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Dilatación y legrado
AUTORES: Dra. Kari P. Braaten, MPH, Dra. Caryn Dutton, MS
EDITOR DE LA SECCIÓN: Dr. Howard T. Sharp
EDITOR ADJUNTO: Dra. Alana Chakrabarti

Todos los temas se actualizan a medida que hay nueva evidencia disponible y se completa nuestro proceso de revisión por
pares .

Revisión de literatura actualizada hasta: mayo de 2025.

Última actualización de este tema: 30 de abril de 2025.

INTRODUCCIÓN

La dilatación y el legrado (D&C) son uno de los procedimientos más comunes en obstetricia y
ginecología. En general, la D&C describe un procedimiento en el que se utilizan dilatadores
cervicales para facilitar la introducción de instrumentos en el útero, y se toma una muestra o se
vacía la cavidad endometrial con una cureta. La D&C puede utilizarse con fines terapéuticos y
diagnósticos, tanto en el útero de mujeres embarazadas como no embarazadas.

Aquí se revisará el procedimiento de dilatación y legrado. Los procedimientos de muestreo en el

consultorio y los enfoques diagnósticos para la evaluación del endometrio se abordan en otra
sección. (Véase "Procedimientos de muestreo endometrial en el consultorio" y "Resumen de la
evaluación del endometrio para detectar enfermedades malignas o premalignas" ).

TERMINOLOGÍA

El legrado realizado por una indicación relacionada con el embarazo también se conoce como
legrado por succión, legrado por aspiración o dilatación y evacuación (D&E). El término D&E
varía según la región: en algunos lugares, en instituciones clínicas, se utiliza para cualquier
procedimiento que implique succión en cualquier etapa de la gestación, mientras que en otras,
se utiliza únicamente para referirse a los procedimientos del segundo trimestre. En este tema,
nos centraremos en los procedimientos del primer trimestre y utilizaremos el término legrado
por aspiración.
INDICACIONES

La D&C puede ser un procedimiento diagnóstico y/o terapéutico; algunos ejemplos de

escenarios clínicos en los que está indicado un D&C incluyen los siguientes:

● Incapacidad para tomar muestra de endometrio en el consultorio debido a estenosis cervical,

dolor o ansiedad.

● Biopsia de endometrio en consultorio con tejido insuficiente para el diagnóstico o resultados

que son inconsistentes con los hallazgos de imágenes (por ejemplo, endometrio inactivo en
un paciente con imágenes sugestivas de masa o pólipo).

● Sangrado uterino anormal persistente (SUA) o sangrado posmenopáusico después de una

biopsia benigna en el consultorio.

● Para descartar carcinoma endometrial en pacientes con diagnóstico de hiperplasia atípica

(también conocida como neoplasia intraepitelial endometrial) en la toma de muestras en el
consultorio. (Véase "Hiperplasia endometrial o neoplasia intraepitelial endometrial:
Características clínicas, diagnóstico y diagnóstico diferencial", sección "Evaluación posterior
de la hiperplasia endometrial con atipia (EIN)" ).

● Instead of office endometrial biopsy when a concomitant procedure such as hysteroscopy or

laparoscopy is planned.

● Examination for villi in the evaluation of a patient with a pregnancy of unknown location. (See
"Approach to the patient with pregnancy of unknown location", section on 'Management'.)

● Temporary management of patients with prolonged or excessive bleeding who are

unresponsive to hormonal therapy, have contraindications to hormonal therapy, or are
hemodynamically unstable and need immediate treatment. (See "Managing an episode of
acute uterine bleeding", section on 'Preferred: Uterine curettage'.)

● Treatment of early pregnancy loss or for procedural abortion. (See "Pregnancy loss
(miscarriage): Terminology, risk factors, and etiology" and "First-trimester pregnancy
termination: Uterine aspiration".)

● Evacuation of suspected molar pregnancy. (See "Initial management of low-risk gestational

trophoblastic neoplasia".)

● Suspicion of retained products of conception postpartum or after procedural evacuation. (See

"Retained products of conception in the first half of pregnancy", section on 'Management'.)
CONTRAINDICATIONS

Absolute contraindication — The only absolute contraindication to D&C is a desired viable

pregnancy.

Precautions

Bleeding diathesis

● Due to anticoagulant therapy – Decisions about holding anticoagulants prior to D&C need
to be made on an individual basis along with other members of the patient's care team (eg,
the prescribing physician and anesthesiologist). Considerations include the indications for
anticoagulation (therapeutic versus prophylactic), risk of complication/thrombosis if
anticoagulants are stopped temporarily, and bleeding risk specific to the patient's case. For
example, patients who are on long-term anticoagulation for atrial fibrillation can often have
their anticoagulants held for several days without significant risk, whereas patients with
recent thromboembolic disease or with artificial heart valves are at much higher risk of
complication if their anticoagulation is held. (See "Perioperative management of patients
receiving anticoagulants".)

