Dilation and Curettage (D&C) The dilation and curettage procedure (D&C) involves dilating the uterine cervix

so that the lining tissue (endometrium) of the uterus can be removed by scraping or suction. The D&C is a safe procedure that is done for a variety of reasons. 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. A D&C is often done as an adjunct procedure to a hysteroscopy and/or polypectomy. In addition, a D&C is often used for the following conditions: 1) Irregular or excessive bleeding: Irregular bleeding includes spotting or bleeding between periods. Bleeding with long, heavy periods, or bleeding aftermenopause, can signal a number of problems. A D&C allows removal of the uterine lining and examination of the tissue under a microscope by a pathologist. This can help establish the cause of the abnormal bleeding. The causes of irregular or abnormal bleeding include:

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. Endometrial cancer: A D&C and hysteroscopy are often performed to make certain patient's symptoms are not caused by uterine cancer or precancerous changes. It is, of course, important to detect cancer in its earliest, most curable stages. 2) 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 fetal or placental tissue inside of the uterus has not been completely expelled. If tissue is left behind, excess bleeding can result, perhaps even life-threatening bleeding. Your health care professional will avoid D&C in the following situations, except when absolutely necessary:

Pelvic infection: If you have an infection involving the reproductive organs, 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, the 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 more risky. In fact, D&C is no longer performed as commonly as it was even a decade ago, thanks to advances in diagnosis (for example, ultrasound and hysteroscopy) and nonsurgical hormonal (for example, oral contraceptives) and antihormonal therapies.

Dilation and Curettage Risks and Complications The following are risk factors of dilation and curettage:

Hemorrhage: Heavy bleeding is rare, but it can happen if an instrument injures the walls of the 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. 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 the doctor suspects this condition has developed, the patient 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 lead to infertility and cessation of menstrual periods. Missed disease: Since the procedure cannot completely remove all the endometrium (lining tissue of the uterus), there is a chance that disease could go undetected. This is why the procedure is seldom done without a hysteroscopy (examination of the uterine lining using an instrument that allows direct visualization ).

Dilation and Curettage Preparation Depending on the type of anesthesia used, the 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 medication and laxatives. Avoid alcohol and tobacco use. Many surgeons now recommend the patient stop taking any herbal supplements at least two weeks before surgery. Talk with the doctor about all medications you take. Chronic conditions: The doctor will most likely want the patient's other medical problems stabilized prior to the surgery. For example, if the patient has uncontrolledhigh blood pressure, she may be put on a strict treatment plan in or out of the hospital to improve blood pressure. This is important to avoid any unnecessary complications during the D&C procedure. Eating and drinking: The doctor will also instruct the patient not to eat or drink for 12 hours before your D&C if it is done under general anesthesia (the patient is completely asleep), or for 8 hours before a local or regional (for example, 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, the doctor may want to obtain certain routine blood, urine, and other tests to be sure no medical problems have been missed.

During the Dilation and Curettage Procedure Anesthesia

Local anesthesia: If the patient has a local anesthetic, she will lie on your back in the standard pelvic examination position: legs apart and the knees drawn up. The doctor will insert an instrument called a speculum into the 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. The anesthesia wears off in 1-3 hours. General anesthesia: If general anesthesia is given, the patient will not be aware of anything including the cleaning step, after the patient loses consciousness. The patient will lie on the table with an anesthesiologist or nurse anesthetist at the head. The paitent may be given an injection of medication to assist in relaxing the patient and to dry up any oral secretions. The patient will then receive an intravenous fast-acting anesthetic and immediately fall asleep for the procedure and the patient's breathing will be monitored. 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 the patient is under local anesthesia, she 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. Hysteroscopy and curettage (the second step): After dilation, the 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 the fibroids, polyps, or endometrial overgrowths may be accomplished.

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, the patient will probably experience a tugging sensation deep in the abdomen as the curetting is performed. If this is too painful, the patient should tell the doctor, who may then order pain medicine. The entire procedure, including curettage takes about 20 minutes. At the end, the patient may have cramps that may last about 30 minutes; however, some women experience cramps for a much longer period of time.

After the Dilation and Curettage Procedure

The recovery time is generally short following a D&C. Cramps, similar to menstrual cramps, will probably be the patient's 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 more. The patient may also have some light bleeding for several days. The patient will most likely be placed in the recovery room immediately after the procedure. Most hospitals and outpatient clinics will keep the patient for an hour or until she is fully awake. The patient will need to arrange for a ride home. It is suggested that the patient not drive for at least 24 hours after anesthesia. This is recommended even after a sedative/local anesthesia because side effects of these drugs can temporarily impair the 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.