Dilation and Curettage (D&C) in India and UAE | Complete Patient Guide

• INDICATED PATIENTS (Medical Eligibility):

• Women with confirmed incomplete or missed abortion (gestational sac ≥25 mm without fetal cardiac activity, or retained products of conception on TVUS)

• Women with abnormal uterine bleeding (AUB) who have failed at least one cycle of medical management (hormonal agents, NSAIDs, tranexamic acid) or for whom pharmacological therapy is contraindicated

• Women with suspected or confirmed endometrial hyperplasia, endometrial polyps, or submucosal fibroids requiring tissue diagnosis

• Women with postmenopausal bleeding (PMB) in whom endometrial thickness exceeds 4 mm on TVUS, mandating histological exclusion of endometrial carcinoma

• Women with suspected gestational trophoblastic disease (GTD) based on serum β-hCG levels disproportionate to gestational age

• Women requiring removal of a retained intrauterine device (IUD) fragment or placental remnant following delivery

• Cervical stenosis preventing adequate office-based endometrial sampling

• REQUIRED PRE-PROCEDURE DIAGNOSTICS:

• Transvaginal ultrasound (TVUS): endometrial thickness, uterine morphology, adnexal assessment

• Serum β-hCG (quantitative): mandatory in all reproductive-age women to confirm or exclude pregnancy and GTD

• Complete blood count (CBC) with differential: to assess anaemia, thrombocytopaenia

• Coagulation profile (PT, aPTT, INR): especially in women with menorrhagia or anticoagulant use

• Blood group and Rh typing: Rh-negative women require anti-D immunoglobulin (300 mcg) post-procedure if pregnancy-related

• Cervicovaginal swab culture (high vaginal swab, HVS): to exclude active infection before elective D&C

• Pap smear (if not current): cervical cytology before instrumentation

• ECG and anaesthesia fitness evaluation: for patients receiving general or spinal anaesthesia

• Hysteroscopy (diagnostic or operative): recommended as the preferred adjunct to curettage to eliminate blind-sampling error

• CONTRAINDICATIONS:

• Active pelvic inflammatory disease (PID) or acute cervicitis — procedure must be deferred until infection is eradicated with appropriate antibiotics

• Known or suspected cervical or uterine carcinoma where sharp curettage risks dissemination (refer for staging and oncology consultation)

• Uncorrected coagulopathy or active anticoagulation therapy (bridging or cessation protocol required)

• Haemodynamically unstable patient (systolic BP <90 mmHg, HR >120 bpm) — requires resuscitation prior to any operative intervention

• Severe uterine anomaly (bicornuate or septate uterus) without prior imaging mapping — increased perforation risk

• Known allergy to misoprostol, prostaglandins, or anaesthetic agents without documented alternative protocol

STANDARD SHARP CURETTAGE (Traditional D&C):

The conventional technique uses a metal sharp curette (Sims or Duncan curette, sizes 4–8 mm) to scrape the endometrial lining in a systematic four-quadrant pattern. While historically the default approach, sharp curettage is associated with a higher risk of uterine perforation (0.8–1.5%), Asherman's syndrome (intrauterine adhesions in 1.5–3% of cases after a single procedure, rising to 30% after three or more procedures), and incomplete evacuation, particularly in gestational tissue. Its contemporary use is largely limited to resource-constrained settings or specific therapeutic indications.

MANUAL VACUUM ASPIRATION (MVA):

MVA uses a handheld 60 mL syringe connected to a flexible or rigid cannula (4–12 mm diameter, selected based on uterine size and cervical dilation achieved) to generate negative pressure of approximately 60 cmHg, aspirating endometrial or gestational tissue. MVA is the WHO-recommended first-line approach for uterine evacuation up to 12 weeks gestation, with a complete evacuation rate of 98–99.5%, median operative time of 3–5 minutes, blood loss 40–60 mL less than sharp curettage, and a uterine perforation rate of <0.1%. It can be performed under paracervical block (lidocaine 1%, 10 mL) without general anaesthesia, making it ideal for outpatient settings.