Additionally, in pregnancy-related suction D&C, the primary physiologic mechanism for

cessation of bleeding is uterine contractility, and thus these cases can often be done
without holding anticoagulants without complication [1]. Typically, even when patients are
fully anticoagulated, no additional bleeding is encountered, and additional measures are
not needed. Uterotonics may be used if needed per usual practice.

● Due to a clotting deficiency – Patients with an inherent clotting deficiency should ideally
have their clotting factors replaced prior to any planned procedure. This may entail
treatment with desmopressin for patients with von Willebrand disease, or treatment with
fresh frozen plasma or cryoprecipitate in patients with significant postpartum hemorrhage
or disseminated intravascular coagulation (DIC). Patients with hemodynamic instability due
to hemorrhage and/or DIC should have general hemorrhage management including
volume and factor replacement prior to or concomitant with any D&C depending on the
level of concern for retained tissue. (See "Overview of postpartum hemorrhage" and
"Perioperative blood management: Strategies to minimize transfusions", section on
'Management of specific hemostatic disorders'.)

Pelvic infection — A nonurgent D&C should generally be avoided in the patient with a known
cervical or uterine infection. D&C performed in the presence of infection may result in further
 ascending infection, pelvic inflammatory disease, or development of intrauterine adhesions.
If the procedure can be delayed, the infection should be treated prior to any instrumentation.
There are, however, exceptions to this:

● Septic abortion or endometritis with suspected retained products of conception – In these

cases, the retained pregnancy tissue is believed to be the nidus of infection, and prompt
evacuation is important for resolution of the infection. Broad-spectrum intravenous
antibiotics are initiated prior to uterine evacuation. (See "Septic abortion: Clinical
presentation and management", section on 'Management'.)

● Pyometra – This may be due to cervical obstruction with superinfection of menstrual blood,
normal secretions, and cellular debris, or to necrosis of submucosal fibroids. D&C is
appropriate to remove the source of infection.

Cervical or cesarean scar ectopic pregnancy — For patients with a cervical or cesarean scar
ectopic pregnancy, the risk of excessive bleeding or hemorrhage may be severe. Thus, the
decision to proceed with D&C must be considered carefully.

For cervical ectopic pregnancies, D&C is generally considered a second-line treatment. These
cases are generally better managed with medical therapy such as methotrexate or potassium
chloride with suction D&C generally reserved for cases of severe hemorrhage, after uterine
artery embolization, or after nonresolution of the pregnancy following medical therapy (see
"Cervical pregnancy: Diagnosis and management", section on 'Treatment').

Cesarean scar ectopic pregnancies may also have a high risk of bleeding but are more
heterogeneous in clinical features, depending on site of implantation and extent of growth
into the myometrium. Management includes surgical (eg, suction D&C, operative resection)
or medical (eg, intragestational injection of methotrexate or potassium chloride) therapies;
the choice of treatment is guided by many factors (ie, hemodynamic stability, thickness of
myometrium, gestational age, desire for future fertility, experience of the physician treating
the patient). (See "Cesarean scar pregnancy", section on 'Management'.)

PREPROCEDURE PREPARATION

Cervical preparation — Cervical preparation to minimize procedural pain with dilation has
unclear advantages when patients are under sedation or general anesthesia. For awake
patients, cervical preparation may be helpful in specific situations. However, because of the
known side effects of misoprostol (eg, nausea, vomiting, diarrhea, fever), we do not routinely
use cervical preparation to reduce pain prior to routine D&C with or without hysteroscopy.
Some surgeons give preoperative misoprostol with the goal of reducing the need for
mechanical dilation, but overall this has not been proven to be effective in clinical studies. In
specific groups of patients, such as adolescents or those late in the first trimester, misoprostol
may decrease the risk of cervical injury [2]. Mifepristone does not appear to be effective for
reducing the need for mechanical dilation [3]. (See "Hysteroscopy: Instruments and procedure",
section on 'Cervical preparation and dilation'.)

Osmotic dilators (laminaria or Dilapan-S) are another method of cervical preparation that is
mainly used for procedural abortion. Placement requires an additional visit the day before the
scheduled surgery and may be uncomfortable for patients. Since significant dilation is not
needed for D&C alone, osmotic dilators are not commonly used.

Intraoperative techniques that may facilitate cervical dilation if cervical stenosis is present are
discussed below (see 'Cervical stenosis' below). Cervical preparation prior to D&C in a pregnant
uterus is addressed elsewhere. (See "Pregnancy termination: Cervical preparation for
procedural abortion", section on '12 to <14 weeks'.)

Prophylactic antibiotics — Guidelines do not support routine use of prophylactic antibiotics in

nonpregnant patients prior to D&C (with or without hysteroscopy ( table 1)). Prophylactic
antibiotics are used in pregnant patients prior to D&C. (See 'Infection' below and "Gynecologic
surgery: Overview of preoperative evaluation and preparation", section on 'Antibiotic
prophylaxis' and "Overview of pregnancy termination".)

