ilation and curettage (D&C) is a brief surgical procedure in which thecervix is dilated and

a special instrument is used to scrape the uterine lining. Knowing what to expect before,
during, and after a D&C may help ease your worries and make the process go more
smoothly. Here's what you need to know.
Reasons for a D&C
You may need a D&C for one of several reasons. It's done to:

Remove tissue in the uterus during or after a miscarriage or abortionor to

remove small pieces of placenta after childbirth. This helps prevent infection or heavy
bleeding.

Diagnose or treat abnormal uterine bleeding. A D&C may help diagnose or

treat growths such as fibroids, polyps, or endometriosis, hormonal imbalances,
or uterine cancer. A sample of uterine tissue is viewed under a microscope to check for
abnormal cells.
What to Expect When Having a D&C
You can have a D&C in your doctor's office, an outpatient clinic, or the hospital. It
usually takes only 10 to 15 minutes, but you may stay in the office, clinic, or hospital for
up to five hours.
Before a D&C, you will have a complete history taken and sign a consent form. Ask
your doctor any questions you have about the D&C. Be sure to tell the doctor if:

You suspect you are pregnant.

You are sensitive or allergic to any medications, iodine, or latex.

You have a history of bleeding disorders or are taking any blood-thinning drugs.

You will receive anesthesia, which your doctor will discuss with you. The type you have
depends on the procedure you need.

If you have general anesthesia, you will not be awake during the procedure.

If you have spinal or epidural (regional) anesthesia, you will not have feeling from
the waist down.

If you have local anesthesia, you will be awake and the area around you cervix
will be numbed.
Before the D&C, you may need to remove clothing, put on a gown, and empty
your bladder.
During a D&C, you lie on your back and place your legs in stirrups like during a pelvic
exam. Then the doctor inserts a speculum into the vaginaand holds the cervix in place
with a clamp. Although the D&C involves no stitches or cuts, the doctor cleanses the
cervix with an antiseptic solution.
What to Expect When Having a D&C continued...
A D&C involves two main steps:

Dilation involves widening the opening of the lower part of the uterus (the cervix)
to allow insertion of an instrument. The doctor may insert a slender rod (laminaria) into
the opening to gradually cause it to widen. Or medication may soften the cervix to help it
widen.

Curettage involves scraping the lining and removing uterine contents with a long,
spoon-shaped instrument (a curette). The doctor may also use a cannula to suction any
remaining contents from the uterus. This can cause some cramping. In many cases, a
tissue sample goes to a lab for examination.

Sometimes other procedures are performed along with a D&C. For example, your
doctor may insert a slender device to view the inside of the uterus
(called hysteroscopy).
After a D&C, there are possible side effects and risks. Common side effects include:

Cramping

Spotting or light bleeding

Complications such as a damaged cervix and perforated uterus or bowel are rare. But
be sure to contact your doctor if you have any of the following symptoms after a D&C:

Heavy or prolonged bleeding or blood clots

Fever

Pain

Abdominal tenderness

Foul-smelling discharge from the vagina

In very rare cases, scar tissue (adhesions) may form inside the uterus. Called
Asherman's syndrome, this may cause infertility and changes in menstrual flow. Surgery
can repair this problem, so be sure to report any menstrual flow changes after a D&C.
Recovery After a D&C
After a D&C, you will need someone to take you home. If you had general anesthesia,
you may feel groggy for a while and have some briefnausea and vomiting. You can
return to regular activities within one or two days. In the meantime, ask your doctor
about any needed restrictions. You may also have mild cramping and light spotting for a
few days. This is normal. You may want to wear a sanitary pad for spotting and take
pain relievers for pain.

You can expect a change in the timing of your next menstrual period. It may come either
early or late. To prevent bacteria from entering your uterus, delay sex and use of
tampons until your doctor says it's OK.
See your doctor for a follow-up visit and schedule any further treatment that's needed. If
any tissue was sent for a biopsy, ask your doctor when to expect results. They are
usually available within several days.
WebMD Medical Reference
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Reviewed by Kecia Gaither, MD, MPH on October 03, 2014
2014 WebMD, LLC. All rights reserved.

Dilation and curettage (D&C) is a procedure to remove tissue from inside your uterus.
Doctors perform dilation and curettage to diagnose and treat certain uterine conditions
such as heavy bleeding or to clear the uterine lining after a miscarriage or
abortion.

In a dilation and curettage sometimes spelled "dilatation" and curettage your

doctor uses small instruments or a medication to open (dilate) your cervix the lower,
narrow part of your uterus. Your doctor then uses a surgical instrument called a curette
to remove uterine tissue. Curettes used in a D&C can be sharp or use suction.
Why it's done
By Mayo Clinic Staff
Dilation and curettage can diagnose or treat a uterine condition.
To diagnose a condition
Your doctor might recommend a D&C to diagnose a condition if:

You have abnormal uterine bleeding

You experience bleeding after menopause

Your doctor discovers abnormal endometrial cells during a routine test for
cervical cancer

To perform the test, your doctor collects a tissue sample from the lining of your uterus
(endometrium) and sends the sample to a lab for testing. The test can check for:

Uterine cancer

Uterine polyps

Endometrial hyperplasia a precancerous condition in which the uterine lining

becomes too thick

To treat a condition
When performing a therapeutic D&C, your doctor removes the entire contents of your
uterus, not just a small tissue sample. Your doctor can do this to:

Remove a molar pregnancy, in which a tumor forms instead of a normal

pregnancy

Treat excessive bleeding after delivery by clearing out any placenta that remains
in the uterus

Remove cervical or uterine polyps, which are usually benign

Remove fibroid tumors, which are benign tumors formed on the uterine wall that
sometimes bulge into the uterine cavity

