There are two superficially similar operations: (1) The evacuation of an incomplete, or septic abortion, which does not usually require that the cervix be dilated, and which is descibed in Section 16.2. And, (2) dilatation and curettage of the uterus, which is described here. Although both operations have similar complications, they have different indications.
A ''D and C' is a complement to a carefully taken history and examination, and is not a substitute for them. It is also one of the commonest operations in gynaecology, and one of the the most abused ones, so make sure that you only do it on the proper indications, which are: (1) To diagnose the cause of abnormal bleeding, unless you have already found the cause in a patient's lower genital tract. (2) To exclude carcinoma of the endometrium and tuberculous endometritis. (3) To make sure that a patient is ovulating, when you are investigating her for infertility. (4) To treat DUB (dysfunctional uterine bleeding), when A ''D and C' can occasionally be life-saving.
Ideally, all curettings should be sent for histology. Unfortunately, this is unlikely to be possible, so you will probably have to send only the most urgent ones. If a patient is less than 40, sending her curettings for histology is less urgent, unless they look abnormal macroscopically (profuse, thick, ''cheesy', or infected), or you suspect choriocarcinoma.
Although a ''D and C' is usually simple, the long list of difficulties described below show that it can be dangerous, and even fatal. The main risks are: (1) Perforating the uterus, perhaps followed by haemorrhage or sepsis. (2) Injuring a nulliparous cervix. Most of the complications we list are very rare.
Fig. 20-1 DILATATION AND CURETTAGE. A, the main danger is perforating the uterus. B, passing a sound. C, inserting Hegar's dilator. Perforation of the uterus is less likely if you use your finger as a guide and steadier like this. After ''Bonney's Gynaecological Surgery'. Bailli[gr]ere Tindall, with kind permission.
DILATATION AND CURETTAGE,''D & C' INDICATIONS. [f41]Use dilatation followed by curettage: (1) To investigate abnormal bleeding. It may reveal: carcinoma of endometrium, endocervical adenocarcinoma (but not squamous carcinoma of the cervix, see below), choriocarcinoma, ''chronic endometritis', tuberculous endometritis, chronic anovulation, or submucous fibroids. (2) To treat post-menopausal cervical occlusion causing pyometra, and to exclude carcinoma as its cause.
Use dilatation only, without curettage: (1) To correct cervical stenosis after amputation, or conization (32.35). (2) To permit the insertion of an IUD.
If you are doing and ''D and C' for infertility, its purpose is to decide whether there is histological evidence of ovulation, and to exclude tuberculous endometritis. So always do it in the premenstrual phase. Send the curettings for histology, and make sure you tell the pathologist that this is what you want to know, or he may merely report them as ''normal'. He will usually make the diagnosis of tuberculosis histologically, but consider sending a separate specimen in a sterile bottle, for culture for tuberculosis, if you think that this is the cause, and are working in an area of high incidence. If your pathological services are under pressure, you won't be able to do this very often.
CAUTION ! (1) Don't do a ''D and C' to treat primary dysmenorrhoea, even if other methods have failed. Persevere with analgesics. If necessary give her a 50[gm]g oestrogen combined pill to suppress ovulation. (2) A ''D and C' will not diagnose squamous carcinoma of the cervix, for which she needs a cone or wedge biopsy (32.35). Don't do a ''D and C' if you suspect she has a tubo-ovarian abscess, which you should be able to diagnose clinically. Infection will have fixed her uterus; moving it with dilators may tear it, spread the pus, and cause a fatal peritonitis.
USING A MENSTRUAL REGULATION SYRINGE If you only want to do a biopsy, consider using a menstrual regulation syringe (M 3.19), which is ideal for assessing whether she is ovulating or not, and for the diagnosis of tuberculous endometritis. You can do it as an outpatient using only a paracervical block (A 6.14).
STANDARD METHOD [s7]FOR DOING A ''D AND C' You can do this as an outpatient. Ask her to empty her bladder. There is no need to catheterize her.
