Dilation and curettage

Authors
Richard S Guido, MD
Dale W Stovall, MD Section Editor
William J Mann, Jr, MD Deputy Editor
Sandy J Falk, MD

Last literature review version 17.1: January 2009 | This topic last updated:
October 30, 2007 (More)

INTRODUCTION The gynecologist has a variety of tools available for

evaluation and treatment of women with abnormal uterine bleeding. Dilation
and curettage (D & C) will be reviewed here. Office procedures for endometrial
sampling are discussed separately. (See "Endometrial sampling procedures").
An overview of diagnostic approaches to endometrial evaluation, including both
noninvasive and invasive assessment, can also be found separately. (See
"Evaluation of the endometrium for malignant or premalignant disease").

INDICATIONS D & C has both diagnostic and therapeutic indications.

Diagnostic indications The development of equipment and techniques for

office based endometrial sampling has obviated the need for diagnostic D & C
in most patients. Numerous studies have shown that the endometrium is
adequately evaluated with sampling techniques. (See "Endometrial sampling
procedures").

However, there are still some indications for diagnostic D & C, such as in
women: With a nondiagnostic office biopsy who are at high risk of endometrial
carcinoma. (See "Endometrial cancer: clinical features, diagnosis, and
screening", section on Risk factors) With endometrial hyperplasia, and in whom
endometrial cancer needs to be excluded. (See "Endometrial hyperplasia") With
insufficient tissue for analysis on office biopsy. In whom cervical stenosis
prevents the completion of an office biopsy. For whom another operative
procedure, such as hysteroscopy or laparoscopy, is deemed necessary.

Diagnostic D & C should be done with hysteroscopy to obtain a visual image of

the endometrial cavity and to exclude focal disease. Hysteroscopy thus turns a
"blind" procedure into one allowing directed curettage. This helps to prevent
missing unsuspected polyps and insures that the most visibly abnormal areas
are sampled. (See "Overview of hysteroscopy").

Therapeutic indications Dilation and evacuation/curettage (D & EC) is used

as a therapeutic modality in the following clinical settings: Treatment of
incomplete, inevitable, missed, septic, and induced abortions. (See
"Spontaneous abortion: Risk factors, etiology, clinical manifestations, and
diagnostic evaluation" and see "Surgical termination of pregnancy: First
trimester"). Initial treatment of molar pregnancies. (See "Malignant gestational
trophoblastic disease: Staging and treatment"). Temporary management of
women with prolonged or excessive vaginal bleeding unresponsive to hormonal
therapy. (See "Menorrhagia", section on Dilation and curettage). Suction
curettage (without dilation) may be used to manage postpartum hemorrhage
due to retained products of conception. (See "Causes and treatment of
postpartum hemorrhage")

CONTRAINDICATIONS The only major contraindication to D & C is viable and

desired intrauterine pregnancy. Bleeding diathesis is a relative contraindication
since bleeding may be excessive in such patients. The management of these
patients, including possibly temporarily withholding anticoagulants, needs to
be decided on a case by case basis in consultation with the patient's other
physicians. In the presence of acute vaginal, cervical, or pelvic infection, the
procedure should be deferred, if possible, until the infection has been treated.
One exception is therapeutic D & C to remove infected products of conception.
Cervical cancer, if obstructing the endocervical canal, also represents a
contraindication as heavy bleeding or perforation may occur. In these patients
cervical biopsy would be diagnostic and D & C would be unnecessary.

PREOPERATIVE PREPARATION D & C is generally performed under general or

regional anesthesia; therefore, the patient should limit oral intake prior to the
procedure. The American Society of Anesthesiologists recommends no intake of
clear liquids in the two hours before and no solid food in the six hours before
procedures involving anesthesia (eight hours in pregnant women) [1] . An
empty stomach is also desirable for patients who plan paracervical block
anesthesia in case the block is inadequate and another anesthetic or sedative
needs to be administered.

Prophylactic antibiotics are not necessary.

Preoperative laboratory tests are generally not necessary, except as indicated

by the patient's age and medical condition. (See "Preoperative medical
evaluation of the healthy patient", section on Routine laboratory evaluation).

ANESTHESIA General, regional, or paracervical block anesthesia can be used.

