View source for Dilation and curettage

{{Short description|Gynecological procedure}}
{{Infobox abortion method |
| name            = Dilation and curettage
| AKA/Abbreviation= D&C
| Abortion_type   = Surgical
| Date_first_use  = Late 19th century
| Date_last_use   = 
| Gestational_age = 4–12 weeks
| Usage_notes     = WHO recommends only when manual vacuum aspiration is unavailable
| Use_AU%         = <!-- Australia -->
|   Use_AU_date   = 
| Use_CA%         = <!-- Canada-->
|   Use_CA_date   = 
| Use_NZ%         = <!-- New Zealand -->
|   Use_NZ_date   = 
| Use_UK%         = <!-- United Kingdom -->
|   Use_UK_date   = 
| Use_US%         = 1.7
|   Use_US_date   = 2003
| Use_ZA%         = <!-- South Africa -->
|   Use_ZA_date   = 
| Medical_notes   = Undertaken under heavy sedation or general anesthesia. Risk of perforation. Day-case procedure
}}

'''Dilation''' (or '''dilatation''') '''and curettage''' ('''D&C''') is a medical procedure that [[Cervical dilation|dilates]] (widens or opens) the [[cervix]] and surgically removes tissue from the lining of the [[uterus]] by scraping or scooping ([[curettage]]).  The D&C [[gynecological|gynecologic]] procedure is used for treatment, diagnostic and therapeutic purposes.  

D&C can be used to end an unwanted pregnancy or to remove the remains of a non-viable fetus.  It can also be used to remove the placenta after childbirth, abortion, or miscarriage.  D&C is a commonly used method for first trimester [[abortion]] or [[miscarriage]].<ref name="Abortion Statistics in the U.S.A. 2010">{{cite journal| last1= Pazol |first1= Karen | first2= Andreea A.| last2= Creanga| first3= Kim D.| last3= Burley| first4= Brenda |last4= Hayes| first5= Denise J. |last5= Jamieson |display-authors= 3| title=Abortion Surveillance – United States, 2010| date= November 29, 2013 | volume= 62| number= ss08| pages= 1–44 |url= https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6208a1.htm?s_cid=ss6208a1_w#tab11| journal= Surveillance Summaries | via= CDC.gov |publisher= Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, [[Centers for Disease Control]] |pmid= 24280963 |access-date=14 January 2014}}</ref><ref name= "webmd abort">{{cite web | title = Dilation and sharp curettage (D&C) for abortion | website = WebMD | date = 2004-10-07 | url = http://women.webmd.com/dilation-and-sharp-curettage-dc-for-abortion | access-date = 2007-04-29 }}</ref><ref name="webmd gyne">{{cite web|last=Hayden |first=Merrill |title=Dilation and curettage (D&C) for dysfunctional uterine bleeding |website= WebMD.com  |date=2006-02-22 |url=http://www.webmd.com/sexual-conditions/Dilation-and-curettage-DC-for-dysfunctional-uterine-bleeding|archive-url= https://archive.today/20071021223925/http://www.webmd.com/sexual-conditions/Dilation-and-curettage-DC-for-dysfunctional-uterine-bleeding |url-status=dead |archive-date=2007-10-21 |access-date=2007-04-29 }}</ref><ref>{{cite web|last=Nissl |first=Jan |title=Dilation and curettage (D&C) for bleeding during menopause |website= WebMD.com |date=2005-01-18 |url=http://www.webmd.com/menopause/Dilation-and-curettage-DC-for-bleeding-during-menopause |access-date=2007-04-29 }}</ref> D&C can also be used to remove tissue from the [[uterus]] for diagnostic purposes. 

D&C normally refers to a procedure involving a [[curette]], also called ''sharp curettage''.<ref name="webmd abort" /> However, some sources use the term ''D&C'' to refer to any procedure that involves the processes of dilation and removal of uterine contents which includes the more common ''suction curettage'' procedures of manual and electric [[vacuum aspiration]].<ref name="webmd miscar">{{cite web |url= http://www.webmd.com/sexual-conditions/pregnancy-loss-neonatal-death?page=3|title=What Every Pregnant Woman Need to Know About Pregnancy Loss and Neonatal Death |date=2004-10-07|website=The Unofficial Guide to Having a Baby|publisher= WebMD|archive-url= https://web.archive.org/web/20080528141252/http://www.webmd.com/baby/pregnancy-loss-neonatal-death?page=3|archive-date=28 May 2008|access-date= 2007-04-29}}</ref>

==Clinical uses==
D&amp;Cs may be performed in pregnant and non-pregnant patients, for different clinical indications. Such examples are for early abortion, removing the remains of a non-viable pregnancy or retention of placenta from a pregnancy loss/abortion. Treatment of menopause induced anomalies with menstrual cycle.

