Dilation and curettage

INTRODUCTION — Dilation and curettage (D&C) is one of the most common procedures performed in obstetrics and gynecology. As a general term, D&C describes a procedure in which cervical dilators are used to facilitate the introduction of instruments into the uterus, and the endometrial cavity is either sampled or emptied with a curette. D&C can be used for therapeutic and diagnostic indications and in both the nonpregnant and pregnant uterus.

The D&C procedure will be reviewed here. Office sampling procedures and diagnostic approaches to evaluation of the endometrium are discussed elsewhere. (See "Endometrial sampling procedures" and "Overview of the evaluation of the endometrium for malignant or premalignant disease".)

TERMINOLOGY — D&C performed for a pregnancy-related indication is sometimes also referred to as suction D&C, aspiration D&C, or dilation and evacuation (D&E). There is some regional variation in use of the term D&E; in clinical institutions in some places, it is used for any procedure involving suction at any gestation, whereas in other areas, it is used to refer only to procedures in the second trimester. For the purposes of this topic, we will focus on procedures in the first trimester and use the term aspiration D&C.

INDICATIONS — D&C can be a diagnostic and/or therapeutic procedure.

Diagnostic indications — As gynecologic techniques have changed, many previous diagnostic indications for D&C have now been replaced with office-based endometrial biopsy. However, there are still clinical scenarios for which a diagnostic D&C is indicated, including:

●Patient intolerance of office endometrial biopsy due to pain or anxiety.

●Inability to sample endometrium in the office due to cervical stenosis.

●Office endometrial biopsy with insufficient tissue for diagnosis.

●Office biopsy results that are inconsistent with imaging findings (such as inactive endometrium in a patient with imaging suggestive of mass or polyp).

●Persistent abnormal uterine bleeding (AUB) or postmenopausal bleeding after a benign office biopsy.

●To exclude endometrial carcinoma in patients with a diagnosis of atypical hyperplasia (also referred to as endometrial intraepithelial neoplasia) on office sampling.

●Instead of office endometrial biopsy when a concomitant procedure such as hysteroscopy or laparoscopy is planned.

●Examination for villi in the evaluation of a patient with an abnormal pregnancy of unknown location.

Should hysteroscopy be performed routinely with dilation and curettage? — When evaluating AUB or endometrial thickening, diagnostic D&C should be done in conjunction 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 biopsy or visual confirmation of pathology. This helps to prevent missing unsuspected polyps and ensures that the most visibly abnormal areas are sampled. Hysteroscopy may be better able to detect abnormalities than blind endometrial sampling alone in the evaluation of AUB [1,2]. In addition, a combined procedure with hysteroscopy may provide options for definitive treatment of AUB (such as polypectomy or resection of submucosal fibroids). (See "Overview of hysteroscopy".)

Therapeutic indications — Indications for therapeutic D&C not associated with pregnancy include:

●Temporary management of patients with prolonged or excessive bleeding who are unresponsive to hormonal therapy, have contraindications to hormonal therapy, or are hemodynamically unstable and need immediate treatment. (See "Managing an episode of acute uterine bleeding", section on 'Preferred: Uterine curettage'.)

Indications for therapeutic D&C associated with pregnancy include:

●Induced abortion. (See "First-trimester pregnancy termination: Uterine aspiration".)

●Treatment of early pregnancy failure – Missed or incomplete spontaneous abortion. (See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology".)

●Evacuation of suspected molar pregnancy. (See "Initial management of low-risk gestational trophoblastic neoplasia".)

●Suspicion of retained products of conception postpartum or after first- or second-trimester evacuation.

CONTRAINDICATIONS

Absolute contraindication — The only absolute contraindication to D&C is desired viable pregnancy.

Precautions

Bleeding diathesis

●Due to anticoagulant therapy – Decisions about holding anticoagulants prior to D&C need to be made on an individual basis along with other members of the patient's care team (eg, the prescribing physician and anesthesiologist). Considerations include the indications for anticoagulation (therapeutic versus prophylactic), risk of complication/thrombosis if anticoagulants are stopped temporarily, and bleeding risk specific to the patient's case. For example, patients who are on long-term anticoagulation for atrial fibrillation can often have their anticoagulants held for several days without significant risk, whereas patients with recent thromboembolic disease or with artificial heart valves are at much higher risk of complication if their anticoagulation is held. (See "Perioperative management of patients receiving anticoagulants".)

