Diagnostic Dilation and Curettage

Diagnostic dilation and curettage was originally intended to detect

intrauterine endometrial abnormalities and assist in the management of
abnormal bleeding. Newer techniques are available to assess the uterine
cavity and endometrial findings.[1]However, dilation and curettage still
has a role in centers where advanced technology is not available or when
other diagnostic modalities are unsuccessful.
Traditionally, dilation and curettage has been performed in a blind
fashion. The procedure can be performed under ultrasound guidance or in
conjunction with visualiation of the uterine cavity by a hysteroscope.
!ndications
Diagnostic dilation and curettage is typically employed to assess
endometrial histology. "ractional dilation and curettage also includes
assessment of the endocervi# and biopsy of the ectocervi# and
transformation one.
!ndications for a diagnostic dilation and curettage include the
following$
Abnormal uterine bleeding $ irregular bleeding, menorrhagia, suspected
malignant or premalignant condition
%etained material in the endometrial cavity
&valuation of intracavitary findings from imaging procedures 'abnormal
endometrial appearance due to suspected polyps or fibroids(
&valuation and removal of retained fluid from the endometrial cavity
'hematometra, pyometra( in conjunction with evaluating the endometrial
cavity and relieving cervical stenosis
)ffice endometrial biopsy insufficient for diagnosis or failed due to
cervical stenosis
&ndometrial sampling in conjunction with other procedures 'eg,
hysteroscopy, laparoscopy (
The evaluation of the uterine cavity by dilation and curettage may be
helpful when an office technique, such as ultrasound, is unable to fully
elucidate the endometrium due to shadowing from leiomyomata, a pelvic
mass, or loops of bowel.
*everal studies have evaluated the effectiveness of obtaining
endometrial tissue by endometrial sampling versus D+C. )ne study
compared aspiration biopsy ',ipelle( with D+C. The D+C procedure was
performed without hysteroscopy. This sample of -./ women underwent
hysterectomy following the endometrial sampling or curettage. The
concordance of results was -.0 between endometrial biopsy and
hysterectomy versus .10 between D+C without hysteroscopy and
hysterectomy. The negative predictive value was 230 for detection of
malignancy. !n their conclusions, the authors recommended a presampling
evaluation of the endometrium by a technique such as transvaginal
ultrasound.[2]
4nother study of /-- women evaluated histopathologic findings obtained
by hysteroscopically directed biopsies, versus pathology results of
tissue obtained at D+C. Concordance of results for the 5 procedures was
33.30. !n their conclusions, the authors stated that although
hysteroscopy with directed biopsy was adequate for obtaining diagnosis
from focal lesions, it may not be sufficient for diagnosis of all
pathologic findings in the endometrium, including hyperplasia. They
recommended global endometrial sampling, such as by D+C, be included for
more thorough diagnosis.[3]
Dilation and curettage may also be a therapeutic procedure. &#amples of
this use include the following$
%emoval of retained products of conception 'eg, incomplete abortion,
missed abortion, septic abortion, induced pregnancy termination(
*uction procedures for management of uterine hemorrhage
Treatment and evaluation of gestational trophoblastic disease
Hemorrhage unresponsive to hormone therapy[1]
!n conjunction with endometrial ablation for histologic evaluation of
the endometrium
Contraindications
There are few contraindications to gentle office dilation and curettage,
but a more vigorous e#amination may require an operative suite with
regional or general anesthesia. ,aracervical bloc6 or intravenous
sedation with an anesthesia team standing by for assistance may also be
an option. !ntolerance to office e#aminations or procedures may
determine the setting for the procedure.
4bsolute contraindications to dilation and curettage include the
following$
7iable desired intrauterine pregnancy
!nability to visualie the cervical os
)bstructed vagina
%elative contraindications to dilation and curettage include the
following$
*evere cervical stenosis
Cervical8uterine anomalies
,rior endometrial ablation
9leeding disorder
4cute pelvic infection 'e#cept to remove infected endometrial contents(
)bstructing cervical lesion
These contraindications may be surmounted in some cases. "or e#ample,
magnetic resonance imaging may define the anatomy of the cervical or
uterine anomaly, allowing safe e#ploration of the endocervi# and
endometrium.
Complications
Complications can occur at the time of diagnostic dilation and
curettage. Careful performance of the procedure should minimie these
events. ,ossible complications include the following$
9leeding or hemorrhage
Cervical laceration
:terine perforation
,ostprocedural infection
,ostprocedural intrauterine synechiae 'adhesions(
4nesthetic complications
Complications, particularly uterine perforation, may be increased in a
patient with a recent pregnancy or gestational trophoblastic disease,
prior endometrial ablation, distorted anatomy, cervical stenosis, or
current uterine infection.