=== During pregnancy or postpartum ===
A D&C may be performed early in pregnancy to remove pregnancy tissue, either in the case of a non-viable pregnancy, such as a [[Missed abortion|missed]] or [[incomplete miscarriage]], or an [[undesired pregnancy]], as in a [[Abortion|surgical abortion]].<ref name=":3" />

Dilation and curettage has been declining as a method of abortion, due to medication-based non-invasive methods of abortion, such as [[misoprostol]] and [[mifepristone]]. Suction curettage is still the most common and preferred method to ensure complete removal of remains, as the method is a completed process used for termination of a first-trimester pregnancy.<ref name=":1">{{Cite web|date=16 June 2015| title= Minor surgical procedure common in O&G associated with increased risk of preterm delivery|url=https://www.eurekalert.org/pub_releases/2015-06/esoh-msp061015.php|access-date=2018-10-17| website= EurekAlert! |publisher=European Society of Human Reproduction and Embryology}}</ref><ref>{{Cite web| date=September 2019|title=INDUCED ABORTION in The United States|url=https://www.guttmacher.org/fact-sheet/induced-abortion-united-states |website= guttmacher.org| publisher= [[Guttmacher Institute]]| access-date=11 October 2019}}</ref> The [[World Health Organization]] recommends D&C with a sharp curette as a method of surgical abortion only when manual [[vacuum aspiration]] with a suction curette is unavailable.<ref>{{Cite book| title=Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Do ctors |year= 2017| isbn= 9789241565493 |page= P-71| publisher=[[World Health Organization]], [[UNICEF]], United Nations Population Fund}}</ref>

For patients who have recently given birth, a D&C may be indicated to remove retained placental tissue that does not pass spontaneously or for postpartum hemorrhage.<ref>{{cite journal|vauthors=Wolman I, Altman E, Fait G, Har-Toov J, Gull I, Amster R, Jaffa A| display-authors= 3 |year=2009|title=Evacuating Retained Products of Conception in the setting of an ultrasound unit|journal=Fertil. Steril.|volume=91|issue=4 Suppl|pages=1586–1588 |doi= 10.1016/j.fertnstert.2008.10.032|pmid=19064261|doi-access=free}}</ref>

=== Non-pregnant patients ===

D&Cs for non-pregnant patients are commonly performed in tandem with  Hysteroscopy another diagnostic procedure, for the diagnosis of gynecological conditions usually involving abnormal bleeding; during menopause or with various abnormal structures growing within the uterus<ref>{{cite journal|vauthors=Anastasiadis PG, Koutlaki NG, Skaphida PG, Galazios GC, Tsikouras PN, Liberis VA|year=2000|title=Endometrial polyps: prevalence, detection, and malignant potential in women with abnormal uterine bleeding|journal=Eur J Gynaecol Oncol.|volume=21|issue=2|pages=180–183|pmid=10843481}}</ref> to remove the excess uterine lining in women who have conditions such as [[polycystic ovary syndrome]];<ref name=":0">{{Cite web|date=2016|title=Dilation and Curettage (D&C)|url=http://www.phyllisgeemd.com/Home/PatientEducation/tabid/10903/ctl/View/mid/18015/Default.aspx?ContentPubID=445|access-date=2018-10-17|website=www.phyllisgeemd.com|publisher=Practice Builders & Health Central Women's Care, PA|archive-date=2009-04-25|archive-url=https://web.archive.org/web/20090425224143/http://www.phyllisgeemd.com/Home/PatientEducation/tabid/10903/ctl/View/mid/18015/Default.aspx?ContentPubID=445|url-status=usurped}}</ref> to remove tissue in the uterus that may be causing abnormal uterine bleeding, such as endometrial [[Endometrial polyp|polyps]] or [[uterine fibroid]]s;<ref name="webmd gyne" /><ref name="webmd abort" /> or to diagnose the cause of [[post-menopausal bleeding]], such as in the case of [[endometrial cancer]].