Clear out any tissue that remains in the uterus after a miscarriage or abortion to
prevent infection or heavy bleeding

Your doctor may perform the D&C along with another procedure called a hysteroscopy.
During a hysteroscopy, your doctor inserts a slim instrument with a light and camera on
the end into your vagina, through your cervix and up into your uterus. Your doctor then
views the lining of your uterus on a screen, noting any areas that look abnormal, making
sure there aren't any polyps, and taking tissue samples as needed. During
hysteroscopy, your doctor can also remove uterine polyps and fibroid tumors.
Dilation and curettage is usually very safe, and complications are rare. However, there
are risks. These include:

Perforation of the uterus. Perforation of the uterus occurs when a surgical

instrument pokes a hole in the uterus. This happens more often in women who
were recently pregnant and in women who have gone through menopause. Most
perforations heal on their own. However, if a blood vessel or other organ is
damaged, a second procedure may be necessary to repair it.

Damage to the cervix. If the cervix is torn during the D&C, your doctor can apply
pressure or medicine to stop the bleeding, or can close the wound with stitches
(sutures).

Scar tissue on the uterine wall. Rarely, a D&C results in development of scar
tissue in the uterus, a condition known as Asherman's syndrome. Asherman's
syndrome happens most often when the D&C is done after a miscarriage or
delivery. This can lead to abnormal, absent or painful menstrual cycles, future
miscarriages and infertility.

Infection. Infection after a D&C is possible, but rare.

Contact your doctor if you experience any of the following after a D&C:

Bleeding that's heavy enough that you need to change pads every hour

Light bleeding that lasts longer than two weeks

Fever

Cramps lasting more than 48 hours

Pain that gets worse instead of better

Foul-smelling discharge from the vagina

Dilation and curettage may be performed in a hospital, clinic or your doctor's office, and
it's usually done as an outpatient procedure.
Before the procedure:

Follow your doctor's instructions on limiting food and drink.

Arrange for someone to help you get home because you may be drowsy after the
anesthesia wears off.

Clear your schedule to allow enough time for the procedure and recovery
afterward. You'll likely spend a few hours in recovery after the procedure.

You should be able to resume your normal activities within a day or two.
In some cases, your doctor may start the process of dilating your cervix a few hours or
even a day before the procedure. This helps your cervix open gradually and is usually
done when your cervix needs to be dilated more than in a standard D&C, such as
during pregnancy terminations or with certain types of hysteroscopy.
To promote dilation, your doctor uses a medication called misoprostol (Cytotec) given
orally or vaginally to soften the cervix or inserts a slender rod made of laminaria into
your cervix. The laminaria gradually expands by absorbing the fluid in your cervix,
causing your cervix to open.

During the procedure

Multimedia

Dilation and curettage

For dilation and curettage, you receive anesthesia. General anesthesia makes you
unconscious and unable to feel pain. Other forms of anesthesia provide light sedation or
use injections to numb only a small area (local anesthesia) or a larger region (regional
anesthesia) of your body. The choice of anesthesia depends on the reason for the D&C
and your medical history.
During the procedure:

You lie on your back on an exam table while your heels rest in supports called
stirrups.

Your doctor inserts an instrument called a speculum into your vagina, as during a
Pap test, in order to see your cervix.

Your doctor inserts a series of thicker and thicker rods into your cervix to slowly
dilate your cervix until it's adequately opened.

Your doctor removes the dilation rods and inserts a spoon-shaped instrument
with a sharp edge or a suction device and removes uterine tissue.

Because you're either unconscious or sedated during D&C, you shouldn't feel any
discomfort. The procedure usually takes about 15 to 30 minutes.

After the procedure

You may spend a few hours in a recovery room after the D&C so that your doctor can
monitor you for heavy bleeding or other complications. This also gives you time to
recover from the effects of anesthesia.
If you had general anesthesia, you may become nauseated or vomit, or you might have
a sore throat if a tube was placed in your windpipe to help you breathe. With general
anesthesia or light sedation, you may also feel drowsy for several hours.
Normal side effects of a D&C may last a few days and include:

Mild cramping

Spotting or light bleeding

For discomfort from cramping, your doctor may suggest taking ibuprofen (Advil, Motrin
IB, others) or another medication.

Wait to put anything in your vagina until your cervix returns to normal to prevent bacteria
from entering your uterus, possibly causing an infection. Ask your doctor when you can
use tampons and resume sexual activity.
Your uterus must build a new lining after a D&C, so your next period may not come on
time. If you had a D&C because of a miscarriage, and you want to become pregnant,
talk with your doctor about when it's safe to start trying again.

Diagnostic dilation and curettage was originally intended to detect intrauterine endometrial abnormalities and assist in
the management of abnormal bleeding. Newer techniques are available to assess the uterine cavity and endometrial
findings.[1] However, dilation and curettage still has a role in centers where advanced technology is not available or
when other diagnostic modalities are unsuccessful.
Traditionally, dilation and curettage has been performed in a blind fashion. The procedure can be performed under
ultrasound guidance or in conjunction with visualization of the uterine cavity by a hysteroscope.