Cervical !njury
;aceration of the cervi# primarily occurs during traction, with a
counterforce applied during dilation. !t seems to occur most frequently
with use of a single<tooth tenaculum, especially when it is placed
vertically on the lip of the cervi#. 4 9ierer multi<toothed tenaculum
penetrates less deeply into the cervical tissue and transfers force over
a greater area, potentially decreasing the ris6 of laceration.
;acerations are generally managed with an interrupted or running
interloc6ing dissolvable suture. The same technique would be applied for
a laceration of the posterior cervical lip.
,lacement of a tenaculum is not recommended at the lateral aspect of the
cervi# because of the location of the cervical branches of the uterine
artery.
The ris6 of laceration is reduced by reducing force at dilation, using
more tapered ,ratt dilators or osmotic preparation before the procedure
with laminaria or prostaglandin.
:terine ,erforation
:terine perforation is one of the more common complications of dilation
and curettage. %is6s are increased when dealing with a pregnant or
recently postpartum uterus '=.>0( and are less frequent at the time of a
dilation and curettage remote from pregnancy '1./0 for premenopausal
women and 5.-0 for postmenopausal women(.[4, 5, 6]
The instruments most commonly associated with uterine perforation are
the uterine sound or dilators. !f perforation is 6nown to have occurred
with a blunt instrument, observation of vital and peritoneal signs for
several hours is all that is needed. !f suspicion that a sharp
instrument, such as a curette, has perforated the uterus or if the fat
has been retrieved by curettage, then intraabdominal injury must be
e#cluded by laparoscopy. 4ctive bleeding may necessitate a laparotomy.
!nfection
!nfection related to diagnostic dilation and curettage is rare and is
most li6ely when cervicitis is present at the time of the procedure. )ne
study of infections related to dilation and curettage documented a =0
incidence of bacteremia following dilation and curettage with a very
rare incidence of septicemia.
,rophylactic antibiotics are not recommended for any dilation and
curettage, including for those women who generally require subacute
bacterial endocarditis prophyla#is.
!ntrauterine 4dhesions
Curettage after delivery or abortion may result in endometrial injury
and subsequent development of intrauterine adhesions, termed 4sherman
syndrome. The development of uterine synechiae may also be associated
with prior endometrial ablation procedures. !ntrauterine adhesions may
ma6e future diagnostic curettage more difficult and increase the ris6 of
uterine perforation. ,revious procedures such as endometrial ablation
may also increase the ris6 of cervical stenosis.
Trophoblastic &mboliation
&mboliation of trophoblastic tissue in the systemic circulation is a
very rare complication of dilation and curettage for removal of
gestational trophoblastic disease. This event has been associated with
thyroid storm, cardiovascular collapse, and death. 4 diagnostic dilation
and curettage in patients for whom gestational trophoblastic neoplasia
is suspected should be performed in an operating room with anesthesia.
,eriprocedural Care
&quipment
4 ?raves speculum may be used to visualie the cervi#. 4lternatively, a
weighted speculum with one or more vaginal retractors in the anterior
and lateral vaginal fornices may be used. The latter arrangement or a
?raves speculum with an open side may be preferred if hysteroscopy is
also planned. *ee the images below.
?raves speculum.
*ide opening ?raves
and weighted speculum.
*everal types of
cervical dilators are
commonly used. 4
dilator has a tapered
end. Common dilator
types include the
,ratt, Hegar, and Han6
dilators. *ee the image
below.
Hegar and ,ratt
dilators.
The ,ratt dilator has
the most gradual taper
and ranges in sie from
>/ to @/ "r. The tips
of the Hegar and Han6 dilators are more blunt and may therefore require
greater force to dilate the cervi#. This could increase the ris6 of
cervical laceration or uterine perforation, particularly in a pregnant
uterus or with an inelastic cervi#.
Tissue is removed with a curette, as shown in the image below.
*harp curettes.
The introduction of a
%andall polyps forceps, as
shown in the image below,
may assist removal of
pedunculated structures
such as polyps or myomas or
remove portions of tissue
loosened during the
curettage. *ee the image
below.
%ing forceps, %andall
forceps, and pac6ing
forceps.
,atient ,reparation
4nesthesia
)ffice procedures may
require no formal preoperative preparation if a need for cervical
dilation is absent or minimal and a small<caliber endometrial sampling
device or suction device is employed.
*ome providers suggest patients undergoing cervical or paracervical
instillation of local anesthetic be instructed to have an empty stomach.
Aanipulation of the cervi# and placement of the curette may induce a
vasovagal response with secondary nausea and vomiting.