[[Hysteroscopy]] is a valid alternative or addition to D&C for many surgical indications, from diagnosis of uterine pathology to the removal of fibroids and even retained tissue of Pregnancy. It allows direct visualization of the inside of the uterus and may allow targeted sampling and removal of tissue inside the uterus.<ref>{{Cite web|title=Hysteroscopy|url=https://my.clevelandclinic.org/health/treatments/10142-hysteroscopy|access-date=11 October 2019|website=Cleveland Clinic}}</ref>

==Procedure==
[[File:Dilation & curettage.svg|thumb|An illustration of a dilation and curettage]] Depending on the anticipated duration and difficulty expected with the procedure, as well as the clinical indication and patient preferences, a D&C may be performed with [[local anesthesia]], [[Conscious sedation|moderate sedation]], deep sedation, or [[General anaesthesia|general anesthesia]].<ref>{{Cite journal|last1=Allen|first1=Rebecca H.|last2=Singh|first2=Rameet|date=2018-06-01|title=Society of Family Planning clinical guidelines pain control in surgical abortion part 1 – local anesthesia and minimal sedation|url=https://www.contraceptionjournal.org/article/S0010-7824(18)30036-2/abstract|journal=Contraception|language=en|volume=97|issue=6|pages=471–477|doi=10.1016/j.contraception.2018.01.014|issn=0010-7824|pmid=29407363|doi-access=free}}</ref> The first step in a D&C is to place a [[Speculum (medical)|speculum]] in the vagina so as to see the cervix. Often, a [[tenaculum]] is placed to steady the cervix. Next, the provider will dilate the [[cervix]]. This can be done with [[Hegar dilators|Hegar]] or similar dilators.<ref name=":3">{{cite web|url=https://www.acog.org/Patients/FAQs/Dilation-and-Curettage|title=ACOG: FAQ: Dilation and Curettage|website=[[American College of Obstetricians and Gynecologists]]|access-date=10 January 2020}}</ref> The amount of dilation depends on the amount of tissue to be removed as well as the size of the instruments to be used. After sufficient dilation, a curette, a metal rod with a handle on one end and a loop on the other, is then inserted into the uterus through the dilated cervix. The curette is used to gently scrape the lining of the uterus and remove the tissue in the uterus. If a [[Suction curettage|suction curette]] is used, as in a [[vacuum aspiration]], a plastic tubular curette will be introduced into the uterus and connected to suction to remove all tissue in the uterus. This tissue is examined for completeness (in the case of abortion or miscarriage treatment) or by [[pathology]] for abnormalities (in the case of treatment for [[Dysfunctional uterine bleeding|abnormal bleeding]]).<ref name="webmd abort" />

==Complications==
The most common complications associated with D&C are infection, bleeding, or damage to nearby organs, including through uterine perforation.<ref>{{cite web|title=Dilation and curettage (D&C)|publisher=Mayo Clinic|url=https://www.mayoclinic.org/tests-procedures/dilation-and-curettage/about/pac-20384910|access-date=24 October 2020}}</ref> Aside from the surgery itself, complications related to [[anesthesia]] administration may also occur.

[[Infection]] is uncommon after D&C for a non-pregnant patient, and society practice guidelines do not recommend routine prophylactic antibiotics to patients.<ref name=":2">{{Cite journal|date=June 2018|title= ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures| publisher= American College of Obstetricians Gynecologists' Committee on Practice Bulletins – Gynecology |journal=Obstetrics & Gynecology |volume= 131 |issue= 6 |pages= e172–e189|doi=10.1097/AOG.0000000000002670|pmid=29794678|s2cid= 44097972|issn=0029-7844}}</ref> However, for curettage of a pregnant patient, the risk of infection is higher, and patients should receive antibiotics that cover the bacteria commonly found in the vagina and gastrointestinal tract; [[doxycycline]] is a common recommendation, though azithromycin may also be used.<ref name=":2" />

Another risk of D&C is [[uterine perforation]]. The highest rate of uterine perforation appears to be in the setting of postpartum hemorrhage (5.1%) compared with a lower rate in diagnostic curettage in non-pregnant patients (0.3% in the premenopausal patient and 2.6% in the postmenopausal patient).<ref>{{Cite journal| last1= Hefler |first1= Lukas |last2= Lemach |first2= Andrea |last3= Seebacher |first3= Veronika |last4= Polterauer |first4=Stephan|last5=Tempfer|first5= Clemens |last6= Reinthaller |first6= Alexander |display-authors=3 |date=June 2009 |title= The Intraoperative Complication Rate of Nonobstetric Dilation and Curettage|journal=Obstetrics & Gynecology |volume= 113 |issue= 6 |pages= 1268–1271| doi= 10.1097/AOG.0b013e3181a66f91|pmid=19461421|s2cid=205471595|issn=0029-7844|doi-access= free }}</ref> Perforation may cause excessive bleeding or damage to organs outside the uterus. If the provider is concerned about ongoing bleeding or the possibility of injury to organs outside the uterus, a [[laparoscopy]] may be done to verify that there has been no undiagnosed injury.