ANAESTHESIA. (1) General anaesthesia. (2) An anaesthetic ''cocktail' (A 8.8). (3) A paracervical block (A 6.14).
EQUIPMENT. A catheter, Sims' and Auvard's vaginal specula, a uterine sound, 2 vulsella, a pair of narrow ovum forceps, sharp curettes of different sizes, and a set of Hegar's uterine dilators. Arrange these in order of size on the trolley.
EXAMINATION. If necessary, empty her bladder. Swab her vulva and vagina. When you dilate her cervix, you will need a mental picture of the shape, length and direction of her uterine cavity. Get this picture by: (1) Examining her bimanually, to feel the size, position, and mobility of her uterus (feel also for disease in her adnexae). Note particularly if her uterus is retroverted, because this increases the chance of perforating it with a misdirected dilator. (2) Measure the depth of her uterus with a sound, except when you suspect an abortion.
DILATATION. Start by making sure that her buttocks are well over the edge of the table. Grasp the anterior lip of her cervix with one, or even two vulsella, and pull it well down. This will bring a sharply anteverted or retroverted uterus towards the axial position, and reduce the risk of perforation. If it is soft, as after labour or an abortion, use sponge forceps.
With the picture of her uterine cavity in your mind, dilate her cervix, starting with the smallest dilator. As you do so, place a finger beside it to act as a ''brake', if you enter her cervix suddenly.
Insert the dilator in the direction which minimizes the resistance to it as far as possible. When it has been in place for at least half a minute, insert the next size without delay, and without waiting for her cervix to contract again. Dilate a large uterus more than a small one. If your purpose is only to do a biopsy, use a fine curette, and don't dilate beyond Hegar size 8[md]larger sizes may tear her cervix.
CAUTION ! (1) Be gentle. (2) Dilate slowly, leave each dilator in place for at least half a minute. (3) Don't twist the dilators. (4) Be particularly careful not to perforate her uterus, if you suspect a missed or incomplete abortion, or carcinoma of her endometrium. All these make it soft, friable and easily perforated. (5) If you suspect a carcinoma, make sure you dilate her cervix enough to let you explore her uterus adequately. (6) Don't allow a dilator or a probe to become trapped in a false passage. (7) Never use a douche.
CURETTAGE. Do a complete or a partial curettage on these indications.
If all you want is some endometrium to find out if she is ovulating, do a partial curettage. Explore her uterus with long, careful strokes, so that you get long thin strips of endometrium for histology.
If you are curetting for an incomplete abortion, or for the diagnosis of intermenstrual bleeding, or other forms of abnormal bleeding, and are anxious not to miss carcinoma of the corpus, do a full curettage. Start scraping at her fundus, and scrape towards you all round the anterior, posterior, and lateral surfaces of her uterine cavity. Continue until there is a scratching feeling.
EARLY DIFFICULTIES [s7]DURING A ''D AND C' See also Sections 16.2 and 6.6a.
If you CANNOT PASS A SOUND or small dilator, her uterus is probably acutely flexed, either forwards or backwards. Feel it carefully.
If her uterus is anteverted (flexed forwards), pass the sound under direct vision though her external os, remove the speculum, and depress the handle of the sound posteriorly on to her perineum. When it is in the axis of her uterine canal it will probably pass.
If her uterus is retoverted (flexed backwards), it may be held in place by adhesions. If a bimanual examination shows that it is fixed, consider abandoning the operation. But, if she must have a ''D and C', put the volsellum on the posterior lip of her cervix and pull it well down; pass the dilators with their points backwards. If you tear the adhesions that are holding her uterus, she may bleed into her pouch of Douglas, or into her peritoneum. You may then have to open her abdomen (rare), and secure the bleeding vessels.
If her CERVIX IS SO RIGID that the larger dilators will not pass without the risk of tearing it, leave one dilator in place for several minutes, before introducing the next one. If a dilator is tightly gripped as you remove it, reinsert it and leave it in a little longer before inserting the next largest size. Nulliparous and senile cervices are often stiff. Don't use excessive force. You can usually do an adequate curettage with a small, sharp curette, when her cervical canal is only dilated to Hegar 6 (20 Ch).
