By Dr Joel Akande
The word “D & C” has been used for as long a anyone could remember. Indeed “D & C” usage in the public doman is often associated with the darker side of Gynaecology or in general, the word is frequently related to a more sinister side of medical practice.
In actual fact, “D & C” is a procedure which simply means “dilatation and curettage” which implies that the attending medical doctor makes the passage in the neck of the womb wider by dilating it with the help of a dilator and then curette by attempting to remove through gentle traction, the contents of the womb. This procedure which I have described, is a common procedure in the field of gynaecology to address several disorders of women and specifically to take samples of the womb/uterine lining such as in cases irregular bleeding, heavy bleeding, when a growth in the womb such as polyps is to be removed, when cancer is suspected to be growing in the womb. Also, during hysteroscopy which is a procedure to pass a camera with a cable into the womb for examination of the inside of the womb. D & C is also used when an operation such as removal of fibroid is to be done.
However, D & C is often associated with the more legitimate use of the procedure in termination of pregnancy that the wider public has come to associate the word and procedure. Millions of pregnancies are terminated in the world annually and Nigeria accounts for a reasonable share of these terminations.
To a specialist physician such as a gynaecologist, a D &C procedure may not be his first option or any of his or her options for such treatment as termination of pregnancy. On the other hand, D & C may be his only option considering the circumstances.
Now, the question remains and of course the object of this article being, why is “D & C” such a dangerous procedure in a non-specialist hand? Why is the procedure such a danger to fertility of women?
The answers to these questions lay in the skills of the operator and the reason for the operation.
For our purpose, D & C is a useful tool in the care of women: preventing undue suffering, abating heavy bleeding, preventing infection, shortening the cost of medical care and indeed preventing death of women and avoiding family grief.
When D & C is carried out by poorly skilled individuals or the procedure is inappropriately applied, a lot of damage may be done to the womb and the health of the women undergoing D & C.
For a start, the blunt instrument used in holding the neck (cervix) of the womb, may be applied so inappropriately as to tear the significant part of the neck of the womb. Further, even if this tear is avoided, the unguarded use of a dilator may cause a perforation to the womb, leading to bleeding and damage to internal organs of the woman undergoing operation. All of these may cause fertility problems for the woman. For one, undue and too frequent dilatation of the neck of the womb may cause Cervical Incompetence. Even if the woman is able to get pregnant, the woman may suffer frequent miscarriages at about 3 months into the pregnancy.
Most significantly, most D & C that are done by inexpert hands results in heavy use of force to remove the contents of the womb in abortion procedures. It’s this use of heavy force that ultimately removed the lining of the womb (endometrium). Once the endometrium is removed, the walls of the womb may come together and become inseparable. Once this situation of the walls of the womb become matted, a dangerous and difficult condition that is called Asherman’s Syndrome develops which is indeed a blockage in the reproductive tract of the individual. Even if there is menstrual blood, the blood may not be able to flow out, leading to collection of blood in the upper segment of the womb and the rest of the abdominal cavity.
With Asherman’s, the woman may not be able to have regular menstruation. Further, during sex, sperms may not be able to travel upstream to meet the released eggs of the woman. Once the sperms cannot meet the eggs, fertility may not happen and the woman or the couple who may have had no fertility issues become infertile.
D & C in poorly skilled hands may also lead to infection. Infection may lead to pelvic inflammatory disease or PID. PID is not compatible with pregnancy and infertility may result.
In sum, while D & C is a vital procedure in good hands, that saves the lives of women, poorly performed D & C procedure is a danger to fertility and the lives of women. My advice would be that women should seek competent doctors and in particular to make use of the services of gynaecologist when the need arises.
[Image credit: Mayo Clinic]