Venous thromboembolism prophylaxis — D&C is a minor procedure with low risk of venous
thromboembolism. Therefore, in patients under 40 years of age without risk factors, no
pharmacologic or mechanical prophylaxis is required other than early ambulation. In patients
40 years old or more, for procedures over 30 minutes or with risk factors, prophylaxis may be
indicated. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical
patients".)

Anesthesia — D&C is typically performed in a surgical suite under procedural sedation or

intravenous general anesthesia. While there is likely no additional benefit of administering a
paracervical block in patients receiving deep sedation or general anesthesia for intrauterine
procedures, it may be useful if minimal or moderate sedation is used [4-6]. (See "Procedural
sedation in adults in the emergency department: General considerations, preparation,
monitoring, and mitigating complications".)

INSTRUMENTS
Dilators — Each provider should use the instruments available and appropriate to their setting
and experience. We prefer use of thin tapered dilators (eg, Hanks or Pratt dilators) compared
with blunt tip dilators (eg, Hegars) because of the enhanced tactile feedback during dilation
( picture 1). In addition, Hanks and Pratts have smaller intervals between each size compared
with standard Hegars. We suggest use of tapered dilators rather than blunt dilators. Tapered
dilators require less force and may therefore minimize risk of uterine perforation [7]. In
particular, we find this helpful in patients with tortuous, nulliparous, or postmenopausal cervical
canals. However, some surgeons prefer blunt tip dilators.

Dilator sizes commonly start at 13 French for Pratt, 9 French for Hanks, and 3 mm diameter for
standard Hegars. French scale measurements are equivalent to circumference in millimeters (or
the diameter multiplied by pi [3.14]).

Small diameter dilators — If the smallest of the usual gynecologic dilators does not easily
pass into the cervical canal, some surgeons will use lacrimal duct probes or narrower metal
cervical dilators (as small as 1 mm diameter) to access the cervix. Care should be taken when
inserting these since a narrower dilator may be more likely to pass through tissue rather than
into the cervical canal or uterine cavity, and can result in injury or the creation of a "false
passage" that may make finding the true cervical canal more difficult. Another option is use of
flexible plastic "os finders" (eg, Comfort-Flex Cervical Dilator Set) that come with both gently
and sharply tapered tips for dilation up to approximately 3.8 mm before transitioning to the
traditional dilator sizes.

Curettes — Sharp metal curettes are typically selected for diagnostic D&C procedures (eg, for
postmenopausal bleeding). These curettes have a long handle and open teardrop shape at the
tip, often with a sharp edge along the superior convex aspect ( picture 2). Metal curettes
come in various sizes corresponding to the largest diameter at the tip, including #00 (3 mm), #0
(5 mm), #1 (7 mm), #2 (8 mm), #3 (9 mm), and larger. We prefer metal curettes that are
malleable, allowing the operator to adjust the curvature of the device to facilitate access to the
fundus in the case of severe uterine flexion. By contrast, metal curettes are not used in D&Cs
performed during pregnancy due to the increased risk of pain, bleeding, and uterine
perforation [8].

Plastic curettes, also called cannulas, are used in suction D&C and are typically used when large
amounts of endometrial tissue are anticipated, such as aspiration D&C associated with
pregnancy or in a patient with heavy active bleeding or known retained clot.

In the nonpregnant patient, a plastic curette diameter between 7 to 10 mm should be sufficient

for evacuation of clot or endometrial tissue. Plastic curettes may be straight or curved, rigid or
flexible; we typically use curved rigid cannulas for electric suction aspiration procedures, though
the choice of cannula should be guided by surgeon comfort and experience ( picture 3).

Aspiration instruments — Electric suction aspiration provides continued negative pressure to

quickly evacuate the uterine contents and thus minimize additional bleeding. This has
traditionally been used as the aspiration source for a therapeutic suction D&C procedure.
However, the pump and unit require a clinic or procedure area with adequate space and
resources.

Manual vacuum aspiration (MVA) refers to a handheld device that is "locked," then utilizes a
large attached syringe that is withdrawn to create negative pressure ( picture 4). Once
connected to the curette in position inside the uterus, the lock is released to allow use of the
negative pressure to evacuate the uterus, collecting tissue in the syringe. This technique is used
over several passes to completely evacuate the uterus. The standard MVA device has a double
lock, whereas a device with a single lock, or with a locking syringe (sometimes referred to as a
Karman device), generates a lower level of negative pressure. The Karman devices are sufficient
for diagnostic purposes, such as examination for villi in evaluation of pregnancy of unknown
location, but cannot reliably be used for complete evacuation.

PROCEDURE

Technique

● Informed consent is obtained, including consent regarding any clinicians or students who will
perform a pelvic examination under anesthesia. (See "Pelvic examination under anesthesia",
section on 'Informed consent'.)

● After anesthesia is adequate, position the patient in dorsal lithotomy position.

● Perform a bimanual pelvic examination to assess the position of the cervix, orientation of the
uterus, uterine size, and any findings that may impact the procedure. The patient should
ideally have already undergone a full evaluation to facilitate procedure planning.