,atients may be instructed to abstain from oral inta6e of solid foods
for -B3 hours and oral inta6e of clear liquids for 5 or more hours,
even in the office setting. 4 preoperative over<the<counter pain
medication, such as a nonsteroidal anti<inflammatory medication, may be
ta6en with a sip of water at home prior to the procedure to assist with
comfort during and after the dilation and curettage.
,rocedures involving conscious sedation or regional or general anesthesia
should follow the 4merican *ociety of 4nesthesiology guidelines for
abstaining from clear liquids and oral consumption prior to surgical
procedures. The current recommendations are no solid food for 3 hours
preprocedure and no clear liquids for @ hours preprocedure.[7]
,ositioning
The procedure is typically performed in the dorsal lithotomy position.
Care should be ta6en to prevent pressure injuries and e#cess abduction
of the hip joint. ,atients with orthopedic limitations may need to be
positioned before sedation or general anesthesia is employed.
Aonitoring + "ollow<up
Cramps and mild vaginal bleeding are the most common symptoms reported
following a diagnostic dilation and curettage. The e#pectations of these
symptoms should be e#plained to the patient prior to her discharge from
the office or outpatient surgery unit. )ver<the<counter medications are
usually sufficient for pain management.
Heavy bleeding, fever, abdominal pain or distention, nausea and
vomiting, or foul vaginal odor should prompt an evaluation to e#clude
infection, perforation, or retained tissue.
Corsening of pree#isting comorbidities should also be assessed based on
any postoperative symptoms that the patient e#periences.
Technique
4pproach Considerations
,rophylactic antibiotics are not necessary. !n the presence of a septic
abortion or 6nown pelvic infection, a full course of broad<spectrum
antibiotics should be completed.[]
,reoperative tests are not required for the procedure itself, but may be
for the anesthesia. ,regnancy should be e#cluded. The presence of
medical comorbidities may dictate preoperative laboratory or imaging
studies in some patients, such as those with unstable pulmonary or
cardiac disease or severe chronic medical conditions.
The procedure may be performed in an office setting or operating suite
based on the patientDs clinical presentation, comfort, medical
comorbidities, and the suspected diagnosis.
4djunctive measures, such as intraoperative ultrasound or hysteroscopy
preceding dilation and curettage, may allow safer more efficient
evaluation of the endometrial cavity, even in patients with anatomic
abnormality.
&#amination
4n e#amination under anesthesia is performed before beginning the
dilation and curettage procedure. To adequately perform the e#amination,
a large distended bladder may need to be emptied. !ncomplete emptying of
the bladder or reinstillation of sterile fluid via "oley catheter may be
helpful if transabdominal ultrasound guidance is planned.
Careful determination of the uterine sie and fle#ion 'the relationship
of the uterine fundus to the cervi#( and version 'the angle or
relationship of the cervi# to the uterine fundus( will reduce ris6 of
perforation of the uterus. The adne#a should also be carefully e#amined
and a rectovaginal e#amination may be employed if further assessment of
the cul<de<sac or uterine sacral ligaments is pertinent.
,reparation and 7isualiation
4n aseptic solution is applied to the vulva and vagina and appropriate
sterile drapes are placed.
4 ?raves speculum may be used to visualie the cervi#. 4lternatively, a
weighted speculum with one or more vaginal retractors in the anterior
and lateral vaginal fornices may be used. The latter arrangement or a
?raves speculum with an open side may be preferred if hysteroscopy is
also planned.
%emoval of the speculum and retractors after the hysteroscope is placed
into the cervi# and uterus increases mobility of the hysteroscope and
may improve visualiation of the endometrial cavity.
Traction
The cervi# is usually grasped on the anterior lip. 4 single<tooth
tenaculum is frequently used, but a double<tooth or 9ierer tenaculum
will penetrate less deeply into the cervical tissue and may reduce the
ris6 of cervical laceration. 4lternative grasping instruments include
ring forceps or 4llis clamp.
4lternatively, the posterior lip can be grasped if there is a cervical
anatomic abnormality or a previous cervical laceration.
Traction on the cervi# is critical while performing a dilation and
curettage. Traction decreases the angle between the cervi# and uterus up
to .= degrees, reducing the necessary force to dilate the cervi# and the
ris6 of perforation.
&ndocervical Curettage
!f an endocervical curettage specimen is necessary, it should be
obtained before performing cervical dilation or endometrial sounding to
decrease histologic contamination of this specimen. The most common
instrument used for this sampling is a Eevor6ian<Founge curette.
