Dilation and curettage (D&C)

INTRODUCTION
 Dilation and curettage (D&C) is a procedure in which material from the inside of
the uterus is removed.
 The "dilation" refers to dilation of the cervix, the lower part of the uterus that
opens into the vagina.
 "Curettage" refers to the scraping or removal of tissue lining the uterine cavity
(endometrium) with a surgical instrument called a curette. Some curettes are
sharp while others use suction.

REASONS FOR D and C

 There are a number of reasons a D&C might be performed. In some cases, the
procedure is used to gain information about the uterus to diagnose a medical
condition (called diagnostic D&C). In other cases, the procedure is used to treat
a medical problem or condition (called therapeutic D&C).

Diagnostic D and C
 The primary reason for a diagnostic D&C is to obtain samples of the
endometrium to evaluate abnormal uterine bleeding or abnormal cells found
during routine screening for cervical cancer.
 In most cases, a healthcare provider will try to obtain a tissue sample with an
office procedure called endometrial biopsy. In some cases, endometrial biopsy is
not possible or insufficient tissue is obtained. When this occurs, D&C must be
done to obtain an adequate tissue sample.
 Diagnostic D&C is usually done with hysteroscopy; this involves dilating the
cervix and inserting a small instrument that allows the physician to examine and
photograph the inside of the uterus. The images are displayed on a monitor,
allowing the physician to visualize the endometrium. This helps the physician to
avoid missing small polyps and ensures that the most visibly abnormal areas are
sampled.
 Examination of the endometrial tissue by a pathologist can help establish certain
diagnoses, including endometrial (uterine) cancer, endometrial polyps, or
precancerous conditions of the lining of the uterus (endometrial hyperplasia).
Therapeutic D and C
 Therapeutic D&C is done to remove the contents of the uterus in the following
circumstances:

1. Miscarriage — In some miscarriages, the tissues from a pregnancy are passed

completely. In other cases, a D&C is needed to remove this tissue or to ensure that
all of it has been passed.

2. Abortion — A D&C can be done to remove the contents of the uterus when a
woman chooses to end a pregnancy.

3. Treatment of molar pregnancies — A molar pregnancy occurs when a tumor

forms in place of normal pregnancy placenta. It is often treated with a D&C.

4. Prolonged or excessive vaginal bleeding — D&C may be done as a treatment in

some cases of prolonged or excessive bleeding that do not respond to medical
treatment.

5. Postpartum hemorrhage — Curettage may be done to manage excessive bleeding

after delivery of an infant (postpartum hemorrhage).

PREPARING FOR D and C

 Some patients will need to have blood testing before D&C (such as a blood
count), although this is not always necessary. Patients should not eat or drink
anything before the procedure. All patients will need someone to accompany
them home because it will not be safe to drive after receiving anesthesia, which
causes sedation.

 Some patients will need to have a device or medication placed in the cervix the
day before their procedure. The purpose is to safely and gradually enlarge the
cervical opening, reducing the risk of cervical injury. Devices are used when the
cervix must be dilated to a larger size than is typically needed for D&C, such as
with pregnancy terminations and some types of hysteroscopy. Some patients
will be instructed to insert a medicine in the vagina to soften the cervix prior to
the procedure.
 After arriving for the procedure, a nurse may place an intravenous (IV) line,
which can be used to give fluids and medicine before, during, and after the
procedure. The nurse or doctor will review the patient's medical history, list of
medications used, and any drug allergies.

PROCEDURE
 D&C can be performed in an operating room in a hospital or clinic. Many
patients have a D&C performed in an outpatient setting. A woman's blood
pressure, pulse, and blood oxygen levels are monitored during the procedure.
The procedure takes 15 to 30 minutes to complete.
 To promote dilation, your doctor uses a medication called misoprostol (Cytotec)
given orally or vaginally, to soften the cervix or inserts a slender rod made of
laminaria into your cervix. The laminaria gradually expands by absorbing the
fluid in your cervix, causing your cervix to open.

During Your D and C

* Just before your D&C, you’ll receive medication to prevent pain. You may be awake
but relaxed during the procedure, or you may be completely asleep.
 Instruments are used to hold the vagina open and to steady the uterus. The
cervical canal is widened using tapered instruments called dilators.
 A hysteroscope (thin, flexible telescope) may be inserted into the vagina. This
allows your healthcare provider to see into the uterus.
 The curette is inserted into the uterus. Tissue samples are taken from several
areas. These samples are sent to a lab to be studied.

Anesthesia
 The procedure can be done using general, regional, or local (Paracervical) block
anesthesia. The type of anesthesia chosen depends upon the reason for the
procedure as well as the medical history.

1. General anesthesia — General anesthesia induces sleeps and completely relaxes

the muscles, which makes it easier for the doctor to perform a pelvic examination.
2. Regional anesthesia — Reginonal anesthesia uses an injection of an anesthetic
into the area around the spinal cord to block pain sensation during surgery. The
patient may be sedated with medicine given through an intravenous (IV) line.

3. Paracervical block — Anesthetic agents are injected directly into and around the
cervix, numbing the area. The woman is given a sedative through an intravenous (IV)
line.

POST-PROCEDURE CARE
 After the procedure, the patient will be cared for in a recovery or post-
anesthesia care unit for a few hours. This is necessary to monitor for excessive
vaginal bleeding or other complications, and allows time for recovery from the
anesthesia. Patients who received general anesthesia occasionally have nausea
and vomiting, which can be treated with medications.