Additionally, in pregnancy-related suction D&C, the primary physiologic mechanism for cessation of bleeding is uterine contractility, and thus these cases can often be done without holding anticoagulants without complication [3]. Typically, even when patients are fully anticoagulated, no additional bleeding is encountered, and additional measures are not needed. Uterotonics may be used if needed per usual practice.

●Due to a clotting deficiency – Patients with an inherent clotting deficiency should ideally have their clotting factors replaced prior to any planned procedure. This may entail treatment with desmopressin for patients with von Willebrand disease, or treatment with fresh frozen plasma or cryoprecipitate in patients with significant postpartum hemorrhage or disseminated intravascular coagulation (DIC). Patients with hemodynamic instability due to hemorrhage and/or DIC should have general hemorrhage management including volume and factor replacement prior to or concomitant with any D&C depending on the level of concern for retained tissue. (See "Overview of postpartum hemorrhage" and "Perioperative blood management: Strategies to minimize transfusions", section on 'Management of specific hemostatic disorders'.)

Pelvic infection — Scheduled or elective D&C should generally be avoided in the patient with a known cervical or uterine infection. D&C performed in the presence of infection may result in further ascending infection, pelvic inflammatory disease, or development of intrauterine adhesions. If the procedure can be delayed, the infection should be treated prior to any instrumentation. There are, however, exceptions to this:

●Septic abortion or endometritis with suspected retained products of conception – In these cases, the retained pregnancy tissue is believed to be the nidus of infection, and prompt evacuation is important for resolution of the infection.

●Pyometra – This may be due to cervical obstruction with superinfection of menstrual blood, normal secretions, and cellular debris or to necrosis of submucosal fibroids. D&C is appropriate to remove the source of infection.

Cervical ectopic pregnancy or cesarean scar implantation pregnancy — Risk of excessive bleeding or hemorrhage may be severe. Thus, the decision to proceed with D&C must be considered carefully.

For cervical ectopic pregnancies, D&C is generally considered a second-line treatment. These cases are generally better managed with medical therapy such as methotrexate or potassium chloride with suction D&C generally reserved for cases of severe hemorrhage, after uterine artery embolization, or after nonresolution of the pregnancy following medical therapy (see "Cervical pregnancy: Diagnosis and management", section on 'Treatment').

Cesarean scar implantation pregnancies may also have a high risk of bleeding but are more heterogeneous in clinical features, depending on site of implantation and extent of growth into the myometrium. Management includes surgical (eg, suction D&C, operative resection) or medical (eg, intragestational injection of methotrexate or potassium chloride) therapies; the choice of treatment is guided by many factors (ie, hemodynamic stability, thickness of myometrium, gestational age, desire for future fertility, experience of the physician treating the patient). (See "Cesarean scar pregnancy", section on 'Management'.)

PREPROCEDURE PREPARATION

Cervical preparation — Cervical preparation to minimize procedural pain with dilation has unclear advantages since patients are typically under sedation or general anesthesia. For this reason, and due to the unclear efficacy and known side effects of misoprostol and the additional visit required for osmotic dilators, we do not routinely use cervical preparation prior to routine D&C with or without hysteroscopy.

Some surgeons give preoperative misoprostol with the goal of reducing the need for mechanical dilation, but this has not been proven to be effective in clinical studies. Mifepristone does not appear to be effective for reducing the need for mechanical dilation [4]. (See "Overview of hysteroscopy", section on 'Cervical preparation and dilation'.)

Osmotic dilators (laminaria or Dilapan-S) are another method of cervical preparation that are mainly used for induced abortion. Placement requires an additional visit the day before the scheduled surgery and may be uncomfortable for patients. Since significant dilation is not usually needed for D&C alone, osmotic dilators are not commonly used.

Intraoperative techniques that may facilitate cervical dilation if cervical stenosis is present are discussed below (see 'Cervical stenosis' below). Cervical preparation prior to D&C in a pregnant uterus is addressed elsewhere. (See "Pregnancy termination: Cervical preparation for procedural abortion", section on '12 to <14 weeks'.)