4n alternate sampling method used in the office setting if a patient
cannot tolerate a rigid curette may include a cervical brush introduced
into the endocervi# through a sheath to prevent ectocervical or
transformation one contamination. 4 specimen obtained with this device
should be sent for pathologic e#amination, not to cytology.[!, 1"]
The endocervical sample should be obtained by wor6ing in a
circumferential or four<quadrant fashion to provide a representative
specimen of all areas.
&ndometrial cancer is staged based on the hysterectomy specimen.
Therefore, endocervical curettage is not required for this purpose.
&ndocervical curettage may be employed to evaluate the presence of
cervical dysplasia. !f it is performed in conjunction with a loop
electrocautery e#cision or coniation of the cervi#, it should be
obtained after the e#cisional specimen is removed.
:terine *ounding
4 uterine sound is placed while traction is applied with the tenaculum.
This assists in obtaining information about the uterine sie and the
presence of remaining version and fle#ion. The sound is held lightly
between the thumb and first finger and placed through the cervi# and
into the endometrium without force. The average length from e#ternal os
to fundus is 3<2 cm.
!f cervical stenosis is present, some dilation of the cervi# may be
required before the sound can be placed. *ounding of a pregnant uterus
is not recommended because of the increased ris6 of perforating the soft
myometrium. Transabdominal ultrasound guidance may assist sounding if
altered anatomy is suspected or stenosis is present.
Cervical Dilation
&ach dilator is grasped with the first finger and thumb, similar to the
grasp used with the uterine sound. !t is held at its midportion and
inserted into the cervical os just past the internal cervical os. !t
should not be inserted to the uterus fundus since this may traumatie
the endometrium and subsequent bleeding may limit visualiation if a
hysteroscope is to be used. !nsertions to the fundus may increase the
chance of uterine perforation.
Dilation should continue until the appropriate diameter of the
instruments to be inserted has been achieved.
Cervical ripening agents, such as laminaria or misoprostol, may enhance
the ease of dilation and decrease force required.[11, 12, 13]
*harp Curettage
Curettage is performed in an organied fashion with each placement
proceeding from the fundus to the internal cervical os. Tissue is
removed with a curette through the e#ternal os and collected for
pathologic e#amination.
The curettage is performed in a circumferential fashion, noting the
Guterine cryG that develops when the endometrial cavity is clean. The
uterine cry is a gritty feel with movement of the curette.
*pecial care is ta6en around the uterine cornua, where the myometrium is
thinnest. )ther cavity irregularities such as fibroids, a septum or
polyps, or even prior scars from uterine incisions may be noted by
tactile e#amination with curette. !f a hysteroscope is used before
curettage is performed, visualiation may note the presence of specific
areas for individual biopsy or special attention during the curettage.
The sensation of abnormalities, such as submucous fibroids, may be
detected tactilely with the use of a curette.
4 classic study of the thoroughness of endometrial curettage performed
in patients preparing for hysterectomy revealed that less than 5=0 of
the uterine cavity was sampled in >-0 of patients, less than =10 of the
cavity was sampled in -10 of patients, and less than .=0 of the cavity
was curetted in 3@0 of patients.[14, 15]These statistics represent
adequate sensitivity for the detection of malignant or premalignant
conditions. This sensitivity may also be increased by preoperative
imaging with directed biopsy or intraoperative hysteroscopy.
The introduction of a %andall polyps forceps may assist removal of
pedunculated structures such as polyps or myomas or remove portions of
tissue loosened during the curettage.
*uction Curettage
*uction curettage is infrequently used for diagnostic dilation and
curettage. !t may be indicated if the patientDs bleeding is e#tremely
heavy, a large amount of tissue is visualied at preoperative imaging,
or gestational trophoblastic disease is suspected. 4 suction curette is
substituted for the sharp curettage.
4 cannula is inserted to the mid portion of the endometrial cavity.
*uction is employed with a vacuum pressure of =1<-1 mm Hg and the
cannula is rotated /-1 degrees. &vacuation of the uterus results in a
decreased uterine sie and the tactile sensation of the uterus gripping
the cannula. The cannula may be removed and replaced at the uterine
fundus. Chen tissue is no longer seen in the suction tubing, the cannula
is removed and a sharp curettage performed. 4 circumferential evaluation
of the endometrial cavity is performed and the curettage is complete
when the uterine cry is noted.
!n the operating room in the presence of gestational trophoblastic
neoplasia, a large uterus with retained tissue or products of
conception, or postdelivery bleeding, o#ytocin or other agents that aid
uterine contractility should be immediately available and employed as
needed to decrease blood loss.
"uture Developments
4 future use of endometrial sampling is as a noninvasive method of
obtaining mature natural 6iller cells and hematopoietic stem cells.[16]