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Monday, April 13, 2009

Dilation, Suction or Curettage

9:16 AM
Also known as
D&C

Description

Dilation and suction and/or curettage are often referred to as a D&C because the name was used before suction was invented. D&C refers to dilation of the cervix (widening the cervix) and curetting or scraping out the endometrium (the lining of the uterus). Suction devices have revolutionized this procedure and the uterus can now be emptied more rapidly and through a smaller opening in the cervix. The material obtained from suction and/or curettage is sent to the laboratory where it is placed on slides, stained, and then examined by a pathologist.


Indications

1. Abnormal or heavy bleeding from the uterus. D&C may temporarily or permanently cure the problem and will at least diagnose the cause of the bleeding.
2. Incomplete abortion (miscarriage) or to make sure abortion is complete.
3. Early termination of pregnancy
a. Genetic analysis of cells collected during amniocentesis reveals a severely abnormal fetus.
b. Pregnancy is inadvisable for medical reasons, e.g., cancer, heart disease.
c. The mother ingested medication(s), alcohol or drugs (teratogens) which could result in the birth of a severely deformed fetus.
d. The mother had an infection early in pregnancy, e.g., rubella, which is known to cause congenital defects.
e. The pregnancy is unwanted.

Treatment

# The patient's cervix is usually numbed or anesthetized with a needle containing a local anesthetic, e.g., lidocaine. Additional medication to put the patient to sleep, eliminate any pain, or decrease anxiety may be given intravenously. If the uterus is large or it is difficult to enter the cervix, e.g., a postmenopausal woman who has not had children vaginally, the physician may recommend that the patient be hospitalized and be given an epidural or general anesthetic.
# Dilation can be carried out in many ways. If the patient is having a miscarriage, the cervix may already be dilated, so the contents of the uterus just have to be suctioned and/or curetted out. If the cervix is not dilated, a series of dilators, starting with a very small one and increasing in size, are introduced through the external os and internal os of the cervix.
# Alternatively, one can use laminaria to dilate the cervix. Laminaria are thin pieces of specially prepared and sanitized seaweed, Laminaria japonicum, which grow in the Sea of Japan. One or more laminaria are inserted into the cervix and left in place for a period of time. They absorb moisture from the surrounding tissue and slowly expand, dilating the cervix over several hours. They are usually inserted the day before a suction and/or curettage procedure. They may cause cramping and require a pain reliever such as acetaminophen (Tylenol); aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided because they inhibit the formation of clots and may increase bleeding.
# Once the cervix is dilated, the interior of the uterus can be probed to determine its size or look for uterine growths, e.g., a polyp or fibroid. If a polyp is suspected, a pair of grasping forceps is inserted into the uterus and closed; the polyp is pulled out of the uterus if it is not too strongly attached.
# In a classic D&C, a uterine curette is inserted into the uterine cavity and the wall of the cavity is scraped. More recently, the cavity is often suctioned first. The material suctioned and scraped away from the wall can then be sent for pathological examination.



Procedures specific to Abortion:

# Vacuum Aspiration: From 6 to 13 weeks, vacuum aspiration is used to empty the uterus. This traditional first trimester abortion involves three main steps: (1) an injection to numb the cervix, (2) insertion of a soft flexible tube through the cervix into the uterus, and (3) suction created by an aspirating machine to remove the uterine contents. It takes less than 5 minutes to complete.
# IPAS Syringe - Early Abortion with Manual Vacuum Aspiration (MVA): As soon as the pregnancy can be detected by ultrasound (typically 3-4 weeks), an abortion can be performed using a manual aspiration device called the IPAS Syringe. Similar to the suction aspiration procedure, the IPAS system consists of thin flexible tubing, but instead of using a machine to create suction a hand-held syringe is used. The procedure usually takes less than 5 minutes to complete. Aftercare is the same as with suction aspiration method.
1. 1. D & E (Dilate and Evacuate):
# From 13 to 24 weeks, the Dilation and Evacuation (D&E) procedure may be administered. Usually, appointments are made for 2-3 consecutive days. On the first day, an ultrasound (sonogram) is performed to determine the size of the fetus. Then, the abortion procedure begins, and the cervix is numbed with injections and dilators are inserted into the cervix. Overnight, these dilators gently expand, opening the entrance to the uterus. The next day, the cervix is again numbed, the dilators are removed, and the doctor uses special instruments inserted into the uterus to remove the fetus. The final step is suction, using the aspirating machine. In more advanced pregnancies, additional dilators are inserted on the second day and the fetus is removed on the third day. Removal of the pregnancy actually takes about 10-15 minutes.



Complications

# Perforation of the uterus with an instrument may occur because the uterus is very soft from pregnancy, distorted by disease, or the uterus is tipped back toward the spine (retroverted) making entrance into the uterus more difficult. The uterus probably heals on its own more often than we realize because the injury goes unrecognized. If an injury is recognized, your physician may recommend a laparoscopy and/or laparotomy (opening the abdomen) to exam and repair the hole.
# Infection: D&C is often done to prevent the development of infection, particularly after an incomplete abortion. However, it the cervix was infected by chlamydia, gonorrhea or other harmful organisms, they may be pushed up into the uterus during the procedure and cause an infection of the uterine lining (endometritis), less commonly the infection spreads into the fallopian tubes (salpingitis), or further. It is important that you report any foul smelling discharge from your vagina, fever, chills, or continuous pelvic pain so the infection can be treated before it causes permanent damage.
# Reaction to anesthetic or other problems associated with anesthesia: Patients rarely have adverse reactions to a local anesthetic, however, if you have had any problems at the dentist or with burn sprays containing anesthetics (Benzocaine), make sure you tell your physician. Serious complications from general anesthesia occur in approximately 1-2 people/10,000, which is why your physician may recommend a local or epidural over a general anesthetic.
# Infertility: Infertility rarely occurs today as a complication of D&C because of the use of suction and effective antibiotics to treat infection.

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