Introduction
Dilation and curettage (D&C) can be used as a therapeutic or diagnostic procedure. Although D&C has in some cases been replaced by hysteroscopy, in carefully selected patients D&C is useful in treating persistent vaginal bleeding that is unresponsive to hormonal manipulation and can be used in the diagnostic approach to vaginal bleeding.
D&C should be used to treat heavy and life-threatening bleeding from missed or incomplete abortion. However, before 8 weeks gestation and if bleeding from a spontaneous abortion is light or not prolonged, observation of the patient for several weeks to see if the patient spontaneously completes the abortion is acceptable. If a gravid uterus is more than 10 to 12 weeks in size, D&C should be done because it is unlikely that the patient will complete expulsion of the products of conception (POC), and retained POC may result in infection or prolonged bleeding. Between 8 and 12 weeks, the choice between expectant and surgical management is based on weighing the severity of bleeding and the patient 's preference.
View OriginalView Original
Equipment
- Consent for procedure (see Appendix A)
- Method of sedation
- If done in the office or outpatient surgery, pretreat with oral benzodiazepine such as diazepam 10 mg 1 hour before the procedure.
- If done in an operating room, the patient will receive intravenous (IV) sedation and oxygen.
- Sterile bivalve or weighted speculum
- Topical antiseptic (see Appendix E)
- Syringe, 10 mL
- Lidocaine (1%) without epinephrine
- Spinal needle, 22 g
- Cervical curette
- Single-toothed tenaculum
- Malleable uterine sound
- Hegar cervical dilators
- Teflon-treated gauze for collection of endocervical curettage specimens
- Suction with trap for uterine contents
- Stone forceps for removal of polyps
- Sharp uterine curette
- Suction curettes
Indications
- Treatment of missed or incomplete abortion
- Treatment of dysfunctional uterine bleeding not responsive to hormonal manipulation
- Diagnosis of dysfunctional uterine bleeding (DUB) after failed endometrial biopsy
- Diagnosis and treatment of postmenopausal bleeding
Contraindications
- Perimenarchal DUB because of the high risk of Asherman syndrome, which is due to the denuded basal endometrium
- Active uterine infection or pelvic inflammatory disease
- Coagulopathy
The Procedure
Step 1
Check the patient 's hemoglobin before starting the procedure. If the hemoglobin is <8 g, order a type and screen, and perform the procedure in the operating room. Check the blood type and Rh in pregnant patients, and treat Rh negative patients with RhoGAM 300 mcg intramuscularly once. Examine the patient under anesthesia to determine uterine position and size. Record the uterine size in terms of weeks of gestation. Insert the speculum. The speculum should be large enough to prevent the vaginal walls from bowing into the operative field.
Step 1 View Original Step 1 View Original
Step 2
Grasp the cervix at 12 o 'clock with the tenaculum.
Step 2 View Original Step 2 View Original
Step 3
Administer a paracervical block with 5 to 10 mL of a local anesthetic, such as lidocaine, at 3 and 9 o 'clock of the vaginal fornices.
Step 4
When doing a D&C for DUB place, Teflon-coated gauze on the inferior blade of the speculum in the posterior fornix.
Step 5
Perform an endocervical curettage (ECC). Curettings should be placed onto the gauze and transferred to a fixative solution.
Step 5 View Original Step 5 View Original
Step 6
For a retroflexed uterus, grasp the inferior aspect of the cervix with a tenaculum to straighten the uterine canal. Failure to do so may result in the perforation of the acutely anteflexed uterus.
Step 6 View Original Step 6 View Original
Step 7
For an anteverted uterus, grasp the superior aspect of the cervix to straighten out the canal. Do not place the tenaculum through the cervical os. Failure to do so may result in the perforation of the retroflexed uterus.
Step 7 View Original Step 7 View Original
Step 8
Mold the sound in the form of the expected curve of the uterine cavity. Retract the cervix with the tenaculum and sound the uterus to determine the depth and direction of the uterine cavity. Hold the sound with a pencil grip, and twist the sound while entering the endocervix. This will help overcome cervical resistance and avoid applying excessive force to the internal os. Because the postmenopausal woman often has a stenotic os, be sure to advance the sound beyond the internal cervical os or the endometrium will not be sampled.
Step 8 View Original Step 8 View Original
Step 9
While retracting the cervix with the tenaculum, dilate the cervix with Hegar dilators, and start with the smallest dilator. Hold the dilator with a pencil grip. In the setting of DUB, dilation to 8 to 9 mm is usually sufficient. In the treatment of missed or incomplete abortion, the amount of dilation in millimeters should equal the uterine size in weeks. One should use the largest curette that can be easily advanced through the dilated cervix.