Prophylactic antibiotics — Guidelines do not support routine use of prophylactic antibiotics in nonpregnant patients prior to D&C (with or without hysteroscopy (table 1)). Prophylactic antibiotics are used in pregnant patients prior to D&C. (See 'Infection' below and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Antibiotic prophylaxis' and "Overview of pregnancy termination".)

Venous thromboembolism prophylaxis — D&C is a minor procedure with low risk of venous thromboembolism. Therefore, in patients under 40 years of age without risk factors, no pharmacologic or mechanical prophylaxis is required other than early ambulation. In patients 40 years old or more, for procedures over 30 minutes or with risk factors, prophylaxis may be indicated. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

Anesthesia — D&C is typically performed in a surgical suite under procedural sedation or intravenous general anesthesia. While there is likely no additional benefit of administering a paracervical block in patients receiving deep sedation or general anesthesia for intrauterine procedures, it may be useful if minimal or moderate sedation is used [5-8]. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)

INSTRUMENTS

Dilators — Each provider should use the instruments available and appropriate to their setting and experience. We prefer use of thin tapered dilators (eg, Hanks or Pratt dilators) compared with blunt tip dilators (eg, Hegars) because of the enhanced tactile feedback during dilation (picture 1). In addition, Hanks and Pratts have smaller intervals between each size compared with standard Hegars. We suggest use of tapered dilators rather than blunt dilators. Tapered dilators require less force and may therefore minimize risk of uterine perforation [9]. In particular, we find this helpful in patients with tortuous, nulliparous, or postmenopausal cervical canals. However, some surgeons prefer blunt tip dilators.

Dilator sizes commonly start at 13 French for Pratt, 9 French for Hanks, and 3 mm diameter for standard Hegars. French scale measurements are equivalent to circumference in millimeters (or the diameter multiplied by pi [3.14]).

Small diameter dilators — If the smallest of the usual gynecologic dilators does not easily pass into the cervical canal, some surgeons will use lacrimal duct probes or narrower metal cervical dilators (as small as 1 mm diameter) to access the cervix. Care should be taken when inserting these since a narrower dilator may be more likely to pass through tissue rather than into the cervical canal or uterine cavity, and can result in injury or the creation of a "false passage" that may make finding the true cervical canal more difficult. Another option is use of flexible plastic "os finders" (eg, Comfort-Flex Cervical Dilator Set) that come with both gently and sharply tapered tips for dilation up to approximately 3.8 mm before transitioning to the traditional dilator sizes.

Curettes — Sharp metal curettes are typically selected for diagnostic D&C procedures (eg, for postmenopausal bleeding). These curettes have a long handle and open teardrop shape at the tip, often with a sharp edge along the superior convex aspect (picture 2). Metal curettes come in various sizes corresponding to the largest diameter at the tip, including #00 (3 mm), #0 (5 mm), #1 (7 mm), #2 (8 mm), #3 (9 mm), and larger. We prefer metal curettes that are malleable, allowing the operator to adjust the curvature of the device to facilitate access to the fundus in the case of severe uterine flexion.

Plastic curettes, also called cannulas, are used in suction D&C and are typically used when large amounts of endometrial tissue are anticipated, such as aspiration D&C associated with pregnancy or in a patient with heavy active bleeding or known retained clot.

In the nonpregnant patient, a plastic curette diameter between 7 to 10 mm should be sufficient for evacuation of clot or endometrial tissue. Plastic curettes may be straight or curved, rigid or flexible; we typically use curved rigid cannulas for electric suction aspiration procedures, though the choice of cannula should be guided by surgeon comfort and experience (picture 3).

Aspiration instruments — Electric suction aspiration provides continued negative pressure to quickly evacuate the uterine contents and thus minimize additional bleeding. This has traditionally been used as the aspiration source for a therapeutic suction D&C procedure. However, the pump and unit require a clinic or procedure area with adequate space and resources.