The type of anesthesia chosen depends upon the indication for the procedure,
as well as the medical history of the woman. General anesthesia provides
complete muscular relaxation, which is important when examination under
anesthesia is a critical element of the procedure. Regional anesthesia provides
adequate muscular blockade without the pulmonary and gastrointestinal risks
of general anesthesia.

Paracervical block with intravenous conscious sedation is a convenient,

inexpensive, and effective technique amenable to the outpatient setting (show
figure 1). The block anesthetizes uterine nerves as they pass through
Frankenhauser's plexus in the cervix. Chloroprocaine 1 percent (Nesacaine)
provides an improved margin of safety over lidocaine because it is rapidly
metabolized and theoretically has a lower risk of toxicity if an inadvertent
intravascular injection occurs. (See "Intravenous conscious sedation for
gynecologic procedures" and see "Overview of pregnancy termination", section
on Paracervical block).

There have been a number of randomized controlled trials comparing the

analgesic effects of intrauterine instillation of anesthetics (eg, 3 to 5 mL of 2

percent lidocaine or 2 percent mepivacaine) versus placebo. Although about

half of the trials showed that topical anesthesia significantly reduced the
patient's perception of pain during an intrauterine procedure [2-7] , the other
half did not [8-12] .

PROCEDURE

General issues A D & C is performed with the woman in the dorsal lithotomy
position. Care must be taken to avoid over-abduction of the hip joint when
placing her in stirrups. Furthermore, the lateral aspect of the legs should not
rest against the stirrups as this can cause peroneal nerve injury with
subsequent foot-drop. (See "Neuropathies associated with gynecological
surgery").

An examination under anesthesia is performed first. (See "Pelvic examination

under anesthesia"). The size, shape, and position of the uterus are noted, with
particular attention to the axis of the cervix and flexion of the fundus.
Appreciation of the latter is critical to reduce the incidence of uterine
perforation. The size, shape, and consistency of the adnexa are determined
next.

After the examination, the perineum, vagina, and cervix are cleansed with an
aseptic solution and drapes are placed; it is not necessary to shave vulvar hair.

Exposure Vaginal retractors or a speculum is inserted into the vagina to

provide exposure. The type of vaginal retraction required for adequate
exposure depends upon the woman's body habitus and the procedure being
performed. The Graves speculum provides adequate exposure of the cervix and
is well-suited for women undergoing a therapeutic D & EC.

When a hysteroscopy is being performed in conjunction with the D & C, a sideopen Graves speculum provides a maximum range of motion to the
hysteroscope during the examination and is easily removed. Alternatively, a
Sims retractor or an Auvard weighted speculum (show figure 2) can be used in
conjunction with Schieden vaginal side wall retractors (show figure 3). (See
"Surgical instruments for gynecologic surgery").

Tenaculum A tenaculum is generally used to grasp the anterior lip of the

cervix (show figure 4). The single tooth tenaculum is useful in women with a
small amount of cervical tissue (eg, postmenopausal women, women who have
undergone previous cone biopsy); however, this instrument is more likely to
cause a laceration of the cervix. We prefer the Bierer (multi-toothed) tenaculum
because it is less traumatic. Ring forceps may also be used to grasp the cervix,
particularly in the pregnant patient in whom the soft, engorged cervix is prone
to laceration and hemorrhage. In some patients, such as women with a
lacerated or torn anterior lip, it will be necessary to attach the tenaculum to the
posterior cervical lip.

Endocervical curettage If indicated, an endocervical curettage (ECC) is

performed before dilation of the cervix to avoid contamination of the histologic
specimen with endometrial cells. A Kevorkian-Younge curette is introduced into
the cervical canal up to the internal os (show figure 5). This instrument is
slightly curved and narrow to accommodate the small endocervical canal. All
four quadrants of the canal are scraped and the specimen placed on a pad (eg,
Telfa).

The ECC is performed to detect the presence of endometrial carcinoma

extending into the cervical canal or the presence of endocervical pathology.
The clinical usefulness of the ECC has been questioned. It is predictive of
cervical involvement of endometrial carcinoma when the histology
demonstrates stromal involvement. However, numerous investigators have
demonstrated a false-positive rate of 80 percent when tumor is detected on
ECC alone [13] . Since surgical staging of endometrial carcinoma does not
require a separate ECC, the need for an ECC is only relevant for patients who
cannot undergo a full staging procedure. If there is a clinical indication for D &
C at the time of a cervical conization, the conization should be performed prior
to the D & C to preserve cervical architecture. (See "Endometrial cancer:
clinical features, diagnosis, and screening").