● Prepare the vagina and cervix with an antiseptic solution. (See "Gynecologic surgery:
Overview of preoperative evaluation and preparation", section on 'Vaginal preparation'.)

● Insert a speculum or use anterior and posterior vaginal retractors.

● Place a tenaculum on the anterior cervix, grasping horizontally or vertically across the 12
o'clock position, to stabilize the uterus during the D&C. Tenacula may be sharp or atraumatic
 (eg, Bierer tenaculum) ( picture 5). Additionally, use of traction to straighten the uterine axis
reduces the angle at the cervicouterine junction, typically from a median of 75 degrees to 10
degrees [9]. This alignment of the cervical canal with the uterine cavity theoretically reduces
the risk of uterine perforation that could occur if instruments are inserted into the uterus with
significant anteversion/retroversion.

● A paracervical block (with or without vasopressin) may be performed before or after

placement of the tenaculum. This may be used for pain control [6]; vasopressin is typically
used in patients at high risk for bleeding (eg, cervical pregnancy, cesarean scar ectopic
pregnancy) [10]. The paracervical block procedure is described in detail separately. (See
"Pudendal and paracervical block", section on 'Procedure'.)

● If indicated for evaluation of cervical dysplasia, perform endocervical curettage prior to

dilation or intrauterine procedures to avoid contamination of the endocervical specimen with
endometrial cells. To perform endocervical curettage, an endocervical curette (eg, Kevorkian
curette) is inserted into the external cervix and curettage performed in all four quadrants
( picture 6). The specimen is then placed onto a nonadherent gauze sponge and given to a
surgical staff member who will place it in the appropriate specimen container.

● Dilation – Initiate dilation with a dilator with a diameter that passes easily through the
external and internal os (see 'Dilators' above). Sequentially increase the dilator size to
accommodate the largest diameter device or instrument that will pass through the cervix. For
a commonly used #2 sharp curette, you will need a diameter of 8 mm; for a hysteroscopy,
dilate to the diameter of the sheath and scope to be used.

● While dilating, gently pass the dilator until the widest part (the end of the tapered section) is
at the internal os ( figure 1). With training, surgeons learn to sense this landmark as the
loss of mild resistance with application of steady pressure. Typically, the dilator is held lightly
between the thumb and first digit of the dominant hand, with the remaining fingers spread
laterally to provide a backstop against the perineum for any sudden loss of resistance. Do not
apply fundal pressure with the tip of the dilators. If resistance is encountered and then
suddenly lost with the dilator advancing notably beyond previous dilators, the clinician should
suspect a uterine perforation. Another sign of perforation is losing a feeling of resistance at
the level of the uterine fundus, either with the dilator or when checking with a uterine sound.

● Routine use of a uterine sound to measure the length of the uterine cavity does not, in our
opinion, add benefit to the procedure unless this information is needed for additional
procedures (intrauterine device insertion, endometrial ablation) or to confirm appropriate
cavity length if difficulty is encountered when trying to use dilators.
● If hysteroscopy is planned, perform this step next. Hysteroscopy depends upon clear
visualization, so it is typically done first before the endometrial surface is disturbed. If a
hysteroscope is not available, consider using polyp forceps to explore the cavity for structural
lesions that may be amenable to removal ( picture 6). (See 'Role of hysteroscopy' below and
"Hysteroscopy: Instruments and procedure", section on 'Procedure'.)

● Curettage – If a D&C is planned in a non-pregnant patient, a metal curette is typically

selected. For a D&C in a pregnant patient, or a non-pregnant patient with a large volume of
tissue or at higher risk for bleeding, suction curettage is preferable.

• Diagnostic D&C – Insert the metal curette into the uterine fundus, and proceed with
curettage by directing pressure with the sharp edge of the curette tip along the uterine
walls in a downward scraping motion to the level of the internal os ( figure 2). Sampling
should be performed along all four walls (anterior, right, posterior, and left) in a systematic
fashion to completely sample the endometrium. Perform several passes with the curette. To
collect the endometrial specimen, place a piece of nonadherent gauze sponge in the
posterior blade of the speculum or retractor. Then bring the curette through the cervix and
remove the endometrial tissue, placing it on the gauze sponge.

• Therapeutic D&C for abnormal uterine bleeding – When suction and a plastic curette are
used (see 'Curettes' above), connect the curette to the plastic tubing used with an electric
suction device with a trap or to a manual vacuum aspiration device. Gently pass the curette
to the fundus before activating the suction. Use a similar systematic technique as for
diagnostic D&C: sample all four quadrants of the uterus by spinning the tip and slowly
withdrawing the curette or by using gentle vertical passes along the walls to the level of the
internal os. The technique for suction curettage for procedural abortion is described in
detail elsewhere. (See "First-trimester pregnancy termination: Uterine aspiration".)

● Curettage should continue until a gritty texture (rather than smooth or slippery texture) is
palpable at the tip of the curette, corresponding to successful removal of overlying
endometrium. If a plastic curette is used for therapeutic suction D&C, then additional use of a
metal curette is generally not needed if the gritty texture of the uterus is noted with the
plastic curette and there is no concern for retained tissue or abnormally adherent tissue.

