Dilation and Curettage With Suction

Updated: Aug 08, 2016
  • Author: Jacqueline D Yancey, DO; Chief Editor: Christine Isaacs, MD  more...
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Overview

Overview

Dilation and curettage with suction is a procedure in which contents from the inside of the uterus are evacuated. "Dilation" refers to the opening of the cervix. "Curettage" refers to the aspiration or removal of tissue within the uterus with an instrument called a curette. This procedure is commonly performed as a treatment for miscarriage, retained placenta after vaginal delivery, or as a method of first-trimester elective abortion.

Relevant Anatomy

The uterus is a dynamic female reproductive organ that is responsible for several reproductive functions, including menses, implantation, gestation, labor, and delivery. It is responsive to the hormonal milieu within the body, which allows adaptation to the different stages of a woman’s reproductive life. The uterus adjusts to reflect changes in ovarian steroid production during the menstrual cycle and displays rapid growth and specialized contractile activity during pregnancy and childbirth. It can also remain in a relatively quiescent state during the prepubertal and postmenopausal years. For more information about the relevant anatomy, see Uterus Anatomy.

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Indications

See the list below:

  • Retained placenta after vaginal delivery (postpartum)
  • Retained products of conception after missed, incomplete, or inevitable abortion/miscarriage (see the image below)
    Ultrasound of a missed miscarriage. Ultrasound of a missed miscarriage.
  • Elective first-trimester abortion
  • Molar pregnancy
  • Evaluation of abnormal uterine bleeding
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Contraindications

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  • Untreated acute pelvic infection (endometritis, salpingitis, pyometra)
  • Coagulopathy
  • Possible fetal viability (except for elective termination)
  • Patient refusal
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Anesthesia

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  • Local anesthesia (paracervical block) with 1% lidocaine
  • Procedural sedation (ie, propofol, fentanyl, midazolam)
  • Regional anesthesia (spinal or epidural nerve blocks)
  • General anesthesia
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Equipment

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  • Sterile gloves, gown, face shield, scrub hat, sterile drapes (sterile precautions), and adequate lighting (see image below)
    Sterile gloves, hat, and face shield. Sterile gloves, hat, and face shield.
  • Betadine or Hibiclens solution for preparation
  • Catheter to empty bladder
  • Sterile speculum  (Operative speculum or deep weighted; see image below). Operative speculums have an open side channel and allow for easy instrument movement within the vaginal vault.
    Speculums. Speculums.
  • Narrow Deaver retractors
  • Single tooth tenaculum, ring forceps, or Jacobs tenaculum (see image below)
    Single-tooth tenaculum. Single-tooth tenaculum.
  • 1% lidocaine, 10 mL syringe on a 22-gauge, extended-length (15 cm) spinal needle (see image below)
    Needle and syringe. Needle and syringe.
  • Hegar or Pratt dilator set (see image below)
    Pratt dilators. Pratt dilators.
  • Silastic os finders
  • Suction curette
  • Suction device with hosing and specimen bucket (see image below)
    Suction device. Suction device.
  • Endometrial curettes, including Banjo curette
  • Monsels solution, silver nitrate sticks
  • Absorbable suture (eg, 2-0 Polysorb or Vicryl) if needed
  • Sponge sticks (4x4 sterile sponges on ringed forceps)
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Positioning

The patient should be placed in the dorsal lithotomy position with her legs in Allen or candy cane stirrups. These stirrups should be adjusted to an equal height and length. The patient's legs should be raised and lowered slowly and simultaneously by 2 individuals.

Ensure that the height of the bed is appropriate and that optimal lighting is available.

Proper placement in the dorsal lithotomy position is very important. The risk of nerve injury increases if excessive torsion, flexion, or extension of the patient's lower extremities exists. For example, extreme abduction of the thigh and external rotation of the hips may injure the femoral nerve. This can lead to difficulty walking and/or decreased sensation, numbness, or tingling of the thigh, knee, or leg. Also, hyperflexion of the knee can cause compression of the peroneal nerve, resulting in foot drop. The risk of nerve injury can be reduced by using Allen stirrups instead of candy cane stirrups; however, either type is acceptable.

