Obstetrics Book

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Suction Dilation and Curettage

Aka: Suction Dilation and Curettage, Dilation and Curettage
  1. Indications
    1. Spontaneous Abortion
    2. Suspected Ectopic Pregnancy
    3. Menorrhagia
    4. Anormal uterine bleeding evaluation
    5. Retained products of conception
  2. Contraindications
    1. Acute pelvic infection
    2. Coagulopathy
    3. Possible fetal viability
    4. Patients religious beliefs prohibit D&C
    5. Uterine Size >12 weeks for inexperienced clinician
      1. Week 12 Uterus correlates with Grapefruit size
  3. Preparation: General
    1. IV Access
    2. Labs
      1. Hemoglobin or Hematocrit
      2. Rh Test
    3. Cervical dilation before procedure
      1. Laminaria placed overnight prior to procedure or
      2. Cytotec 600 mcg PO or 400 mcg vaginal 2-4 hours prior
    4. Bimanual exam
      1. Determine uterine fundal position
      2. Evaluate Uterine Size (Consider consult if >12 weeks)
  4. Preparation: Additional for heavy bleeding
    1. Labs: Coagulation disorder suspected
      1. Complete Blood Count
      2. Prothrombin Time (PT or INR)
      3. Partial Thromboplastin Time (PTT)
      4. Fibrin split products
      5. Blood type and screen
    2. Medications if Menorrhagia or Uterine Size > 12 weeks
      1. Oxytocin 20 units per liter of IV fluid
  5. Anesthesia: Conscious Sedation
    1. Sedation
      1. Versed 2-5 mg IV
    2. Analgesia
      1. Fentanyl 50-100 mcg
    3. Anesthesia
      1. Regional: Paracervical Block (see below)
      2. Consider light general anesthesia
    4. Precautions
      1. Use Pulse Oximeter
      2. Flumazenil and Naloxone at bedside
  6. Procedure
    1. Anesthesia as above
    2. Prepare Cervix
      1. Expose Cervix with medium Graves speculum
      2. Use antiseptic over Cervix and posterior fornix
      3. Apply single toothed tenaculum to anterior Cervix lip
    3. Paracervical Block indications
      1. General anesthesia not used and
      2. Cervix requires manual dilation
    4. Cervical dilation
      1. See preparation above regarding cervical dilation or
      2. Serial cervical dilators progressively dilate Cervix
        1. Risk of uterine perforation
        2. Use Hagar dilators to open Cervix to 8-9 mm
    5. Uterine sound
      1. Determine orientation of Cervix and uterine depth
      2. Normal non-pregnant Uterus may approach 8 cm
    6. Insert suction curette
      1. Use largest curette that will easily pass via Cervix
        1. Curettes sizes used are usually 8-12 french
        2. Use Uterine Size in weeks to estimate curette size
        3. Example: Use a 9 french curette for 9 week Uterus
      2. Curette shape
        1. Curved curette: Anteflexed or retroflexed Uterus
        2. Straight curette: Mid-position Uterus
      3. Insertion precautions
        1. Insert while stabilizing Cervix with tenaculum
        2. Do not force the curette (risk of perforation)
        3. Stop inserting when curette meets resistance
    7. Apply suction
      1. Attach suction hosing and turn suction machine on
      2. Close suction valve on handle
      3. Increase suction to at least 60 to 65 mmHg
      4. Alternative device: Manual Vacuum Aspiration
        1. Plastic syringe requires no suction pump
        2. May be used in early gestation
    8. Rotate curette
      1. Move curette slightly in and out while rotating
        1. Avoid jabbing motions due to risk or perforation
      2. Rotate suction curette clockwise several times
      3. Rotate suction curette counterclockwise several times
      4. Withdraw curette and turn suction off
      5. Do not allow curette to touch vagina with suction on
      6. Reinsert curette and repeat suction again
  7. Lab: Products of Conception
    1. Examine suction contents
      1. Products will be grey intermixed with blood
      2. Yellow fluid may be present
    2. Send to pathology
      1. Confirm intrauterine pregnancy (chorionic villi)
  8. Post-Procedure Care
    1. RhoGAM 50 mcg if Rh Negative (early pregnancy dose)
    2. Observe for complications (see below)
    3. Routine management for excessive bleeding
      1. See below under complications
  9. Complications
    1. Uterine perforation
      1. Consider broad-spectrum Cephalosporin
      2. Blunt perforation (e.g. uterine sound): Observe
      3. Sharp perforation (e.g. curette)
        1. High risk for bowel perforation, peritonitis
        2. Requires immediate surgical Consultation
    2. Retained products of conception
      1. May result in persistent cramping and bleeding
      2. Confirmed by Ultrasound
      3. Management
        1. Broad spectrum Cephalosporin
        2. Repeat procedure under Ultrasound guidance
        3. Consider Oxytocic (Pitocin, Methergine or Cytotec)
    3. Excessive bleeding
      1. See Post-procedure care
      2. Consider differential diagnosis
        1. Uterine perforation
        2. Retained products of conception
        3. Trauma to vagina, Cervix or Uterus from D&C
        4. Bleeding Disorder (e.g. Von Willebrand's Disease)
      3. Initial management after procedure (routine)
        1. Pitocin 20 units in 1 Liter IV or 10 units IM or
        2. Methergine 0.2 mg IM or PO
      4. Later management
        1. Methergonovine 0.2 mg PO qid for 2 days
        2. Misoprostel 200 mcg PO qid for 2 days (not FDA)
    4. Infection (Endometritis)
      1. Presents as fever, uterine tenderness, Leukocytosis
      2. Hospitalize ill appearing patients
      3. Antibiotic selection
        1. Broad spectrum Cephalosporin or
        2. Ampicillin, Gentamycin, and Clindamycin
    5. Asherman's Syndrome
      1. Rare late complication
      2. More common if D&C performed at time of infection
  10. References
    1. Curran in Pfenninger (1994) Procedures, p. 672-7
    2. Eisinger in Pfenninger (1994) Procedures, p. 699-713
    3. Deutchman (2000) ALSO Course Syllabus, p. A17-21

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