● Once the procedure is completed, the tenaculum should be removed and the cervix inspected
for bleeding. Bleeding from tenaculum sites typically responds to direct pressure or
application of silver nitrate or ferric subsulfate (Monsel solution). If a laceration is present,
suturing may be required. (See 'Cervical injury' below.)
Role of hysteroscopy — D&C should be done in conjunction with hysteroscopy in selected
patients (eg, nonpregnant patients with AUB or endometrial thickening) to obtain a visual
image of the endometrial cavity and to exclude focal disease. Hysteroscopy thus turns a "blind"
procedure into one allowing directed biopsy or visual confirmation of pathology. This helps to
prevent missing unsuspected polyps and ensures that the most visibly abnormal areas are
sampled. Hysteroscopy may be better able to detect abnormalities than blind endometrial
sampling alone in the evaluation of AUB [11,12]. In addition, a combined procedure with
hysteroscopy may provide options for definitive treatment of AUB (such as polypectomy or
resection of submucosal fibroids). (See "Overview of the evaluation of the endometrium for
malignant or premalignant disease", section on 'Role of hysteroscopy' and "Hysteroscopy:
Instruments and procedure".)

CHALLENGING CASES

Cervical stenosis — Cervical stenosis is common, and indeed, an unsuccessful attempt at

endometrial biopsy in the office due to stenosis may be the sole indication for bringing a
patient to the operating room for D&C.

Cervical stenosis can be caused by congenital anomalies (eg, due to in utero diethylstilbestrol
exposure), prior surgery or other trauma to the cervix (eg, loop electrosurgical excision
procedure [LEEP], cone biopsy, obstetric laceration, or cerclage placement), infection, or
menopause. Anatomical variations such as severe uterine anteversion/retroversion or uterine
fibroids may also impede access to the uterine cavity by causing deviation of the cervical canal.
In a series of over 31,000 patients undergoing office hysteroscopy, cervical stenosis was
documented in 29.9 percent of premenopausal patients and 70.1 percent of postmenopausal
patients [13].

When stenosis is known or anticipated, measures should be taken to facilitate cervical dilation
and avoid cervical or uterine injury. While we do not use cervical preparation with
prostaglandins or osmotic dilators for most D&C procedures, these may be considered in some
cases of known cervical stenosis or obstruction (ie, history of LEEP, cervical fibroids), nulliparous
patients, adolescents, or some abortion procedures. Of note, there are no studies that have
demonstrated successful use of cervical ripening agents such as misoprostol or mifepristone
prior to D&C in patients with documented cervical stenosis. (See "Pregnancy termination:
Cervical preparation for procedural abortion", section on '12 to <14 weeks'.)

Intraoperative ultrasound guidance can be extremely useful by providing visualization and

facilitating access to the cervix and uterine cavity. To perform a D&C under ultrasound
guidance, consider back-filling the bladder through a urethral catheter with at least 200 to 300
mL of sterile water or saline to allow transabdominal views of the uterus and cervical canal.
Direct visualization of dilators in the cervical canal and then into the endometrial cavity during
placement can aid navigation of tortuous cervical canals and avoid creation of false passages
[14].

The suggestions below are based on techniques described in the medical literature or used in
our practice or by our colleagues for management of cervical stenosis.

Options for management of stenosis at the external cervical os include:

● For postmenopausal patients or in patients with suspected hypoestrogenic states (eg,

following treatment with gonadotropin-releasing hormone agonists), an option is
preoperative low-dose vaginal estrogen therapy (eg, for two to four weeks).

● Applying cautious blunt pressure to the external cervical os to release adhesions. A narrow
dilator may be used or the narrow end of an Adson forceps. Care should be taken to avoid
creating a false tract rather than passing the dilator into the cervical canal. Of note, if
ultrasound guidance is used, the external os and lower cervical canal may be difficult to
define since having a speculum in place will cause interference with the image.

● Injection of saline into the presumed external os for hydro-dissection to allow identification of
the canal and create a patent opening.

● Making a small stab incision at the known cervical opening or using a small cautery loop to
excise scar tissue at the external os. This is particularly useful in the setting of scar tissue from
prior LEEP or cone biopsy procedures.

Options for management of stenosis in the cervical canal or at the internal os include:

● As described above, use of a small metal or plastic dilator under ultrasound guidance to
define the cervical canal.

● It may help to reposition the tenaculum and/or to place a posterior tenaculum to maximize
traction and effectively straighten the cervical canal.

● Insertion of a flexible diagnostic hysteroscope or standard rigid diagnostic hysteroscope with

instillation of fluid to identify the canal under direct visualization.

● Occasionally, a flexible hysteroscope can be passed through the cervical canal, but further
dilation with rigid dilators is unsuccessful. In such cases, a small flexible plastic cannula and
 suction aspiration may be attempted instead of malleable metal instruments. This may be a
successful approach because the straight tips of the smallest plastic cannula are often
narrower in diameter than the smallest metal curettes, and the flexible design can
accommodate abnormal anatomy.

