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Dilation and curettage

authors: Kari P Braaten, MD, MPH, Caryn Dutton, MD, MS
section editor: Howard T Sharp, MD
deputy editor: Alana Chakrabarti, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2023.

This topic last updated: Jul 06, 2023.

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.

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces
are longer, more sophisticated, and more detailed. These articles are written at the 10th to
12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

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)")
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links:
Gynecologic surgery".)

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.

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. Angioni S, Loddo A, Milano F, et al. Detection of benign intracavitary lesions in

postmenopausal women with abnormal uterine bleeding: a prospective comparative
study on outpatient hysteroscopy and blind biopsy. J Minim Invasive Gynecol 2008;
15:87.

2. Loffer FD. Hysteroscopy with selective endometrial sampling compared with D&C for
abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstet
Gynecol 1989; 73:16.
3. Kaneshiro B, Tschann M, Jensen J, et al. Blood loss at the time of surgical abortion up
to 14 weeks in anticoagulated patients: a case series. Contraception 2017; 96:14.

4. Cooper NA, Smith P, Khan KS, Clark TJ. Does cervical preparation before outpatient
hysteroscopy reduce women's pain experience? A systematic review. BJOG 2011;
118:1292.

5. Kan AS, Ng EH, Ho PC. The role and comparison of two techniques of paracervical
block for pain relief during suction evacuation for first-trimester pregnancy
termination. Contraception 2004; 70:159.

6. Hall G, Ekblom A, Persson E, Irestedt L. Effects of prostaglandin treatment and

paracervical blockade on postoperative pain in patients undergoing first trimester
abortion in general anesthesia. Acta Obstet Gynecol Scand 1997; 76:868.
7. Lazenby GB, Fogelson NS, Aeby T. Impact of paracervical block on postabortion pain
in patients undergoing abortion under general anesthesia. Contraception 2009;
80:578.
 8. Renner RM, Edelman AB, Nichols MD, et al. Refining paracervical block techniques for
pain control in first trimester surgical abortion: a randomized controlled
noninferiority trial. Contraception 2016; 94:461.

9. Hulka JF, Lefler HT Jr, Anglone A, Lachenbruch PA. A new electronic force monitor to
measure factors influencing cervical dilation for vacuum curettage. Am J Obstet
Gynecol 1974; 120:166.

10. Johnson N, Bromham DR. Effect of cervical traction with a tenaculum on the
uterocervical angle. Br J Obstet Gynaecol 1991; 98:309.
11. Schulz KF, Grimes DA, Christensen DD. Vasopressin reduces blood loss from second-
trimester dilatation and evacuation abortion. Lancet 1985; 2:353.

12. Bettocchi S, Bramante S, Bifulco G, et al. Challenging the cervix: strategies to

overcome the anatomic impediments to hysteroscopy: analysis of 31,052 office
hysteroscopies. Fertil Steril 2016; 105:e16.

13. Christianson MS, Barker MA, Lindheim SR. Overcoming the challenging cervix:
techniques to access the uterine cavity. J Low Genit Tract Dis 2008; 12:24.
14. Ben-Baruch G, Menczer J, Shalev J, et al. Uterine perforation during curettage:
perforation rates and postperforation management. Isr J Med Sci 1980; 16:821.

15. Hefler L, Lemach A, Seebacher V, et al. The intraoperative complication rate of

nonobstetric dilation and curettage. Obstet Gynecol 2009; 113:1268.

16. Kaali SG, Szigetvari IA, Bartfai GS. The frequency and management of uterine
perforations during first-trimester abortions. Am J Obstet Gynecol 1989; 161:406.

17. ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures.
Obstet Gynecol 2018; 131:e172. Reaffirmed 2022.

