When is admission recommended for a dilation and curettage (D&C) procedure?

Indications for Admission for Dilation and Curettage (D&C)

Admission for dilation and curettage (D&C) is recommended for patients with atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN) or grade 1 endometrioid endometrial cancer (G1 EEC), especially when part of fertility-preserving therapy protocols or when comprehensive evaluation is needed. 1

Clinical Scenarios Requiring Admission for D&C

Diagnostic Indications

• D&C with admission is indicated for patients with suspected endometrial cancer who need comprehensive evaluation, particularly when hysteroscopy is also performed 1
• Patients with AH/EIN or suspected G1 EEC requesting fertility-preserving therapy must undergo D&C (with or without hysteroscopy) in specialized centers, which typically requires admission 1
• Cases requiring specialist gynaecopathologist confirmation of diagnosis, which may necessitate more extensive tissue sampling under controlled conditions 1

Patient Risk Factors

• Patients with high-risk factors for complications during D&C should be admitted, including:
  • Postmenopausal status (associated with 3x higher complication risk) 2
  • Nulliparity (independently increases risk of complications) 2
  • Retroverted uterus (significant risk factor for uterine perforation) 2
  • Cesarean scar thickness <3mm (50% failure rate for outpatient D&C) 3

Procedural Complexity

• D&C procedures at 20-24 weeks' gestation require at least one day of cervical preparation with osmotic dilators, necessitating admission 4
• Cases requiring serial osmotic dilators over multiple days for adequate cervical preparation 4
• When adjunctive medications like mifepristone are administered one day pre-operatively, requiring monitoring 4

Medical Conditions

• Patients with unstable vital signs or significant comorbidities that increase procedural risk 1
• Cases with suspected or confirmed advanced disease requiring comprehensive staging 1
• Patients with impaired performance status requiring additional monitoring 1

Potential Complications Requiring Inpatient Management

• Risk of uterine perforation (0.9% of cases), which may require surgical repair 2
• Severe hemorrhage (0.1% of cases), which may require blood transfusion or additional interventions 2
• False passage creation (0.8% of cases), which may require extended monitoring 2
• Patients at risk for postpartum hemorrhage in future pregnancies (significantly higher risk after D&C) 5

Special Considerations

• Patients undergoing D&C as part of damage control surgery for unstable conditions should be admitted for comprehensive management 1
• Patients requiring pre-operative optimization before D&C (particularly in emergency settings) should be admitted for stabilization 1
• Multiple D&Cs significantly increase the risk of future preterm birth (OR 1.74), which may warrant additional counseling and monitoring in an inpatient setting 6

Algorithm for D&C Setting Decision

1. Assess patient stability:

   • If unstable (hemorrhagic shock, severe anemia, infection) → Admit 1
   • If stable → Continue assessment

2. Evaluate procedural complexity:

   • If requiring overnight cervical preparation → Admit 4
   • If requiring specialist pathology review → Consider admission 1
   • If part of fertility-preserving protocol → Admit to specialized center 1

3. Assess patient risk factors:

   • If multiple high-risk factors present (postmenopausal, nulliparous, retroverted uterus) → Admit 2
   • If history of cesarean with thin scar (<3mm) → Admit 3
   • If low risk → Consider outpatient procedure

4. Consider indication:

   • If for suspected/confirmed endometrial cancer → Admit to specialized center 1
   • If for routine miscarriage or simple bleeding → Consider outpatient procedure 6, 5