The Practitioner Le praticien

The occasional D & C

Nancy Humber, MD ilatation and curettage (D & before misoprostol is given. For preg- Lillooet, BC D C) is a surgical procedure nancy terminations, ultrasonography involving a scraping or may help to confirm gestational age. Correspondence to: Dr. Nancy Humber, curettage of the lining of the uterus Box 850, Lillooet BC (endometrium). There are several elec- PERIOPERATIVE MEDICATIONS V0K 1V0; tive and emergency reasons for perform- [email protected] ing a D & C: Anxiety This article has been peer • evacuation of remaining placental reviewed. tissue in a postpartum woman Perioperative anxiety can be treated • evacuation of tissue following an with 1 mg of sublingual lorazepam. incomplete miscarriage This does not significantly compound • evacuation and examination of tissue the effect of other sedating intravenous that may be causing irregular, heavy medication used later in the procedure. or dysfunctional uterine bleeding • termination of pregnancy Misoprostol

PATIENT PREPARATION The use of buccal misoprostol has revo- lutionized cervical dilation. This medica- History tion softens and opens the , mak- ing dilation quite easy. It is particularly Before performing any surgical proce- useful in primiparous patients. Miso- dure, a pertinent medical, obstetric and prostol 200–400 µg is taken bucally surgical history is taken. This includes 2 hours before the procedure. It is less Rh and gravida status and anesthetic useful when the cervix has recently been risk assessment. When appropriate, or is currently dilated. Because of the counselling about pregnancy options prostaglandin effect, patients who have and postprocedure contraception asthma that is currently active should should be offered. Following a discus- not receive this medication. Common sion of complications, including discus- side effects include nausea, cramping, sion of blood transfusion, consent is vaginal bleeding and diarrhea. Miso- obtained and booking completed. prostol can also be used to prevent sig- nificant postprocedure bleeding. Physical examination Perioperative antibiotics Patients requiring this procedure are often otherwise healthy. If necessary, a All high-risk patients should receive physical examination can be done at 1 g azithromycin and/or 400 mg cefixime the time of the procedure. It includes orally before the procedure for chlamydia cardiovascular and airway assessment and gonorrhea prophylaxis, respectively. to ensure grade 1 sedation risk. Pap All patients should receive 2 g metronida- test, vaginal swabs for sexually trans- zole orally. Because of perioperative nau- mitted infection (STI) testing and a sea from medication and pregnancy, it is 115 bimanual examination are performed. acceptable for the metronidazole to be Gestational age should be confirmed given after the procedure.

© 2009 Society of Rural Physicians of Canada Can J Rural Med 2009; 14 (3) SURGICAL PROCEDURE TECHNIQUE PROCEDURE

Equipment 1. With intravenous line in situ, the patient is posi- tioned in the semilithotomy position with legs in Both hand-held Ipas syringe (Ipas MVA Plus stirrups or foot rests, similar to the position for a Aspirator) and traditional Berkeley floor routine pelvic examination. Bimanual examina- techniques will be described. Both require the tion confirms uterine orientation. same instrument tray. The Berkeley suction D & C 2. insertion. This procedure can be per- requires a sized rigid or flexible with floor formed using either an “aseptic, no touch” tech- suction tubing. The Ipas technique requires a sized nique or a traditional sterile field. This article flexible curette and Ipas syringe (Fig. 1). will describe the aseptic technique. It is not nec- essary to cleanse the perineum. After insertion Instrument tray of a sterile speculum and after vaginal swabs for STI testing have been taken, the cervix is The following instruments are required (Fig. 2): cleansed with gauze soaked in antiseptic. • tray Although gloves are used, the operator must • sterile kidney basin for holding tissue (Ipas avoid touching the patient or gloves with por- technique) tions of the instruments that will enter the uter- • proviodine or chlorhexidine in a small cup ine cavity. • ten 4 × 4 sterile radiopaque gauze 3. Paracervical block. The anterior lip of the cervix • 10-mL syringe is grasped with a nontraumatic . • small sterile metal cup with mixture of 20 mL of Using a buffered lidocaine solution, as listed in 1% lidocaine, 2 mL of 8.4% bicarbonate (used in the equipment section, an intracervical block is Advanced Cardiac Life Support protocols) and performed. A total of 10–20 mL of solution is 20 U vasopressin injected intracervically in 4 quadrants: at the 3, 1 • 25-gauge 1 /2" needle 5, 7 and 9 o’clock positions. This provides sub- • nontraumatic (Teale) tenaculum and single-tooth stantial anesthetic that requires little intravenous tenaculum. Pratt 5-12 or Hegar are also medication for the remainder of the procedure. acceptable 4. Intravenous sedation. Both fentanyl and midazo- • small and medium sharp lam are used intravenously. Usually 2–6 mg of • blunt curette for gravid postpartum uterus, and lidazolam and 25–100 µg of fentanyl are needed. appropriately sized suction curette These are given in 2-mg and 25-µg aliquots, • 2 small stainless steel bowls (1 for lidocaine mix- respectively. Propofol 5–10 mL can also be used ture, 1 for chorhexidine) if a second experienced physician is present to • uterine sound monitor sedation and airway. • stainless steel speculum 5. Uterine sound and cervical dilation. After the • Ipas syringe if needed intracervical block, the uterine sound is inserted gently until it reaches the dome of the uterus.