Indications
Diagnostic dilation and curettage is typically employed to assess endometrial histology. Fractional dilation and
curettage also includes assessment of the endocervix and biopsy of the ectocervix and transformation zone.
Indications for a diagnostic dilation and curettage include the following:

Abnormal uterine bleeding: irregular bleeding, menorrhagia, suspected malignant or premalignant condition
Retained material in the endometrial cavity
Evaluation of intracavitary findings from imaging procedures (abnormal endometrial appearance due to
suspected polyps or fibroids)
Evaluation and removal of retained fluid from the endometrial cavity (hematometra, pyometra) in conjunction
with evaluating the endometrial cavity and relieving cervical stenosis
Office endometrial biopsy insufficient for diagnosis or failed due to cervical stenosis
Endometrial sampling in conjunction with other procedures (eg, hysteroscopy, laparoscopy)

The evaluation of the uterine cavity by dilation and curettage may be helpful when an office technique, such as
ultrasound, is unable to fully elucidate the endometrium due to shadowing from leiomyomata, a pelvic mass, or loops
of bowel.
Several studies have evaluated the effectiveness of obtaining endometrial tissue by endometrial sampling versus
D&C. One study compared aspiration biopsy (Pipelle) with D&C. The D&C procedure was performed without
hysteroscopy. This sample of 673 women underwent hysterectomy following the endometrial sampling or curettage.
The concordance of results was 67% between endometrial biopsy and hysterectomy versus 70% between D&C
without hysteroscopy and hysterectomy. The negative predictive value was 98% for detection of malignancy. In their
conclusions, the authors recommended a presampling evaluation of the endometrium by a technique such as
transvaginal ultrasound.[2]
Another study of 366 women evaluated histopathologic findings obtained by hysteroscopically directed biopsies,
versus pathology results of tissue obtained at D&C. Concordance of results for the 2 procedures was 88.8%. In their
conclusions, the authors stated that although hysteroscopy with directed biopsy was adequate for obtaining diagnosis
from focal lesions, it may not be sufficient for diagnosis of all pathologic findings in the endometrium, including
hyperplasia. They recommended global endometrial sampling, such as by D&C, be included for more thorough
diagnosis.[3]
Dilation and curettage may also be a therapeutic procedure. Examples of this use include the following:

Removal of retained products of conception (eg, incomplete abortion, missed abortion, septic abortion,
induced pregnancy termination)
Suction procedures for management of uterine hemorrhage
Treatment and evaluation of gestational trophoblastic disease
Hemorrhage unresponsive to hormone therapy [1]
In conjunction with endometrial ablation for histologic evaluation of the endometrium

Contraindications
There are few contraindications to gentle office dilation and curettage, but a more vigorous examination may require
an operative suite with regional or general anesthesia. Paracervical block or intravenous sedation with an anesthesia
team standing by for assistance may also be an option. Intolerance to office examinations or procedures may
determine the setting for the procedure.
Absolute contraindications to dilation and curettage include the following:

Viable desired intrauterine pregnancy

Inability to visualize the cervical os
Obstructed vagina
Relative contraindications to dilation and curettage include the following:

Severe cervical stenosis

Cervical/uterine anomalies
Prior endometrial ablation
Bleeding disorder
Acute pelvic infection (except to remove infected endometrial contents)
Obstructing cervical lesion
These contraindications may be surmounted in some cases. For example, magnetic resonance imaging may define
the anatomy of the cervical or uterine anomaly, allowing safe exploration of the endocervix and endometrium.

Complications
Complications can occur at the time of diagnostic dilation and curettage. Careful performance of the procedure
should minimize these events. Possible complications include the following:

Bleeding or hemorrhage
Cervical laceration
Uterine perforation
Postprocedural infection
Postprocedural intrauterine synechiae (adhesions)
Anesthetic complications

Complications, particularly uterine perforation, may be increased in a patient with a recent pregnancy or gestational
trophoblastic disease, prior endometrial ablation, distorted anatomy, cervical stenosis, or current uterine infection.
Cervical Injury
Laceration of the cervix primarily occurs during traction, with a counterforce applied during dilation. It seems to occur
most frequently with use of a single-tooth tenaculum, especially when it is placed vertically on the lip of the cervix. A
Bierer multi-toothed tenaculum penetrates less deeply into the cervical tissue and transfers force over a greater area,
potentially decreasing the risk of laceration.
Lacerations are generally managed with an interrupted or running interlocking dissolvable suture. The same
technique would be applied for a laceration of the posterior cervical lip.
Placement of a tenaculum is not recommended at the lateral aspect of the cervix because of the location of the
cervical branches of the uterine artery.
The risk of laceration is reduced by reducing force at dilation, using more tapered Pratt dilators or osmotic preparation
before the procedure with laminaria or prostaglandin.
Uterine Perforation
Uterine perforation is one of the more common complications of dilation and curettage. Risks are increased when
dealing with a pregnant or recently postpartum uterus (5.1%) and are less frequent at the time of a dilation and
curettage remote from pregnancy (0.3% for premenopausal women and 2.6% for postmenopausal women).[4, 5, 6]
The instruments most commonly associated with uterine perforation are the uterine sound or dilators. If perforation is
known to have occurred with a blunt instrument, observation of vital and peritoneal signs for several hours is all that is
needed. If suspicion that a sharp instrument, such as a curette, has perforated the uterus or if the fat has been
retrieved by curettage, then intraabdominal injury must be excluded by laparoscopy. Active bleeding may necessitate
a laparotomy.
Infection
Infection related to diagnostic dilation and curettage is rare and is most likely when cervicitis is present at the time of
the procedure. One study of infections related to dilation and curettage documented a 5% incidence of bacteremia
following dilation and curettage with a very rare incidence of septicemia.
Prophylactic antibiotics are not recommended for any dilation and curettage, including for those women who
generally require subacute bacterial endocarditis prophylaxis.
Intrauterine Adhesions
Curettage after delivery or abortion may result in endometrial injury and subsequent development of intrauterine
adhesions, termed Asherman syndrome. The development of uterine synechiae may also be associated with prior
endometrial ablation procedures. Intrauterine adhesions may make future diagnostic curettage more difficult and
increase the risk of uterine perforation. Previous procedures such as endometrial ablation may also increase the risk
of cervical stenosis.
Trophoblastic Embolization
Embolization of trophoblastic tissue in the systemic circulation is a very rare complication of dilation and curettage for
removal of gestational trophoblastic disease. This event has been associated with thyroid storm, cardiovascular
collapse, and death. A diagnostic dilation and curettage in patients for whom gestational trophoblastic neoplasia is
suspected should be performed in an operating room with anesthesia.

