Difference between revisions of "Dilation and curettage"

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(updated basic case table.)
(Updated intraoperative approach and variant table. Added several citations from the literature.)
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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  Diagnostic D&C has largely been replaced by an office endometrial biopsy.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<ref name=":0">{{Citation|last=Cooper|first=Danielle B.|title=Dilation and Curettage|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK568791/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=33760550|access-date=2021-05-08|last2=Menefee|first2=Gary W.}}</ref>.
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  Diagnostic D&C has largely been replaced by an office endometrial biopsy.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<ref name=":0">{{Citation|last=Cooper|first=Danielle B.|title=Dilation and Curettage|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK568791/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=33760550|access-date=2021-05-08|last2=Menefee|first2=Gary W.}}</ref>.


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<ref name=":0" />.
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.<ref name=":0" />
 
 


Therapeutic D&C may be indicated as a temporizing measure in the non-pregnant patient with abnormal uterine bleeding<ref>{{Cite journal|date=2013-04-XX|title=Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women|url=https://journals.lww.com/00006250-201304000-00042|journal=Obstetrics & Gynecology|language=en|volume=121|issue=4|pages=891–896|doi=10.1097/01.AOG.0000428646.67925.9a|issn=0029-7844}}</ref>.{{Infobox surgical case reference
Therapeutic D&C may be indicated as a temporizing measure in the non-pregnant patient with abnormal uterine bleeding<ref>{{Cite journal|date=2013-04-XX|title=Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women|url=https://journals.lww.com/00006250-201304000-00042|journal=Obstetrics & Gynecology|language=en|volume=121|issue=4|pages=891–896|doi=10.1097/01.AOG.0000428646.67925.9a|issn=0029-7844}}</ref>.{{Infobox surgical case reference
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| lines_access = PIV
| lines_access = PIV
| monitors = Standard Monitors
| monitors = Standard Monitors
| considerations_preoperative =  
| considerations_preoperative = Anxiety provoking procedure
| considerations_intraoperative =  
| considerations_intraoperative = Vasovagal response during cervical dilation
| considerations_postoperative =  
| considerations_postoperative = Hemorrhage; infection (1-2%); cervical lacerations; uterine perforation
}}
}}


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=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
Paracervical or intracervical block: Lidocaine 1% placed by obstetrician in 5mL aliquots


Spinal anesthesia: Shorter acting agents including mepivicaine, chloroprocaine, or low-dose hyperbaric bupivicaine 0.75%.  
* Paracervical or intracervical block: Lidocaine 1% placed by obstetrician in 5mL aliquots
* 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.<ref>{{Citation|last=Dalby|first=Patricia|title=Anesthesia for Medical Termination of Pregnancy|date=2018|url=http://link.springer.com/10.1007/978-3-319-74766-8_54|work=Anesthesiology|pages=527–534|editor-last=Goudra|editor-first=Basavana G.|place=Cham|publisher=Springer International Publishing|language=en|doi=10.1007/978-3-319-74766-8_54|isbn=978-3-319-74765-1|access-date=2021-05-08|last2=Coffin|first2=Erica|editor2-last=Duggan|editor2-first=Michael|editor3-last=Chidambaran|editor3-first=Vidya|editor4-last=Venkata|editor4-first=Hari Prasad Krovvidi}}</ref> 


== Intraoperative management ==
== Intraoperative management ==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* Standard ASA monitors


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
* Local anesthesia/sedation/neuroaxial: 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<ref>{{Citation|last=Coffman|first=John C.|title=Anesthesia for Non-delivery Obstetric Procedures|date=2018|url=http://link.springer.com/10.1007/978-3-319-74766-8_52|work=Anesthesiology|pages=497–515|editor-last=Goudra|editor-first=Basavana G.|place=Cham|publisher=Springer International Publishing|language=en|doi=10.1007/978-3-319-74766-8_52|isbn=978-3-319-74765-1|access-date=2021-05-08|last2=Herndon|first2=Blair H.|last3=Thakkar|first3=Mitesh|last4=Fiorini|first4=Kasey|editor2-last=Duggan|editor2-first=Michael|editor3-last=Chidambaran|editor3-first=Vidya|editor4-last=Venkata|editor4-first=Hari Prasad Krovvidi}}</ref>)


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Dorsal lithotomy with stirrups


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* Cervical dilation during the start of the procedure may induce a vasovagal response with bradycardia and decreased cardiac output.