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Fig. 1. Sized flexible curette and Ipas MVA Plus Aspirator. Fig. 2. Tray set-up for the dilatation and curettage procedure.

Can J Rural Med 2009; 14 (3) The depth of the sound helps guide the depth to pressure is required to move the curette in and out of which other instruments should be inserted for the uterus and results in a jerky movement as the evacuation. The sound is a thin instrument and a flexible curette moves along the endometrial lining, recently pregnant uterus is particularly soft and particularly toward the end of the procedure. If suc- prone to perforation. If the internal orifice (os) is tion is lost, the Ipas syringe is removed, the tissue difficult to find, there are “os finders,” a simple evacuated from the syringe, the suction replaced in plastic set of small instruments that are particu- the Ipas syringe and the Ipas syringe reattached to larly efficient at finding and guiding the uterine the curette that has been left in situ. Many women sound or first through the opening of experience increased cramping during the latter part the internal os (Fig. 3). Another option for a of the procedure. A sharp curettage can be used to tortuous cervix is to grasp the posterior cervix confirm complete removal of the uterine lining, fol- or anterior and posterior cervix together to lowed by a second Ipas syringe, although this is not straighten the cervical canal and allow sound necessary. This technique is not an option for the ear- and dilation. If there is a difficult opening of the ly postpartum period (i.e., retained placenta D & C). internal os, care must be taken at this stage to avoid creating a “false channel” within the cervi- B. Standard Berkeley suction technique cal canal. Early postpartum patients will rarely need any cervical dilation. An appropriately sized rigid suction curette is insert- Pratt dilators are then used to dilate the cervix. ed until it reaches the dome of the uterus. The suction To facilitate the introduction of a sharp curette, a tubing is attached and floor suction turned on. With a minimum of #7 dilator and size of curette needs to rotating motion, the curette is continuously turned be inserted. During termination of pregnancy, the 360 degrees in the uterus. An “in and out” motion is size of the dilator approximately matches the gesta- not required. To confirm complete evacuation of the tional age. uterus an “in and out” motion with the suction or At this stage the operator can continue using a sharp curette will produce the typical “sandpaper” hand-held Ipas syringe or the standard Berkeley feel as the curette scrapes the uterine lining. suction method. Both will be described. COMPLETION AND POSTPROCEDURE A. Ipas syringe technique This is the same for both procedures. The suction An appropriately sized flexible suction curette is curette and tenaculum are removed. A bimanual inserted until it reaches the dome of the uterus. With examination should confirm a small firm uterus. the Ipas syringe in the ready position, it is attached to There should be very little bleeding. The speculum the curette. Pinch the plastic buttons together at the is removed and a nonsteroidal anti-inflammatory front of the Ipas syringe to activate the suction. With rectal suppository is inserted. Patient can then be one hand on the tenaculum and one hand maintain- moved to the recovery room. Patients should stay ing the join between the Ipas syringe and the curette, 1 hour in recovery before discharge home in the care move the curette and Ipas syringe in and out of the of a responsible adult, and should abide by common uterus while rotating clockwise 90 degrees and coun- postsedation guidelines with regard to driving. terclockwise 90 degrees to allow the curette to ade- Complete evacuation of the uterus is confirmed quately clear the entire uterine cavity. Substantial clinically by finding a small involuted uterus on bimanual examination and/or with postprocedure ultrasonography. Tissue can be examined grossly to ensure an adequate specimen and/or confirmation of gestational sac. This latter step is particularly helpful at sites where confirmation of ectopic pregnancy cannot be performed ultrasonically and the D & C at this point can confirm uterine gesta- tional sac. Postprocedure discharge instruction sheets should be given and reviewed with the patient. 117 Patients should be followed up at 2 weeks postpro- Fig. 3. Os finders. cedure to evaluate for complications and to do a