Manual vacuum aspiration (MVA) refers to a handheld device that is "locked," then utilizes a large attached syringe that is withdrawn to create negative pressure (picture 4). Once connected to the curette in position inside the uterus, the lock is released to allow use of the negative pressure to evacuate the uterus, collecting tissue in the syringe. The standard MVA device has a double lock, whereas a device with a single lock, or with a locking syringe (sometimes referred to as a Karman device), generates a lower level of negative pressure. The Karman devices are sufficient for diagnostic purposes, such as examination for villi in evaluation of pregnancy of unknown location, but cannot reliably be used for therapeutic purposes.

PROCEDURE

●Informed consent is obtained, including consent regarding any clinicians or students who will perform a pelvic examination under anesthesia. (See "Pelvic examination under anesthesia", section on 'Informed consent'.)

●After anesthesia is adequate, position the patient in dorsal lithotomy position.

●Perform a bimanual pelvic examination to assess the position of the cervix, orientation of the uterus, uterine size, and any findings that may impact the procedure. The patient should ideally have already undergone a full evaluation to facilitate procedure planning.

●Prepare the vagina and cervix with an antiseptic solution. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Vaginal preparation'.)

●Insert a speculum or use anterior and posterior vaginal retractors.

●Place a tenaculum on the anterior cervix, grasping horizontally or vertically across the 12 o'clock position, to stabilize the uterus during the D&C. Tenacula may be sharp or atraumatic (eg, Bierer tenaculum) (picture 5). Additionally, use of traction to straighten the uterine axis reduces the angle at the cervicouterine junction, typically from a median of 75 degrees to 10 degrees [10]. This alignment of the cervical canal with the uterine cavity theoretically reduces the risk of uterine perforation that could occur if instruments are inserted into the uterus with significant anteversion/retroversion.

●A paracervical block (with or without vasopressin) may be performed before or after placement of the tenaculum. This may be used for pain control [8], or in anticipation of bleeding in patients at high risk for bleeding (eg, cervical pregnancy, cesarean scar pregnancy) [11]. The paracervical block procedure is described in detail separately. (See "Pudendal and paracervical block", section on 'Procedure'.)

●If indicated for evaluation of cervical dysplasia, perform endocervical curettage prior to dilation or intrauterine procedures to avoid contamination of the endocervical specimen with endometrial cells. To perform endocervical curettage, an endocervical curette (eg, Kevorkian curette) is inserted into the external cervix and curettage performed in all four quadrants (picture 6). The specimen is then placed onto a nonadherent gauze sponge and given to a surgical staff member who will place it in the appropriate specimen container.

●Dilation – Initiate dilation with a dilator with a diameter that passes easily through the external and internal os (see 'Dilators' above). Sequentially increase the dilator size to accommodate the largest diameter device or instrument that will pass through the cervix. For a commonly used #2 sharp curette, you will need a diameter of 8 mm; for a hysteroscopy, dilate to the diameter of the sheath and scope to be used.

●While dilating, gently pass the dilator until the widest part (the end of the tapered section) is at the internal os (figure 1). With training, surgeons learn to sense this landmark as the loss of mild resistance with application of steady pressure. Typically, the dilator is held lightly between the thumb and first digit of the dominant hand, with the remaining fingers spread laterally to provide a backstop against the perineum for any sudden loss of resistance. Do not apply fundal pressure with the tip of the dilators. If resistance is encountered and then suddenly lost with the dilator advancing notably beyond previous dilators, the clinician should suspect a uterine perforation. Another sign of perforation is losing a feeling of resistance at the level of the uterine fundus, either with the dilator or when checking with a uterine sound.

●Routine use of a uterine sound to measure the length of the uterine cavity does not, in our opinion, add benefit to the procedure unless this information is needed for additional procedures (intrauterine device insertion, endometrial ablation) or to confirm appropriate cavity length if difficulty is encountered when trying to use dilators.

●If hysteroscopy is planned, perform this step next. Hysteroscopy depends upon clear visualization, so it is typically done first before the endometrial surface is disturbed. If a hysteroscope is not available, consider using polyp forceps to explore the cavity for structural lesions that may be amenable to removal (picture 6). (See "Overview of hysteroscopy", section on 'Procedure'.)

●Curettage – If a diagnostic D&C is planned, a metal curette is typically selected. For a therapeutic D&C, suction curettage is preferable when, for example, a larger amount of tissue or blood is anticipated).

