Dilatation and Curettage

(D&C)
BSN III – F
Group 18
Dilatation and Curretage
 It is a gynecological procedure in which the lining of
the uterus (endometrium) is scraped away this
procedure involves expanding or enlarging the
entrance of a woman's uterus so that a thin, sharp
instrument can scrape or suction away the lining of
the uterus and take tissue samples.It is minor
surgery performed in a hospital or ambulatory
surgery center or clinic. D&C is usually a diagnostic
procedure and seldom is therapeutic. It may stop
bleeding for a little while (2-6 months), then the prior
abnormal bleeding tends to return.
Purpose
 D&C is commonly used to obtain tissue for
microscopic evaluation to rule out cancer. The
procedure may also be used to diagnose and treat
heavy menstrual bleeding and to diagnose
endometrial polyps and uterine fibroids. D&C can be
used to remove pregnancy tissue after a
miscarriage, incomplete abortion, or childbirth, or as
an early abortion technique up to 16 weeks.
Endometrial polyps may be removed, and
sometimes benign uterine tumors (fibroids) may be
scraped away.
A D&C is often used for the following conditions:

o Irregular bleeding: You may experience irregular

bleeding from time to time, including spotting
between periods. If the spotting develops into
continuous midcycle bleeding, your health care
provider may perform a D&C to investigate the
cause of bleeding.
 Too much bleeding: Bleeding with long, heavy periods, or bleeding after
menopause, can signal a number of problems. These symptoms may
not need immediate investigation. You may observe and record them. At
some point, though, your doctor may look for a cause that is best
detected with a hysteroscopy.
 Fibroids and polyps: These conditions are very common. In fact, they
are thought to occur in about 20% of all women. Fibroid tumors are
noncancerous growths appearing in and on the uterus. Some even
grow out from the uterine wall on a stalk. Fibroids can cause chronic
pain and heavy bleeding. Polyps, like fibroids, are noncancerous
growths and are a common cause of irregular bleeding. Polyps and
fibroids can have symptoms that resemble other more serious causes
of bleeding. Your doctor may still want to perform a hysteroscopy.
 Endometrial cancer: Cancer is a scary word, especially when it is said about
you. A D&C and hysteroscopy are often performed to make certain your
symptoms are not caused by uterine cancer. It is, of course, important to detect
cancer in its earliest, most curable stages
 Therapeutic D&C: A D&C is often planned as
treatment when the source of the problem is already
known. One situation is an incomplete miscarriage or
even full-term delivery when, for some reason, the
uterus has not pushed out all the fetal or placental
tissue inside of it. If tissue is left behind, excess
bleeding can result, perhaps even life-threatening
bleeding. This is an important reason why your doctor
will want to remove any remaining tissue with a D&C.
Your health care provider will avoid D&C in the following
situations, except when absolutely necessary:

 there is a chance the surgical instruments that will enter the

vagina and cervix can carry the bacteria from your vagina or
cervix into your uterus. There is also an increased risk of injury to
infected tissue. For these reasons, your doctor may prefer to wait
until after the infection is cleared up with antibiotics before
performing the D&C.
 Blood clotting disorders: Doctors depend on the body's natural
ability to clot to stop bleeding after curettage. Women with certain
blood disorders are usually not given this surgery.
 Serious medical problems: Heart and lung disease, for example,
can make general, and sometimes local, anesthesia risky.

