Obstetrics 4: Dilatation and Curettage Portal
Place an IV line (large bore if the patient is bleeding heavily).
Check hemoglobin and Rh status. If the patient is bleeding heavily and/or you suspect a coagulopathy, draw platelets, PT, PTT, fibrin split products, and blood for type and screen.
Identify the size and position of the uterus by bimanual exam. If the uterus is larger than 12-week size, the risk of life-threatening hemorrhage increases. The inexperienced operator should consider consultation.
Give meperidine (Demerol) 25 to 50 mg and diazepam (Valium) 5 to 10 mg. Give midazolam (Versed) 2 to 5 mg as an alternative to diazepam. In many situations, the patient's partner or another support person may sit with her during the procedure.
If bleeding is heavy or the uterus is larger than 12-week size, add oxytocin 20 U/L of IV fluid.
Expose the cervix with the largest speculum the patient can comfortably tolerate. Cleanse the cervix and posterior fornix with an antiseptic solution. Grasp the anterior lip of the cervix with a single-toothed tenaculum.
Consider spinal analgesia, IV sedation with midazolam to limit physical and psychological pain. The patient should not be able to hear the suctioning occur. Administer a paracervical block with 10 cc of 1% lidocaine (Xylocaine) via a 20-gauge spinal needle. At the 3, 5, 7, and 9 o'clock positions, administer 1/4 of the amount where the cervix meets the vagina. Aspirate before injecting and raise a superficial wheal. Wait 3 to 5 minutes before further manipulation.
If the cervix is closed or insufficiently dilated to easily admit a #10 or #12 suction curette, progressively and carefully dilate using cervical dilators. Dilators and uterine sounds cause the largest number of uterine perforations. If the patient is stable, consider placement of laminaria on the day prior to the procedure.
You can sound with a ring forceps or blunt curette if the cervical os is open. Withdraw any loose tissue.
Select the largest suction curette that will easily pass through the cervix. Size #10 or #12 French are the most commonly used. A curved curette is used if the uterus is anteverted. A straight curette is used if the uterus is mid-position. Insert the suction curette along the previously determined axis of the uterus, until slight resistance is felt, while exerting slight traction on the tenaculum to stabilize the cervix and straighten out the cervico-uterine angle. Never force the curette after passing the internal os, as perforation is the most serious potential complication of the procedure. (Try matching the curette to the weeks of gestation: ie, 8 weeks = 8 French curette.)
Once the curette in place, attach the suction hosing and turn on the suction machine to 40 cm Hg. Enter the cervix with the suction valve open, and then close the valve when in the uterus.
With the suction on, rotate the curette several times in one direction, then several times in the other direction, with slight in-and-out motion. Withdraw the curette slowly, being careful not to touch the vaginal side wall while the suction is operating.
Repeat the suction and rotation sequence. Carefully observe the amount and nature of tissue that appears in the clear plastic curette.
Some physicians recommend a light, sharp curettage of the uterus followed by one more pass of the suction curette to determine that the uterus is indeed empty.
Examine the tissue. The tissue can be suspended in saline and examined for chorionic villi either with the naked eye or with a colposcope. Send the tissue to pathology for confirmation of diagnosis. To confirm an intrauterine pregnancy, chorionic villi must be identified.
After the suction D & C has been completed, monitor the patient for excessive bleeding. Give oxytocics as appropriate (Pitocin 10 U given either in a liter of IV fluid or IM or methergine 0.2 mg IM or PO). Continue oral methergine for a few doses. Transfusions are rarely required. Continued heavy bleeding indicates either that the uterus has not been adequately emptied or that injury has occurred. Consider an antibiotic such as doxycycline for 3 to 7 days.
Always determine Rh status (or obtain from prenatal records). If the patient is Rh-negative, give 50 µg RhoGAM (mini-dose RhoGAM).