•Diagnostic D&C – Insert the metal curette into the uterine fundus, and proceed with curettage by directing pressure with the sharp edge of the curette tip along the uterine walls in a downward scraping motion to the level of the internal os (figure 2). Sampling should be performed along all four walls (anterior, right, posterior, and left) in a systematic fashion to completely sample the endometrium. Perform several passes with the curette. To collect the endometrial specimen, place a piece of nonadherent gauze sponge in the posterior blade of the speculum or retractor. Then bring the curette through the cervix and remove the endometrial tissue, placing it on the gauze sponge.

•Therapeutic D&C for abnormal uterine bleeding – When suction and a plastic curette are used (see 'Curettes' above), connect the curette to the plastic tubing used with an electric suction device with a trap or to a manual vacuum aspiration device. Gently pass the curette to the fundus before activating the suction. Use a similar systematic technique as for diagnostic D&C: sample all four quadrants of the uterus by spinning the tip and slowly withdrawing the curette or by using gentle vertical passes along the walls to the level of the internal os. The technique for suction curettage for induced abortion is described in detail elsewhere. (See "First-trimester pregnancy termination: Uterine aspiration".)

●Curettage should continue until a gritty texture (rather than smooth or slippery texture) is palpable at the tip of the curette, corresponding to successful removal of overlying endometrium. If a plastic curette is used for therapeutic suction D&C, then additional use of a metal curette is generally not needed if the gritty texture of the uterus is noted with the plastic curette and there is no concern for retained tissue or abnormally adherent tissue.

●Once the procedure is completed, the tenaculum should be removed and the cervix inspected for bleeding. Bleeding from tenaculum sites typically responds to direct pressure or application of silver nitrate or ferric subsulfate (Monsel solution). If a laceration is present, suturing may be required. (See 'Cervical injury' below.)

CHALLENGING CASES

Cervical stenosis — Cervical stenosis is common, and indeed, an unsuccessful attempt at endometrial biopsy in the office due to stenosis may be the sole indication for bringing a patient to the operating room for D&C.

Cervical stenosis can be caused by congenital anomalies (eg, due to in utero diethylstilbestrol exposure), prior surgery or other trauma to the cervix (eg, loop electrosurgical excision procedure [LEEP], cone biopsy, obstetric laceration, or cerclage placement), infection, or menopause. Anatomical variations such as severe uterine anteversion/retroversion or uterine fibroids may also impede access to the uterine cavity by causing deviation of the cervical canal. In a series of over 31,000 patients undergoing office hysteroscopy, cervical stenosis was documented in 29.9 percent of premenopausal patients and 70.1 percent of postmenopausal patients [12].

When stenosis is known or anticipated, measures should be taken to facilitate cervical dilation and avoid cervical or uterine injury. While we do not use cervical preparation with prostaglandins or osmotic dilators for most D&C procedures, these may be considered in some cases of known cervical stenosis or obstruction (ie, history of LEEP, cervical fibroids), nulliparous patients, adolescents, or some induced abortion procedures. Of note, there are no studies that have demonstrated successful use of cervical ripening agents such as misoprostol or mifepristone prior to D&C in patients with documented cervical stenosis. (See "Pregnancy termination: Cervical preparation for procedural abortion", section on '12 to <14 weeks'.)

Intraoperative ultrasound guidance can be extremely useful by providing visualization and facilitating access to the cervix and uterine cavity. To perform a D&C under ultrasound guidance, the bladder should be back-filled through a urethral catheter with at least 200 to 300 mL of sterile water or saline to allow transabdominal views of the uterus and cervical canal. Direct visualization of dilators in the cervical canal and then into the endometrial cavity during placement can aid navigation of tortuous cervical canals and avoid creation of false passages [13].

The suggestions below are based on techniques described in the medical literature or used in our practice or by our colleagues for management of cervical stenosis.

Options for management of stenosis at the external cervical os include:

●For postmenopausal patients or in patients with suspected hypoestrogenic states (eg, following treatment with gonadotropin-releasing hormone agonists), an option is preoperative low-dose vaginal estrogen therapy (eg, for two to four weeks).