Sounding Traction is applied to the tenaculum to align the axis of the cervix
and the uterine canal. The uterus is sounded to document the size and confirm
the position. The sound is held between the thumb and the index finger to
avoid application of excessive pressure. In some cases, dilation of the cervix
may be required before sounding the uterus. A normal uterus sounds to 8 to 9
cm.

The pregnant uterus, however, should never be sounded because there is a

high risk of uterine perforation.

Cervical dilation After sounding the uterus, the cervix is dilated. The most
common dilators are the Pratt and Hegar (show figure 6). The Pratt dilator
comes in sizes ranging from 13 to 43 French; each French unit is equivalent to
0.33 mm in diameter. It is characterized by a gradual taper at the end of the
instrument. By comparison, Hegar dilators have a blunt end and come in sizes
ranging from 1 to 26 mm in diameter. We prefer the tapered end of the Pratt
dilator to the Hegar dilator. The former has been shown to require less force for
dilation and is less likely to cause a perforation of the uterus [14] .

The dilator is grasped in the middle of the instrument with the thumb and index
finger (show figure 7). The cervix is gradually dilated beginning with the #13
French Pratt dilator. The dilator should be inserted through the internal os,
without entering the uterine cavity excessively. This is helpful in preventing
uterine perforation and avoids damage to the endometrium, which obscures
optimal visualization if hysteroscopic examination is also planned.

The degree of cervical dilation is dependent upon the indication for the
procedure. When diagnostic hysteroscopy and D & C are performed, the
dilation is conducted to a point at which the hysteroscope may be comfortably
inserted. The #17 French Pratt dilator will easily accommodate a 5 mm
hysteroscope or a #3 sharp curette.

When products of conception are to be removed, the cervix is generally dilated

to a diameter in millimeters equal to the gestational age of the uterus. Dilation
is easily accomplished up to 9 mm, at which time the cervix may become
difficult to dilate [15] . When cervical dilation beyond 9.0 mm is required (eg,
second trimester pregnancy termination or operative hysteroscopy), osmotic
dilators should be placed preoperatively to allow gradual, atraumatic cervical
dilatation. (See "Overview of pregnancy termination", section on Osmotic
dilators).

Cervical ripening agents (prostaglandins, mifepristone) have been used to

soften the cervix prior to dilation in pregnant women, but are not useful in
nonpregnant women [16] .

Complicated cases A stenotic cervical os if often present in postmenopausal

patients and sometimes in women who have had previous cervical surgery.
Stenosis increases the risk of cervical laceration and uterine perforation;
therefore, these women are best dilated beginning with a series of small (1 to 4
mm) Hegar dilators.

Transabdominal ultrasound can be useful in guiding a difficult dilation and may

be prudent in women with a previous perforation of the uterus [17] . Lacrimal
duct probes may also help identify the cervical axis. This technique is
especially useful in completing a D & C if a perforation is suspected or if there
is a question as to the adequacy of the evacuation. Rarely it may be necessary
to perform a conization to open the cervical canal.

Curettage

Curettes Metal curettes are available in blunt and sharp styles, ranging in
size from #1 to #6, with 1 being the smallest (show figure 8). The curette is
malleable, which allows the instrument to be bent slightly to conform to the
ante- or retro-flexed uterus.

Sharp curettes are typically used for gynecologic procedures, including first
trimester pregnancy termination. The blunt curette is best suited for the
removal of small fragments of retained products of conception in the second
trimester and postpartum uterus, and is often used after suction curettage. The
blunt edge prevents excessive removal of the basalis layer of the
endometrium, which can occur in the soft postpartum uterus and lead to
formation of intrauterine adhesions (see "Intrauterine adhesions" below).

Plastic suction curettes are used for initial removal of products of conception
from the uterus. Some surgeons also prefer the suction curette for diagnostic
curettage [18] . Suction curettes range in size from 2 to 16 mm in diameter.
Curettes 6 mm are flexible while the larger curettes are rigid (show figure 9).