ELECTRIC VACUUM ASPIRATION (EVA):

EVA uses a motorised suction pump (pressure range: 40–80 mmHg adjustable) with rigid metal or plastic cannulae, generating consistent negative pressure superior to MVA for gestational ages 10–14 weeks or cases with a larger uterine cavity. EVA is the technique of choice for second-trimester incomplete abortion evacuation and for cases requiring more complete endometrial clearance in diagnostic D&C for abnormal bleeding.

HYSTEROSCOPY-GUIDED D&C (Gold Standard):

Hysteroscopy-directed D&C is the current evidence-based standard for diagnostic and therapeutic indications beyond simple gestational evacuation. Using a 3–5 mm rigid or flexible hysteroscope with normal saline or glycine distension medium (intrauterine pressure 80–100 mmHg), the operator directly visualises the uterine cavity before and after curettage. This approach achieves:

• Targeted biopsy of focal lesions (polyps, submucosal fibroids, suspicious endometrial areas) missed in 50–80% of cases by blind curettage

• Simultaneous operative intervention: polypectomy with resectoscope loop or bipolar energy (VersaPoint™ system), myomectomy (submucosal fibroids ≤4 cm, FIGO Type 0–1), adhesiolysis for Asherman's syndrome

• Chromopertubation (concurrent fallopian tube patency assessment)

• Endometrial ablation as a definitive treatment for AUB in women who have completed childbearing, using NovaSure™ impedance-controlled radiofrequency ablation (90-second treatment cycle, 80–85% amenorrhoea rate at 12 months)

ROBOTIC-ASSISTED HYSTEROSCOPY (Emerging Technology):

For complex cases — including large submucosal fibroids, severe Asherman's syndrome, or uterine septa requiring extensive resection — robotic-assisted hysteroscopic platforms (da Vinci Surgical System in conjunction with rigid hysteroscopes, or dedicated robotic hysteroscopy platforms under investigation) are available at tertiary-level JCI-accredited hospitals in Mumbai, Delhi, Chennai, Dubai, and Abu Dhabi. These provide tremor-free 3D visualisation, wristed instrument movement, and motion scaling.

MEDICAL MANAGEMENT ALTERNATIVE (When D&C Can Be Avoided):

For select patients with incomplete abortion <8 weeks and retained tissue <15 mm on TVUS, expectant management or misoprostol 800 mcg vaginally (repeat dose at 48 hours if needed) achieves complete evacuation in 80–85% of cases, deferring surgical intervention. Mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally 24–48 hours later achieves complete evacuation in 95% of cases. These pharmacological protocols are discussed at the pre-operative consultation and offered where medically appropriate, avoiding anaesthesia and instrumentation risk.

PHASE 1 — PRE-ARRIVAL TELECONSULTATION (1–2 Weeks Before Travel):

• GAF Healthcare's assigned patient coordinator schedules a video consultation with a board-certified gynaecologist in your chosen destination (India or UAE)

• Patient submits: prior TVUS reports, serum β-hCG results, CBC, coagulation profile, and a summary of menstrual/obstetric history

• Gynaecologist reviews imaging and blood work, confirms D&C indication, selects surgical approach (MVA vs. hysteroscopy-guided), and provides a personalised pre-operative protocol

• Misoprostol cervical preparation instructions (timing, dose, route) are communicated in writing

• Anaesthesia preference discussed: local (paracervical block), sedation/IV analgesia, or general anaesthesia

• Written informed consent documentation dispatched electronically for review

PHASE 2 — ARRIVAL AND PRE-OPERATIVE ASSESSMENT (Day 0–1):

• Airport pickup by GAF Healthcare's dedicated transport partner

• Check-in to hospital or affiliated hotel accommodation (for companion/attendant)