●Applying cautious blunt pressure to the external cervical os to release adhesions. A narrow dilator may be used or the narrow end of an Adson forceps. Care should be taken to avoid creating a false tract rather than passing the dilator into the cervical canal. Of note, if ultrasound guidance is used, the external os and lower cervical canal may be difficult to define since having a speculum in place will cause interference with the image.

●Injection of saline into the presumed external os for hydro-dissection to allow identification of the canal and create a patent opening.

●Making a small stab incision at the known cervical opening or using a small cautery loop to excise scar tissue at the external os. This is particularly useful in the setting of scar tissue from prior LEEP or cone biopsy procedures.

Options for management of stenosis in the cervical canal or at the internal os include:

●As described above, use of a small metal or plastic dilator under ultrasound guidance to define the cervical canal.

●It may help to reposition the tenaculum and/or to place a posterior tenaculum to maximize traction and effectively straighten the cervical canal.

●Insertion of a flexible diagnostic hysteroscope or standard rigid diagnostic hysteroscope with instillation of fluid to identify the canal under direct visualization.

●Occasionally, a flexible hysteroscope can be passed through the cervical canal, but further dilation with rigid dilators is unsuccessful. In such cases, a small flexible plastic cannula and suction aspiration may be attempted instead of malleable metal instruments. This may be a successful approach because the straight tips of the smallest plastic cannula are often narrower in diameter than the smallest metal curettes, and the flexible design can accommodate abnormal anatomy.

●In selected cases, surgeons have described use of hysteroscopic techniques (with a miniature loop, bipolar tip, or scissors) to resect endocervical tissue or adhesions under direct visualization [12,13]. This requires experience with this technique.

When accessing the cavity is difficult, the possibility of an undiagnosed uterine anomaly or intrauterine adhesion should be considered. If intraoperative ultrasound and the above attempts fail, the D&C attempt should be abandoned, and imaging with a different modality, such as magnetic resonance imaging or saline-infusion sonography, may be useful to better define the anatomy.

If the above maneuvers are unsuccessful and it is important to sample the endometrium, an option is to perform ultrasound-guided biopsy through the cervix or myometrium. This can be done with an extra-long 18- or 20-gauge spinal needle to aspirate intrauterine contents or fluid and obtain a sample for pathologic examination [13].

Obesity — Adequate visualization and access to the cervix may be significantly impacted by a patient's body mass index due to difficulty placing instruments. Measures to facilitate a D&C in patients with obesity include:

●Careful positioning of the patient on a bariatric operative bed and with bariatric leg supports is needed for safety of the patient and optimal exposure.

●Though procedural sedation may be more challenging in patients with obesity, it can facilitate relaxation and visualization that is often not possible in the office setting to allow endometrial sampling.

●To prevent vaginal side wall prolapse into the visual field, a plastic glove finger or a condom with the end cut off can be placed around the speculum blades to form a tube. Vaginal wall retractors are often more useful than speculums in patients with obesity, as they allow for more flexible and directed visualization of the cervix.

●Vaginoscopy can be useful in identifying the cervix and entering the cervical canal, as can placement of an atraumatic tenaculum by palpation alone if the cervix cannot be visualized using a speculum or other vaginal retractors.

●Bariatric length vaginal instruments are available.

COMPLICATIONS — D&C is a very safe procedure, and complications are rare. Potential complications include:

●Uterine perforation

●Cervical injury

●Infection

●Hemorrhage

●Incomplete procedure

●Formation of intrauterine adhesions

●Anesthesia-related complications

Uterine perforation — Uterine perforation is the most common immediate complication of D&C. Rates of perforation depend on the indication for D&C. The highest rate of uterine perforation appears to be in the setting of postpartum hemorrhage (5.1 percent) compared with a lower rate in diagnostic curettage (0.3 percent in the premenopausal patient and 2.6 percent in the postmenopausal patient) [14,15]. Perforation rates overall are higher in the pregnant than the nonpregnant uterus due to softening of the uterine wall and enlargement of the uterine cavity. In general, perforation rates tend to increase with increasing uterine size (lowest in the first trimester and highest in the postpartum uterus).

