Difference between revisions of "Dilation and curettage"
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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. | 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 Diagnostic D&C has largely been replaced by an office endometrial biopsy.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<ref name=":0">{{Citation|last=Cooper|first=Danielle B.|title=Dilation and Curettage|date=2021|url= | 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 Diagnostic D&C has largely been replaced by an office endometrial biopsy.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=https://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.|volume=|pages=}}</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 in the post-partum period.<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 | Therapeutic D&C may be indicated as a temporizing measure in the non-pregnant patient with abnormal uterine bleeding<ref>{{Cite journal|date=April 2013|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|last=|first=|via=}}</ref>.{{Infobox surgical case reference | ||
| anesthesia_type = General, sedation, regional or neuroaxial | | anesthesia_type = General, sedation, regional or neuroaxial | ||
| airway = Spontaneous (for sedation, regional, or neuroaxial) | | airway = Spontaneous (for sedation, regional, or neuroaxial) | ||
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* Cervical laceration (< 1%) | * 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). --> == | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
<nowiki>*</nowiki>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 heterogenity among existing studies, and the authors concluded that choice of anesthetic technique should be influenced by other considerations, such as availbility, effectiveness, safety, practitioner and patient preference.<ref>{{Cite journal|last=Calvache|first=Jose Andres|last2=Delgado-Noguera|first2=Mario F|last3=Lesaffre|first3=Emmanuel|last4=Stolker|first4=Robert J|date=2012-04-18|editor-last=Cochrane Pregnancy and Childbirth Group|title=Anaesthesia for evacuation of incomplete miscarriage|url=http://doi.wiley.com/10.1002/14651858.CD008681.pub2|journal=Cochrane Database of Systematic Reviews|language=en|doi=10.1002/14651858.CD008681.pub2}}</ref> | |||
! | ! | ||
!Regional | !Regional |
Revision as of 16:52, 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].
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 | |
User likes | 0 |
Preoperative management
Patient evaluation
System | Considerations |
---|---|
Neurologic | |
Cardiovascular | |
Respiratory | |
Gastrointestinal | |
Hematologic | Uncontrolled uterine bleeding |
Renal | |
Endocrine | |
Other | Emotional distress |
Labs and studies
- CBC
- coagulation studies
- blood type and antibody screen, possible crossmatching[3]
Operating room setup
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[3]
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.[4]
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[3])
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
- ↑ 1.0 1.1 Cooper, Danielle B.; Menefee, Gary W. (2021), "Dilation and Curettage", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 33760550, retrieved 2021-05-08
- ↑ "Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women". Obstetrics & Gynecology. 121 (4): 891–896. April 2013. doi:10.1097/01.AOG.0000428646.67925.9a. ISSN 0029-7844.
- ↑ 3.0 3.1 3.2 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
- ↑ 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
- ↑ "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.
- ↑ Calvache, Jose Andres; Delgado-Noguera, Mario F; Lesaffre, Emmanuel; Stolker, Robert J (2012-04-18). Cochrane Pregnancy and Childbirth Group (ed.). "Anaesthesia for evacuation of incomplete miscarriage". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD008681.pub2.