The following interventions help to minimize nerve trauma in the dorsal lithotomy position: [1]

  • Minimal abduction and external hip rotation should exist.
  • The hips, lateral fibulas, posterior thighs, and heels should be padded.
  • The hips and knees should be moderately flexed and securely supported.
  • The weight of the lower extremities should be directed toward the soles of the feet.
  • Knee stirrups should be adjusted so that tissue is not folded over metal and the stirrup edges do not cut into the calf (eg, peroneal nerve), posterior thigh, or low on the Achilles tendon.
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Technique

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  • Administer preoperative antibiotic prophylaxis.
  • Administer anesthesia (usually IV sedation).
  • Properly place patient in dorsal lithotomy position with legs in Allen or candy cane stirrups. Ensure adequate lighting is available and that bed height is appropriate.
  • Perform bimanual examination under anesthesia to determine cervical dilation, uterine fundal position and uterine size (see image below).
    Bimanual examination. Bimanual examination.
  • Prepare the patient's vulva, perineum, and inside the vagina with Betadine or Hibiclens solution.
  • Perform urine catheterization.
  • Drape the patient under sterile precautions.
  • Place a sterile speculum (operative or deep weighted) in the patient's vagina to adequately visualize the cervix.
  • Place a tenaculum on the anterior lip of the cervix (12 o'clock position) and use for gentle traction. A single toothed tenaculum is commonly used; however, many practitioners discourage this because of increased bleeding associated with the perforating tenaculum sites. Therefore, less traumatic tenaculums are preferable, such as a ring forceps or Jacobs tenaculum.
  • Perform an intracervical or paracervical block with 10-20 mL of 1% lidocaine.
  • Injection techniques vary in location, depth, and number of injection sites. [2] For example, if a 4-injection-site technique is chosen, inject 5 mL of lidocaine at the 12, 3, 6, and 9 o'clock positions of the cervix approximately 1 cm deep. If a 2-injection-site technique is chosen, inject 5-10 mL of lidocaine at one position and the other 5-10 mL of lidocaine at the other position. Common sites used for the 2-injection-site technique are 3 and 9 o'clock, 4 and 8 o'clock, or 5 and 7 o'clock. Randomized controlled trials have shown that intracervical and paracervical blocks have comparable effects on pain, and a wide variety of injection sites are acceptable and equally effective (see image below). [2, 3]
    Paracervical block. Paracervical block.
  • Uterine sounding may be performed to confirm uterine size and position to bimanual examination findings. Please note, however, many practitioners specifically discourage sounding the pregnant uterus because it increases the risk of uterine perforation.
  • Choose suction curette. Curettes are available in sizes 6-14. Optimal curette size is determined by uterine or pregnancy estimated size. (Example: if bimanual examination findings suggest a 10-week-size uterus, use a size 10 curette.) Do not determine curette size solely on gestational age. Although uterine size and weeks of gestation often match, this is not always the case. For instance, a patient's gestational age may be 10 weeks by her last menstrual period but bimanual examination as well as ultrasound findings may suggest a uterine size of only 8 weeks. In this scenario, a size 8 curette should be used instead of a size 10.
  • Curettes are also available in flexible or rigid types. Uterine axis and/or surgeon preference determine which type is used.
  • If the cervix is not already dilated, use Hegar or Pratt dilators to dilate the cervical os. Silastic os finders may be useful, especially in a patient with cervical stenosis. Be sure to dilate the cervical os enough so that the selected curette may easily pass through.
  • Insert the curette into the uterine cavity while stabilizing the cervix with the tenaculum. With the suction valve turned off, attach the suction hosing securely either before or after insertion of the curette.
  • The curette should be inserted gently to the uterine fundus and withdrawn slightly. To decrease the risk of perforation, do not force the curette.
  • Turn the suction machine on, close the suction valve on the handle, and wait until the suction pressure increases to 60-65 mmHg (see the image below).
    Suction device (close up). Suction device (close up).
  • Rotate the curette 360 º continuously until no more material is aspirated. Then, withdraw the suction curette being sure not to touch the vaginal walls while suction is on. Avoid jerking movements to decrease risk of perforation. The suction curette may need to be removed, reinserted, and rotated several times before the uterine cavity is completely evacuated.
  • At this point, sharp endometrial curettage can be performed. Use the largest curette that will easily pass through the cervix. The handle of the curette should never be held against the palm of the hand. [4] Instead, it should be held gently, as one would hold a pencil. [4] Vibrations, or a gritty texture, felt in the hand holding the curette (known as the uterine "cry") is often used as a sign that adequate tissue has been removed. [4] Excessive curettage increases the risk of Asherman's syndrome and should be avoided (see images below).
    Sharp endometrial curettage. Sharp endometrial curettage.
    Hysteroscopic view of Asherman syndrome. Hysteroscopic view of Asherman syndrome.
  • Send all specimens to pathology and for genetic analysis if deemed appropriate. Circumstances in which this may be necessary include molar pregnancy or to aid in the workup of patients with habitual miscarriage. However, in cases of elective terminations or when products of conception are obvious, this step may be omitted.
  • Remove the tenaculum from the anterior lip of the cervix.
  • If needed, apply pressure with a sponge stick to the tenaculum sites to obtain hemostasis. Apply Monsels solution to the cervix or use silver nitrate sticks if necessary. Suturing the cervix with an absorbable stitch (ie, 2-0 Polysorb) may be used if the previous options fail.
  • Remove speculum.
  • Complete course of prophylactic antibiotics.
  • Administer RhoGAM within 72 hours after procedure if patient's blood type is Rh negative. [5] Appropriate dosing is as follows: For less than 13 weeks gestation, an intramuscular injection of 50 mcg x 1 is used. For 13 weeks gestation or more, intramuscular injection of 300 mcg x 1 is used.
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Pearls