We prefer 6 to 8 mm curettes when performing suction curettage in a small

uterus (less than 8 week size). When a larger rigid suction curette is used, the
curved instrument provides better tactile sensation compared to the straight
curette.

Sharp curettage Curettage is performed systematically beginning at the

fundus. Even pressure is applied to the endometrial surface along the entire
length of the uterus from the fundus to the internal cervical os (show figure
10). The endometrial tissue is deposited on a Telfa pad, which should be placed
in the vagina to catch any spillage. The entire surface of the endometrium is
sampled by moving around the uterus in a consistent and systematic fashion.

The curettage procedure is completed when the "uterine cry" (grittiness to

palpation) is appreciated on all surfaces of the uterus. The size and shape of
any submucous fibroids detected by tactile sensation should be noted as part
of the operative note. Curettage followed by blind extraction with Randall polyp
forceps (show figure 5) improves the rate of detection of polyps over curettage
alone [19] .

A study evaluating the surface area sampled in 50 patients undergoing

prehysterectomy D & C found that less than one-fourth of the cavity had been
curetted in 16 percent of specimens; less than one-half of the cavity had been
curetted in 60 percent; and less than three-quarters of the cavity had been
effectively curetted in 84 percent [20] . Despite these limitations, D & C
provides adequate sensitivity for detecting endometrial pathology because
pathologic conditions usually cover a large proportion of the surface area of the
endometrial cavity and are therefore detectable by sampling techniques. Focal
pathologic processes may, however, go undetected by any blind procedure.
(See "Evaluation of the endometrium for malignant or premalignant disease").

Suction curettage Diagnostic Suction curettage may be used for diagnostic

purposes. The preferred method uses the Pipelle device and is performed as an
office procedure, usually without anesthesia or cervical dilation. (See
"Endometrial sampling procedures").

The external cervical os is then checked for any evidence for excessive
bleeding. The tenaculum is removed and the cervix is examined for any

trauma. Bleeding from the tenaculum site generally responds to direct pressure
or the application of Monsel's solution. Occasionally a suture or cautery is
required. Pregnant uterus Suction curettage is typically used for the
evacuation of products of conception, such as for incomplete or missed
spontaneous abortion or for early pregnancy termination. (See "Surgical
termination of pregnancy: First trimester", section on Curettage).

Large bore plastic cannulas (12 to 16 mm) are used for second trimester
pregnancy termination or removal of retained placental fragments/membranes
postpartum. (See "Termination of pregnancy: Second trimester"). These
cannulas should not be inserted deeply into the pregnant or postpartum uterus
due to the risk of perforation. Placing a hand on the fundus of the uterus during
the procedure may help to decrease the risk of perforation when the uterus is
large and assists with assessment of the changing uterine size and position. For
the same reason, it is preferable to explore the uterus with a large curette
instead of narrower instruments, such as forceps or a small suction cannula.

The cannula is rotated 360 degrees around its long axis under vacuum
pressures of 50 to 60 cm Hg. As tissue is evacuated, the uterus will contract
and the suction curette may be advanced to the fundus. Rotation is continued
until no more tissue is drawn into the cannula. Oxytocin is usually begun as
soon as the suction curettage is started and continued for one or more hours
postoperatively. A few passes with a large blunt curette (eg, banjo curette) can
be performed after the suction procedure to remove any remaining products of
conception. Gestational trophoblastic neoplasia There are additional
technical aspects of curettage in this setting. (See "Gestational trophoblastic
disease: Management of hydatidiform mole", section on Procedure).

COMPLICATIONS Complications are rare and include: Anesthesia related

complications Hemorrhage Uterine perforation Infection Formations of
intrauterine adhesions Trophoblast embolization (if gestational trophoblastic
disease present)

Uterine perforation Perforation of the uterus at the time of D & C is the most
common immediate complication. The rate of perforation varies with the
indication for the procedure. Perforation is most common when attempting
control of postpartum hemorrhage (5.1 percent), and is less frequent during
diagnostic curettage (0.3 percent in the premenopausal patient and 2.6 percent

in the postmenopausal patient) [21] . The risk of perforation is increased in

pregnancy due to softening of the uterine wall and the increased size of the
endometrial cavity.