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
* Monitor for PONV


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* Fast-track discharge
* Post-anesthesia care unit


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
* Oral or IV acetaminophen
* Low dose IV narcotics
* ± ketorolac


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* 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<ref>{{Cite journal|last=|first=|date=2013|title=Practice Bulletin No. 135: Second-Trimester Abortion|url=https://journals.lww.com/00006250-201306000-00042|journal=Obstetrics & Gynecology|language=en|volume=121|issue=6|pages=1394–1406|doi=10.1097/01.AOG.0000431056.79334.cc|issn=0029-7844|via=}}</ref>
* Cervical laceration (< 1%)


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
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|+
|+
!
!
!Variant 1
!Regional
!Variant 2
!Sedation
!Neuroaxial
!General Anesthesia
|-
|-
|Unique considerations
|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
|Position
|
|Lithotomy with
|
 
stirrups
|Lithotomy with
 
stirrups
|Lithotomy with
 
stirrups
|Lithotomy with
 
stirrups
|-
|-
|Surgical time
|Surgical time
|
|5-20min
|
|5-20min
|5-20min
|5-20min
|-
|-
|EBL
|EBL
|50-100mL
|50-100mL
|50-100mL
|50-100mL
|-
|Postoperative disposition
|
|
|
|
|-
|Postoperative disposition
|
|
|
|
|-
|-
|Pain management
|Pain management
|
|
|
|
|
|
|-
|-
|Potential complications
|Potential complications
|Local anesthetic toxicity
Patient discomfort
Vasovagal response
|
|
|
|
|

Revision as of 15:49, 8 May 2021

Dilation and curettage (D&C), a commonly performed procedure in obstetrics and gynecology, 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[1].

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.[1]


Therapeutic D&C may be indicated as a temporizing measure in the non-pregnant patient with abnormal uterine bleeding[2].

Dilation and curettage
Anesthesia type

General, sedation, regional or neuroaxial

Airway

Spontaneous (for sedation, regional, or neuroaxial) 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

Article quality
Editor rating
In development
User likes
0

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic Uncontrolled uterine bleeding
Renal
Endocrine
Other

Labs and studies

Operating room setup

Patient preparation and premedication

Regional and neuraxial techniques

  • Paracervical or intracervical block: Lidocaine 1% placed by obstetrician in 5mL aliquots
  • 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.[3]

Intraoperative management

Monitoring and access

  • Standard ASA monitors

Induction and airway management

  • Local anesthesia/sedation/neuroaxial: 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[4])

Positioning

  • Dorsal lithotomy with stirrups

Maintenance and surgical considerations

  • Cervical dilation during the start of the procedure may induce a vasovagal response with bradycardia and decreased cardiac output.

Emergence

  • Monitor for PONV

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[5]
  • Cervical laceration (< 1%)

Procedure variants

Regional Sedation Neuroaxial 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
Pain management
Potential complications Local anesthetic toxicity

Patient discomfort

Vasovagal response

References

  1. ↑ 1.0 1.1 Cooper, Danielle B.; Menefee, Gary W. (2021), "Dilation and Curettage", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 33760550, retrieved 2021-05-08
  2. ↑ "Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women". Obstetrics & Gynecology. 121 (4): 891–896. 2013-04-XX. doi:10.1097/01.AOG.0000428646.67925.9a. ISSN 0029-7844. Check date values in: |date= (help)
  3. ↑ Dalby, Patricia; Coffin, Erica (2018), Goudra, Basavana G.; Duggan, Michael; Chidambaran, Vidya; Venkata, Hari Prasad Krovvidi (eds.), "Anesthesia for Medical Termination of Pregnancy", Anesthesiology, Cham: Springer International Publishing, pp. 527–534, doi:10.1007/978-3-319-74766-8_54, ISBN 978-3-319-74765-1, retrieved 2021-05-08
  4. ↑ Coffman, John C.; Herndon, Blair H.; Thakkar, Mitesh; Fiorini, Kasey (2018), Goudra, Basavana G.; Duggan, Michael; Chidambaran, Vidya; Venkata, Hari Prasad Krovvidi (eds.), "Anesthesia for Non-delivery Obstetric Procedures", Anesthesiology, Cham: Springer International Publishing, pp. 497–515, doi:10.1007/978-3-319-74766-8_52, ISBN 978-3-319-74765-1, retrieved 2021-05-08
  5. ↑ "Practice Bulletin No. 135: Second-Trimester Abortion". Obstetrics & Gynecology. 121 (6): 1394–1406. 2013. doi:10.1097/01.AOG.0000431056.79334.cc. ISSN 0029-7844.

Top contributors: Nirav Kamdar, Maryte Gylys, Barrett Larson, Richard W. Hong and Chris Rishel

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