Equipment
A Graves speculum may be used to visualize the cervix. Alternatively, a weighted speculum with one or more vaginal
retractors in the anterior and lateral vaginal fornices may be used. The latter arrangement or a Graves speculum with
an open side may be preferred if hysteroscopy is also planned. See the images below.

Graves speculum.

Side opening Graves and weighted speculum.

Several types of cervical dilators are commonly used. A dilator has a tapered end. Common dilator types include the
Pratt, Hegar, and Hank dilators. See the image below.

Hegar and Pratt dilators.

The Pratt dilator has the most gradual taper and ranges in size from 13 to 43 Fr. The tips of the Hegar and Hank
dilators are more blunt and may therefore require greater force to dilate the cervix. This could increase the risk of
cervical laceration or uterine perforation, particularly in a pregnant uterus or with an inelastic cervix.
Tissue is removed with a curette, as shown in the image below.

Sharp curettes.

The introduction of a Randall polyps forceps, as shown in the image below, may assist removal of pedunculated
structures such as polyps or myomas or remove portions of tissue loosened during the curettage. See the image
below.

Ring forceps, Randall forceps, and packing forceps.

Patient Preparation
Anesthesia
Office procedures may require no formal preoperative preparation if a need for cervical dilation is absent or minimal
and a small-caliber endometrial sampling device or suction device is employed.
Some providers suggest patients undergoing cervical or paracervical instillation of local anesthetic be instructed to
have an empty stomach. Manipulation of the cervix and placement of the curette may induce a vasovagal response
with secondary nausea and vomiting.
Patients may be instructed to abstain from oral intake of solid foods for 68 hours and oral intake of clear liquids for 2
or more hours, even in the office setting. A preoperative over-the-counter pain medication, such as a nonsteroidal
anti-inflammatory medication, may be taken with a sip of water at home prior to the procedure to assist with comfort
during and after the dilation and curettage.
Procedures involving conscious sedation or regional or general anesthesia should follow the American Society of
Anesthesiology guidelines for abstaining from clear liquids and oral consumption prior to surgical procedures. The
current recommendations are no solid food for 8 hours preprocedure and no clear liquids for 4 hours preprocedure.[7]
Positioning
The procedure is typically performed in the dorsal lithotomy position. Care should be taken to prevent pressure
injuries and excess abduction of the hip joint. Patients with orthopedic limitations may need to be positioned before
sedation or general anesthesia is employed.

Monitoring & Follow-up

Cramps and mild vaginal bleeding are the most common symptoms reported following a diagnostic dilation and
curettage. The expectations of these symptoms should be explained to the patient prior to her discharge from the
office or outpatient surgery unit. Over-the-counter medications are usually sufficient for pain management.
Heavy bleeding, fever, abdominal pain or distention, nausea and vomiting, or foul vaginal odor should prompt an
evaluation to exclude infection, perforation, or retained tissue.
Worsening of preexisting comorbidities should also be assessed based on any postoperative symptoms that the
patient experiences.

Technique
Approach Considerations
Prophylactic antibiotics are not necessary. In the presence of a septic abortion or known pelvic infection, a full course
of broad-spectrum antibiotics should be completed.[8]
Preoperative tests are not required for the procedure itself, but may be for the anesthesia. Pregnancy should be
excluded. The presence of medical comorbidities may dictate preoperative laboratory or imaging studies in some
patients, such as those with unstable pulmonary or cardiac disease or severe chronic medical conditions.
The procedure may be performed in an office setting or operating suite based on the patient's clinical presentation,
comfort, medical comorbidities, and the suspected diagnosis.
Adjunctive measures, such as intraoperative ultrasound or hysteroscopy preceding dilation and curettage, may allow
safer more efficient evaluation of the endometrial cavity, even in patients with anatomic abnormality.

Examination
An examination under anesthesia is performed before beginning the dilation and curettage procedure. To adequately
perform the examination, a large distended bladder may need to be emptied. Incomplete emptying of the bladder or
reinstillation of sterile fluid via Foley catheter may be helpful if transabdominal ultrasound guidance is planned.
Careful determination of the uterine size and flexion (the relationship of the uterine fundus to the cervix) and version
(the angle or relationship of the cervix to the uterine fundus) will reduce risk of perforation of the uterus. The adnexa
should also be carefully examined and a rectovaginal examination may be employed if further assessment of the culde-sac or uterine sacral ligaments is pertinent.

Preparation and Visualization

An aseptic solution is applied to the vulva and vagina and appropriate sterile drapes are placed.
A Graves speculum may be used to visualize the cervix. Alternatively, a weighted speculum with one or more vaginal
retractors in the anterior and lateral vaginal fornices may be used. The latter arrangement or a Graves speculum with
an open side may be preferred if hysteroscopy is also planned.
Removal of the speculum and retractors after the hysteroscope is placed into the cervix and uterus increases mobility
of the hysteroscope and may improve visualization of the endometrial cavity.

Traction
The cervix is usually grasped on the anterior lip. A single-tooth tenaculum is frequently used, but a double-tooth or
Bierer tenaculum will penetrate less deeply into the cervical tissue and may reduce the risk of cervical laceration.
Alternative grasping instruments include ring forceps or Allis clamp.
Alternatively, the posterior lip can be grasped if there is a cervical anatomic abnormality or a previous cervical
laceration.