Perforation of the uterus should be suspected when there is a loss of resistance

during instrumentation of the uterus or when an instrument is found to extend
into the uterine cavity for a distance that is greater than the known depth of
the uterus. Severe vaginal bleeding may be a sign of a perforation, especially if
the lateral aspect of the uterus is perforated and the uterine vessels are
lacerated. Occult retroperitoneal or intraabdominal hemorrhage can also occur,
with perioperative hypotension the first sign of a complication. The diagnosis of
perforation is occasionally made when abdominal viscera are brought through a
perforation and visualized in the vagina.

The most frequent site of uterine perforation is the fundus (30 to 50 percent of
cases). Less frequently, the anterior or posterior wall of the uterus is
perforated. Fortunately, the lateral wall of the uterus is perforated in less than
5 percent of cases since perforations in this region can produce profound
hemorrhage. The uterine sound and sharp curette are the most common
instruments producing a perforation; however, perforations may also be caused
by suction curettes, cervical dilators, or any other instrument placed in the
uterus.

Management depends upon the clinical setting. Fundal perforations that are
recognized during sounding of the uterus or during cervical dilation rarely
produce significant hemorrhage or visceral trauma; therefore, they can be
managed with observation and serial hemoglobin measurements. Perforation in
other areas of the uterus or with other instruments are more likely to be
associated with hemorrhage or visceral (bowel, bladder) injury. Laparoscopy
provides an elegant means of assessing for potential intraabdominal problems.
Management of these perforations is discussed in detail separately. (See
"Overview of pregnancy termination", section on Uterine perforation).

Cervical injury Cervical injuries can arise as a direct result of dilation or from
trauma during curettage. Cervical lacerations frequently occur when excessive
traction is applied to the tenaculum. The single tooth tenaculum is particularly
vulnerable to such injuries, therefore, we prefer the Bierer tenaculum.

Lacerations can be managed with direct pressure, application of Monsel's

solution, cautery, or, in severe cases, suture control. Lacerations that involve
the cervical branch of the uterine artery can produce extensive hemorrhage
that may be controlled with direct suture application, by placing hemostatic
sutures at the internal os, or therapeutic embolization. Rarely, hysterectomy is
required to control bleeding [22] . (See "Interventional radiology in
management of obstetrical and gynecological disorders").

The risk of cervical injury can be reduced by avoiding use of excessive force
during dilation. The Pratt dilators generally require less force to insert into the
cervix than Hegar dilators. Osmotic dilators are helpful in decreasing the force
required to dilate the cervix and are useful when dilation of 9 mm or greater
are anticipated. (See "Overview of pregnancy termination", section on Osmotic
dilators).

Infection Infection after dilation and curettage is rare. Although bacteremia

has been demonstrated in 5 percent of D & Cs, the incidence of septicemia is
very low [23] . Very little is known about risk factors for infection in patients
undergoing D & C for diagnostic purposes. In one study, the use of a rigid
versus flexible cannula, general versus local anesthesia, and resident versus
attending physician were all associated with an increased risk of febrile
morbidity [24] .

No data support the routine use of prophylactic antibiotics in diagnostic D & C,

nor is subacute bacterial endocarditis (SBE) prophylaxis recommended for a
routine diagnostic D & C [25] . (See "Antimicrobial prophylaxis for bacterial
endocarditis").

Intrauterine adhesions Asherman's syndrome refers to the presence of

intrauterine adhesions that typically result from endometrial damage due to
uterine surgery, especially after curettage. Most, if not all, cases of Asherman
syndrome arise from curettage performed on the pregnant uterus. In one large
series of women with intrauterine adhesions, the underlying etiology was
related to curettage for incomplete abortion (50 percent), postpartum bleeding
(24 percent), elective abortion (18 percent), missed abortion (6 percent), or
hydatidiform mole (2 percent) [26] . The remaining 2 percent of patients had
various other etiologies.