In fact, D&C is no longer performed as commonly as it was even a

decade ago, thanks to advances in diagnosis (e.g., ultrasound
and hysteroscopy) and nonsurgical hormonal (e.g., oral
contraceptives) and antihormonal (e.g., Lupron) therapies.
Description
 D&C is usually performed under general anesthesia, although local or
epidural anesthesia can also be used. Using local anesthesia reduces risk and
costs, but the patient will feel cramping during the procedure. The type of
anesthesia used often depends upon the reason for the D&C.
 To begin the procedure (which takes only minutes to perform), the doctor inserts
an instrument to hold open the vaginal walls, and then stretches the opening of
the uterus to the vagina (the cervix). This is done by inserting a series of
tapering rods, each thicker than the previous one, or by using other specialized
instruments. The process of opening the cervix is called dilation.
 Once the cervix is dilated, the physician inserts a spoon-shaped surgical device
called a curette into the uterus. The curette is used to scrape away the uterine
lining. One or more small tissue samples from the lining of the uterus or the
cervical canal are sent for analysis by microscope to check for abnormal cells.
 Although simpler, less expensive techniques such as a vacuum aspiration are
quickly replacing the D&C as a diagnostic method, it is still often used to
diagnose and treat a number of conditions, especially when cancer is
suspected.
Preparation
 Because opening the cervix can be painful, sedatives may be
given before the procedure begins. Deep breathing and other
relaxation techniques may help ease cramping during cervical
dilation.