Traction on the cervix is critical while performing a dilation and curettage. Traction decreases the angle between the
cervix and uterus up to 75 degrees, reducing the necessary force to dilate the cervix and the risk of perforation.

Endocervical Curettage
If an endocervical curettage specimen is necessary, it should be obtained before performing cervical dilation or
endometrial sounding to decrease histologic contamination of this specimen. The most common instrument used for
this sampling is a Kevorkian-Younge curette.
An alternate sampling method used in the office setting if a patient cannot tolerate a rigid curette may include a
cervical brush[9] introduced into the endocervix through a sheath to prevent ectocervical or transformation zone
contamination. A specimen obtained with this device should be sent for pathologic examination, not to cytology.[10, 11]
The endocervical sample should be obtained by working in a circumferential or four-quadrant fashion to provide a
representative specimen of all areas.
Endometrial cancer is staged based on the hysterectomy specimen. Therefore, endocervical curettage is not required
for this purpose. Endocervical curettage may be employed to evaluate the presence of cervical dysplasia. If it is
performed in conjunction with a loop electrocautery excision or conization of the cervix, it should be obtained after the
excisional specimen is removed.

Uterine Sounding
A uterine sound is placed while traction is applied with the tenaculum. This assists in obtaining information about the
uterine size and the presence of remaining version and flexion. The sound is held lightly between the thumb and first
finger and placed through the cervix and into the endometrium without force. The average length from external os to
fundus is 8-9 cm.
If cervical stenosis is present, some dilation of the cervix may be required before the sound can be placed. Sounding
of a pregnant uterus is not recommended because of the increased risk of perforating the soft myometrium.
Transabdominal ultrasound guidance may assist sounding if altered anatomy is suspected or stenosis is present.

Cervical Dilation
Each dilator is grasped with the first finger and thumb, similar to the grasp used with the uterine sound. It is held at its
midportion and inserted into the cervical os just past the internal cervical os. It should not be inserted to the uterus
fundus since this may traumatize the endometrium and subsequent bleeding may limit visualization if a hysteroscope
is to be used. Insertions to the fundus may increase the chance of uterine perforation.
Dilation should continue until the appropriate diameter of the instruments to be inserted has been achieved.
Cervical ripening agents, such as laminaria or misoprostol, may enhance the ease of dilation and decrease force
required.[12, 13, 14]

Sharp Curettage
Curettage is performed in an organized fashion with each placement proceeding from the fundus to the internal
cervical os. Tissue is removed with a curette through the external os and collected for pathologic examination.

The curettage is performed in a circumferential fashion, noting the "uterine cry" that develops when the endometrial
cavity is clean. The uterine cry is a gritty feel with movement of the curette.
Special care is taken around the uterine cornua, where the myometrium is thinnest. Other cavity irregularities such as
fibroids, a septum or polyps, or even prior scars from uterine incisions may be noted by tactile examination with
curette. If a hysteroscope is used before curettage is performed, visualization may note the presence of specific
areas for individual biopsy or special attention during the curettage. The sensation of abnormalities, such as
submucous fibroids, may be detected tactilely with the use of a curette.
A classic study of the thoroughness of endometrial curettage performed in patients preparing for hysterectomy
revealed that less than 25% of the uterine cavity was sampled in 16% of patients, less than 50% of the cavity was
sampled in 60% of patients, and less than 75% of the cavity was curetted in 84% of patients.[15, 16] These statistics
represent adequate sensitivity for the detection of malignant or premalignant conditions. This sensitivity may also be
increased by preoperative imaging with directed biopsy or intraoperative hysteroscopy.
The introduction of a Randall polyps forceps may assist removal of pedunculated structures such as polyps or
myomas or remove portions of tissue loosened during the curettage.

Suction Curettage
Suction curettage is infrequently used for diagnostic dilation and curettage. It may be indicated if the patient's
bleeding is extremely heavy, a large amount of tissue is visualized at preoperative imaging, or gestational
trophoblastic disease is suspected. A suction curette is substituted for the sharp curettage.
A cannula is inserted to the mid portion of the endometrial cavity. Suction is employed with a vacuum pressure of 5060 mm Hg and the cannula is rotated 360 degrees. Evacuation of the uterus results in a decreased uterine size and
the tactile sensation of the uterus gripping the cannula. The cannula may be removed and replaced at the uterine
fundus. When tissue is no longer seen in the suction tubing, the cannula is removed and a sharp curettage
performed. A circumferential evaluation of the endometrial cavity is performed and the curettage is complete when
the uterine cry is noted.
In the operating room in the presence of gestational trophoblastic neoplasia, a large uterus with retained tissue or
products of conception, or postdelivery bleeding, oxytocin or other agents that aid uterine contractility should be
immediately available and employed as needed to decrease blood loss.

Future Developments
A future use of endometrial sampling is as a noninvasive method of obtaining mature natural killer cells and
hematopoietic stem cells.[17]

ation and curettage (D&C) is a brief surgical procedure in which thecervix is dilated and a
special instrument is used to scrape the uterine lining. Knowing what to expect before, during,
and after a D&C may help ease your worries and make the process go more smoothly. Here's
what you need to know.

Reasons for a D&C

You may need a D&C for one of several reasons. It's done to:

Remove tissue in the uterus during or after a miscarriage or abortionor to remove

small pieces of placenta after childbirth. This helps prevent infection or heavy bleeding.
Diagnose or treat abnormal uterine bleeding. A D&C may help diagnose or treat
growths such as fibroids, polyps, or endometriosis, hormonal imbalances, or uterine cancer. A
sample of uterine tissue is viewed under a microscope to check for abnormal cells.

