Patient information: Dilation and curettage (D and C)

DILATION AND CURETTAGE OVERVIEW

Dilation and curettage (D and 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 (picture 1). "Curettage" refers to the scraping or removal of tissue lining the uterine cavity (endometrium) with a surgical instrument called a curette.

D&C may be done to diagnose a problem, such as abnormal uterine bleeding, or as a treatment for miscarriage or excessive bleeding. This topic discusses the reasons for D&C, how to prepare for the procedure, and what to expect afterwards.

REASONS FOR D AND C

There are a number of reasons a D and 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 and C). In other cases, the procedure is used to treat a medical problem or condition (called therapeutic D and C).

Diagnostic D and C — The primary reason for a diagnostic D and C is to obtain samples of the endometrium to evaluate abnormal uterine bleeding or abnormal cells found during routine screening for cervical cancer. (See "Patient information: Cervical cancer screening".)

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 and C must be done to obtain an adequate tissue sample.

Diagnostic D and C is usually done with hysteroscopy; this involves dilating the cervix and inserting a small instrument 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. (See "Patient information: Abnormal uterine bleeding".)

A pathologist then examines the tissue with a microscope to establish certain diagnoses, including endometrial (uterine) cancer, endometrial polyps, or precancerous conditions of the lining of the uterus (endometrial hyperplasia). (See "Patient information: Endometrial cancer diagnosis and staging".)

Therapeutic D and C — Therapeutic D and C is done to remove the contents of the uterus in the following circumstances:

Miscarriage — In some miscarriages, the tissues from a pregnancy are passed completely. In other cases, a D and C is needed to remove this tissue or to ensure that all of it has been passed. (See "Patient information: Miscarriage".)

Abortion — A D and C can be done to remove the contents of the uterus when a woman chooses to end a pregnancy. (See "Overview of pregnancy termination".)

Treatment of molar pregnancy — A molar pregnancy occurs when a tumor forms in place of normal pregnancy placenta. It is often treated with a D and C. (See "Gestational trophoblastic disease: Management of hydatidiform mole".)

Prolonged or excessive vaginal bleeding — D and C may be done as a treatment in some cases of prolonged or excessive bleeding that do not respond to medical treatment. (See "Patient information: Abnormal uterine bleeding".)

Postpartum hemorrhage — Curettage may be done to manage excessive bleeding after delivery of an infant (postpartum hemorrhage). (See "Causes and treatment of postpartum hemorrhage".)

PREPARING FOR D AND C

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

You may need to have a device or medication placed in the cervix the day before your 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 and C, such as with pregnancy terminations and some types of hysteroscopy. You may be instructed to insert a medicine in your vagina to soften your 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 your medical history, list of medications used, and any drug allergies.

D AND C PROCEDURE

D and C can be performed in an operating room in a hospital or clinic. Your blood pressure, pulse, and blood oxygen levels are monitored during the procedure. The procedure takes 15 to 30 minutes to complete.

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

CARE AFTER D AND C

After the procedure, you will rest 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 you to recover from the anesthesia. If you were given general anesthesia, you may have nausea and vomiting, which can be treated with medications.

Recovery at home — You should be able to resume your 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®). You should not put anything into the vagina (tampons, douches) during this time and should ask when you can safely have sexual intercourse. Your next menstrual period usually occurs within four to six weeks of the procedure.

When to call for help — You should call your physician if you develop fever (temperature greater than 100.4º F), cramps lasting longer than 48 hours, increasing rather than decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.

D AND C COMPLICATIONS

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

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.

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.

Infection — Infection from D and C is rare.

Intrauterine adhesions — Adhesions (areas of scar tissue) can sometimes form in the uterus following D and C. Adhesion is most common when D and C is performed during or after pregnancy. In some cases, this can lead to abnormalities in the menstrual cycle, painful menstrual cycles, infertility, or miscarriage. If adhesions are extensive, you can be treated with hormones to encourage growth of healthy uterine tissue and the scar tissue can be removed with a surgical procedure. (See "Intrauterine adhesions".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people 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.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Cervical cancer screening
Patient information: Abnormal uterine bleeding
Patient information: Endometrial cancer diagnosis and staging
Patient information: Miscarriage

Professional Level Information:
Dilation and curettage
Endometrial sampling procedures
Evaluation of the endometrium for malignant or premalignant disease
Menorrhagia
Mifepristone for the medical termination of pregnancy
Overview of pregnancy termination
Surgical termination of pregnancy: First trimester
Termination of pregnancy: Second trimester
Gestational trophoblastic disease: Management of hydatidiform mole
Causes and treatment of postpartum hemorrhage
Intrauterine adhesions

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The Mayo Clinic

      (www.mayoclinic.com)

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