When should clopidogrel be held before a dilation and curettage (D&C)?

When to Hold Clopidogrel Before D&C

For dilation and curettage (D&C), discontinue clopidogrel 5 days before the procedure, or 7 days if feasible, to allow adequate platelet function recovery. 1

Standard Timing Recommendations

The American College of Cardiology recommends discontinuing clopidogrel at least 5 days before elective surgery with significant bleeding risk, and preferably 7 days before for optimal platelet function recovery. 1 This timing is based on the irreversible platelet inhibition caused by clopidogrel, which affects platelets for their entire 7-10 day lifespan. 2

• D&C involves significant mucosal disruption and bleeding risk in a closed space (uterine cavity), making it a procedure where the full 5-7 day discontinuation period is appropriate. 1, 3
• Discontinuing clopidogrel less than 5 days before surgery is ineffective because restoration of adequate platelet function requires at least 5 days. 4

Critical Pre-Procedure Risk Assessment

Before stopping clopidogrel, you must assess the patient's thrombotic risk, particularly regarding recent coronary stents or acute coronary syndrome. 1, 4

High-Risk Patients Requiring Cardiology Consultation:

• Drug-eluting stent placed within the prior 12 months 4
• Bare metal stent placed within the prior 4 weeks 4
• Recent acute coronary syndrome within 12 months 4
• History of stent thrombosis 4
• Angioplasty for acute coronary syndrome (may benefit from continued therapy for 12 months even without stent placement) 1

Never stop clopidogrel without consulting the prescribing cardiologist in these high-risk patients. 4, 3

Management Algorithm

For Low Thrombotic Risk Patients:

• Stop clopidogrel 5-7 days before D&C 1
• Resume clopidogrel within 12-24 hours post-operatively once hemostasis is achieved 1, 3

For High Thrombotic Risk Patients:

• Consult cardiology before stopping clopidogrel 1, 4
• Consider deferring elective D&C until it is safer to interrupt clopidogrel 3
• If urgent D&C is required and cannot be delayed, the American Heart Association suggests a minimum of 24 hours discontinuation, though this carries increased bleeding risk 1

For Patients with Recent ACS or Stents:

• The decision must balance thrombotic risk against bleeding risk 1
• If the risk of morbidity from bleeding outweighs the benefit of continued clopidogrel, earlier discontinuation should be considered 5, 3
• For patients at high risk of fatal ischemic events, consider proceeding without discontinuation after cardiology consultation 6

Post-Procedure Management

Resume clopidogrel as soon as hemostasis is achieved after D&C. 2 The FDA label states that when clopidogrel must be temporarily discontinued for surgery with major bleeding risk, restart it as soon as possible. 2

• Typical resumption time is within 12-24 hours if no bleeding complications occur 1, 3
• Discontinuation of clopidogrel increases the risk of cardiovascular events 2

Common Pitfalls to Avoid

• Do not stop clopidogrel without consulting the prescribing physician in patients with recent coronary stents 4, 3
• Do not bridge with heparin or low-molecular weight heparin - this does not provide protection against coronary artery or stent thrombosis and may increase bleeding risk 7
• Do not discontinue clopidogrel too close to surgery (less than 5 days) - this increases bleeding risk without allowing adequate platelet function recovery 4
• Do not stop antiplatelet therapy for too long in high-risk cardiac patients - this can lead to stent thrombosis 3

Emergency Situations

If D&C is urgent and cannot wait 5-7 days, platelet transfusions may be considered to restore hemostasis, though they may be less effective within 4 hours of the loading dose or 2 hours of the maintenance dose. 2 However, at least 20% of circulating platelets must have normal function for adequate hemostasis, and fresh platelets are the only way to rapidly restore this. 7