 Most patients should be able to resume their regular activities within a day or
two. Mild cramping and spotting may occur for a few hours or days; cramping
can be treated with nonsteroidal antiinflammatory medications such as
ibuprofen (Advil, Motrin). Patients should not put anything into the vagina
(tampons, douches) during this time and should ask when they can safely have
sexual intercourse. The next menstrual period usually occurs within 4 to 6 weeks
of the procedure.

 A woman should call her physician if she develops fever (temperature greater
than 100.4 F), cramps lasting longer than 48 hours, increasing rather than
decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.

COMPLICATIONS
D&C is a commonly performed procedure that is usually very safe. Yet as with any
operation, complications occur. Complications of D&C can include:

1. Uterine perforation — Uterine perforation occurs when one of the surgical

instruments makes a hole in the uterus. It is more common when the procedure is
done during pregnancy due to softening of the uterine wall.
 Fortunately, most uterine perforations heal on their own and do not require any
treatment. Two potential problems caused by perforation are bleeding from injury to
a blood vessel and injury to other internal organs. A second procedure may be
needed to repair these types of injury.

2. Cervical injury — Injuries to the cervix can occur during dilation or from trauma
related to the curettage. Lacerations (cuts) to the cervix are managed with pressure
to the area, application of medications that help stop bleeding, or in some cases,
stitches in the cervix.

3. Infection — Infection from D&C is rare. There is always a slight possibility of

infection once instruments are inserted into the uterus. Most infections can be easily
cured with antibiotics.

4. Intrauterine adhesions — Adhesions (areas of scar tissue) can sometimes form in

the uterus following D&C. Adhesion is most common when D&C is performed
postpartum or post abortion. In some cases, this can lead to abnormalities in the
menstrual cycle, painful menstrual cycles, infertility, or miscarriage. If adhesions are
extensive, a woman can be treated with hormones to encourage growth of healthy
uterine tissue and the scar tissue can be removed with a surgical procedure.

WHERE TO GET MORE INFORMATION

 Your health care provider is the best source of information for questions and
concerns related to your medical problem. Because no two patients are exactly
alike and recommendations can vary from one person to another, it is important
to seek guidance from a provider who is familiar with your individual situation.

D and C TRAY
 Sponge holding-2
 Sims vaginal speculum
 Sims vaginal wall retractor
 Cusco`s vaginal speculum.
 Vulsellum forceps 2
 Cervical dilator(Hegar`s dilator)
 Sims uterine curette
 Ayre`s spatula
 Uterine sounds.

SIMS VAGINAL SPECULUM- used for exposing and inspecting the vaginal wall and
cervix. For collecting discharge from vagina and cervix for microscopy. Used in
D&C ,IUCD insertions etc. To detect vesicovaginal fistula, vaginal wall prolapse like
cystocele, enterocele etc. To detect cervical carcinomas and its different diagnosis.

Sims vaginal wall retractor- used to retract the lax vaginal wall to expose the cervix.
To visualize cervix , cystocele and growth on vagina. To visualize site of fistula like
vesico vaginal fistula etc. Can be rarely used as a curette to remove the retained bits
of placenta.
Vulsellum forceps- has multiple sharp teeth at the end which, when locked , give a
firm grip on the cervix . Used to grasp or hold the anterior lip of the cervix in
operations. To steady the cervix to get firm grip on cervix so as to pass any
instrument inside the uterus during procedure like D&C. To determine the degree of
uterine prolapse.

Uterine sounds- to determine the uterocervical length,position of uterus. Used in

diagnosis of cervical elongation. To determine the location of the displaced
intrauterine contraceptive device(IUCD). Used to diagnose cervical stenosis. Used to
drain pyometra in case of carcinoma cervix/endometrium.

Cervical dilator(HEGAR`S DILATOR)- they are double ended or single ended metal
dilators with a suitable curve for the uterocervical canal in pregnant uterus. Used
mainly in obstetrical indications. Used to dilate the internal os of the cervix in cases
of abortion or in medical termination of pregnancy for suction and evaculation. Used
to dilate the cervix during the LSCS for the draining of lochia.

Cusco`s vaginal speculum- self retaining retractor, it causes least discomfort during
the introduction. It gives good exposure as it can be adjusted to the size of the
vagina. Used for inspection of vagina and cervix. Useful in pap smear, cervical biopsy,
high vaginal swab etc.

Sims uterine curette- the ends of the curette may be blunt and sharp or both ends
sharp or both blunt. Loops are of various sizes-small ,medium, large.
USES OF SHARP CURETTE - used for gynecological conditions for both diagnostic and
therapeutic purposes. In DUB(dysfunctional uterine bleeding) for histopathology of
endometrium. Used in suspected cases of tuberculous endometritis. In patients with
postmenopausal bleeding. Used before certain operations like fothergill`s operation.

USES OF BLUNT CURETTE - mainly used in obstetrical conditions, used to curette

retained bits of products in incomplete abortion. Used to curette the retained bits of
placenta

Ayer`s spatula- made up of wood or plastic, one end is rounded and the other end is
used for scraping squamocolumnar junction. Used to take smear directly from the
cervix or pap smear. Used for screening of carcinoma cervix.

CASE STUDY
Dilatation and Curettage
 Prepared by:

Miguel, Melody

Valencia, Shiela Mae

Lutu, Donna Mae

Presented To:

Sir Manuel, Mark Denver RN,

January 31, 2020