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  • Antibiotic prophylaxis decreases infection with elective abortion and is thought to be similarly effective for missed abortion. [6] Doxycycline 100 mg by mouth prior to the procedure and 200 mg by mouth after the procedure is recommended because it is one of the most effective and inexpensive regimens to prevent postabortal pelvic inflammatory disease (PID). [6] Ideally, preoperative antibiotics should be administered within 1 hour of the start of the procedure. No specified time is recommended for postoperative administration, but this can be given prior to discharging the patient home. In patients who are allergic to doxycycline, the alternative recommendation is metronidazole 500 mg orally twice daily for 5 days. [6]
  • Local anesthesia (either intracervical or paracervical block) has been shown to improve pain with suction curettage when compared with placebo. [2] Several acceptable and equally effective injection techniques exist; therefore, surgeon preference should determine which one is used.
  • During cervical dilation, pain signals are carried by parasympathetic fibers from S2-S4, which form ganglia lateral to the cervix and enter along with the uterine blood vessels. [7] This is why the 3 and 9 o'clock positions of the cervix are often targeted. In addition to pain with cervical dilation, contractions or cramping pain is transmitted by sympathetic fibers from the ovarian plexus and inferior hypogastric nerve, which travels in the uterosacral ligament and inserts into the cervix at the 5 and 7 o'clock positions. [2] Administration into these sites, or similarly at the 4 and 8 o'clock positions, allow the anesthetic to diffuse anteriorly and posteriorly and avoid the risk of injecting lidocaine directly into the uterine vessels. [2, 3] Aspiration of the needle prior to injecting is therefore recommended to avoid intravascular injection (see image below). [3]
    Paracervical block. Paracervical block.
  • Studies have also shown that a delay between paracervical or intracervical block and cervical dilation is not needed. In fact, immediate dilation after placement of local anesthesia provides equal pain relief to a waiting technique. [8]
  • In cases of refractory bleeding and uterine atony, bimanual uterine massage can be used, as well as several medications. Pitocin (either 10-40 units IV in 1 liter of normal saline or lactated ringers or 10 units IM) is a common choice. Another option that should be available in the operating room is Methergine. Methergine can be given by the anesthesiologist during the procedure (0.2 mg IM x 1 and can be repeated every 2 hours) or can be prescribed postoperatively (0.2 mg by mouth every 8 hours x 24 hours). Methergine is contraindicated in the hypertensive patient. These medical therapies are available options to be used in selective treatment of bleeding and are not required in routine prophylaxis. If hemorrhage continues despite these conservative measures, consider using a Foley balloon with traction or a uterine balloon as a tamponade. If vital signs are stable, uterine artery embolization is another option in severe cases of refractory bleeding and uterine atony that may avoid hysterectomy. [9]
  • Dilation and curettage with suction, an otherwise blind procedure, can be done under ultrasound guidance to decrease the risk of uterine perforation and retained products of conception (RPOC). [10] These risks are decreased because the curette can be visualized at all times, and allows the surgeon to look for a well-defined endometrial stripe after the procedure, an indication that the uterus is successfully evacuated. Although this concomitant ultrasound guidance is not essential for a safe and successful uterine evacuation, it often facilitates the evacuation procedure, particularly in problematic cases such as severe uterine anteflexion or fibroids. [11]
  • If uterine perforation is suspected, the suction should be turned off and the curette should be removed with caution to prevent injury to the intestine. [12]
  • Patients should be observed for at least 2 hours after the procedure for hemorrhage prior to discharge home.
  • Patients should be advised to have pelvic rest for 1-2 weeks following this procedure. This means no sexual intercourse, no tampons, and no douching. [13]
  • Cramping is the most common side effect after this procedure. NSAIDs are generally most helpful for this discomfort. However, the patient should be further evaluated if she experiences uncontrolled pain, fever, chills, or continued heavy vaginal bleeding.
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Complications

See the list below:

  • Bleeding
  • Infection
  • Uterine perforation
  • Cervical laceration
  • Bowel and bladder injury
  • Endometritis and salpingitis
  • Asherman syndrome: This is a pathological condition of intrauterine adhesions that can cause secondary amenorrhea, other menstrual irregularities, infertility, or recurrent abortion
  • Adverse reactions to anesthesia (ie, rash, itching, swelling, dizziness, anaphylaxis, hypotension, bradycardia)
  • Incomplete evacuation of products of conception, warranting a repeat procedure
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