Dilatation & Curettage (D&C, Suction D&C, Vacuum Aspiration)

Last updated 12.12.13

Definition

-  Mechanical +/- medical dilatation of cervix & curettage of uterine cavity

 

Features

-  Women with Chlamydia, Gonorrhoea or BV have increased incidence of PID post D&C

-  May use cervical priming prior to procedure

-  Sublingual Misoprostol reduces dilation force required, haemorrhage & uterine/cervical trauma

-  Failure rate 0.2-0.3%  

- Caution in >12 weeks as uterus larger & softer with higher complication rates

- Day procedure

- Therapeutic or diagnostic

 

Indications

-  Miscarriage

-  Incomplete or Missed (inevitable) especially if

-  Persistant excessive bleeding

-  Haemodynamic instability

-  Suspected gestational trophoblastic disease

-  Suspected infection POC

-  Preferred option by patient (34% women strong preference for)

-  TOP up to 15/40

- RPOC

- Menorrhagia or abnormal bleeding

 

Equipment

- In-out catheter

-  Simms speculum

-  Hagar dilators

- Tenaculum

-  Suction curette

-  Metal curette - blunt

- Spongue forceps

- Drapes

- Sample pot for histopathology

 

Procedure

-  Pre Procedure  

- Discuss options of management

- Consent

- Consideration of pre procedure Abx (case by case basis)

-  If suspected infection of POC delay for 12hrs for IV Abx

-  Sublingual Misoprostol 400mcg 3+hrs prior

-  Confirm nil further passage of POC/tissue +/- with US ie: complete miscarriage

- Confirm blood group for need of Anti-D

- If significant bleeding Hb +/- group & hold

- Sterile procedure

- Gown & glove: Double glove

-  Patient in lithotomy

-  GA or LA +/- sedation

- Bucket below perineum

- Plastic drape under perineum

-  Prep perineum, thighs & vagina with Chlorhexidine or Betadine

- Drape legs & abdomen plus perineum drape (windowed)

-  In-out catheter to drain bladder

-  +/- US to confirm location of POC

- Bimanual palpation to determine if anteverted or retroverted

- Insert Simms speculum

- Anterior cervix grasped with Tenaculum

- Uterine sounding is not required for miscarriage or TOP

-  Cervix dialted progressively with Hagar dilators

-  Usually 8cm is maximum required

- Pre-procedure Misoprostol redcues need for this

-  +/- Hysteroscopy

-  Suction cannula inserted into uterine cavity

-  Suction of uterine cavity & endometrial lining

-  +/- Blunt curettage

-  Routine use of metal curette after suction curettage not required

-  Curetting/suction material to histopathology

- +/- Forceps exploration of uterine cavity

-  +/- US to confirm empty cavity

- Ensure haemostasis & fundus well contracted

-  +/- Syntocinon to reduce blood loss (controversial)

-  10 Units IM or 5 Units IV

- Remove tenaculum

- Remove Simms speculum

-  Anti-D for all Rhesus negative women (regardless of gestation)

- Post procedure

-  Discharge same day once recovered from anaesthetic

-  Debrief patient about pain/cramping & bleeding

- Advise next period may be irregular

- Discuss warning signs of endometritis, RPOC

- Analgesia PRN

- R/V in clinc PRN

- Chase histology to confirm POC

- No sexual intercourse for 2 weeks

 

Complications

- Vasovagal response: hypotension, shock

-  Serious morbidity 2.1%

-  Mortality 0.0005% (5 per million)

-  Perforation of uterus 0.1-0.4%

-  Intra-abdominal trauma

-  Tearing of cervix <1%

-  Intra-uterine adhesions (Ashermans)

-  Heavy blood loss, haemorrhage

-  0.05-0.2% requiring transfusion

-  Cramping post op

-  Infection: Endometritis (PID) 10%

-  Retained products +/- requiring repeat D&C 1-2%

-  Long term risks

-  Future miscarriage

-  Preterm births

-  Placenta praevia

 

 

 

Reference

 

RCOG: Greentop Guideline 25: Management of Early Pregnancy Loss, Oct 2006

NICE Guideline: Ectopic pregnancy & Miscarriage, CG154, December 2012

RANZCOG: Termination of Pregnancy, November 2005

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