Dilation and curettage

Dilation and curettage

Anesthesia type	General, sedation, regional or neuraxial
Airway	Spontaneous (for sedation, regional, or neuraxial) LMA for general
Lines and access	PIV
Monitors	Standard Monitors
Primary anesthetic considerations
Preoperative	Anxiety provoking procedure
Intraoperative	Vasovagal response during cervical dilation
Postoperative	Hemorrhage; infection (1-2%); cervical lacerations; uterine perforation
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Dilation and curettage, also known as D&C, is a commonly performed procedure in obstetrics and gynecology which refers to dilation of the cervix in order to introduce instruments into the uterus, with a curette being used to empty or sample the endometrial cavity.

The indication for a D&C may be diagnostic or therapeutic. Diagnostic D&C has largely been replaced by an office endometrial biopsy. However, certain scenarios, including (but not limited to) the inability to tolerate office biopsy due to pain or anxiety, insufficient sampling, the need to exclude endometrial cancer, and cervical stenosis, may necessitate an operative diagnostic D&C over office endometrial biopsy.

Indications for therapeutic D&C in the pregnant patient are: elective termination of pregnancy (< 14 weeks gestational age), treatment of early pregnancy failure (missed or incomplete spontaneous abortion), evacuation of suspected molar pregnancy, treatment for cervical stenosis, and removal of suspected retained products of conception in the post-partum period.

Therapeutic D&C may be indicated as a temporizing measure in the non-pregnant patient with abnormal uterine bleeding.

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular	Hemodynamic instability due to uterine bleeding or possibly septic from retained products of conception
Respiratory
Gastrointestinal	If the patient was pregnant, you may need aspiration precautions depending on how many weeks pregnant
Hematologic	Uncontrolled uterine bleeding
Renal
Endocrine
Other	Emotional distress

Labs and studies

• CBC
• coagulation studies
• blood type and antibody screen, possible crossmatching

Operating room setup

• If high-risk for uterine bleeding, consider having Oxytocin (Pitocin), Methylergonovine (Methergine), and/or Carboprost tromethamine (Hemabate) available.

Patient preparation and premedication

• Special considerations for evacuation of molar pregnancy: hyperemesis gravidarum, preeclampsia, anemia, hyperthyroid, trophoblastic embolization, cardiorespiratory distress; may require additional pre-operative optimization or post-operative monitoring
• Anxiolysis: D&C for miscarriage or termination of pregnancy can be highly anxiety provoking and may instigate severe emotional distress prior to the the procedure.
• Consider pre-operative acetaminophen.

Regional and neuraxial techniques

• Paracervical or intracervical block: Lidocaine 1% can be injected by the obstetrician in 5mL aliquots to facilitate passage through the cervix and instrumentation of the uterus. Note that this does not block sensation for the manipulation and instrumentation of the vaginal canal. Patients who could not tolerate an intra-office procedure may also require sedation in addition to block placement.
• Spinal anesthesia: Shorter acting agents including mepivicaine, chloroprocaine, or low-dose hyperbaric bupivicaine 0.75%. TNS symptoms may follow patients in the ambulatory settings after lithotomy position. A T10-L1 sensory level is needed to provide anesthesia for intrauterine procedures. Additionally, S2-S4 nerve root blockade is needed to blunt sensations to the vaginal canal (mediated by the pudendal nerve).

Intraoperative management

Monitoring and access

• Standard ASA monitors
• PIV

Induction and airway management

• Local anesthesia/sedation/neuraxial: Monitor airway with end-tidal CO2 monitoring
• General Anesthesia (GA): May use LMA or ETT based upon aspiration risks (GA used for emotional distress, request, ongoing hemorrhage, sepsis, or hemodynamic instability)

Positioning

• Dorsal lithotomy with stirrups
• Arms out
• Slight Trendelenburg

Maintenance and surgical considerations

• Cervical dilation during the start of the procedure may induce a vasovagal response with bradycardia and decreased cardiac output.
• If GA, consider keeping MAC < 1.0 to reduce risk of uterine atony

Emergence

• Monitor for PONV (high risk demographic)

Postoperative management

Disposition

• Fast-track discharge
• Post-anesthesia care unit

Pain management

• Oral or IV acetaminophen
• Low dose IV narcotics
• ± ketorolac

Potential complications

• Peroneal nerve injury from lithotomy and stirrup position
• Infection (1-2%)
• Hemorrhage
• Uterine perforation (0.63%). More common in pregnant patients with increasing gestational age
• Cervical laceration (< 1%)

Procedure variants*

*A Cochrane review compared trials assessing the anesthetic technique for evacuation of an incomplete miscarriage (general vs. regional vs. sedation). There was a high level of heterogeneity among existing studies, and the authors concluded that choice of anesthetic technique should be influenced by other considerations, such as availability, effectiveness, safety, practitioner and patient preference.

	Regional	Sedation	Neuraxial	General Anesthesia
Unique considerations		Medical termination in early gestational age or missed/incomplete abortion	Consider for advanced gestation or anticipated patient discomfort	Consider for emotional distress, ongoing hemorrhage, hemodynamic instability, retention of placental products requiring uterine relaxation
Position	Lithotomy with stirrups	Lithotomy with stirrups	Lithotomy with stirrups	Lithotomy with stirrups
Surgical time	5-20min	5-20min	5-20min	5-20min
EBL	50-100mL	50-100mL	50-100mL	50-100mL
Postoperative disposition	Ambulatory	Ambulatory	PACU	PACU
Pain management
Potential complications	Local anesthetic toxicity Patient discomfort Vasovagal response	Unprotected airway and aspiration risk in advanced pregnancies	Transient Neurologic Symptoms (TNS)