What to Expect When Having a D&C

You can have a D&C in your doctor's office, an outpatient clinic, or the hospital. It usually takes
only 10 to 15 minutes, but you may stay in the office, clinic, or hospital for up to five hours.
Before a D&C, you will have a complete history taken and sign a consent form. Ask your doctor
any questions you have about the D&C. Be sure to tell the doctor if:

You suspect you are pregnant.

You are sensitive or allergic to any medications, iodine, or latex.
You have a history of bleeding disorders or are taking any blood-thinning drugs.
You will receive anesthesia, which your doctor will discuss with you. The type you have depends
on the procedure you need.

If you have general anesthesia, you will not be awake during the procedure.
If you have spinal or epidural (regional) anesthesia, you will not have feeling from the
waist down.

If you have local anesthesia, you will be awake and the area around you cervix will be
numbed.
Before the D&C, you may need to remove clothing, put on a gown, and empty your bladder.
During a D&C, you lie on your back and place your legs in stirrups like during a pelvic exam.
Then the doctor inserts a speculum into the vaginaand holds the cervix in place with a clamp.
Although the D&C involves no stitches or cuts, the doctor cleanses the cervix with an antiseptic
solution.

What to Expect When Having a D&C continued...

A D&C involves two main steps:

Dilation involves widening the opening of the lower part of the uterus (the cervix) to
allow insertion of an instrument. The doctor may insert a slender rod (laminaria) into the opening
to gradually cause it to widen. Or medication may soften the cervix to help it widen.
Curettage involves scraping the lining and removing uterine contents with a long,
spoon-shaped instrument (a curette). The doctor may also use a cannula to suction any
remaining contents from the uterus. This can cause some cramping. In many cases, a tissue
sample goes to a lab for examination.
Sometimes other procedures are performed along with a D&C. For example, your doctor may
insert a slender device to view the inside of the uterus (called hysteroscopy).
After a D&C, there are possible side effects and risks. Common side effects include:

Cramping
Spotting or light bleeding
Complications such as a damaged cervix and perforated uterus or bowel are rare. But be sure
to contact your doctor if you have any of the following symptoms after a D&C:

Heavy or prolonged bleeding or blood clots

Fever
Pain
Abdominal tenderness
Foul-smelling discharge from the vagina
In very rare cases, scar tissue (adhesions) may form inside the uterus. Called Asherman's
syndrome, this may cause infertility and changes in menstrual flow. Surgery can repair this
problem, so be sure to report any menstrual flow changes after a D&C.

Recovery After a D&C

After a D&C, you will need someone to take you home. If you had general anesthesia, you may
feel groggy for a while and have some briefnausea and vomiting. You can return to regular
activities within one or two days. In the meantime, ask your doctor about any needed
restrictions. You may also have mild cramping and light spotting for a few days. This is normal.
You may want to wear a sanitary pad for spotting and take pain relievers for pain.
You can expect a change in the timing of your next menstrual period. It may come either early or
late. To prevent bacteria from entering your uterus, delay sex and use of tampons until your
doctor says it's OK.
See your doctor for a follow-up visit and schedule any further treatment that's needed. If any
tissue was sent for a biopsy, ask your doctor when to expect results. They are usually available
within several days.
WebMD Medical Reference
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Reviewed by Kecia Gaither, MD, MPH on October 03, 2014
2014 WebMD, LLC. All rights reserved.

Postoperative care involves the precautions that we need to follow after a

Dilatation and Curettage (D&C) procedure.

The precautions that need to followed after the surgery are:

Some cramping or mild abdominal discomfort is considered usual after

a D&C, consult the doctor if the pain is severe.

Medications should be taken as per the prescription of the doctor.

Ensure to take the entire course of antibiotic.

Refrain from the use of internal tampons and sexual intercourse for
about a week or as advised by your doctor.

Use sanitary napkins during this time period.

If there are any signs of infection such as fever, pain or discharge

consult the doctor immediately.

Definition

Abortion is a medical term for the disruption of a pregnancy before the fetus reaches its viable
age of more than 20 to 24 weeks of gestation or weighs at least 500g.

Pathophysiology

The most common cause of an abortion is abnormal fetal development, which is either due to
a chromosomal aberration or a teratogenic factor.

Another common cause is the abnormal implantation of the zygote, where there is inadequate
endometrial formation or the zygote was implanted on an inappropriate site.

This would cause inadequate development of the placental circulation, leading to poor nutrition
of the fetus and eventually, to an abortion.

Risk Factors
There are always precipitating factors for every condition. Here are the risk factors that concerns abortion:

Congenital Structural Defect. This structural defect may be due to chromosomal aberration
or a serious physical defect.

Low Progesterone. Progesterone maintains the decidua basalis. If the corpus luteum fails to
produce enough progesterone, it would risk the life of the fetus inside the uterus.

Rh Incompatibility. The fetus could get rejected from a mothers body if they have an
incompatible Rh.

Undernutrition. Lack of nutrients would cause undernourishment to both the mother and the
fetus, leading to abortion.

Drugs. There are drugs which are contraindicated for pregnant women. Ingestion might
compromise the fetus and lead to abortion.

Infection. In infection, the fetus would fail to grow and estrogen and progesterone production
would fall. This would lead to endometrial sloughing, then prostaglandins would be released
leading to uterine contractions and cervical dilatation along with expulsion of the products of
pregnancy.

Types
Several types of abortion are used to classify every case for a pregnant woman. Once a thorough
assessment is done, that would be the time that the type of abortion that occurred could be established.

Threatened abortion. The embryo is already viable. The products of conception are still intact
and the cervix is closed, but there is vaginal bleeding present.

Inevitable/Imminent abortion. The embryo is dead with the products of conception either
intact or expelled. The cervix is already dilated and there is presence of vaginal bleeding.