If LARGER DILATORS DO NOT GO IN as far as smaller ones, you are inserting successive dilators a progressively shorter distance into her uterus. If you fail to realize what you are doing, you may only curette her cervical canal, and not the body of her uterus. Return to the smaller dilators, and start again.
If you find that INSERTING LARGER DILATORS IS UNNATURALLY EASY, stop! You have probably lacerated her cervix, and increased the risk of bleeding and sepsis. The tear may run into her vaginal vault from her external os, or it may start near her internal os, so that the tips of succeeding dilators catch in it, and ultimately enter her broad ligament.
If a DILATOR SUDDENLY SLIPS IN much further than the one before (not uncommon), you have probably perforated her uterus into her peritoneal cavity, or into her broad ligament on either side, or into her bladder. Even experts occasionally do this, especially if a patient is pregnant, postpartum, or postabortion, or if her uterus has been softened by an endometrial carcinoma: (1) Abandon the operation, and don't try to confirm the diagnosis by probing her uterus. (2) Don't irrigate her uterus. What you do now depends on whether she is a clean case, or a septic one.
If she is a ''clean case', take her pulse, blood pressure, and temperature half-hourly. She will probably recover. If her pulse rises and her blood pressure falls, and there are signs of fresh blood in her peritoneal cavity (rare), restore her blood volume and do a laparotomy.
If she is potentially ''septic' as after an abortion, give her antibiotics, and observe her as above.
If you perforate her uterus and a LOOP OF GUT APPEARS AT HER VAGINA (rare), don't: (1) be tempted to resect it and anastomose it at her vagina, or (2) to push it back through the tear and plug her uterus with gauze. Instead, open her abdomen and draw the prolapsed gut back. Clean it, resect it, if it is damaged, and inspect the rest of her gut.
If you SPLIT THE TIGHT VAGINA of a postmenopausal patient with a speculum, suture it if it bleeds.
If the LACERATION which is causing the bleeding runs up from her external os (rare), you may be able to seize the bleeder with a haemostat and secure it with a mattress suture.
LATER DIFFICULTIES [s7]WITH A ''D AND C' If, as she recovers from the anaesthetic, her PULSE RATE IS FASTER than it should be after a simple dilatation, she complains of pain (which she should never do), she is pale, cold, and restless, and has some lower abdominal rigidity: (1) She has probably bled into her peritoneal cavity after a perforation. (2) You may have missed an ectopic pregnancy and ruptured it with your ''D and C'. Immediately explore her pelvis through an abdominal incision. Find and suture the perforation. If it is extensive, and sutures will not control the bleeding (rare), tie her internal iliac arteries. If this fails, remove her uterus. Leave her vagina open to allow free drainage.
If she develops symptoms of low abdominal PAIN AND FEVER, suspect salpingitis, and treat it as usual. This is an unusual complication of a ''D and C'.
If, postoperatively, she has PAIN on one side, and a swelling develops in her broad ligament, a haematoma has formed. Occasionally, it may be so severe as to raise the peritoneum of the side wall of her pelvis, and extend even to her loin. If so, she will have the signs of a mass and of hypovolaemia. You may need to open her abdomen and secure the bleeding vessel.
If she develops symptoms of PERITONITIS (lower abdominal tenderness, and rigidity), her prognosis is worse if they appear early, and you cannot feel a pelvic mass, which shows that the infection is localizing. The difficult decision to make is whether you should explore her abdomen or not.
If her symptoms are not severe or worsening, give her antibiotics (2.7), wait and watch her closely. Her peritonitis or pelvic cellulitis may only be local, and symptoms may subside.
If her symptoms are severe or worsening, or generalized, or you have inadvisedly given her an irritant douche, open her abdomen, repair the tear, and mop out her pelvis. If her peritonitis is generalized, wash out her peritoneal cavity and instil tetracycline (6.2). Don't remove her uterus. Make quite sure that her gut has not also been injured.