Dilatation and Curettage of the Nonpregnant Uterus

General Principles

Differential Diagnosis

Abnormal uterine bleeding, perimenopausal bleeding, postmenopausal bleeding, fibroids, endocervical or endometrial polyps, cervical cancer, endometrial hyperplasia, uterine cancer, pyometra, hematometra, retained products of conception.

Anatomic Considerations

In cases of Mullerian defects, such as uterus didelphys, bicornuate uterus, or septate uterus, D&C should be performed under ultrasound guidance.

Nonoperative Management

IPAS is a double-valve manual vacuum aspiration syringe that can be used in the office, obviating the operating room.¹ The World Health Organization has approved its use for endometrial sampling in the setting of abnormal uterine bleeding.

Imaging and other Diagnostics

Pelvic ultrasound and/or saline-infused sonogram characterize the uterine contour, endometrium, intracavitary polyps and fibroid, as well as intramural, subserosal, and submucosal fibroids. Furthermore, the classic heterogeneous pattern of adenomyosis may be recognized.
In rare cases, MRI may be used to detect the presence of Müllerian defects such as unicornuate uterus, uterus didelphys, bicornuate uterus, or septate uterus.

Preoperative Planning

A complete history and physical examination is necessary to rule out pregnancy, to determine the ease or difficulty of uterine access, to illicit any medical comorbidities that will affect anesthesia, and to determine coagulation risks.
Cervical stenosis prevents the passage of a 2.5-mm Pratt dilator. Stenosis can be anticipated if there is a history of prior cervical or uterine procedures such as a LEEP or cone biopsy, routine biopsies, cryotherapy, laser surgery, or endometrial ablation. It can result from lack of vaginal deliveries, infection, or estrogen deficiency.
Treat cervical stenosis with preoperative Misoprostol 400 mcg, oral or sublingual, 12 hours prior to D&C. Various regimens have been recommended and may facilitate cervical access.²^,³ Alternatively, laminaria are osmotic dilators that can soften and dilate the cervix in order to prevent uterine perforation during the dilatation process. They are placed in the office at least 12 to 24 hours before the D&C is performed and removed intraoperatively.

Surgical Management

Positioning

The patient is placed in the lithotomy position with her legs in candy cane or Allen stirrups. Be careful not to hyperflex the hips or hyperextend the knees (Fig. 6.1).

Approach

Perform a pelvic examination, carefully sound the uterus, serially dilate the cervix, and then systematically scrape the
uterine lining. If there is a high suspicion for the presence of uterine polyps, a polypectomy should be done before the curettage. If endometrial carcinoma is highly suspected, a fractional curettage is performed. Tissue is first obtained from the endocervical canal. Then, the endometrial canal is sampled. This is done in order to avoid contamination of the sites.

Figure 6.1. Lithotomy position. Hyperflexion of the hip and hyperextension of the knee are avoided to prevent injury of the femoral nerve and lumbosacral trunk.

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