Complete abortion. All products of conception are expelled and the embryo is dead. The
cervix is dilated, and there is mild bleeding.

Incomplete abortion. The embryo is dead but some products of conception are still intact.
The cervix is already dilated and there is severe vaginal bleeding.

Missed abortion. The embryo is already dead while inside the uterus. The products of
conception are still intact and the cervix is closed. There are brown vaginal discharges
present.

Recurrent/Habitual abortion. Abortion becomes recurrent once the woman has had 3
consecutive miscarriages at the same gestational age.

Signs and Symptoms

As nurses, we are tasked with assessing our patient to provide baseline and accurate information to other
caregivers. The signs and symptoms of abortion must be identified first before ruling out any other relative
causes.

Vaginal spotting. Vaginal spotting appears as small brownish to reddish spots of blood
coming out of the womans vaginal opening. This usually occurs when the cervix slightly
dilates because the woman may have tried to lift heavy objects or mild trauma to the abdomen
occurred.

Vaginal bleeding. Bleeding is a serious occurrence during pregnancy because it might

indicate that the cervix has opened and products of conception might be expelled.

Cramping/sharp/dull pain in the symphysis pubis. This could occur on both sides and
could be caused by trauma or premature contractions that might cause cervical dilation.

Uterine contractions felt by the mother. Uterine contractions can be false or true, but either
of the two could be alarming during the early stages of pregnancy because it could expel the
contents of the uterus thereby leading to abortion.

Diagnostic Tests

Pregnancy test. This is to confirm the pregnancy first if vaginal bleeding occurs. If test turns
out negative, then the woman would be subjected to other diagnostic tests that could confirm
the nature and cause of the vaginal bleeding. If it is positive, then abortion would be
considered and it would be classified according to the presenting signs and symptoms.

Ultrasound. The safest and confirmatory test for pregnancy, the ultrasound would be able to
confirm if the pregnancy is positive, and also confirm if the products of conception are still
intact.

Medical Management
Medical interventions should also be incorporated in the patients care plan to reinforce his treatment.
These are physicians orders wherein nurses and other caregivers would assist or take into action, thus
ensuring the recovery of the patient.

Aside from our own nursing management, physicians would also have to order a series of
therapeutic management for the pregnant woman.

Administration of intravenous fluids. Such as Lactated Ringers, IV therapy should be

anticipated by the nurse as well as administration of oxygen regulated at 6-10L/minute by a
face mask to replace intravascular fluid loss and provide adequate fetal oxygenation.

Avoid vaginal examinations. The physician would also avoid further vaginal examinations to
avoid disturbing the products of conception or triggering cervical dilatation.

The physician might also order an ultrasound examination to glean more information about the
fetal and also maternal well-being.

Our role as nurses in these medical interventions would be to assist in every aspect possible, and ensure
the wellbeing of both the mother and the fetus. Through our nursing interventions, we could initiate care
without needing to run after the physicians and ask for their orders. We should be able to function
independently as caregivers and promote their wellness in our own way as nurses. The most vital pieces
of information are always handed to us first, so it would be up to us to initiate the first intervention to make
or break the condition of the client before a doctor arrives. Nurses are the first line of defense of every
hospital, and we should live up to that expectation.

Surgical Management
Aside from the medical interventions ordered by physician, incidences might occur which would lead to a
surgical operation.

Dilatation and evacuation. This is to make sure that all products of conception would be
removed from the uterus. However, before undergoing this intervention, the physician must be
sure that no fetal heart sounds could be heard anymore and the ultrasound must show an
empty uterus.

Dilation and curettage. This is most commonly performed for incomplete abortions to remove
the remainder of the products of conception from the uterus. Since the uterus would not be
able to contract effectively, the contents might be trapped inside and could cause serious
bleeding and infection.

Nursing Management
Nurses must also have their own independent functions to ensure the safety and well-being of the patient.
The following are measures that would allow the nurse to act independently.
Nursing Assessment

The presenting symptom of an abortion is always vaginal spotting, and once this is noticed by
the pregnant woman, she should immediately notify her healthcare provider

As nurses, we are always the first to receive the initial information so we should be aware of
the guidelines in assessing bleeding during pregnancy.

Ask of the pregnant womans actions before the spotting or bleeding occurred and identifies
the measures she did when she first noticed the bleeding.

Inquire of the duration and intensity of the bleeding or pain felt. Lastly, identify the clients
blood type for cases of Rh incompatibility.

Nursing Diagnosis

Risk for deficient fluid volume related to bleeding during pregnancy

Nursing Interventions

If bleeding is profuse, place the woman flat in bed on her side and monitor uterine contractions
and fetal heart rate through an external monitor.

Also measure intake and output to establish renal function and assess the womans vital signs
to establish maternal response to blood loss.

Measure the maternal blood loss by saving and weighing the used pads.

Save any tissue found in the pads because this might be a part of the products of conception.

Evaluation

The aim for evaluation is inclined towards restoring the maternal blood volume and stopping
the source of the bleeding.

The clients blood pressure must be maintained above 100/60 mmHg.

The pulse rate should be below 100 beats per minute and the fetal heart rate must be at a
normal level of 120-160 beats per minute.

The clients urine output should be more than 30 mL/hr, and only minimal bleeding should be
apparent for not more than 24 hours.

A medical abortion is the use of medicines to end a pregnancy. Medical care for a medical
abortion is different from medical care for a surgical abortion. This is because a medical
abortion is like a miscarriage (in this case, caused by medicines) that takes place at home over
1 to 2 days and does not require your doctor to be present. After a couple of weeks of bleeding,
you then see your doctor for a follow-up examination.