 Aftercare
 A woman who has had a D&C performed in a hospital can
usually go home the same day or the next day. Many women
experience backache and mild cramps after the procedure, and
may pass small blood clots for a day or so. Vaginal staining or
bleeding may continue for several weeks.
 Most women can resume normal activities almost immediately.
Patients should avoid sexual intercourse, douching, and tampon
use for at least two weeks to prevent infection while the cervix is
closing and to allow the endometrium to heal completely.
Risks
 The primary risk after the procedure is infection. Signs of
infection include:
 Fever
 severe cramps
 foul-smelling vaginal discharge A woman should report any of
these symptoms to her doctor, who can treat the infection with
antibiotics before it becomes serious.
 Hemorrhage: Heavy bleeding is rare, but it can happen if an
instrument injures the walls of your uterus. It also can occur if an
undetected fibroid is cut during curettage.
 Infection: There is always a slight possibility of infection once
instruments are inserted into the uterus. Most infections can be
easily cured with antibiotics. Some can be very serious.
Cont…..
 Perforated uterus: This complication, though rare, is more common in women
who have a uterine infection at the time of the procedure, in elderly
postmenopausal women, and if the procedure is being done for a miscarriage. If
your doctor suspects this condition has developed, you may be asked to stay in
the hospital for observation or further surgery.
 Asherman syndrome: This complication is rare and involves the formation of
scar tissue in the uterus, caused by aggressive scraping or abnormal reaction to
the scraping. Thick scars can result, which can fill up the uterus completely. This
can cause your menstrual periods to stop and make you infertile (unable to get
pregnant).
 Missed disease: Studies indicate that only 10-20% of the endometrial cavity is
actually scraped during a D&C, so there is a chance the disease could go
undetected. This is why the procedure is seldom done without a hysteroscopy
anymore.
 D&C is a surgical operation, which carries certain risks associated with general
anesthesia. Rare complications include puncture of the uterus (which usually
heals on its own) or puncture of the bowel or bladder (which requires further
surgery to repair)
Normal Results
 Results are considered normal if no unusual
thickening, growths, or cancers are found.
Removal of the uterine lining causes no side
effects, and may be beneficial if the lining has
thickened so much that it causes heavy
periods. The uterine lining soon grows again
normally, as part of the menstrual cycle.
 Abnormal Results
 Some types of uterine thickening, called hyperplasia, are considered abnormal.
Simple hyperplasia is a benign condition in which the uterine lining becomes
thicker and with more endometrial glands. In complex hyperplasia, another
condition where the uterine lining has thickened, the endometrial glands are
crowded together. In 80% of cases these conditions will improve, and there is little
risk of cancer. Only 1% of simple hyperplasia and 3% of complex hyperplasia will
become cancerous.
 Atypical hyperplasia is a more serious finding. In this type of endometrial
thickening, the cells are abnormal. Twenty-nine percent of women with atypical
hyperplasia develop cancer. In fact, in 17% to 25% of women with atypical
hyperplasia who have a hysterectomy within one month of diagnosis, a carcinoma
is found elsewhere in the endometrium.A D&C is not a fool-proof procedure
because only a portion of the uterine lining is sampled. Therefore, it is possible for
a cancer to be missed. Because of this, patients with atypical hyperplasia must
have another D&C in three or four months. Combining a hysteroscopy (a
procedure where a physician can see the lining of the uterus using a special tool)
with D&C may increase the accuracy of the diagnosis in some cases. However,
this combination is not recommended when endometrial carcinoma is suspected
because of the possibility that the hysteroscopy itself can aid in the spread of
cancer through the fallopian tubes.
ANATOMY AND PHYSIOLOGY
 THE FEMALE REPRODUCTIVE SYSTEM
Cont….
 The female reproductive system is designed to carry out several functions. It
produces the female egg cells necessary for reproduction, called the ova or
oocytes. The system is designed to transport the ova to the site of fertilization.
Conception, the fertilization of an egg by a sperm, normally occurs in the
fallopian tubes. After conception, the uterus offers a safe and favorable
environment for a baby to develop before it is time for it to make its way into the
outside world. If fertilization does not take place, the system is designed to
menstruate (the monthly shedding of the uterine lining). In addition, the female
reproductive system produces female sex hormones that maintain the
reproductive cycle.
 During menopause the female reproductive system gradually stops making the
female hormones necessary for the reproductive cycle to work. When the body
no longer produces these hormones a woman is considered to be menopausal.
 What parts make-up the female anatomy?
 The female reproductive anatomy includes internal and external structures. The
function of the external female reproductive structures (the genital) is twofold: To
enable sperm to enter the body and to protect the internal genital organs from
infectious organisms. The main external structures of the female reproductive
system include:
EXTERNAL FEMALE
GENITALIA
Cont…..
 The external organs of the female reproductive
system include the mons pubis, labia majora, labia