Another potential risk is [[Asherman's syndrome]], a condition where intrauterine adhesions lead to [[Infertility|subfertility]], [[amenorrhea]], or [[Recurrent miscarriage|recurrent pregnancy loss]]. Although older studies<ref name="freidler">{{cite journal |display-authors=3 |vauthors=Friedler S, Margalioth EJ, Kafka I, Yaffe H |year=1993 |title=Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy – a prospective study |journal=Hum. Reprod. |volume=8 |issue=3 |pages=442–444 |doi=10.1093/oxfordjournals.humrep.a138068 |pmid=8473464}}</ref><ref name="Schenker">{{cite journal |vauthors=Schenker JG, Margalioth EJ |year=1982 |title=Intra-uterine adhesions: an updated appraisal |journal=Fertility and Sterility |volume=37 |issue=5 |pages=593–610 |doi=10.1016/S0015-0282(16)46268-0 |pmid=6281085 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Kodaman PH, Arici A |year=2007 |title=Intrauterine adhesions and fertility outcome:how to optimize success? |journal=Current Opinion in Obstetrics and Gynecology |volume=19 |issue=3 |pages=207–214 |doi=10.1097/GCO.0b013e32814a6473 |pmid=17495635 |s2cid=3082867}}</ref> described a high (25-30%) risk of developing this condition after dilation and curettage for treatment of miscarriage, these procedures were likely done using sharp curettage, which is no longer routinely performed in modern miscarriage and abortion care. Newer studies<ref name=":4">{{Cite journal |last1=Sevinç |first1=Fahrünnisa |last2=Oskovi-Kaplan |first2=Z. Asli |last3=Çelen |first3=Şevki |last4=Ozturk Atan |first4=Deniz |last5=Topçu |first5=Hasan Onur |date=2021 |title=Identifying the risk factors and incidence of Asherman Syndrome in women with p ost-abortion uterine curettage |url=https://onlinelibrary.wiley.com/doi/10.1111/jog.14667 |journal=Journal of Obstetrics and Gynaecology Research |language=en |volume=47 |issue=4 |pages=1549–1555 |doi=10.1111/jog.14667 |pmid=33462894 |s2cid=231642553 |issn=1341-8076|url-access=subscription }}</ref><ref name=":5">{{Cite journal |last1=Gilman Barber |first1=Ashley R. |last2=Rhone |first2=Stephanie A. |last3=Fluker |first3=Margo R. |date=2014 |title=Curettage and Asherman's Syndrome—Lessons to (Re-) Learn? |journal=Journal of Obstetrics and Gynaecology Canada |volume=36 |issue=11 |pages=997–1001 |doi=10.1016/s1701-2163(15)30413-8 |pmid=25574677 |issn=1701-2163|doi-access=free }}</ref> reflect the common technique of suction curettage and demonstrate a much lower risk of Asherman's syndrome, with incidence in large prospective trials ranging from 0.7 to 1.6%. A history of multiple (>3) procedures<ref name=":4" /> and sharp curettage<ref name=":5" /> were identified as risk factors for developing clinical Asherman's syndrome. A systematic review in 2013 concluded that recurrent miscarriage treated with D&C is the main risk factors for intrauterine adhesions.<ref name="Hooker2013">{{cite journal |display-authors=3 |vauthors=Hooker AB, Lemmers M, Thurkow AL, Heymans MW, Opmeer BC, Brölmann HA, Mol BW, Huirne JA |year=2013 |title=Systematic review and meta-analysis of intrauterine adhesions after miscarriage: Prevalence, risk factors and long-term reproductive outcome |url=https://academic.oup.com/humupd/article-pdf/20/2/262/17158384/dmt045.pdf |journal=Human Reproduction Update |volume=20 |issue=2 |pages=262–278 |doi=10.1093/humupd/dmt045 |pmid=24082042 |doi-access=free}}</ref> There are currently no studies linking asymptomatic intrauterine adhesions and long-term reproductive outcomes, and similar pregnancy outcomes have been found after miscarriage regardless of whether surgical treatment, medication management, or conservative management (i.e. [[watchful waiting]]) was chosen.<ref name="Hooker2013" />

==See also==
* [[Dilation and evacuation]]
* [[Menstrual extraction]]
* [[Vacuum aspiration]]

==References==
{{reflist}}

==External links==
* [https://www.mayoclinic.org/tests-procedures/dilation-and-curettage/about/pac-20384910 Dilation and curettage (D&C)] at [[Mayo Clinic]]
<!--* http://womanworldonline.pl/ May be a good site, but doesn't point to the topic of the article, and it's in Polish-->

{{Abortion}}
{{Urogenital surgical procedures}}

{{DEFAULTSORT:Dilation And Curettage}}
[[Category:Obstetrical and gynaecological procedures]]
[[Category:Miscarriage]]
[[Category:Methods of abortion]]
[[Category:Cervix]]
[[Category:Uterus]]