Care before a medical abortion

Before a medical abortion, your doctor may:

Evaluate your medical history, including any medicines you are taking.
Do a physical exam, including a pelvic examination, to evaluate your health, how long
you have been pregnant, and location of the embryo or fetus.
Perform an ultrasound to confirm how far along and where the pregnancy is. Not all
doctors choose to do this step.
Discuss your decision to have an abortion and your feelings about the decision.
Discuss your plans for future pregnancies and birth control use.
Explain how the medicines will work, possible side effects (nausea,vomiting,

and diarrhea are common), and when to call your doctor. It is important for your doctor to know
whether you:
Have access to a telephone, to call if you have problems.
Have transportation to a health care facility if you need to be evaluated.
Will be able to return for a follow-up appointment.
Are prepared for the cramping pain and bleeding that will occur as the uterine

contents are passed.

Understand that a surgical abortion will be needed if a medical abortion fails to

o
o
o

complete the process.

In addition to the medicines used to cause an abortion, your doctor will give you medicines to
minimize side effects, with specific instructions for their use. These medicines are used:

For cramping pain caused by uterine contractions.

To prevent nausea or vomiting.
To prevent infection.

All women who have Rh-negative blood type will be given Rh immunoglobulin to prevent Rh
sensitization after an abortion.
If you need to call your doctor about your symptoms during a medical abortion, be
prepared to provide information about:

How heavy the bleeding is, compared with your normal menstrual bleeding. The
heaviest bleeding should stop 1 to 2 hours after passing the pregnancy tissue.
The number and types of pads used in 1 hour and the total number of soaked pads
used.

The presence and size of blood clots.

Whether any pregnancy tissue has been passed.
The severity of your cramping or pain.

Care after a medical abortion

Carefully follow all of your doctor's instructions and review what-to-expect information after a
medical abortion.
Follow these instructions:

Most women can return to normal activities in 1 to 2 days after the uterus has cleared.

Avoid strenuous exercise for 1 to 2 weeks.

Do not have sexual intercourse for 1 to 2 weeks or as advised by your doctor.
Be sure to use birth control when you start having sex again. And usecondoms to

prevent infection. For more information, see the topic Birth Control.
Do not rinse the vagina with fluids (douche). This could increase your risk of infections

that can lead to pelvic inflammatory disease.

Normal symptoms that most women will experience after a medical abortion include:

Bleeding or spotting for up to 14 days. Bleeding may last longer for pregnancies of more

than 7 weeks.
Cramping for the first 2 weeks. Some women may have cramping (like

menstrual cramps) for as long as 6 weeks.

Emotional reactions for 2 to 3 weeks, often influenced by changes in pregnancy
hormones. It's normal to feel one or more emotions such as relief, guilt, sadness, and/or grief.
Call your doctor immediately if you have any of these symptoms after an abortion:

Severe bleeding. Both medical and surgical abortions usually cause bleeding that is
different from a normal menstrual period. Severe bleeding can mean:

o
o
o

Passing clots that are bigger than a golf ball, lasting 2 or more hours.
Soaking more than 2 large sanitary pads in an hour, for 2 hours in a row.
Bleeding heavily for 12 hours in a row.
Signs of infection in your whole body, such as headache, muscle
aches, dizziness, or a general feeling of illness. Severe infection is possible without fever.
Severe pain in the belly that is not relieved by pain medicine, rest, or heat
Hot flushes or a fever of 100.4F (38C) or higher that lasts longer than 4 hours
Vomiting lasting more than 4 to 6 hours
Sudden belly swelling or rapid heart rate
Vaginal discharge that has increased in amount or smells bad
Pain, swelling, or redness in the genital area

Care after a medical abortion continued...

Call your doctor for an appointment if you have had any of these symptoms after a recent
abortion:

No bleeding. If bleeding does not occur, then the medicines may not be working. A
second dose of misoprostol may be needed.Methotrexate and misoprostol may take up to 3
weeks to be effective.
Bleeding (not spotting) for longer than 2 weeks
New, unexplained symptoms that may be caused by medicines used in your treatment
No menstrual period within 6 weeks after the procedure
Signs and symptoms of depression. Hormonal changes after a pregnancy can cause
depression that requires treatment.
Complications that can occur include:

Tissue remaining in the uterus (retained products of conception). Cramping belly pain

and bleeding will occur again within a week of the procedure.

Infection. Symptoms of fever of 100.4F (38C) or higher, pain, and belly tenderness will

usually start within 2 to 3 days of the procedure. But you can have a serious infection without
fever.
Blood clots blocking the cervix (hematometra). If the uterus doesn't contract to pass all of

o
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o

the tissue, the cervical opening can become blocked. This prevents blood from leaving the
uterus. The uterus will become enlarged and tender. Belly pain, cramping, and nausea may be
present.
Moderate to severe bleeding (hemorrhage). Bleeding may be more than normal if:
Products of conception are retained in the uterus.
The uterus has not contracted toward its prepregnancy size (atony).
Uterine muscle rupture has occurred. In rare cases, a uterine incision scar tears
open when a medicine is used to induce contractions.

When a medical abortion fails, a surgical abortion must be done as follow-up to prevent
complications or development of a fetus with abnormalities.

Follow-up examination after a medical abortion

A follow-up examination is done about 2 weeks after a medical abortion. The examination may
include:

A physical exam, to check the cervix and uterus

.
A lab test to check for a low human chorionic gonadotropin (hCG) level, which shows the
pregnancy has ended.
A blood test, to check for anemia.
An ultrasound, to confirm the uterus is empty.
A discussion of birth control use. If birth control measures were started immediately after
the abortion procedure, the proper use of the method can be discussed again.

WebMD Medical Reference from Healthwise

Last Updated: November 14, 2014
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