Can J Rural Med 2009; 14 (3) review of curettage pathology. It is possible to the cervical canal becomes blocked and, as a become pregnant in the few weeks following D & C. result, the uterus expands. Hematometra pre- It is recommended that sexual intercourse be avoid- sents with significantly increased pain and nau- ed for 2 weeks postprocedure to reduce the risk of sea and is treated with repeat evacuation of the pregnancy as well as other complications. retained blood and clot.

RECOVERY Late complications

Patients can expect to return to work the day after • Incomplete evacuation of the uterus. Usually tis- a D & C. Ibuprofen and/or acetaminophen can be sue left behind is passed spontaneously; howev- given for cramping and pain. Contraception, if er, prolonged bleeding with retained tissue may needed, can be started on the day of surgery. require a repeat procedure. Patients will experience bleeding and cramping for • Infection/endometritis. This usually occurs with about 2 weeks after the procedure. an untreated STI. However, bacterial vaginosis is also commonly associated with postprocedure COMPLICATIONS endometritis. Perioperative antibiotics lessen, but do not eliminate, the risk of endometritis. The overall complication rate is between 0.01% and Endometritis related to an STI usually presents 1.16% for immediate complications.1 2–3 days after the procedure. • Postprocedure depression. More than 2 weeks Immediate complications of mood-related symptoms should trigger health professionals to obtain an Edinburgh Postnatal • Allergic reaction, acute asthma attack and vaso- Depression Scale symptom screen and assess for vagal reaction. postpartum depression. • Bleeding, which is usually secondary to retained • Fertility. Having 2 or more D & C procedures products or atonic uterus. The treatment is to can increase scar tissue and affect future fertility, ensure the uterus is completely empty, massage and can increase the risk of ectopic pregnancy, the uterus and give intravenous fluids, oxytocin miscarriage and placenta previa. 20–40 U in 1-L normal saline bolus and 10 U by intramuscular injection. Applying 5 minutes of POST–D & C PATIENT continuous bimanual pressure may also help. INSTRUCTION SHEET Buccal misoprostol 300 mg can also be used for less severe but persistent bleeding. Patient instruction and complication sheets are • Pain. Ensure this is not secondary to increased available through the BC Health Guide (health bleeding or other more serious complications listed linkbc.ca). below. Treat with 30 mg ketorolac by intramuscu- lar injection, and/or 25 µg intravenous fentanyl. START-UP COSTS • Uterine perforation. This is more likely in a gravid uterus. It presents as the instrument passes through All tray instruments together would cost less than the uterus or extra uterine passage through the cer- $1000. The Ipas syringe is about $50. Many instru- vical canal. Patients may feel increased pain, vagal ments can be taken from other procedural trays to reaction, generalized peritonismus or diaphragm minimize start-up costs. A Berkeley floor suction is irritation (if the peritoneum is significantly disrupt- a few thousand dollars; however, many larger hospi- ed). If perforation with suction curette occurs, peri- tals are willing to donate older models of floor suc- toneum or abdominal contents may be seen in the tion machines. suction tubing. Competing interests: None declared. • Rare complications include air embolism, pul- monary embolism and cervical laceration with REFERENCE bleeding, unrecognized ectopic pregnancy and

hematometra. Hematometra occurs when the 1. Soulat C, Gelly M. Immediate complications of surgical . 118 uterus does not contract to pass all of the tissue, J Gynecol Obstet Biol Reprod 2006;35:157-62.

Can J Rural Med 2009; 14 (3)