• Hospital admission for pre-operative workup: repeat TVUS on the day of procedure, blood group confirmation, IV access establishment, anaesthesia fitness sign-off

• Cervical preparation: misoprostol 400 mcg vaginally or sublingually administered 2–4 hours before procedure time

• Patient remains NPO (nil per os) for 4–6 hours if general anaesthesia or IV sedation is planned; oral intake permitted up to 2 hours before procedure under local anaesthesia protocol

PHASE 3 — THE PROCEDURE (Day 1; Duration: 10–30 Minutes):

• Patient transferred to operating theatre or dedicated procedure room

• Anaesthesia administered per agreed protocol (GA induction with propofol 1.5–2.5 mg/kg IV; or midazolam 1–2 mg + fentanyl 50–100 mcg IV sedation; or lidocaine 1% paracervical block 10 mL bilaterally)

• Lithotomy position; bimanual examination to confirm uterine size and anteversion/retroversion

• Cervical exposure with Sims speculum; anterior lip grasped with single-toothed tenaculum

• Uterine sounding to confirm cavity depth and direction

• Sequential cervical dilation to required cannula diameter (typically 8–10 mm for diagnostic D&C; smaller for MVA in first-trimester gestational evacuation)

• Hysteroscopy performed (if included): uterine cavity systematically inspected, focal lesions identified and biopsied or resected

• Suction evacuation or sharp curettage performed per chosen technique

• Tissue specimens placed in formalin-filled containers, labelled, and dispatched to histopathology laboratory

• Post-procedure TVUS (in theatre or recovery room) to confirm complete evacuation and exclude perforation

• If Rh-negative: anti-D immunoglobulin 300 mcg administered IM before discharge

PHASE 4 — IMMEDIATE RECOVERY (Day 1; 1–4 Hours Post-Procedure):

• Recovery room monitoring: vital signs every 15 minutes for 1 hour, urine output, pain score assessment

• Expected: mild-to-moderate uterine cramping (similar to dysmenorrhoea) managed with ibuprofen 400–600 mg PO or ketorolac 15–30 mg IV

• Vaginal bleeding assessed: spotting to light flow is expected; soaking more than one pad per hour is abnormal

• Light oral intake commenced once fully awake (day-care patients)

• Day-care discharge criteria (Modified Aldrete Score ≥9): stable vitals, pain VAS ≤3, ability to void, responsible adult escort confirmed

• Discharge medications: ibuprofen 400 mg TDS for 3–5 days, doxycycline 100 mg BD for 7 days (prophylaxis), tranexamic acid 500 mg TDS if prescribed for bleeding management

PHASE 5 — HOTEL/HOME RECOVERY (Days 2–7):

• Mild cramping and light vaginal spotting for 5–14 days post-procedure: normal and expected

• Pelvic rest: no sexual intercourse, tampon use, or swimming for a minimum of 2 weeks

• Avoid strenuous physical activity, heavy lifting (>5 kg), and prolonged standing for 5–7 days

• Histopathology results typically available within 3–5 working days; GAF Healthcare coordinator delivers results to the patient with gynaecologist interpretation

• Follow-up TVUS (if indicated) at Day 5–7 to confirm complete evacuation in high-risk cases

• Emergency contact line maintained 24/7 by GAF Healthcare for pain escalation, fever (>38°C), or heavy bleeding

PHASE 6 — FIT-TO-FLY CLEARANCE AND DEPARTURE:

• Short-haul flights (<4 hours): cleared at Day 3–5 post-procedure if bleeding is minimal and patient is afebrile

• Long-haul flights (>6 hours): clearance typically at Day 7–10, subject to gynaecologist's written sign-off

• Histopathology results, operative notes, discharge summary, and post-op prescription translated into English (or patient's language) by GAF Healthcare and delivered digitally

• Telehealth follow-up with GAF Healthcare's partner gynaecologist scheduled at 2 weeks and 6 weeks post-procedure