What is a D & C?

The D&C (Dilation and curettage) is an archaic procedure. It is a procedure where the doctor is working in a uterus blindly, trying to spoon out tissue. It is important for you the patient to know that the Doctor cannot see what he or she is doing, and it is all done by feel only. Would you park your car in your garage blindfolded?

Why are Gynaecologists the only surgeons allowed to work inside a human organ blindly?

We have a hysteroscope, which is a telescope with a camera attached that we place into the uterus, and we can both see what we are doing and treat at the same time. We can remove polyps, fibroids, we can remove a miscarriage and very seldomly harm the uterus. One should not use electricity in the uterus, only mechanical instruments. As we said before – Would you park your precious car in a garage blindfolded?

In this video, we have placed a hysteroscope into the uterus, and in our view, we unfortunately see an identical twin miscarriage which was diagnosed on ultrasound. The video shows the pregnancy sac, the placenta is obviously at the back what we call posterior, as well as the tubal openings. There is very healthy decidua tissue or the pregnancy lining of the uterus which we, unfortunately as gynaecologists, have been trained to remove. By removing all this tissue blindly, 1/3 of our patients end up with intra-uterine scar tissue better known as Asherman’s syndrome afterwards. This decidua tissue should never be removed; we should not scrape in the uterus, there should be no need to do a D&C to terminate a pregnancy that is not viable. Patients need to refuse the D & C. The D & C should in fact be banned. Remember, it may also be referred to as an EVAC or evacuation.

In this video we can see how we open the sac and evaluate the foetus. We can also see the villi and will send that off for a biopsy to determine if the pregnancy was abnormal. There is small foetus, it should be nine weeks, and we can see how the foetus has not grown.

We used a mechanical tissue removal system, and we only removed the pregnancy. This uterus should heal up beautifully. The other important thing about this instrument is that we can use it to aspirate and shave – so we don’t have products of conception that get in the way. We leave the rest of the decidua because that is going to heal nicely and reduce the risk of Asherman’s Syndrome. In the video you can see that we also only concentrated on the area where the placental implantation was, leaving the rest of the healthy decidua. This is done within a couple of minutes and the procedure is far less traumatic and complete, than a blind D&C.

The direct visualisation ensures that the uterus is empty – the placental bed, completely removed, only concentrating on removing the placental bed and removed only the pregnancy and we leave the decidua to heal up and reduce the risk of Asherman’s Syndrome.

The pregnancy was genetically abnormal, a Trisomy 3 which is a sporadic abnormality. The gender was male. Since we have the answer as to the cause of the miscarriage, this helps the couple to come to terms with this and move on. Should the genetics have been normal, this will prompt us to do more tests to assess why the patient miscarried a genetically normal pregnancy.

 

To recap: why we should not perform a D&C:

It is a blind and dangerous procedure.

 

  1. Infection: As with any surgical procedure, there is a risk of infection, which can lead to fever, pelvic pain, and vaginal discharge and infertility. Less so with a Hysteroscope
  2. Bleeding: Some bleeding is normal after a D&C, but excessive bleeding can occur, which may require further treatment and is often related to a uterine perforation.
  3. Perforation: the uterus may be punctured or perforated during the procedure due to the blind nature of the procedure. A pregnant uterus is very soft and can easily be perforated when you are working blindly.
  4. Asherman’s syndrome – Intrauterine scar tissue formation: a condition that occurs when adhesions or scar tissue develop inside the uterus after a Blind D&C, which can cause infertility, recurrent miscarriages, or abnormal menstrual bleeding.

 

The chance of developing Ashermans Syndrome with a blind D&C is 30%

Mechanically with Hysteroscopy and direct vision- 1-2%