Difference between revisions of "Dilation and curettage"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = General, MAC, neuraxial, or regional | ||
| airway = | | airway = Noninvasive O2 (for sedation, regional, or neuraxial) | ||
| lines_access = | LMA/ETT if GA | ||
| monitors = | | lines_access = PIV | ||
| considerations_preoperative = | | monitors = Standard | ||
| considerations_intraoperative = | | considerations_preoperative = Anxiety | ||
| considerations_postoperative = | | considerations_intraoperative = Vasovagal response during cervical dilation | ||
}} | | considerations_postoperative = Hemorrhage | ||
Infection | |||
Cervical lacerations | |||
Uterine perforation | |||
}}'''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 Diagnostic D&C has largely been replaced by an office endometrial biopsy.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<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" /> | |||
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>. | |||
== Preoperative management == | == Preoperative management == | ||
Line 18: | Line 26: | ||
!System | !System | ||
!Considerations | !Considerations | ||
|- | |||
|Airway | |||
| | |||
|- | |- | ||
|Neurologic | |Neurologic | ||
Line 23: | Line 34: | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Hemodynamic instability due to uterine bleeding or possibly septic from retained products of conception | ||
|- | |- | ||
| | |Pulmonary | ||
| | | | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | |If the patient was pregnant, you may need aspiration precautions depending on how many weeks pregnant | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Uncontrolled uterine bleeding | ||
|- | |- | ||
|Renal | |Renal | ||
Line 41: | Line 52: | ||
|- | |- | ||
|Other | |Other | ||
| | |Emotional distress | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* CBC | |||
* coagulation studies | |||
* blood type and antibody screen, possible crossmatching<ref name=":1" /> | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* If high-risk for uterine bleeding, consider having Oxytocin (Pitocin), Methylergonovine (Methergine), and/or Carboprost tromethamine (Hemabate) available. | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* 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<ref name=":1" /> | |||
* <u>Anxiolysis</u>: 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<!-- 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. --> === | ||
* <u>Paracervical</u> or <u>intracervical block</u>: 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. | |||
* <u>Spinal anesthesia</u>: Shorter acting agents including mepivicaine, chloroprocaine<ref>{{Cite journal|last=Goldblum|first=E.|last2=Atchabahian|first2=A.|date=2013|title=The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia|url=http://doi.wiley.com/10.1111/aas.12071|journal=Acta Anaesthesiologica Scandinavica|language=en|volume=57|issue=5|pages=545–552|doi=10.1111/aas.12071|via=}}</ref>, 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> 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 == | == 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 | |||
* PIV | |||
=== 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/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<ref name=":1">{{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 | |||
* Arms out | |||
* Slight Trendelenburg | |||
=== 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. | |||
* If GA, consider keeping MAC < 1.0 to reduce risk of uterine atony | |||
=== 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 (high risk demographic) | |||
== 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. --> === | ||
== 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). --> == | * 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). --> == | |||
{| 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 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.<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 | ||
! | !Sedation | ||
!Neuraxial | |||
!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 | ||
|Ambulatory | |||
|Ambulatory | |||
|PACU | |||
|PACU | |||
|- | |||
|Pain management | |||
| | | | ||
| | | | ||
| | | | ||
| | | | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
| | |Local anesthetic toxicity | ||
Patient discomfort | |||
Vasovagal response | |||
|Unprotected airway and | |||
aspiration risk in advanced | |||
pregnancies | |||
|Transient Neurologic | |||
Symptoms (TNS) | |||
| | | | ||
|} | |} | ||
Line 112: | Line 213: | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
<references /> | |||
[[Category:Obstetric and gynecologic surgery]] |
Latest revision as of 00:35, 5 April 2022
Anesthesia type |
General, MAC, neuraxial, or regional |
---|---|
Airway |
Noninvasive O2 (for sedation, regional, or neuraxial) LMA/ETT if GA |
Lines and access |
PIV |
Monitors |
Standard |
Primary anesthetic considerations | |
Preoperative |
Anxiety |
Intraoperative |
Vasovagal response during cervical dilation |
Postoperative |
Hemorrhage Infection Cervical lacerations Uterine perforation |
Article quality | |
Editor rating | |
User likes | 0 |
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[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].
Preoperative management
Patient evaluation
System | Considerations |
---|---|
Airway | |
Neurologic | |
Cardiovascular | Hemodynamic instability due to uterine bleeding or possibly septic from retained products of conception |
Pulmonary | |
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[3]
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[3]
- 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[4], or low-dose hyperbaric bupivicaine 0.75%. TNS symptoms may follow patients in the ambulatory settings after lithotomy position.[5] 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[3])
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[6]
- Cervical laceration (< 1%)
Procedure variants*
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) |
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
- ↑ Goldblum, E.; Atchabahian, A. (2013). "The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia". Acta Anaesthesiologica Scandinavica. 57 (5): 545–552. doi:10.1111/aas.12071.
- ↑ 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.