When is dilatation and curettage contraindicated?

Explanation

## Correct Answer: A. Pelvic inflammatory disease Dilatation and curettage (D&C) is contraindicated in **active pelvic inflammatory disease (PID)** because instrumentation of the uterus during acute infection risks disseminating pathogens into the upper genital tract, bloodstream, and peritoneal cavity, precipitating sepsis and septic shock. In acute PID, the endometrium and myometrium are inflamed and friable; mechanical curettage can perforate the uterus and convert localized infection into life-threatening peritonitis or bacteremia. Indian guidelines and standard obstetric practice mandate that any suspected or confirmed PID must be treated medically (antibiotics per RNTCP/NTEP protocols) before any instrumentation is considered. D&C should be deferred until inflammation resolves (typically 4–6 weeks post-treatment) and clinical signs of infection have cleared. This is a critical safety principle in gynecology: never instrument an infected uterus. The risk of iatrogenic dissemination of infection outweighs any diagnostic or therapeutic benefit of the procedure during active disease. ## Why the other options are wrong **B. Ectopic pregnancy** — D&C is **not** contraindicated in ectopic pregnancy; it is actually indicated to rule out intrauterine pregnancy and confirm the diagnosis. D&C with histopathology (absence of chorionic villi) helps differentiate ectopic from intrauterine pregnancy. The contraindication applies to instrumentation of the fallopian tube or ovary where the ectopic pregnancy resides, not the uterus itself. This is a common NBE trap—confusing the site of pathology with the site of instrumentation. **C. Menstrual irregularities** — D&C is a **standard diagnostic and therapeutic procedure** for menstrual irregularities, including abnormal uterine bleeding, polymenorrhea, and oligomenorrhea. Curettage removes abnormal endometrium and allows histopathological examination to rule out malignancy or hyperplasia. It is one of the primary indications for D&C in gynecology. Choosing this option reflects misunderstanding of D&C's role in managing bleeding disorders. **D. Endometriosis** — D&C is **not contraindicated** in endometriosis; in fact, curettage may provide symptomatic relief by removing ectopic endometrial tissue from the uterine cavity. While endometriosis primarily affects the myometrium and peritoneum, D&C can be part of multimodal management. The procedure does not worsen endometriosis or increase dissemination risk as it does in active infection. This option conflates a chronic inflammatory condition with acute infectious inflammation. ## High-Yield Facts - **PID is an absolute contraindication** to D&C because instrumentation risks converting localized infection into sepsis, bacteremia, or peritonitis. - **D&C is indicated in ectopic pregnancy** to confirm absence of intrauterine pregnancy and rule out concurrent intrauterine gestation. - **D&C is a first-line diagnostic tool** for abnormal uterine bleeding and menstrual irregularities; histopathology excludes malignancy and hyperplasia. - **Active infection of any genital tract organ** (endometritis, cervicitis, vaginitis) mandates deferral of D&C until antimicrobial therapy resolves inflammation. - **Post-treatment interval before D&C in PID** is typically 4–6 weeks after completing antibiotics and resolution of clinical signs (fever, tenderness, elevated WBC). ## Mnemonics **NEVER Instrument Infection (NII)** **N**ever, **E**ver **V**enture **E**ntry **R**outinely in **I**nfection. When any genital tract infection (PID, endometritis, cervicitis) is active, defer all instrumentation. Use this when deciding whether to perform D&C, IUD insertion, or hysteroscopy in a patient with fever or pelvic tenderness. **D&C Indications: AMEN** **A**bnormal bleeding, **M**issed abortion, **E**ctopic (rule out), **N**eoplasia (rule out). These are the four main indications for D&C. PID is NOT an indication—it is a contraindication. Use this to quickly recall when D&C is appropriate. ## NBE Trap NBE pairs PID with D&C to test whether students conflate "infection present" with "procedure contraindicated." The trap is that students may think D&C is used to treat PID (by removing infected tissue), when in fact it worsens outcomes by disseminating infection. Ectopic pregnancy is a secondary trap—students may confuse the site of pathology (fallopian tube) with the site of instrumentation (uterus). ## Clinical Pearl In Indian tertiary centers, a common error is performing D&C in a febrile patient with lower abdominal pain and cervical discharge, assuming it will help diagnose the cause. Always rule out PID clinically (fever, cervical motion tenderness, elevated ESR/CRP) and defer instrumentation until antibiotics have cleared the infection. A single episode of iatrogenic sepsis from instrumented PID can lead to infertility, chronic pelvic pain, and medicolegal consequences. _Reference: DC Dutta's Textbook of Obstetrics Ch. 18 (Abnormal Uterine Bleeding & D&C); Harrison Ch. 297 (Pelvic Inflammatory Disease)_