How to manage a dilation and curettage (D&C) in the presence of an abscess?

Management of Dilation and Curettage in the Presence of an Abscess

Do not perform dilation and curettage when an active pelvic or uterine abscess is present; instead, prioritize source control through drainage of the abscess first, followed by appropriate antibiotic therapy. 1, 2

Critical Initial Assessment

The presence of an abscess represents an absolute contraindication to elective D&C until the infection is adequately controlled. Your immediate priorities are:

• Obtain focused history including fever, pelvic pain severity, vaginal discharge, and immunocompromised status 1, 2
• Perform complete physical examination with pelvic examination to assess abscess location and extent 1, 2
• Check serum glucose, hemoglobin A1c, and urine ketones to identify undiagnosed diabetes mellitus, which is common in abscess patients 1, 2
• For patients with systemic infection or sepsis signs, obtain complete blood count, serum creatinine, C-reactive protein, procalcitonin, and lactate levels 1, 2

Imaging Strategy

Obtain imaging before any procedural intervention when abscess is suspected:

• Use MRI, CT scan with IV contrast, or endoscopic ultrasound based on abscess location and available resources 1, 2
• Imaging is mandatory for atypical presentations or suspected complex/deep abscesses 1, 2
• Look for abscess size, location, presence of loculations, and proximity to vital structures 1

Source Control: The Primary Treatment

Surgical drainage with incision and drainage is the definitive treatment and must precede any D&C procedure:

For Accessible Abscesses:

• Perform incision and drainage as close to the abscess as possible while ensuring adequate drainage 1, 2, 3
• Time surgery based on sepsis severity—emergent drainage required for sepsis, immunosuppression, or diffuse cellulitis 1, 3
• Consider percutaneous drainage (US or CT-guided) for deep pelvic abscesses that are accessible 1

For Small Abscesses (<3 cm):

• In immunocompetent, non-critically ill patients without fistula, antibiotics alone for 7 days may be attempted 1
• Close clinical monitoring is mandatory with repeat imaging if no improvement within 3-5 days 1

For Large Abscesses (>6 cm):

• Percutaneous drainage combined with antibiotics is preferred over antibiotics alone 1
• If percutaneous drainage fails or is not feasible in critically ill/immunocompromised patients, proceed to surgical intervention 1

Antibiotic Therapy

Initiate broad-spectrum antibiotics covering Gram-negative bacteria and anaerobes:

For Immunocompetent, Non-Critically Ill Patients with Adequate Source Control:

• Piperacillin/tazobactam 4 g/0.5 g q6h for 4 days 1
• Alternative: Ertapenem 1 g q24h 1
• Alternative: Eravacycline 1 mg/kg q12h 1

For Immunocompromised or Critically Ill Patients:

• Continue antibiotics up to 7 days based on clinical response and inflammatory markers 1
• If septic shock: Meropenem 1 g q6h by extended infusion, or Doripenem 500 mg q8h by extended infusion, or Imipenem/cilastatin 500 mg q6h 1

For Beta-Lactam Allergy:

• Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 1

Timing of D&C After Abscess Treatment

Only proceed with D&C after:

• Complete drainage of abscess with clinical improvement (decreased fever, pain, inflammatory markers) 1
• Completion of appropriate antibiotic course (4-7 days depending on patient status) 1
• Resolution of sepsis if present 1, 2
• Repeat imaging confirms abscess resolution if initial abscess was large or complex 1

Critical Pitfalls to Avoid

• Never perform D&C in the presence of active infection—this will seed bacteria systemically and worsen sepsis 4
• Do not rely on antibiotics alone for abscesses >3 cm or in immunocompromised patients without attempting drainage 1
• Avoid inadequate drainage or failure to identify loculations, which increases recurrence risk to 44% 3
• Do not discontinue antibiotics prematurely—patients requiring >7 days of treatment warrant diagnostic re-evaluation 1
• Recognize that percutaneous drainage may fail with bowel wall thickness, disease length >6 cm, or bowel dilation 1

Special Considerations

• If D&C is urgently needed for hemorrhage control in the setting of septic abortion with abscess, coordinate simultaneous source control with drainage while performing minimal necessary uterine instrumentation 4
• Bacteremia occurs in 5% of routine D&C procedures, making infection control paramount when abscess is present 4
• Sample drained pus in high-risk patients or those with multidrug-resistant organism risk factors to guide antibiotic therapy 2