Curettage of the endometrium, especially within the first four weeks

postpartum, can result in trauma to the basalis layer with subsequent granular
tissue healing on opposing surfaces of the uterus, which eventually fuse to
produce tissue bridges. These intrauterine adhesions range from filmy
adhesions composed of endometrial tissue to dense adhesions consisting
entirely of connective tissue. The resulting adherence of the uterine walls, with
partial or complete obliteration of the uterine cavity, accounts for the
menstrual abnormalities, frequent dysmenorrhea, infertility, and habitual
abortion.

Asherman syndrome is typically diagnosed by either hysterosalpingogram

(HSG) or hysteroscopy. The combination of the two techniques is helpful since
HSG shows the location and extent of the adhesions, while hysteroscopy
provides information as to their character. Before the widespread use of
hysteroscopy, careful D & C of the uterus followed by the placement of an
intrauterine Foley catheter along with estrogen therapy had been the mainstay
of therapy. Current therapy for Asherman syndrome includes hysteroscopic
resection of the adhesions under direct visualization followed by long-term
estrogen administration to stimulate regrowth of endometrial tissue [27] . (See
"Overview of hysteroscopy", section on Lysis of adhesions).

Trophoblastic embolization A rare complication of D & C of a molar

pregnancy is embolization of trophoblastic tissue into the systemic circulation
[28] . Fatalities from cardiovascular collapse due to trophoblastic embolization
have been described [29] . Thyroid storm is also encountered rarely. For these
reasons, D & C for trophoblastic disease should be performed in a formal
operating room, with full anesthesia support and patient monitoring available.
(See "Malignant gestational trophoblastic disease: Staging and treatment").

POSTOPERATIVE CARE AND FOLLOW-UP Patients may resume normal

activities as soon as the effects of anesthesia have worn off and they are
comfortable.

Cramps are the most common side effect. They usually rapidly subside after
the procedure, but may last for a day or two. Nonsteroidal antiinflammatory
drugs provide adequate analgesia.

Light bleeding can persist for several days. Heavy bleeding, such as saturating
a sanitary pad within one hour more than once, is abnormal.

The patient should call her provider if she develops fever (more than 100.4F),
cramps lasting longer than 48 hours, increasing pain, prolonged or heavy
bleeding, or a foul-smelling vaginal discharge.

Follow-up of patients with gestational trophoblastic disease is discussed

separately. (See "Malignant gestational trophoblastic disease: Staging and
treatment").

INFORMATION FOR PATIENTS Educational materials on this topic are available

for patients. (See "Patient information: Dilation and curettage (D & C)"). We
encourage you to print or e-mail this topic review, or to refer patients to our
public web site, www.uptodate.com/patients, which includes this and other
topics.

SUMMARY AND RECOMMENDATIONS Office based endometrial sampling,

whenever feasible, is recommended over dilation and curettage for diagnosis of
abnormal uterine bleeding. (See "Indications" above). If use of a large curette is
planned, osmotic, rather than mechanical, cervical dilators are recommended
for cervical dilation greater than 9 mm. (See "Cervical dilation" above)
Sounding the pregnant uterus is not recommended because there is a high risk
of uterine perforation. (See "Sounding" above). In general, suction and blunt
curettes are recommended for use in the pregnant or postpartum uterus as
they are less likely to cause uterine perforation or intrauterine adhesions.
Traditionally, sharp curettes are used in nonpregnant women, but suction or
blunt curettes are also acceptable. Endometrial pathology usually covers a
large proportion of the surface area of the endometrial cavity and is therefore
detectable by any of these sampling techniques, which have not been directly
compared in randomized trials. Focal pathologic processes may, however, go
undetected by any blind procedure. (See "Curettage" above). Perforation of the
fundus of the uterus is the most common immediate complication. It should be
suspected when there is a loss of resistance during instrumentation of the
uterus, when an instrument is found to extend into the uterine cavity for a
distance that is greater than the known depth of the uterus, or, obviously, if
heavy bleeding or viscera are observed in the vagina. Laparoscopy or
laparotomy is often necessary to look for and repair visceral or vascular injuries

and to allow completion of the procedure under direct vision. (See "Uterine
perforation" above). The blunt curette is recommended for use in the pregnant
and postpartum uterus. The blunt edge prevents excessive removal of the
basalis layer of the endometrium, which can lead to formation of intrauterine
adhesions. (See "Curettes" above and see "Intrauterine adhesions" above).

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