● In selected cases, surgeons have described use of hysteroscopic techniques (with a miniature
loop, bipolar tip, or scissors) to resect endocervical tissue or adhesions under direct
visualization [13,14]. This requires experience with this technique.

When accessing the cavity is difficult, the possibility of an undiagnosed uterine anomaly or
intrauterine adhesion should be considered. If intraoperative ultrasound and the above
attempts fail, the D&C attempt should be abandoned, and imaging with a different modality,
such as magnetic resonance imaging or saline-infusion sonography, may be useful to better
define the anatomy.

If the above maneuvers are unsuccessful and it is important to sample the endometrium, an
option is to perform ultrasound-guided biopsy through the cervix or myometrium. This can be
done with an extra-long 18- or 20-gauge spinal needle to aspirate intrauterine contents or fluid
and obtain a sample for pathologic examination [14].

Obesity — Adequate visualization and access to the cervix may be significantly impacted by a
patient's body mass index due to difficulty placing instruments. Measures to facilitate a D&C in
patients with obesity include:

● Careful positioning of the patient on a bariatric operative bed and with bariatric leg supports
is needed for safety of the patient and optimal exposure.

● Though procedural sedation may be more challenging in patients with obesity, it can facilitate
relaxation and visualization that is often not possible in the office setting to allow endometrial
sampling.

● To prevent vaginal side wall prolapse into the visual field, a plastic glove finger or a condom
with the end cut off can be placed around the speculum blades to form a tube. Vaginal wall
retractors are often more useful than speculums in patients with obesity, as they allow for
more flexible and directed visualization of the cervix.

● Vaginoscopy can be useful in identifying the cervix and entering the cervical canal, as can
placement of an atraumatic tenaculum by palpation alone if the cervix cannot be visualized
using a speculum or other vaginal retractors.

● Bariatric length vaginal instruments are available.

COMPLICATIONS

D&C is a very safe procedure, and complications are rare. Potential complications include:

● Uterine perforation
● Cervical injury
● Infection
● Hemorrhage
● Incomplete procedure
● Formation of intrauterine adhesions
● Anesthesia-related complications

Uterine perforation — Uterine perforation is the most common immediate complication of

D&C. Rates of perforation depend on the indication for D&C. The highest rate of uterine
perforation appears to be in the setting of postpartum hemorrhage (5.1 percent) compared
with a lower rate in diagnostic curettage (0.3 percent in the premenopausal patient and 2.6
percent in the postmenopausal patient) [15,16]. Be aware of the estimated uterine length
measurement (by ultrasound or pelvic examination) prior to starting the procedure; for
example, a postmenopausal patient may have a uterus measuring only 5 cm. Perforation rates
overall are higher in the pregnant than the nonpregnant uterus due to softening of the uterine
wall and enlargement of the uterine cavity. In general, perforation rates tend to increase with
increasing uterine size (lowest in the first trimester and highest in the postpartum uterus).

The evaluation and management of uterine perforation are discussed in detail separately. (See
"Uterine perforation during gynecologic procedures".)

Cervical injury — Injury to the cervix during D&C can occur in the form of an injury to the
external cervix from the tenaculum or internal damage to the cervical canal or stroma from
dilation or passage of instruments through the cervical canal.

The most common cervical injury is a laceration to the cervical lip when too much traction is
applied to a sharp-toothed tenaculum. Most of these injuries can be managed expectantly or
become hemostatic with the application of pressure, silver nitrate, or ferric subsulfate (Monsel
solution), though in some cases a suture may be needed.

To avoid cervical laceration, some providers prefer atraumatic tenacula or application of a

single-toothed tenaculum in the vertical orientation with one tooth in the internal os. This
places the force of the tenaculum perpendicular to the circular muscle fibers of the cervix,
though this may be more challenging to place the tenaculum in this position if the external os is
narrow (eg, postmenopausal patient or cervical stenosis). Also, if an injury occurs with the
tenaculum in the vertical configuration, suturing can be done in the transverse direction, which
may be technically easier. When the cervix is enlarged and softer as in the case of pregnancy
evacuation in the late first and second trimester or postpartum period, we routinely use an
atraumatic grasper such as the Bierer tenaculum or a ring forceps to minimize cervical trauma.

Internal cervical lacerations are less common but can occur in the setting of a dilator or curette
making a false passage or perforation. To reduce the risk of internal cervical injury, excessive
force should be avoided during dilation. There is a risk of laceration of a cervical branch of the
uterine artery, which may result in significant bleeding. Internal cervical injuries can be
controlled with pressure or direct suture application if injury is relatively minimal. If there is
more severe bleeding, options include balloon tamponade with or without therapeutic
embolization if bleeding is more significant. Rarely, with high internal cervical injuries, bleeding
may extend abdominally or retroperitoneally, requiring further surgical exploration.