Step 9 View Original Step 9 View Original
D&C for DUB
Step 10
Explore the uterine cavity with stone forceps to search for uterine polyps. Explore the dome, lateral, anterior, and posterior walls of the uterus.
Step 10 View Original Step 10 View Original
Step 11
Choose a medium-sized sharp curette.
Step 11 View Original Step 11 View Original
Step 12
Insert into the uterus while holding the curette in a pencil grip. Curette the anterior, posterior, lateral walls, and dome of uterus. When a rough sandpaper sensation is palpable through the curette, the endometrium has been sufficiently curetted. Place the curettings onto the gauze pad, and transfer the sample to a fixative solution.
Step 12 View Original Step 12 View Original
D&C for Missed or Incomplete Abortion
Step 13
Attach a suction curette to suction tubing while keeping the O-ring away from the hole in the curette to prevent suction from forming. The size of the suction curette in millimeters should approximately equal the size of the uterus in weeks of gestation.
Step 14
Gently advance curette through the cervix to the depth of the uterus estimated by uterine sound. Have an assistant activate the suction. Then close the hole with the O-ring on the curette and curette the uterus as with a sharp curette.
Step 15
When the suction curettage is complete, raise the O-ring to allow the POC to be suctioned into the suction trap. If all POC are not removed with the suction curettage, perform sharp curettage as described previously and repeat suction curettage of the uterus. Observe the patient for uterine bleeding after completion of the procedure. Clean the vaginal vault of all blood because patients can be very concerned if they discharge a large amount of blood after standing. Check the tenaculum site for bleeding, and apply silver nitrate or a suture if the ectocervix is bleeding actively. Remove the speculum.
Step 15 View Original Step 15 View Original
Complications
- Uterine perforation: lateral perforation can lead to intraperitoneal hemorrhage and broad ligament hematoma.
- Bleeding.
- Infection, including peritonitis, abscess, and endometritis. There is controversy over whether or not to prophylactically treat with antibiotics after a D&C, but most physicians do not.
- Trauma to abdominal viscera, including the bowel, omentum, mesentery, ureter, or fallopian tube.
- Asherman syndrome.
Pediatric Considerations
Although it may be tempting to use D&C in a menarchal patient who is having heavy anovulatory bleeding, the endometrium in young girls is often denuded by bleeding. A D&C is more likely to cause scaring (Asherman syndrome) that may result in permanent infertility.
Postprocedure Instructions
Properly complete a pathology request form. For DUB patients, the ECC and endometrial portions should be labeled separately. In the case of missed and incomplete abortion, submit specimens for routine pathology and genetic analysis. Genetic abnormalities are common in spontaneous abortion, and it is important not to miss a molar pregnancy.
Observe the patient in the office or recovery room for at least 1 hour after the procedure. Monitor her vital signs and development of pain or vaginal bleeding.
Pain management is often accomplished using nonsteroidal anti-inflammatory drugs (NSAIDs). Be aware, however, that uterine cramping after D&C for pregnancy-related problems can be intense.
Inform the patient that postprocedure bleeding should be lighter than the patient 's usual menses. Set a follow-up appointment for 1 week after the procedure to check bleeding and the patient 's status.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 58120 Endometrial tissue retrieval $977.00 10 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
ICD-9 Codes
View Large 626 Disorders of menstruation and other abnormal bleeding from genital tract 627 Menopausal and premenopausal bleeding 627.1 Postmenopausal bleeding 632 Missed abortion 634 Spontaneous abortion
Suppliers
- McKesson Medical-Surgical, One Post Street, San Francisco, CA 94104. Phone: 1-800-283-1558. Web site: http://www.mckesson.com/en_us/McKesson.com/.
- PSS World Medical, Inc., 4345 Southpoint Boulevard, Jacksonville, FL 32216. Phone: 904-332-3000. Web site: http://www.pssd.com/pss/index.htm
Bibliography
1
Chen BA, Creinin A, Mitchell D. Contemporary management of early pregnancy failure.
Clin Obstet Gynecol
. 2007;50(1):67 " 88. [View Abstract]
2
Harris LH, Dalton VK, Johnson TR. Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care.
Am J Obstet Gynecol
. 2007;196(5):445.e1 " 5. 3
Nanda K, Peloggia A, Grimes D, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database of Systematic Reviews (2):CD003518; 2006. 4
Rock JA, Jones III HW.
TeLinde 's Operative Gynecology
. 9th ed. Philadelphia: Lippincott Williams & Wilkins. 461 " 478. 5
Ramphal SR, Moodley J. Best practice and research in clinical obstetrics and gynaecology.
Emerg Gynaecol
. 2006;20(5):729 " 750. [View Abstract]
6
2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.