minora, vestibule, perineum, and the Bartholin's
glands. As a group, these structures that surround
the openings of the urethra and vagina compose the
vulva, from the Latin word meaning covering.
 a. Mons Pubis. This is the fatty rounded area
overlying the symphysis pubis and covered with
thick coarse hair.
 b. Labia Majora. The labia majora run posteriorly
from the mons pubis. They are the 2 elongated hair
covered skin folds. They enclose and protect other
external reproductive organs.
Cont….
 c. Labia Minora. The labia minora are 2 smaller folds enclosed
by the labia majora. They protect the opening of the vagina and
urethra.
 d. Vestibule. The vestibule consists of the clitoris, urethral
meatus, and the vaginal introitus.
 The clitoris is a short erectile organ at the top of the vaginal
vestibule whose function is sexual excitation.
 The urethral meatus is the mouth or opening of the urethra. The
urethra is a small tubular structure that drains urine from the
bladder.
 The vaginal introitus is the vaginal entrance.
 e. Perineum. This is the skin covered muscular area between
the vaginal opening (introitus) and the anus. It aids in constricting
the urinary, vaginal, and anal opening. It also helps support the
pelvic contents.
Cont….
 f. Bartholin's Glands (Vulvovaginal or
Vestibular Glands). The Bartholin's glands
lie on either side of the vaginal opening. They
produce a mucoid substance, which provides
lubrication for intercourse.
INTERNAL FEMALE ORGANS
Cont….
 The internal organs of the female consists of the uterus, vagina,
fallopian tubes, and the ovaries.
 a. Uterus. The uterus is a hollow organ about the size and shape
of a pear. It serves two important functions: it is the organ of
menstruation and during pregnancy it receives the fertilized
ovum, retains and nourishes it until it expels the fetus during
labor.
 Location: The uterus is located between the urinary bladder and
the rectum. It is suspended in the pelvis by broad ligaments.
 Divisions of the uterus: The uterus consists of the body or
corpus, fundus, cervix, and the isthmus. The major portion of the
uterus is called the body or corpus. The fundus is the superior,
rounded region above the entrance of the fallopian tubes. The
cervix is the narrow, inferior outlet that protrudes into the vagina.
The isthmus is the slightly constricted portion that joins the
corpus to the cervix.
 Walls of the uterus: The walls are thick and are composed of
three layers: the endometrium, the myometrium, and the
perimetrium. The endometrium is the inner layer or mucosa. A
fertilized egg burrows into the endometrium (implantation) and
resides there for the rest of its development. When the female is
not pregnant, the endometrial lining sloughs off about every 28
days in response to changes in levels of hormones in the blood.
This process is called menses. The myometrium is the smooth
muscle component of the wall. These smooth muscle fibers are
arranged. In longitudinal, circular, and spiral patterns, and are
interlaced with connective tissues. During the monthly female
cycles and during pregnancy, these layers undergo extensive
changes. The perimetrium is a strong, serous membrane that
coats the entire uterine corpus except the lower one fourth and
anterior surface where the bladder is attached.
Cont….
 b. Vagina.
 Location: The vagina is the thin in walled muscular tube about 6 inches long
leading from the uterus to the external genitalia. It is located between the
bladder and the rectum.
 Function: The vagina provides the passageway for childbirth and menstrual flow;
it receives the penis and semen during sexual intercourse.
 c. Fallopian Tubes
 Location: Each tube is about 4 inches long and extends medially from each
ovary to empty into the superior region of the uterus.
 Function: The fallopian tubes transport ovum from the ovaries to the uterus.
There is no contact of fallopian tubes with the ovaries.
 Description: The distal end of each fallopian tube is expanded and has finger-
like projections called fimbriae, which partially surround each ovary. When an
oocyte is expelled from the ovary, fimbriae create fluid currents that act to carry
the oocyte into the fallopian tube. Oocyte is carried toward the uterus by
combination of tube peristalsis and cilia, which propel the oocyte forward. The
most desirable place for fertilization is the fallopian tube.
Cont…
 b. Vagina.
 Location: The vagina is the thin in walled muscular tube about 6 inches long leading from
the uterus to the external genitalia. It is located between the bladder and the rectum.
 Function: The vagina provides the passageway for childbirth and menstrual flow; it
receives the penis and semen during sexual intercourse.
 c. Fallopian Tubes
 Location: Each tube is about 4 inches long and extends medially from each ovary to empty
into the superior region of the uterus.
 Function: The fallopian tubes transport ovum from the ovaries to the uterus. There is no
contact of fallopian tubes with the ovaries.
 Description: The distal end of each fallopian tube is expanded and has finger-like
projections called fimbriae, which partially surround each ovary. When an oocyte is
expelled from the ovary, fimbriae create fluid currents that act to carry the oocyte into the
fallopian tube. Oocyte is carried toward the uterus by combination of tube peristalsis and
cilia, which propel the oocyte forward. The most desirable place for fertilization is the
fallopian tube.
 d. Ovaries
 Functions: The ovaries are for oogenesis-the production of eggs (female sex cells) and for
hormone production (estrogen and progesterone).
Dilation and Curettage Preparation

