Dilation and curettage
|Anesthesia type||General, sedation, regional or neuraxial|
|Airway||Spontaneous (for sedation, regional, or neuraxial) LMA for general|
|Lines and access||PIV|
|Primary anesthetic considerations|
|Preoperative||Anxiety provoking procedure|
|Intraoperative||Vasovagal response during cervical dilation|
|Postoperative||Hemorrhage; infection (1-2%); 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 Diagnostic D&C has largely been replaced by an office endometrial biopsy.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.
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.
|Cardiovascular||Hemodynamic instability due to uterine bleeding or possibly septic from retained products of conception|
|Gastrointestinal||If the patient was pregnant, you may need aspiration precautions depending on how many weeks pregnant|
|Hematologic||Uncontrolled uterine bleeding|
Labs and studies
- 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).
Monitoring and access
- Standard ASA monitors
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)
- 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
- Monitor for PONV (high risk demographic)
- Fast-track discharge
- Post-anesthesia care unit
- Oral or IV acetaminophen
- Low dose IV narcotics
- ± ketorolac
- Peroneal nerve injury from lithotomy and stirrup position
- Infection (1-2%)
- Uterine perforation (0.63%). More common in pregnant patients with increasing gestational age
- Cervical laceration (< 1%)
|Unique considerations||Medical termination
in early gestational age
|Consider for advanced
gestation or anticipated
|Consider for emotional distress,
ongoing hemorrhage, hemodynamic
instability, retention of placental
products requiring uterine relaxation
|Potential complications||Local anesthetic toxicity
|Unprotected airway and
aspiration risk in advanced
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- 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.