Infection — Infection associated with D&C is rare. Very little is known about the incidence or
risk factors for infection at the time of diagnostic D&C. The American College of Obstetrics and
Gynecology (ACOG) guidelines for antibiotic prophylaxis for gynecologic procedure do not
specifically address diagnostic D&C; however, for similar procedures such as endometrial biopsy
or procedures often done in concert with D&C including hysteroscopy and endometrial ablation,
antibiotic prophylaxis is not recommended [17].

For suction D&C done in the setting of pregnancy, infection risk is higher, and therefore,
antibiotic prophylaxis is recommended in these patients. (See "First-trimester pregnancy
termination: Uterine aspiration", section on 'Antibiotic prophylaxis' and "Second-trimester
pregnancy termination: Dilation and evacuation", section on 'Prophylactic antibiotics'.)

There are no specific data on infection risk specifically after suction D&C done for pregnancy
loss; however, the risks and incidence are assumed to be similar to procedural abortion, and
recommendations for prophylaxis and treatment are the same.

Patients with a postprocedure endometritis should be treated per Centers for Disease Control
and Prevention (CDC) guidelines for treatment of pelvic inflammatory disease. (See "Pelvic
inflammatory disease: Treatment in adults and adolescents".)

Hemorrhage — Hemorrhage is extremely rare with D&C. For diagnostic procedures and
therapeutic procedures in the nonpregnant patient, excess bleeding may occur in the setting of
cervical injury or perforation, as noted above.
For pregnancy-related suction D&C, in addition to these causes of bleeding, hemorrhage may
be due to uterine atony or retained products of conception. (See 'Incomplete procedure' below.)

Management should be aimed at diagnosing and treating the underlying cause, and may
include fluid or blood product resuscitation, uterotonics, re-evacuation, or additional measures
such as uterine artery embolization or surgical exploration. (See "First-trimester pregnancy
termination: Uterine aspiration", section on 'Hemorrhage'.)

Abnormal placentation is rare in the first trimester but may be associated with cesarean scar
pregnancy or a history of other uterine scarring and can be a cause of significant hemorrhage
during first-trimester suction D&C. (See "First-trimester pregnancy termination: Uterine
aspiration", section on 'Hemorrhage'.)

Unsuspected placenta accreta or percreta may also be cause of notable hemorrhage at the time
of postpartum D&C for retained placenta. (See "Placenta accreta spectrum: Management",
section on 'Unexpected placenta accreta' and "Overview of postpartum hemorrhage".)

Incomplete procedure — D&C may be complicated by an incomplete procedure, either due to

need to abort the procedure or as manifested by retained products of conception after a
pregnancy-related suction D&C.

Diagnostic procedures may need to be aborted in the event of severe cervical stenosis or in the
event of complications such as hemorrhage or perforation. In cases of unsurmountable cervical
stenosis, a repeat procedure may be considered at another time if preprocedure cervical
preparation had not previously been used, or other surgical procedures such as hysterectomy
may be required.

D&C procedures done in concert with hysteroscopy may need to be aborted if perforation
occurs and uterine distension is lost or if there is excessive absorption of distending fluid. In
cases of uterine perforation, if there is no accompanying hemorrhage or other instability,
careful curettage under ultrasound guidance may still be performed if the boundaries of the
endometrial cavity can be carefully ensured. Otherwise, the uterine perforation should be
allowed to heal for at least one to two weeks, and then repeat procedure may be performed,
preferably with ultrasound guidance.

Management of retained products of conception after pregnancy termination is discussed

elsewhere. (See "First-trimester pregnancy termination: Uterine aspiration", section on
'Incomplete or failed abortion'.)
Intrauterine adhesions — Approximately 90 percent of cases of severe intrauterine adhesive
disease are related to curettage for pregnancy complications, such as missed or incomplete
abortion, postpartum hemorrhage, or retained placental remnants [18,19]. Other risk factors
include infection at the time of D&C procedure (septic abortion, endometritis) and concomitant
hysteroscopic myomectomy. (See "Intrauterine adhesions: Clinical manifestation and diagnosis"
and "Intrauterine adhesions: Treatment and prevention".)

POSTOPERATIVE CARE AND FOLLOW-UP

Patients may resume normal activities as soon as the effects of anesthesia have worn off and
they are comfortable.

Cramps are the most common side effect. They usually subside soon after the procedure but
may last for a day or two. Nonsteroidal anti-inflammatory drugs provide adequate analgesia.
Light bleeding can persist for several days. Heavy bleeding, such as saturating a sanitary pad
within one hour more than once, is abnormal.

The patient should call the surgeon if they experience fever (more than 100.4°F), cramps lasting
longer than 48 hours, increasing pelvic or abdominal pain, prolonged or heavy bleeding, or a
foul-smelling vaginal discharge.

