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

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 Diagnostic D&C has largely been replaced by an office endometrial biopsy.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
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[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-op acetaminophen

Regional and neuraxial techniques

  • Paracervical or intracervical block: Lidocaine 1% placed by obstetrician in 5mL aliquots
  • 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]
  • At T10 sensory level is needed to provide anesthesia for uterine procedures

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*

*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.[7]
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. 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. April 2013. doi:10.1097/01.AOG.0000428646.67925.9a. ISSN 0029-7844.
  3. 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
  4. 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.
  5. 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
  6. "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.
  7. 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.