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Dapus 4
Dapus 4
https://emedicine.medscape.com/article/1848239-overview#a1
Overview
Background
Diagnostic dilation and curettage was originally intended to detect intrauterine endometrial
abnormalities and assist in the management of abnormal bleeding. Newer techniques are
available to assess the uterine cavity and endometrial findings. [1] However, dilation and
curettage still has a role in centers where advanced technology is not available or when other
diagnostic modalities are unsuccessful.
Traditionally, dilation and curettage has been performed in a blind fashion. The procedure
can be performed under ultrasound guidance or in conjunction with visualization of the
uterine cavity by a hysteroscope.
Indications
The evaluation of the uterine cavity by dilation and curettage may be helpful when an office
technique, such as ultrasound, is unable to fully elucidate the endometrium due to shadowing
from leiomyomata, a pelvic mass, or loops of bowel.
Dilation and curettage may also be a therapeutic procedure. Examples of this use include the
following:
Contraindications
There are few contraindications to gentle office dilation and curettage, but a more vigorous
examination may require an operative suite with regional or general anesthesia. Paracervical
block or intravenous sedation with an anesthesia team standing by for assistance may also be
an option. Intolerance to office examinations or procedures may determine the setting for the
procedure.
Complications
Complications can occur at the time of diagnostic dilation and curettage. Careful performance
of the procedure should minimize these events. Possible complications include the following:
Bleeding or hemorrhage
Cervical laceration
Uterine perforation
Postprocedural infection
Postprocedural intrauterine synechiae (adhesions)
Anesthetic complications
Cervical Injury
Laceration of the cervix primarily occurs during traction, with a counterforce applied during
dilation. It seems to occur most frequently with use of a single-tooth tenaculum, especially
when it is placed vertically on the lip of the cervix. A Bierer multi-toothed tenaculum
penetrates less deeply into the cervical tissue and transfers force over a greater area,
potentially decreasing the risk of laceration.
Placement of a tenaculum is not recommended at the lateral aspect of the cervix because of
the location of the cervical branches of the uterine artery.
The risk of laceration is reduced by reducing force at dilation, using more tapered Pratt
dilators or osmotic preparation before the procedure with laminaria or prostaglandin.
Uterine Perforation
Uterine perforation is one of the more common complications of dilation and curettage. Risks
are increased when dealing with a pregnant or recently postpartum uterus (5.1%) and are less
frequent at the time of a dilation and curettage remote from pregnancy (0.3% for
premenopausal women and 2.6% for postmenopausal women). [4, 5, 6]
The instruments most commonly associated with uterine perforation are the uterine sound or
dilators. If perforation is known to have occurred with a blunt instrument, observation of vital
and peritoneal signs for several hours is all that is needed. If suspicion that a sharp
instrument, such as a curette, has perforated the uterus or if the fat has been retrieved by
curettage, then intraabdominal injury must be excluded by laparoscopy. Active bleeding may
necessitate a laparotomy.
Infection
Infection related to diagnostic dilation and curettage is rare and is most likely when cervicitis
is present at the time of the procedure. One study of infections related to dilation and
curettage documented a 5% incidence of bacteremia following dilation and curettage with a
very rare incidence of septicemia.
Prophylactic antibiotics are not recommended for any dilation and curettage, including for
those women who generally require subacute bacterial endocarditis prophylaxis.
Intrauterine Adhesions
Curettage after delivery or abortion may result in endometrial injury and subsequent
development of intrauterine adhesions, termed Asherman syndrome. The development of
uterine synechiae may also be associated with prior endometrial ablation procedures.
Intrauterine adhesions may make future diagnostic curettage more difficult and increase the
risk of uterine perforation. Previous procedures such as endometrial ablation may also
increase the risk of cervical stenosis.
Trophoblastic Embolization