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Dilation and curettage

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Dilation and curettage
D&C
Background
Abortion typeSurgical
First useLate 19th century
Gestation4-12 weeks
Usage
WHO recommends only when manual vacuum aspiration is unavailable
United States1.7% (2003)
Medical notes
Undertaken under heavy sedation or general anesthesia. Risk of perforation. Day-case procedure
Infobox references

Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). It is a therapeutic gynecological procedure as well as a rarely used method of first trimester abortion.[1][2]

D&C normally refers to a procedure involving a curette, also called sharp curettage.[1] However, some sources use the term D&C to refer more generally to any procedure that involves the processes of dilation and removal of uterine contents, which includes the more common suction curettage procedures of manual and electric vacuum aspiration.[3]

Procedure

The first step in a D&C is to dilate the cervix, usually done a few hours before the surgery. The woman is usually put under general anesthesia before the procedure begins. A curette, a metal rod with a handle on one end and a sharp loop on the other, is inserted into the uterus through the dilated cervix. The curette is used to gently scrape the lining of the uterus and remove the tissue in the uterus. This tissue is examined for completeness (in the case of abortion or miscarriage treatment) or pathologically for abnormalities (in the case of treatment for abnormal bleeding).[1]

Clinical uses

D&Cs are commonly performed for the diagnosis of gynecological conditions leading to 'abnormal uterine bleeding';[4] to resolve abnormal uterine bleeding (too much, too often or too heavy a menstrual flow);[2] to remove the excess uterine lining in women who have conditions such as polycystic ovary syndrome (which cause a prolonged buildup of tissue with no natural period to remove it);[citation needed] to remove tissue in the uterus that may be causing abnormal vaginal bleeding,[1] including postpartum retained placenta;[5] to remove retained tissue (also known as retained POC or retained products of conception) in the case of a missed or incomplete miscarriage;[3] and as a method of abortion that is now uncommon.[1] In contrast, D&C remains 'standard care' for missed and incomplete miscarriage in many countries despite the existence of alternatives currently used for abortions.

Because medical and non-invasive methods of abortion now exist, and because D&C requires heavy sedation or general anesthesia and has higher risks of complication, the procedure has been declining as a method of abortion. The World Health Organization recommends D&C as a method of surgical abortion only when manual vacuum aspiration is unavailable.[6] According to the Centers for Disease Control and Prevention, D&C only accounted for 2.4% of abortions in the United States in the year 2002,[7] down from 23.4% in 1972.[8] Most D&Cs are now carried out for miscarriage management and other indications such as diagnosis.

Hysteroscopy is a valid alternative to D&C for many surgical indications from diagnosis ot uterine pathology to removal of fibroids and even retained products of conception. It is less risky due to the ability of the doctor to view inside the uterus during surgery, unlike with blind D&C.

Medical management of miscarriage and medical abortion using drugs such as misoprostol and mifepristone are safe, non-invasive and cheaper alternatives to D&C.

Complications

Complications may arise from either the introduction or spreading of infection, adverse reaction to general anesthesia required during the surgery or from instrumentation itself, as the procedure is performed blindly (without the use of any imaging technique such as ultrasound or hysteroscopy).

One risk of sharp curettage is uterine perforation. Although normally no treatment is required for uterine perforation, a laparoscopy may be done to verify that bleeding has stopped on its own. Infection of the uterus or fallopian tubes is also a possible complication, especially if the woman has an untreated sexually transmitted infection.[1]

Another risk is intrauterine adhesions, or Asherman's syndrome. One study found that in women who had one or two sharp curettage procedures for miscarriage, 14-16% developed some adhesions.[9] Women who underwent three sharp curettage procedures for miscarriage had a 32% risk of developing adhesions.[9] The risk of Asherman's syndrome was found to be 30.9% in women who had D&C following a missed miscarriage [10], and 25% in those who had a D&C 1–4 weeks postpartum.[11][12][13] Untreated Asherman's syndrome, especially if severe, also increases the risk of complications in future pregnancies, such as ectopic pregnancy, miscarriage, and abnormal placentation (eg.placenta previa and placenta accreta).[1] According to recent case reports, use of vacuum aspiration can also lead to intrauterine adhesions.[14]

See also

References

  1. ^ a b c d e f g ""Dilation and sharp curettage (D&C) for abortion"". Women's Health. WebMD. 2004-10-07. Retrieved 2007-04-29.
  2. ^ a b Hayden, Merrill (2006-02-22). "Dilation and curettage (D&C) for dysfunctional uterine bleeding". Healthwise. WebMD. Retrieved 2007-04-29.
    Nissl, Jan (2005-01-18). "Dilation and curettage (D&C) for bleeding during menopause". Healthwise. WebMD. Retrieved 2007-04-29.
  3. ^ a b "What Every Pregnant Woman Needs to Know About Pregnancy Loss and Neonatal Death". The Unofficial Guide to Having a Baby. WebMD. 2004-10-07. Retrieved 2007-04-29.
  4. ^ Anastasiadis PG, Koutlaki NG, Skaphida PG, Galazios GC, Tsikouras PN, Liberis VA. (2000). "Endometrial polyps: prevalence, detection, and malignant potential in women with abnormal uterine bleeding". Eur J Gynaecol Oncol. 21 (2): 180-183. PMID 10843481.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ^ Wolman I, Altman E, Fait G, Har-Toov J, Gull I, Amster R, Jaffa A. (2009). "Evacuating retained products of conception in the setting of an ultrasound unit". Fertil Steril. 91 ((4 Suppl)): 1586-88. PMID 19064261.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ "Dilatation and curettage". A-Z Managing Complications in Pregnancy and Childbirth by WHO. Retrieved February 20, 2006.
  7. ^ "Abortion Surveillance --- United States, 2002". MMWR Surveillance Summaries. Retrieved February 20, 2006.
  8. ^ "Abortion Surveillance -- United States, 1990". MMWR Surveillance Summaries. Retrieved February 20, 2006.
  9. ^ a b Friedler S, Margalioth EJ, Kafka I, Yaffe H (1993). "Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy--a prospective study". Hum. Reprod. 8 (3): 442–4. PMID 8473464.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Schenker JG, Margalioth EJ (1982). "Intra-uterine adhesions: an updated appraisal". Fertility Sterility. 37 (5): 593–610. PMID 6281085.
  11. ^ Kodaman P, Arici A (2007). "Intrauterine adhesions and fertility outcome:how to optimize success?". Curr Opin Obstet Gynecol. 19 (3): 207–214. doi:10.1097/GCO.0b013e32814a6473. PMID 17495635.
  12. ^ Rochet Y, Dargent D, Bremond A; et al. (1979). "The obstetrical outcome of women with surgically treated uterine synechiae (in French)". J Gynecol Obstet Biol Reprod. 8 (8): 723–726. PMID 553931. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  13. ^ Buttram VC, Turati G (1977). "Uterine synechiae: variations in severity and some conditions which may be conducive to severe adhesions". Int. J. Fertil. 22 (2): 98–103. PMID 20418.
  14. ^ Dalton VK, Saunders NA, Harris LH, Williams JA, Lebovic DI (2006). "Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure". Fertil. Steril. 85 (6): 1823.e1–3. doi:10.1016/j.fertnstert.2005.11.065. PMID 16674955.{{cite journal}}: CS1 maint: multiple names: authors list (link)

External links

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