18. March CM. Intrauterine adhesions. Obstet Gynecol Clin North Am 1995; 22:491.

19. Schenker JG. Etiology of and therapeutic approach to synechia uteri. Eur J Obstet
Gynecol Reprod Biol 1996; 65:109.
Topic 3273 Version 30.0
GRAPHICS

Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults*

ACOG
Alternative
Procedure preferred Dose Dose
regimens Δ [3,4]
regimen ¶ [1,2]

Hysterectomy Cefazolin, Cefazolin: Regimen:

(abdominal, including cefoxitin or
<120 kg: 2 Ampicillin- 3 g IV
supracervical, vaginal, cefotetan
g IV sulbactam
laparoscopic, or
robotic) ≥120 kg: Regimen:
3 g IV
Pelvic reconstruction Clindamycin OR 900 mg IV ◊
procedures, including
Cefoxitin or Vancomycin ¶ 15 mg/kg IV
colporrhaphy or
cefotetan: (not to exceed
those involving mesh
2 g per dose)
or vaginal sling 2 g IV
placement PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if

overweight or
obese, based
on adjusted
body weight) §

Aztreonam OR 2 g IV

Fluoroquinolone ¶ ¥

Regimen:

Metronidazole 500 mg IV

PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if

overweight or
obese, based
on adjusted
body weight) §

Fluoroquinolone ¶ ¥

Cesarean delivery Cefazolin <120 kg: 2 g Clindamycin 900 mg IV ◊

(intact membranes, IV
PLUS
not in labor)
≥120 kg: 3 g
Gentamicin 5 mg/kg IV (if
IV
overweight or
 obese, based
on adjusted
body weight) §

Cesarean delivery (in Cefazolin <120 kg: 2 g Clindamycin 900 mg IV

labor, ruptured IV
membrane)
>120 kg: 3 g
IV

PLUS PLUS

Azithromycin 500 mg IV Gentamicin 5 mg/kg IV (if

overweight,
or obese,
based on
adjusted body
weight)

PLUS

Azithromycin 500 mg IV

Uterine evacuation Doxycycline 200 mg

(including surgical orally
abortion, suction
D&C, and D&E)

Hysterosalpingogram, Not recommended ‡

including
chromotubation or
saline infusion
sonography

Laparotomy without Consider <120 kg: 2 g

entry into bowel or cefazolin IV
vagina
≥120 kg: 3 g
IV

Laparoscopy Not recommended

(diagnostic, tubal
sterilization, operative
except for
hysterectomy)

Other transcervical
procedures:
Cystoscopy †
Hysteroscopy
(diagnostic or
operative)
Intrauterine
 device insertion
Endometrial
biopsy
Oocyte retrieval
D&C for non-
pregnancy
indication
Cervical tissue
biopsy, including
LEEP or
endocervical
curettage

ACOG: American College of Obstetricians and Gynecologists; IV: intravenous; D&C: dilation and
curettage; D&E: dilation and evacuation; LEEP: loop electrosurgical excision procedure; IDSA:
Infectious Diseases Society of America; ASHP: American Society of Health-System Pharmacists;
HSG: hysterosalpingogram; PID: pelvic inflammatory disease.
* Common pathogens: Enteric gram-negative bacilli, anaerobes, group B Streptococcus,
enterococci.
¶ Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes
before the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be given
over 60 to 90 minutes and started within 60 to 120 minutes before the initial incision.
Δ An alternative regimen should be used in women with history of immediate hypersensitivity to
beta-lactam agents. Due to increasing resistance of Escherichia coli to ampicillin-sulbactam and
fluoroquinolones, local sensitivity profiles should be reviewed prior to use.
◊ When clindamycin prophylaxis is warranted, UpToDate authors prefer a single dose of 900 mg
based upon pharmacokinetic considerations according to 2013 IDSA/ASHP surgical antibiotic
prophylaxis guidelines. [3] However, a 600 mg dose consistent with ACOG guidance may be
sufficient. [1,2]
§ Gentamicin use for surgical antibiotic prophylaxis should be limited to a single dose given
preoperatively. Based on evidence from colorectal procedures, a single dose of approximately 5
mg/kg gentamicin appears more effective for the prevention of surgical site infection than multiple
doses of gentamicin 1.5 mg/kg every 8 hours. [4] For overweight and obese patients (ie, actual
weight is >125% of ideal body weight), a dosing weight should be used. A calculator to determine
ideal body weight and dosing weight is available in UpToDate.
¥ Ciprofloxacin 400 mg IV OR levofloxacin 500 mg IV OR moxifloxacin 400 mg IV. Fluoroquinolones
are contraindicated in pregnancy and in women who are breastfeeding.
‡ Antimicrobial prophylaxis is recommended for women undergoing HSG or chromotubation with
a history of PID or abnormal tubes noted on HSG or laparoscopy. For these women, an antibiotic
prophylaxis regimen of doxycycline, 100 mg twice daily for 5 days, can be considered to reduce the
incidence of post-procedural PID. [5,6] For women undergoing chromotubation, a single
preoperative 2 gram dose of intravenous cefazolin is recommended, and the patient can be
discharged on the same doxycycline regimen recommended for abnormal HSG.
† Most clinicians exclude urinary tract infection with a urinalysis before cystoscopy, with
subsequent urine culture performed to confirm findings suggestive of infection. Patients with
positive test results should be given antibiotic treatment.