Uterine perforation may be unrecognized perioperatively, as found in one series of 706 patients undergoing laparoscopic tubal ligation after a first-trimester surgical abortion [16]. The provider-suspected rate of perforation was 0.28 percent, but the rate of perforation noted on laparoscopy was 1.98 percent.

Uterine perforation is discussed in detail separately. (See "Uterine perforation during gynecologic procedures".)

Cervical injury — Injury to the cervix during D&C can occur in the form of an injury to the external cervix from the tenaculum or internal damage to the cervical canal or stroma from dilation or passage of instruments through the cervical canal.

The most common cervical injury is a laceration to the cervical lip when too much traction is applied to a sharp-toothed tenaculum. Most of these injuries can be managed expectantly or become hemostatic with the application of pressure, silver nitrate, or ferric subsulfate (Monsel solution), though in some cases a suture may be needed.

To avoid cervical laceration, some providers prefer atraumatic tenacula or application of a single-toothed tenaculum in the vertical orientation with one tooth in the internal os. This places the force of the tenaculum perpendicular to the circular muscle fibers of the cervix, though this may be more challenging to place the tenaculum in this position if the external os is narrow (eg, postmenopausal patient or cervical stenosis). Also, if an injury occurs with the tenaculum in the vertical configuration, suturing can be done in the transverse direction, which may be technically easier. When the cervix is enlarged and softer as in the case of pregnancy evacuation in the late first and second trimester or postpartum period, we routinely use an atraumatic grasper such as the Bierer tenaculum or a ring forceps to minimize cervical trauma.

Internal cervical lacerations are less common but can occur in the setting of a dilator or curette making a false passage or perforation. To reduce the risk of internal cervical injury, excessive force should be avoided during dilation. There is a risk of laceration of a cervical branch of the uterine artery, which may result in significant bleeding. Internal cervical injuries can be controlled with pressure or direct suture application if injury is relatively minimal. If there is more severe bleeding, options include balloon tamponade with or without therapeutic embolization if bleeding is more significant. Rarely, with high internal cervical injuries, bleeding may extend abdominally or retroperitoneally, requiring further surgical exploration.

Infection — Infection associated with D&C is rare. Very little is known about the incidence or risk factors for infection at the time of diagnostic D&C. The American College of Obstetrics and Gynecology (ACOG) guidelines for antibiotic prophylaxis for gynecologic procedure do not specifically address diagnostic D&C; however, for similar procedures such as endometrial biopsy or procedures often done in concert with D&C including hysteroscopy and endometrial ablation, antibiotic prophylaxis is not recommended [17].

For suction D&C done in the setting of pregnancy, infection risk is higher, and therefore, antibiotic prophylaxis is recommended in these patients. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Antibiotic prophylaxis' and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Prophylactic antibiotics'.)

There are no specific data on infection risk specifically after suction D&C done for spontaneous abortion; however, the risks and incidence are assumed to be similar to induced abortion, and recommendations for prophylaxis and treatment are the same.

Patients with a postprocedure endometritis should be treated per Centers for Disease Control and Prevention (CDC) guidelines for treatment of pelvic inflammatory disease. (See "Pelvic inflammatory disease: Treatment in adults and adolescents".)

Hemorrhage — Hemorrhage is extremely rare with D&C. For diagnostic procedures and therapeutic procedures in the nonpregnant patient, excess bleeding may occur in the setting of cervical injury or perforation, as noted above.

For pregnancy-related suction D&C, in addition to these causes of bleeding, hemorrhage may be due to uterine atony or retained products of conception. (See 'Incomplete procedure' below.)

Management should be aimed at diagnosing and treating the underlying cause, and may include fluid or blood product resuscitation, uterotonics, re-evacuation, or additional measures such as uterine artery embolization or surgical exploration. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Hemorrhage'.)

Abnormal placentation is rare in the first trimester but may be associated with cesarean scar pregnancy or a history of other uterine scarring and can be a cause of significant hemorrhage during first-trimester suction D&C. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Hemorrhage'.)

Unsuspected placenta accreta or percreta may also be cause of notable hemorrhage at the time of postpartum D&C for retained placenta. (See "Placenta accreta spectrum: Management", section on 'Unexpected placenta accreta' and "Overview of postpartum hemorrhage".)

