شنبه سیزدهم مرداد 1386
Patient information: Dilation and curettage (D&C)
Richard S Guido, MD
Dale W Stovall, MD
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.1 is current through December 2006; this topic was last changed on September 12, 2006. The next version of UpToDate (15.2) will be released in June 2007.
INTRODUCTION — Dilation and curettage (D&C) is a procedure in which material from the inside of the uterus is removed. The "dilation" refers to dilation of the cervix, the lower part of the uterus that opens into the vagina (show figure 1). "Curettage" refers to the scraping or removal of tissue lining the uterine cavity (endometrium) with a surgical instrument called a curette. Some curettes are sharp while others use suction.
REASONS FOR DC — There are a number of reasons a D&C might be performed. In some cases, the procedure is used to gain information about the uterus to diagnose a medical condition (called diagnostic D&C). In other cases, the procedure is used to treat a medical problem or condition (called therapeutic D&C).
Diagnostic DC — The primary reason for a diagnostic D&C is to obtain samples of the endometrium to evaluate abnormal uterine bleeding or abnormal cells found during routine screening for cervical cancer. (See "Patient information: Abnormal Pap smear").
In most cases, a healthcare provider will try to obtain a tissue sample with an office procedure called endometrial biopsy. In some cases, endometrial biopsy is not possible or insufficient tissue is obtained. When this occurs, D&C must be done to obtain an adequate tissue sample.
Diagnostic D&C is usually done with hysteroscopy; this involves dilating the cervix and inserting a small instrument that allows the physician to examine and photograph the inside of the uterus. The images are displayed on a monitor, allowing the physician to visualize the endometrium. This helps the physician to avoid missing small polyps and ensures that the most visibly abnormal areas are sampled. (See "Patient information: Abnormal uterine bleeding").
Examination of the endometrial tissue by a pathologist can help establish certain diagnoses, including endometrial (uterine) cancer, endometrial polyps, or precancerous conditions of the lining of the uterus (endometrial hyperplasia).
Therapeutic DC — Therapeutic D&C is done to remove the contents of the uterus in the following circumstances:
Miscarriage — In some miscarriages, the tissues from a pregnancy are passed completely. In other cases, a D&C is needed to remove this tissue or to ensure that all of it has been passed. (See "Patient information: Miscarriage").
Abortion — A D&C can be done to remove the contents of the uterus when a woman chooses to end a pregnancy.
Treatment of molar pregnancies — A molar pregnancy occurs when a tumor forms in place of normal pregnancy placenta. It is often treated with a D&C.
Prolonged or excessive vaginal bleeding — D&C may be done as a treatment in some cases of prolonged or excessive bleeding that do not respond to medical treatment. (See "Patient information: Abnormal uterine bleeding").
Postpartum hemorrhage — Curettage may be done to manage excessive bleeding after delivery of an infant (postpartum hemorrhage).
PREPARING FOR DC — Some patients will need to have blood testing before D&C (such as a blood count), although this is not always necessary. Patients should not eat or drink anything before the procedure. All patients will need someone to accompany them home because it will not be safe to drive after receiving anesthesia, which causes sedation.
Some patients will need to have a device or medication placed in the cervix the day before their procedure. The purpose is to safely and gradually enlarge the cervical opening, reducing the risk of cervical injury. Devices are used when the cervix must be dilated to a larger size than is typically needed for D&C, such as with pregnancy terminations and some types of hysteroscopy. Some patients will be instructed to insert a medicine in the vagina to soften the cervix prior to the procedure.
After arriving for the procedure, a nurse may place an intravenous (IV) line, which can be used to give fluids and medicine before, during, and after the procedure. The nurse or doctor will review the patient's medical history, list of medications used, and any drug allergies.
PROCEDURE — D&C can be performed in an operating room in a hospital or clinic. Many patients have a D&C performed in an outpatient setting. A woman's blood pressure, pulse, and blood oxygen levels are monitored during the procedure. The procedure takes 15 to 30 minutes to complete.
Anesthesia — The procedure can be done using general, regional, or local (paracervical) block anesthesia. The type of anesthesia chosen depends upon the reason for the procedure as well as the medical history.
General anesthesia — General anesthesia induces sleep and completely relaxes the muscles, which makes it easier for the doctor to perform a pelvic examination.
Regional anesthesia — Reginonal anesthesia uses an injection of an anesthetic into the area around the spinal cord to block pain sensation during surgery. The patient may be sedated with medicine given through an intravenous (IV) line.
Paracervical block — Anesthetic agents are injected directly into and around the cervix, numbing the area. The woman is given a sedative through an intravenous (IV) line.
POST-PROCEDURE CARE — After the procedure, the patient will be cared for in a recovery or post-anesthesia care unit for a few hours. This is necessary to monitor for excessive vaginal bleeding or other complications, and allows time for recovery from the anesthesia. Patients who received general anesthesia occasionally have nausea and vomiting, which can be treated with medications.
Most patients should be able to resume their regular activities within a day or two. Mild cramping and spotting may occur for a few hours or days; cramping can be treated with nonsteroidal antiinflammatory medications such as ibuprofen (Advil®, Motrin®). Patients should not put anything into the vagina (tampons, douches) during this time and should ask when they can safely have sexual intercourse. The next menstrual period usually occurs within 4 to 6 weeks of the procedure.
A woman should call her physician if she develops fever (temperature greater than 100.4º F), cramps lasting longer than 48 hours, increasing rather than decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.
COMPLICATIONS — D&C is a commonly performed procedure that is usually very safe. Yet as with any operation, complications occur. Complications of D&C can include:
Uterine perforation — Uterine perforation occurs when one of the surgical instruments makes a hole in the uterus. It is more common when the procedure is done during pregnancy due to softening of the uterine wall.
Fortunately, most uterine perforations heal on their own and do not require any treatment. Two potential problems caused by perforation are bleeding from injury to a blood vessel and injury to other internal organs. A second procedure may be needed to repair these types of injury.
Cervical injury — Injuries to the cervix can occur during dilation or from trauma related to the curettage. Lacerations (cuts) to the cervix are managed with pressure to the area, application of medications that help stop bleeding, or in some cases, stitches in the cervix.
Infection — Infection from D&C is rare.
Intrauterine adhesions — Adhesions (areas of scar tissue) can sometimes form in the uterus following D&C. Adhesion is most common when D&C is performed postpartum or postabortion. In some cases, this can lead to abnormalities in the menstrual cycle, painful menstrual cycles, infertility, or miscarriage. If adhesions are extensive, a woman can be treated with hormones to encourage growth of healthy uterine tissue and the scar tissue can be removed with a surgical procedure.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
The Mayo Clinic
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, May 2002.
2. Chen, SS, Lee, L. Reappraisal of endocervical curettage in predicting cervical involvement by endometrial carcinoma. J Reprod Med 1986; 31:50.
3. Gebauer, G, Hafner, A, Siebzehnrubl, E, Lang, N. Role of hysteroscopy in detection and extraction of endometrial polyps: results of a prospective study. Am J Obstet Gynecol 2001; 184:59.
Normal female reproductive anatomy
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