References:
1. ACOG practice bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol 2018;
131:e172.
2. ACOG practice bulletin No. 199: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2018; 132:e103.
3. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
4. Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-blind study of single high
dose versus multiple standard dose gentamicin both in combination with metronidazole for colorectal surgical
prophylaxis. J Hosp Infect 2000; 46:135.
5. Pittaway DE, Winfield AC, Maxson W, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during the
utilization of assisted reproductive technologies: a systematic review. Am J Obstet Gynecol 1983; 147:623.
6. Pereira N, Hutchinson AP, Lekovich JP, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during
the utilization of assisted reproductive technologies: a systematic review. J Pathog 2016; 2016:4698314.
Adapted from: Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.

Graphic 87200 Version 36.0

Pratt and Hegar cervical dilators

(A) Pratt dilator.

(B) Hegar dilator.

Courtesy of William J Mann, Jr, MD.

Graphic 55448 Version 4.0

Sharp uterine curettes

Courtesy of William J Mann, Jr, MD.

Graphic 68468 Version 3.0

Suction uterine curettes

(A) No. 16.

(B) No. 12.
(C) No. 6.

Courtesy of William J Mann, Jr, MD.

Graphic 69749 Version 4.0

Uterine manual vacuum aspiration syringe with flexible suction cannula

From: Krause MS, Nakajima ST. Assessment of the endometrial lining and evacuation of the uterus. In: Operative
Techniques in Gynecologic Surgery: Reproductive Endocrinology and Infertility, Nakajima ST, McCoy TW, Krause MS (Eds),
Wolters Kluwer, Philadelphia 2017. Copyright © 2017. Reproduced with permission from Wolters Kluwer Health.
Unauthorized reproduction of this material is prohibited.

Graphic 119438 Version 2.0

Tenaculums

(A) Beirer tenaculum.

(B) Single tooth tenaculum.

Courtesy of William J Mann, Jr, MD.

Graphic 77725 Version 3.0

Uterine polyp forceps and Kevorkian curette

(A) Kevorkian-Younge curette.

(B) Randall-Stone polyp forceps.

Courtesy of William J Mann, Jr, MD.

Graphic 62722 Version 4.0

Cervical dilation

Courtesy of William J Mann, Jr, MD.

Graphic 77607 Version 1.0

Sharp curette inserted into uterine cavity

Courtesy of William J Mann, Jr, MD.

Graphic 56727 Version 1.0

Contributor Disclosures
Kari P Braaten, MD, MPH No relevant financial relationship(s) with ineligible companies to
disclose. Caryn Dutton, MD, MS No relevant financial relationship(s) with ineligible companies to
disclose. Howard T Sharp, MD No relevant financial relationship(s) with ineligible companies to
disclose. Alana Chakrabarti, MD No relevant financial relationship(s) with ineligible companies to
disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
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