What are the steps involved in a Dilation and Curettage (D&C) procedure?

Dilation and Curettage (D&C) Procedural Steps

D&C is performed by first dilating the cervix with sequential Hegar dilators, then systematically curettaging the endocervix followed by the uterine cavity, with hysteroscopic guidance recommended to reduce perforation risk, particularly in narrow cervical canals. 1

Pre-Procedure Preparation

• Patient positioning: Place patient in dorsal lithotomy position with appropriate anesthesia (general or conscious sedation) 2
• Bimanual examination: Determine uterine size, position (anteverted vs. retroverted), and axis to guide instrument insertion 2
• Speculum insertion: Visualize cervix and cleanse with antiseptic solution 2
• Tenaculum placement: Grasp anterior or posterior cervical lip to stabilize and straighten the uterine axis 2

Cervical Dilation

The most critical and high-risk phase is blind cervical dilation, where most perforations occur. 1, 3

• Sound the uterus: Gently insert uterine sound to measure cavity depth and confirm direction (typically 6-8 cm) 2
• Sequential dilation: Begin with smallest Hegar dilator (2-3 mm) and progressively increase to 7-9 mm, using gentle pressure without force 1
• Hysteroscopic guidance for difficult cases: When encountering very narrow cervical canal, dilate external os to 7 mm, then pass rigid hysteroscope under direct visualization through internal os to prevent perforation 1
• Alternative for stenotic internal os: Use minigrasping forceps under hysteroscopic vision to dilate internal os when smallest dilator cannot pass 1

Common pitfall: Endoscopists performing fewer than 500 procedures are four times more likely to cause uterine perforation. 4, 5

Fractional Curettage Technique

Fractional D&C provides comprehensive sampling by separately curettaging endocervix first, then uterine cavity. 2

Endocervical Curettage

• Insert sharp curette into cervical canal without entering uterine cavity 2
• Systematic scraping: Curette all four quadrants (anterior, posterior, lateral walls) of endocervical canal 2
• Collect specimen separately: Place endocervical tissue in separate container for pathology 2

Uterine Curettage

• Insert curette to fundus: Advance sharp or suction curette to uterine fundus based on previously measured depth 2
• Systematic coverage: Curette all uterine walls in organized pattern—anterior, posterior, right lateral, left lateral, and both cornual regions 2
• Adequate sampling: Continue until gritty sensation indicates reaching myometrium, but avoid excessive force 2
• Minimize overlap: Avoid repeatedly curettaging same areas to reduce trauma while ensuring complete coverage 2

Assessment indices for quality: Cervical coverage index, cervical overlap index, uterine coverage index, and uterine overlap index quantify completeness and quality of curettage. 2

Post-Procedure Assessment

• Inspect tissue: Examine curetted material for completeness and send for histopathologic examination 6, 2
• Estimate blood loss: Monitor for excessive bleeding during and immediately after procedure 7
• Remove instruments systematically: Curette, tenaculum, then speculum 2

Critical Warnings and Complications

Uterine perforation is the most serious intraoperative complication, typically occurring during cervical dilation. 4, 1, 3

• Perforation recognition: Sudden loss of resistance, instrument advancing beyond expected depth, or grasping tissue that appears non-uterine 3
• Intestinal prolapse risk: If forceps grasp tissue that prolapses into vagina when pulled, suspect bowel herniation through perforation requiring immediate laparotomy 3
• Post-procedure infection: Fever >100.4°F (38°C) with pelvic pain and purulent discharge indicates endometritis, with risk increasing with retained products and prolonged procedure time 4, 7
• Excessive bleeding: Soaking through more than one pad per hour for 2 consecutive hours requires immediate evaluation 4, 7

Special Considerations

For fertility-sparing evaluation in young women with grade 1 endometrial cancer or atypical hyperplasia, D&C with or without hysteroscopy is required for definitive histologic diagnosis. 6, 5

• D&C is superior to office biopsy (Pipelle/Vabra) for accurate tumor grading, despite office methods having 99.6% and 97.1% sensitivity for detecting carcinoma 5
• Office biopsy has 10% false-negative rate: Negative office biopsy in symptomatic patients requires fractional D&C under anesthesia 4, 5
• Hysteroscopy adjunct: Helps evaluate focal lesions like polyps in patients with persistent undiagnosed bleeding 4