Clinical Updates in Reproductive Health

Uterine evacuation: Replace sharp curettage with aspiration or medications

Last reviewed: December 2, 2019

Recommendation:

  • Vacuum aspiration or medical abortion should replace sharp curettage (also known as dilatation and curettage [D&C]) for the treatment of abortion and postabortion care.

Strength of recommendation: Strong

Quality of evidence: Moderate

The World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO) state that vacuum aspiration or medication regimens should replace sharp curettage (FIGO, 2011; WHO, 2012). In places where no uterine evacuation services exist, vacuum aspiration and medical abortion should be introduced.

A 2010 Cochrane review showed that vacuum aspiration is as effective as sharp curettage in treating incomplete abortion while reducing procedure time, blood loss and pain (Tuncalp, Gulmezoglu, & Souza, 2010). In a retrospective case series of 80,437 women seeking induced abortion, vacuum aspiration was associated with less than half the rate of major and minor complications compared to sharp curettage (Grimes, Schulz, Cates Jr, & Tyler Jr., 1976). A more recent series, including more than 100,000 abortion procedures, found that sharp curettage performed alone or in combination with vacuum aspiration was significantly more likely to be associated with complications, particularly incomplete abortion, than vacuum aspiration without curettage (Sekiguchi, Ikeda, Okamura, & Nakai, 2015).

Multiple studies on induced abortion and postabortion care have shown that because vacuum aspiration can be performed in an outpatient setting by physicians or midlevel providers without general anaesthesia, the costs to both the health system and women are significantly less (Benson, Okoh, KrennHrubec, Lazzarino, & Johnston, 2012; Choobun, Khanuengkitkong, & Pinjaroen, 2012; Farooq, Javed, Mumtaz, & Naveed, 2011; Johnston, Akhter, & Oliveras, 2012).

Although no trials exist comparing sharp curettage to medical management of induced, incomplete, or missed abortion, the safety and tolerability of medical regimens for uterine evacuation are well documented and appear as effective as vacuum aspiration in the management of incomplete abortion (Kulier et al., 2011; Neilson, Gyte, Hickey, Vazquez, & Dou, 2013).

The use of sharp curettage to manage incomplete or missed abortion may be associated with Asherman’s syndrome (intrauterine adhesions). A retrospective review from one tertiary care center reported on 884 women who underwent sharp curettage, manual vacuum aspiration or misoprostol for early pregnancy failure (Gilman Barber, Rhone, & Fluker, 2014). In follow-up, 1.2% of women managed with sharp curettage were found to have Asherman’s syndrome (6 out of 483 women), while no cases were found in the 401 women managed by manual vacuum aspiration or misoprostol.

References

Benson, J., Okoh, M., KrennHrubec, K., Lazzarino, M. A., & Johnston, H. B. (2012). Public hospital costs of treatment of abortion complications in Nigeria. International Journal of Gynecology & Obstetrics, 118(2), 60012-60015.

Choobun, T., Khanuengkitkong, S., & Pinjaroen, S. (2012). A comparative study of cost of care and duration of management for first-trimester abortion with manual vacuum aspiration (MVA) and sharp curettage. Archives of Gynecology and Obstetrics, 286(5), 1161-1164.

Farooq, F., Javed, L., Mumtaz, A., & Naveed, N. (2011). Comparison of manual vacuum aspiration, and dilatation and curettage in the treatment of early pregnancy failure. Journal of Ayub Medical College Abbottabad, 23(3), 28-31.

FIGO. (2011). Consensus statement on uterine evacuation. Retrieved from https://www.figo.org/news/new-download-uterine-evacuation-figo-consensus-statement-0014150

Gilman Barber, A. R., Rhone, S. A., & Fluker, M. R. (2014). Curettage and Asherman’s syndrome-lessons to (re-) learn? Journal of Obstetrics and Gynaecology Canada, 36(11), 997-1001.

Grimes, D. A., Schulz, K. F., Cates Jr, W., & Tyler, C. W., Jr. (1976). The Joint Program for the Study of Abortion/CDC: A Preliminary Report. Paper presented at the Abortion in the Seventies: Proceeding of the Western Regional Conference on Abortion, Denver, Colorado.

Johnston, H. B., Akhter, S., & Oliveras, E. (2012). Quality and efficiency of care for complications of unsafe abortion: A case study from Bangladesh. International Journal of Gynecology & Obstetrics, 118(2), 60013-60017.

Kulier, R., Kapp, N., Gulmezoglu, A. M., Hofmeyr, G. J., Cheng, L., & Campana, A. (2011). Medical methods for first trimester abortion. Cochrane Database of Systematic Reviews, 9(11).

Neilson, J. P., Gyte, G. M., Hickey, M., Vazquez, J. C., & Dou, L. (2013). Medical treatments for incomplete miscarriage. Cochrane Database of  Systematic Reviews, 28(3).

Sekiguchi, A., Ikeda, T., Okamura, K., & Nakai, A. (2015). Safety of induced abortions at less than 12 weeks of pregnancy in Japan. International Journal of Gynecology & Obstetrics, 129(1), 54-57.

Tuncalp, O., Gulmezoglu, A. M., & Souza, J. P. (2010). Surgical procedures for evacuating incomplete miscarriage. Cochrane Database of Systemtatic Reviews, 8(9).

World Health Organization. (2012). Safe abortion: Technical and policy guidance for health systems (2nd ed.). Geneva: World Health Organization Press.