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- What is dilation and curettage (D and C)?
- Why is a D and C done?
- What are reasons not to perform a D and C?
- Pre-op: What happens before surgery?
- What type of anesthesia is used for a D and C?
- How is a D and C performed?
- What are possible complications of a D and C?
- What happens after a D and C?
- Why is the D and C procedure becoming less common?
What is dilation and curettage (D and C)?
Dilation and curettage (D and C) is a procedure in which the cervix of the uterus is expanded (dilated) so that the uterine lining (endometrium) can be removed with a spoon-shaped instrument called a curet or curette. The procedure is performed for a variety of reasons. Most commonly, this surgery is done in order to help determine the cause of abnormal uterine bleeding. It can also be done to help determine the degree of abnormality of the endometrium in cancer cases or pre-cancerous cells that are detected by an in-office biopsy. D and C is also sometimes necessary to remove tissue after a miscarriage.
Why is a D and C done?
In general, a D and C is used to help determine the health of the uterine lining or to remove abnormal tissue. Occasionally, the procedure can correct some of the problems in the uterus such as polyps, scar tissue, or tissue overgrowth.
What are reasons not to perform a D and C?
There are very few contraindications to D and C. Generally if a patient is too ill to undergo surgery, she should probably not have this procedure. Furthermore, if the patient is unable to move her legs apart, such as with severe arthritis in the hips, the surgeon may not be able to perform the procedure since it requires enough movement of the legs to accommodate a speculum. If the patient is pregnant or thinks that she could be pregnant, she should not have the operation unless the D and C is for the purpose of an abortion or to treat a miscarriage.
Pre-op: What happens before surgery?
Before a D and C, the same general recommendations for other outpatient procedures apply. It is recommended that the patient take nothing by mouth (food, water, etc.) for at least 6 to 8 hours prior to the scheduled operation. Often, the doctor will see the patient the day before surgery to discuss the procedure and potential complications in greater detail.
What type of anesthesia is used for a D and C?
Most D and Cs are done under general anesthesia. The procedure is typically very short, and general anesthetic can be quickly reversed, with the patient going home later the same day. Some patients prefer or require spinal or epidural blocks, but these forms of anesthesia take more time for the anesthesiologist to perform and require more recovery time for the patient. Occasionally, in a very motivated patient, the procedure can be done under a local anesthetic with or without intravenous pain medication or twilight sleep. Overall, the choice of anesthetic is a generally determined by the surgeon, the anesthesiologist, and the patient.
How is a D and C performed?
The actual procedure is done in an operating room, either in a hospital, surgery center, or a specially designated room in a physician's office. After adequate anesthesia has been administered, and with the patient in position (similar to that for a Pap smear), the vagina and cervix are cleansed with an antibacterial scrub (usually Betadine). An instrument is used to grasp the upper portion of the cervix, and then the opening to the uterus is gradually widened with metal dilators to about the size of a large pencil.
Once the dilation has been completed, the curette, which is an instrument with a flat metal loop at the end, is inserted into the uterine cavity and is used to gently scrape the lining of the uterus. When the surgeon feels the gritty layer of cells just above the muscle of the uterus, then he/she knows that the scraping has gone deep enough to sample the tissue adequately. This scraping is done throughout the uterus, and the tissue that is removed is then sent to a pathologist for microscopic examination.
After the surgeon feels that enough tissue has been obtained, that the entire uterine cavity has been sampled, or that any abnormal growths that were seen on ultrasound were removed, then the procedure is stopped. Often, the doctor uses a viewing instrument to examine the uterus visually (hysteroscopy) prior to the D and C to make the procedure more complete. This is not, however, always necessary.
What are possible complications of a D and C?
The D and C procedure has a low risk of serious complications. It is normal to experience vaginal bleeding and/or pelvic cramping (similar to menstrual cramping) for a few days following a D and C. Typically, over-the-counter pain medications are sufficient for pain control.
The most common complication that can occur is perforation of the uterus with either the dilators or the curette. When this happens, as long as no internal organs (intestines, bladder, or rectum) or large blood vessels are damaged, the hole will almost always heal itself without further surgery. The risk for this problem is increased in patients with a narrowed opening to the cervix (cervical stenosis) or in patients with distorted internal uterine anatomy. This risk is also increased if the uterus is infected or has undergone previous surgeries such as cesarean sections or myomectomies.
Injury to the cervix is another possible complication. Tears or cuts in the cervix can usually be treated by application of pressure and application of local medications to stop bleeding. In some cases, stitches in the cervix may be required, but this is not common.
Other complications, as with any surgery, include bleeding and infection. Most bleeding is mild and resolves on its own. Infection is also rare and can normally be managed with oral antibiotics. Most D and Cs do not require the routine use of post-operative antibiotics. On occasion, in patients with certain heart defects, the surgeon may give the patient antibiotics before and after the surgery to prevent bacteria from the vagina from infecting the heart valves.
What happens after a D and C?
After the surgery, the patient is cared for in a post-anesthesia care unit during recovery from the anesthesia. Most patients can return to normal activities within a few days. Nonsteroidal anti-inflammatory medications may be recommended to relieve the mild pain and cramping that may follow. To decrease the chance of developing an infection, doctors advise that patients not use tampons or insert anything into the vagina for two weeks following the surgery, and to abstain from sexual intercourse for the same time period.
The follow-up office care depends on the surgeon. Most doctors have the patient return to the office to make sure that all is well and to discuss the results of the tissue samples that were removed. Usually, this is done 2 to 6 weeks post-operatively. Sometimes, the patient will simply be notified by a phone call with the results, and no direct contact with a health professional is necessary.
Why is the D and C procedure becoming less common?
In general, the number of D and Cs being performed has declined over the years. This procedure is no longer done to regulate abnormal bleeding patterns in women. Most of these problems are now managed with medications, such as hormones. Ultrasound and other imaging techniques are likewise playing a greater role in helping to evaluate the uterus without surgery.
Probably the single greatest reason for fewer D and Cs is the option of in-office endometrial sampling (biopsy) that can be performed with a very thin plastic suction curette. This procedure is very quick and easy, and generally is only as painful as a bad menstrual cramp. If the patient is given some oral pain medications before the procedure, the cramps are minimal. Furthermore, the tissue sample obtained is in many instances as good as that achieved during a D and C surgery.
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Previous contributing medical author: Leon J. Baginski, MD, FACOG
"Patient information: Dilation and curettage (D and C) (Beyond the Basics)"
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