pregnancy
termination. (See "Surgical termination of pregnancy: First trimester", section on
'Curettage' .)

Large bore plastic cannulas (12 to 16 mm) are used for second trimester pregnancy termination
or removal of retained placental fragments/membranes postpartum. (See "Termination of
pregnancy: Second trimester" .) These cannulas should not be inserted deeply into the pregnant
or postpartum uterus due to the risk of perforation. Placing a hand on the fundus of the uterus
during the procedure may help to decrease the risk of perforation when the uterus is large and
assists with assessment of the changing uterine size and position. For the same reason, it is
preferable to explore the uterus with a large curette instead of narrower instruments, such as
forceps or a small suction cannula.
The cannula is rotated 360 degrees around its long axis under vacuum pressures of 50 to 60 cm
Hg. As tissue is evacuated, the uterus will contract and the suction curette may be advanced to
the fundus. Rotation is continued until no more tissue is drawn into the cannula. Oxytocin is
usually begun as soon as the suction curettage is started and continued for one or more hours
postoperatively. A few passes with a large blunt curette (eg, banjo curette) can be performed after
the suction procedure to remove any remaining products of conception.

Gestational trophoblastic neoplasia There are additional technical aspects of curettage

in this setting. (See "Gestational trophoblastic disease: Management of hydatidiform
mole", section on 'Procedure' .)

COMPLICATIONS Complications are rare and include:

Anesthesia related complications

Hemorrhage

Uterine perforation

Infection

Formations of intrauterine adhesions

Trophoblast embolization (if gestational trophoblastic disease present)

Uterine perforation Perforation of the uterus at the time of D&C is the most common
immediate complication. The rate of perforation varies with the indication for the procedure.
Perforation is most common when attempting control of postpartum hemorrhage (5.1 percent),
and is less frequent during diagnostic curettage (0.3 percent in the premenopausal patient and 2.6
percent in the postmenopausal patient) [ 20,21 ]. The risk of perforation is increased in
pregnancy due to softening of the uterine wall and the increased size of the endometrial cavity.
Uterine perforation is discussed in detail separately. (See "Uterine perforation during
gynecologic procedures" .)

Cervical injury Cervical injuries can arise as a direct result of dilation or from trauma during
curettage. Cervical lacerations frequently occur when excessive traction is applied to the
tenaculum. The single tooth tenaculum is particularly vulnerable to such injuries, therefore, we
prefer the Bierer tenaculum.
Lacerations can be managed with direct pressure, application of ferric subsulfate solution,
cautery, or, in severe cases, suture control. Lacerations that involve the cervical branch of the
uterine artery can produce extensive hemorrhage that may be controlled with direct suture
application, by placing hemostatic sutures at the internal os, or therapeutic embolization. Rarely,
hysterectomy is required to control bleeding [ 22 ]. (See "Interventional radiology in
management of gynecological disorders" .)
The risk of cervical injury can be reduced by avoiding use of excessive force during dilation. The
Pratt dilators generally require less force to insert into the cervix than Hegar dilators. Osmotic
dilators are helpful in decreasing the force required to dilate the cervix and are useful when
dilation of 9 mm or greater are anticipated. (See "Overview of pregnancy termination", section
on 'Osmotic dilators' .)
Infection Infection after dilation and curettage is rare. Although bacteremia has been
demonstrated in 5 percent of D&Cs, the incidence of septicemia is very low [ 23 ]. Very little is
known about risk factors for infection in patients undergoing D&C for diagnostic purposes. In
one study, the use of a rigid versus flexible cannula, general versus local anesthesia, and resident
versus attending physician were all associated with an increased risk of febrile morbidity [ 24 ].
No data support the routine use of prophylactic antibiotics in diagnostic D&C, nor is subacute
bacterial endocarditis (SBE) prophylaxis recommended for a routine diagnostic D&C [ 25 ]. (See
"Antimicrobial prophylaxis for bacterial endocarditis" .)
Intrauterine adhesions Asherman's syndrome refers to the presence of intrauterine adhesions
that typically result from endometrial damage due to uterine surgery, especially after curettage.
Most, if not all, cases of Asherman syndrome arise from curettage performed on the pregnant
uterus. In one large series of women with intrauterine adhesions, the underlying etiology was
related to curettage for incomplete abortion (50 percent), postpartum bleeding (24 percent),
elective abortion (18 percent), missed abortion (6 percent), or hydatidiform mole (2 percent) [ 26
]. The remaining 2 percent of patients had various other etiologies.
Curettage of the endometrium, especially within the first four weeks postpartum, can result in
trauma to the basalis layer with subsequent granular tissue healing on opposing surfaces of the
uterus, which eventually fuse to produce tissue bridges. These intrauterine adhesions range from
filmy adhesions composed of endometrial tissue to dense adhesions consisting entirely of
connective tissue. The resulting adherence of the uterine walls, with partial or complete
obliteration of the uterine cavity, accounts for the menstrual abnormalities, frequent
dysmenorrhea, infertility, and habitual abortion.
Asherman syndrome is typically diagnosed by either hysterosalpingogram (HSG) or
hysteroscopy. The combination of the two techniques is helpful since HSG shows the location

and extent of the adhesions, while hysteroscopy provides information as to their character.
Before the widespread use of hysteroscopy, careful D&C of the uterus followed by the placement
of an intrauterine Foley catheter along with estrogen therapy had been the mainstay of therapy.
Current therapy for Asherman syndrome includes hysteroscopic resection of the adhesions under
direct visualization followed by long-term estrogen administration to stimulate regrowth of
endometrial tissue [ 27 ]. (See "Overview of hysteroscopy", section on 'Rigid versus flexible' .)
Trophoblastic embolization A rare complication of D&C of a molar pregnancy is
embolization of trophoblastic tissue into the systemic circulation [ 28 ]. Fatalities from
cardiovascular collapse due to trophoblastic embolization have been described [ 29 ]. Thyroid
storm is also encountered rarely. For these reasons, D&C for trophoblastic disease should be
performed in a formal operating room, with full anesthesia support and patient monitoring
available. (See "Gestational trophoblastic neoplasia: Staging and treatment" .)
POSTOPERATIVE CARE AND FOLLOW-UP Patients may resume normal activities as
soon as the effects of anesthesia have worn off and they are comfortable.
Cramps are the most common side effect. They usually rapidly subside after the procedure, but
may last for a day or two. Nonsteroidal antiinflammatory drugs provide adequate analgesia.
Light bleeding can persist for several days. Heavy bleeding, such as saturating a sanitary pad
within one hour more than once, is abnormal.
The patient should call her provider if she develops fever (more than 100.4F), cramps lasting
longer than 48 hours, increasing pain, prolonged or heavy bleeding, or a foul-smelling vaginal
discharge.