Incomplete procedure — D&C may be complicated by an incomplete procedure, either due to need to abort the procedure or as manifested by retained products of conception after a pregnancy-related suction D&C.

Diagnostic procedures may need to be aborted in the event of severe cervical stenosis or in the event of complications such as hemorrhage or perforation. In cases of unsurmountable cervical stenosis, a repeat procedure may be considered at another time if preprocedure cervical preparation had not previously been used, or other surgical procedures such as hysterectomy may be required.

D&C procedures done in concert with hysteroscopy may need to be aborted if perforation occurs and uterine distension is lost or if there is excessive absorption of distending fluid. In cases of uterine perforation, if there is no accompanying hemorrhage or other instability, careful curettage under ultrasound guidance may still be performed if the boundaries of the endometrial cavity can be carefully ensured. Otherwise, the uterine perforation should be allowed to heal for at least one to two weeks, and then repeat procedure may be performed, preferably with ultrasound guidance.

Management of retained products of conception after pregnancy termination is discussed elsewhere. (See "First-trimester pregnancy termination: Uterine aspiration", section on 'Incomplete or failed abortion'.)

Intrauterine adhesions — Approximately 90 percent of cases of severe intrauterine adhesive disease are related to curettage for pregnancy complications, such as missed or incomplete abortion, postpartum hemorrhage, or retained placental remnants [18,19]. Other risk factors include infection at the time of D&C procedure (septic abortion, endometritis) and concomitant hysteroscopic myomectomy. (See "Intrauterine adhesions: Clinical manifestation and diagnosis" and "Intrauterine adhesions: Treatment and prevention".)

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 subside soon after the procedure but may last for a day or two. Nonsteroidal anti-inflammatory 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 the surgeon if she has fever (more than 100.4°F), cramps lasting longer than 48 hours, increasing pelvic or abdominal pain, prolonged or heavy bleeding, or a foul-smelling vaginal discharge.

Most surgeons recommend pelvic rest for some duration of time, ranging from three days to two weeks, to prevent bleeding and/or infection. There is no evidence to support any specific recommendations.

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Dilation and curettage (D&C) (The Basics)")

●Beyond the Basics topics (see "Patient education: Dilation and curettage (D&C) (Beyond the Basics)")

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SUMMARY AND RECOMMENDATIONS

●Dilation and curettage (D&C) describes a procedure in which cervical dilators are used to facilitate the introduction of instruments into the uterus and the endometrial cavity is either sampled or emptied with a curette. D&C can be used for therapeutic and diagnostic indications and in both the nonpregnant and pregnant uterus. (See 'Introduction' above.)

●There are many indications for D&C, some of these include unsuccessful office endometrial biopsy, further evaluation for endometrial neoplasia after office biopsy, temporary management of patients with abnormal uterine bleeding, and evacuation of products of conception in induced or spontaneous abortion. (See 'Indications' above.)

●Desired ongoing pregnancy is an absolute contraindication to D&C, and D&C should be performed with precautions for patients with risks of increased bleeding including those on anticoagulation or with bleeding diatheses, pelvic infection, or cervical or cesarean scar pregnancy. (See 'Contraindications' above.)

●Use of preoperative misoprostol or osmotic dilators for cervical preparation may reduce the need for mechanical dilation; however, they have potential side effects or limitations that do not support routine use prior to D&C. (See 'Cervical preparation' above.)

●Prophylactic antibiotics are used in pregnant patients prior to D&C. Prophylactic antibiotics are not used in nonpregnant patients undergoing D&C given the low risk of infection. (See 'Prophylactic antibiotics' above.)

●We suggest use of tapered dilators for D&C rather than blunt dilators (Grade 2C). Tapered dilators require less force. (See 'Dilators' above.)

●Cervical stenosis is common. A variety of intraoperative techniques, including use of ultrasound guidance, may facilitate successful D&C and therefore reduce the risk of uterine perforation or creation of a false passage in the cervix. (See 'Cervical stenosis' above.)

●Complications of D&C are rare and may include uterine perforation, cervical injury, infection, hemorrhage, or incomplete procedure. (See 'Complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dale W Stovall, MD, who contributed to an earlier version of this topic review.