 Depending on the type of anesthesia used, your doctor's

instructions before a D&C will most likely include the following:
 Avoid unnecessary drugs: A few days before your D&C, stop
taking drugs such as aspirin, which can cause increased risk of
bleeding, and any over-the-counter medications, such as cold
tablets and laxatives. Avoid alcohol and tobacco use. Many
surgeons now recommend you stop taking any herbal
supplements at least 2 weeks before surgery. Talk with your
doctor about all medications you take.
 Chronic conditions: Your doctor will probably want your other
medical problems to be under good control before the surgery.
For example, if you have uncontrolled high blood pressure, you
may be put on a strict treatment plan in or out of the hospital to
improve your blood pressure. This is important to avoid any
unnecessary complications during the D&C procedure.
Cont……
 Eating and drinking: Your doctor will also instruct
you not to eat or drink for 12 hours before your D&C
if it is done under general anesthesia (you are
completely asleep) or for 8 hours before a local or
regional (eg, spinal) anesthesia (just the lower
portion of your body is numbed and you have no
feeling) is used.
 Preliminary tests: On the day before or day of the
procedure, your doctor may want to obtain certain
routine blood, urine, and other tests to be sure no
problems have been missed.
During the Procedure
 Anesthesia
 Local anesthesia: If you have a local anesthetic, you will lie on
your back in the standard pelvic examination position: legs apart
and your knees drawn up. Your doctor will insert an instrument
called a speculum into your vagina to hold the vagina wall apart.
The doctor or assistant will then clean the inner and outer
vagina, including the cervix, with a cleaning solution. The doctor
will then steady the cervix with a clamp and inject a local
anesthetic into the cervix on either side. This is called a
paracervical block and relieves pain from the dilating of the
cervix. It does not numb any of the rest of the body.
 Spinal anesthesia: A needle is placed in the lower back, usually
while the patient is sitting up. Anesthetic is injected through this
needle into the spinal fluid that surrounds the spinal cord. This
causes numbness usually from the level of the belly button on
down. It wears off in 1-3 hours.
Cont….
 General anesthesia: If general anesthesia is
given, you will not be aware of anything
including the cleaning step, after you lose
consciousness. You will lie on the table with
an anesthesiologist or nurse anesthetist at
your head. You may be given an injection of
medication to relax you and to dry up any oral
secretions. You will then receive an
intravenous fast-acting anesthetic and
immediately fall asleep for the procedure.
Cont…

Dilation (the first step): While grasping the cervix with a clamp, the
doctor will pass a thin, flexible piece of metal called a sound to
determine the depth and angle of the uterus. These measurements
allow the doctor to know how far into the uterus the curette can be
safely inserted. The usual method of dilation is to insert a thin, smooth
metal rod gently along the vaginal canal and up into the tiny cervical
opening. The rod is left in place for a moment, then withdrawn and
replaced by a slightly larger rod. This process is repeated until the
cervix has expanded to about the width of a finger. This method takes
about 10 minutes. If you are under local anesthesia, you may
experience crampy discomfort caused by stretching of the cervical
muscles to accommodate the rods. Another method being used with
increasing frequency is to insert laminaria tents (cigarette-shaped
pieces of a special dried seaweed) into the cervix 8-20 hours before the
procedure. The laminaria absorb water from the tissues and swell up,
slowly distending and dilating the cervical canal. This is less traumatic
than using the metal dilators.
Cont….

Hysteroscopy and curettage (the second step): After
dilation, your doctor holds the vagina open again
with the speculum. The doctor may also reach into
the cervix with a tiny spoon to obtain a specimen of
the cervical lining. At this point, the hysteroscope is
usually inserted into the uterus so that the doctor
may look at the inside of the uterus. The doctor may
see fibroids, polyps, or overgrowths of the
endometrium. At that time, instruments may be
inserted through the hysteroscope and biopsy, or
removal, of these things may be accomplished.
Cont…..
 The doctor will now place a slightly longer and larger curette
through the dilated cervix and up into the uterus. This is a metal
loop on the end of a long, thin handle. With steady, gentle
strokes, the doctor will scrape or suction the uterine wall. This
tissue is sent to the lab for analysis. When the curettage is
completed, the instruments are removed.
 If under local anesthesia, you will probably experience a tugging
sensation deep in your abdomen as the curetting is performed. If
this is too painful, you should tell the doctor, who may then order
pain medicine.
 The entire procedure, including curettage takes about 20
minutes. At the end, you may have cramps. This may last about
30 minutes
After the Procedure
 Cramps, like menstrual cramps, will probably be your strongest
sensation immediately after a D&C. Although most women experience
cramps for less than an hour, some women may have cramps for a day
or longer.
 You may also have some light bleeding for several days.
 You will most likely be placed in the recovery room immediately after the
procedure. Most hospitals and outpatient clinics will keep you for an
hour or until you become fully awake. You will need to arrange for a ride
home.
 It is suggested that you do not drive for at least 24 hours after
anesthesia. This is recommended even after a sedative/local anesthesia
because these drugs can temporarily impair your coordination and
response time.
 Naproxen or ibuprofen are usually given for relief from cramping.
Narcotics are seldom, if ever, needed for the pain following the D&C.