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Dilation and curettage (D&C) is one of the most common invasive procedures in the United States. The procedure can be performed on a pregnant or nonpregnant patient and be either diagnostic or therapeutic. Sometimes the circumstances lead to a diagnostic procedure becoming therapeutic. A D&C occurs in 2 steps: dilation of the cervix and curettage of the endometrial cavity. While current recommendations for endometrial sampling in the nonpregnant patient include hysteroscopy with directed endometrial sampling, if necessary resources are unavailable, a simple D&C may be performed to acquire tissue for histologic evaluation. Contraindications to D&C are few, and the overall mortality rate is low. This activity reviews the indications, absolute and relative contraindications, equipment needs, technique, and complications of diagnostic and therapeutic D&C in pregnant and nonpregnant patients. In addition, the role of the healthcare team in improving care for patients undergoing D&C is highlighted. Objectives: Select patients who may benefit from preoperative cervical preparation or preoperative antibiotic therapy. Identify the equipment needs, the role of cervical preparatory agents and pre-operative antibiotics, and the commonly encountered complications of dilation and curettage. Counsel patients regarding the risks, benefits, and alternatives to the procedure. Apply effective interprofessional team processes for patients undergoing dilation and curettage in the outpatient or hospital settings. Access free multiple choice questions on this topic.

Dilation and curettage (D&C) is one of the most common invasive procedures in the United States. The procedure can be performed on a pregnant or nonpregnant patient and be either diagnostic or therapeutic. Sometimes the circumstances lead to a diagnostic procedure becoming therapeutic. A patient seeking elective termination or management of a missed, incomplete, or inevitable abortion in the first trimester of pregnancy at less than 14 weeks of estimated gestational age could be offered this surgical procedure or medical management. Dilation and evacuation is a similar procedure employed at an estimated gestational age of greater than 14 weeks and is outside this activity's scope. Approximately 30% of females will have an abortion by age 45 years; most of these occur in an outpatient setting.[1] In 2013, first-trimester aspiration procedures were the most common therapeutic intervention accounting for 74% of abortions.[1] However, more recent data from high-income countries indicate that medical abortions account for approximately half of all abortions, and about 90% of all abortions were completed before 13 weeks.[2] A D&C may be performed in the evaluation of abnormal uterine bleeding. However, with the advent of aspiration devices for endometrial biopsy and advances in ultrasound technology, the D&C is rarely the first step in the evaluation. D&C may also be used to manage abnormal uterine bleeding refractory to medical therapy.[3] A D&C occurs in 2 steps: dilation of the cervix and curettage of the endometrial cavity. The first cervical dilators were available in the early 19th century. Recamier is credited with inventing the first curette in 1843, which resembled a small scoop or spoon with a long handle.[4] The instruments used in a D&C have remained essentially unchanged from the original dilators and curettes.

The overall mortality rate associated with D&C is low. The rate is 0.6 per 100,000 legally-performed induced abortions. To put this in perspective, the risk of death associated with childbirth is 14 times this rate. However, the risk of morbidity and mortality increases with increasing gestational age.[13] Infection, bleeding, cervical lacerations, uterine perforation, and postoperative uterine adhesions are complications of D&C in pregnant and nonpregnant patients. Overall infection rates are low at 1% to 2%, and prophylactic antibiotic use is recommended in pregnant patients.[14] Infection rates are even rarer in nonpregnant patients, and prophylactic antibiotics are not recommended. Uterine perforation is the most common immediate complication of a D&C in pregnant or nonpregnant patients. Uterine perforation is more likely to occur at the fundus of the uterus, and risk factors for uterine perforation are postpartum hemorrhage, postmenopausal status, nulliparity, and a retroverted uterus.[15] Uterine perforation rates increase in pregnant patients with increasing gestational age.[13] Management of uterine perforation depends on when it occurs during the procedure. If bowel injury is suspected, the procedure may need to be completed under direct visualization using laparoscopy. Laparoscopy should also be performed if there is significant hemorrhage or suspicion of perforation of the lateral uterine wall. Cervical injury or lacerations to the lip of the cervix typically occur when too much traction is applied to the cervix during dilation or manipulation. Most lacerations can be managed with pressure, silver nitrate, or ferric subsulfate. Occasionally suture ligation is needed. If there is an injury to the endocervical canal, pressure or suture should be attempted first. If there is no response, then balloon tamponade or uterine artery embolization with further evaluation for abdominal or retroperitoneal bleeding should be considered.

Cervical injury or lacerations to the lip of the cervix typically occur when too much traction is applied to the cervix during dilation or manipulation. Most lacerations can be managed with pressure, silver nitrate, or ferric subsulfate. Occasionally suture ligation is needed. If there is an injury to the endocervical canal, pressure or suture should be attempted first. If there is no response, then balloon tamponade or uterine artery embolization with further evaluation for abdominal or retroperitoneal bleeding should be considered. Hemorrhage is extremely rare in nonpregnant patients undergoing D&C. The operator should consider uterine perforation or cervical injury as the most likely cause in this setting and manage it appropriately. Hemorrhage is more common in a pregnant patient undergoing D&C, and the risk increases with increasing gestational age and in the postpartum period. Retained products of conception, uterine atony, abnormal placentation, and injury to the cervix or uterus can potentially cause significant hemorrhage in pregnant or postpartum patients undergoing D&C.[13] Management of complications should be specific to the underlying etiology. Postoperative endometrial adhesions, or Asherman syndrome, is a rare complication of D&C and is most likely to occur in the setting of a septic abortion. These patients may have symptoms of infertility, menstrual cycle changes, or dysmenorrhea. Postoperative endometrial adhesions are definitively diagnosed with hysteroscopy; treatment can be complex depending on the severity of the adhesions.[16]

A D&C is an invasive procedure with obvious risks and benefits for pregnant and nonpregnant patients. These must be made transparent in an informed consent process that allows the patient to ask questions about all alternative options and associated issues. Understanding these risks does not diminish the rate of complications but allows the patient and physician to engage in shared decision-making. Elective abortion is controversial; providers and staff must be aware of potential legal implications and discuss any ethical dilemmas they may face. These discussions should be held well in advance of any patient care, and no one should be asked to participate in any patient encounter if they are uncomfortable with the care being provided. This is where clear and effective interprofessional communication and collaboration in D&C cases are essential to improve patient outcomes and benefit the healthcare team members. [Level 5]