Most surgeons recommend pelvic rest for some duration of time, ranging from three days to
two weeks, to prevent bleeding and/or infection. There is no evidence to support any specific
recommendations.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Dilation and curettage (D&C) (The Basics)" and "Patient
education: Hysteroscopy (The Basics)")

● Beyond the Basics topic (see "Patient education: Dilation and curettage (D&C) (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

● Terminology – Dilation and curettage (D&C) describes a procedure in which cervical dilators
are used to facilitate the introduction of instruments into the uterus and the endometrial
cavity is either sampled or emptied with a curette. D&C can be used for therapeutic and
diagnostic indications and in both the nonpregnant and pregnant uterus. (See 'Introduction'
above and 'Terminology' above.)

● Indications – There are many indications for D&C, some of these include unsuccessful office
endometrial biopsy, further evaluation for endometrial neoplasia after office biopsy,
temporary management of patients with abnormal uterine bleeding, and evacuation of
products of conception in patients with pregnancy loss or those undergoing procedural
abortion. (See 'Indications' above.)

● Contraindications – Desired ongoing pregnancy is an absolute contraindication to D&C. D&C

should be performed with precautions for patients with risks of increased bleeding, including
those on anticoagulation or with bleeding diatheses, pelvic infection, or cervical or cesarean
scar pregnancy. (See 'Contraindications' above.)

● Preprocedure preparation

• Use of preoperative misoprostol or osmotic dilators for cervical preparation may reduce the
need for mechanical dilation; however, they have potential side effects or limitations that
do not support routine use prior to D&C. (See 'Cervical preparation' above.)
 • Prophylactic antibiotics are used in pregnant patients prior to D&C. Prophylactic antibiotics
are not used in nonpregnant patients undergoing D&C given the low risk of infection. This
is discussed in detail separately. (See 'Prophylactic antibiotics' above and "Pregnancy loss
(miscarriage): Description of management techniques", section on 'For all gestational
durations' and "First-trimester pregnancy termination: Uterine aspiration", section on
'Antibiotic prophylaxis' and "Gynecologic surgery: Overview of preoperative evaluation and
preparation", section on 'Antibiotic prophylaxis'.)

● Instruments

• We suggest use of tapered dilators for D&C rather than blunt dilators (Grade 2C). Tapered
dilators require less force. (See 'Dilators' above.)

• Sharp metal curettes are typically selected for diagnostic D&C procedures (eg, for
postmenopausal bleeding), whereas plastic curettes (also called cannulas) are used in
pregnant patients or nonpregnant patients with a large volume of tissue or at higher risk
for bleeding. (See 'Curettes' above and 'Technique' above.)

● Challenging cases – For patients with cervical stenosis or obesity, a variety of intraoperative
techniques (eg, use of ultrasound guidance, vaginal wall retractors) may facilitate successful
D&C and reduce the risk of uterine perforation or creation of a false passage in the cervix.
(See 'Cervical stenosis' above.)

● Complications – Complications of D&C are rare and may include uterine perforation, cervical
injury, infection, hemorrhage, or incomplete procedure. (See 'Complications' above.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Dale W Stovall, MD, who contributed to an earlier
version of this topic review.

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. Kaneshiro B, Tschann M, Jensen J, et al. Blood loss at the time of surgical abortion up to 14
weeks in anticoagulated patients: a case series. Contraception 2017; 96:14.

2. Allen RH, Goldberg AB. Cervical dilation before first-trimester surgical abortion (<14 weeks'
gestation). Contraception 2016; 93:277.
 3. Cooper NA, Smith P, Khan KS, Clark TJ. Does cervical preparation before outpatient
hysteroscopy reduce women's pain experience? A systematic review. BJOG 2011; 118:1292.
4. Kan AS, Ng EH, Ho PC. The role and comparison of two techniques of paracervical block for
pain relief during suction evacuation for first-trimester pregnancy termination.
Contraception 2004; 70:159.
5. Lazenby GB, Fogelson NS, Aeby T. Impact of paracervical block on postabortion pain in
patients undergoing abortion under general anesthesia. Contraception 2009; 80:578.

6. Renner RM, Edelman AB, Nichols MD, et al. Refining paracervical block techniques for pain
control in first trimester surgical abortion: a randomized controlled noninferiority trial.
Contraception 2016; 94:461.
7. Hulka JF, Lefler HT Jr, Anglone A, Lachenbruch PA. A new electronic force monitor to
measure factors influencing cervical dilation for vacuum curettage. Am J Obstet Gynecol
1974; 120:166.
8. 2024 Clinical Policy Guidelines for Abortion Care. National Abortion Federation. Available at:
https://prochoice.org/wp-content/uploads/2024-CPGs-FINAL-1.pdf.

9. Johnson N, Bromham DR. Effect of cervical traction with a tenaculum on the uterocervical
angle. Br J Obstet Gynaecol 1991; 98:309.
10. Schulz KF, Grimes DA, Christensen DD. Vasopressin reduces blood loss from second-
trimester dilatation and evacuation abortion. Lancet 1985; 2:353.
11. Angioni S, Loddo A, Milano F, et al. Detection of benign intracavitary lesions in
postmenopausal women with abnormal uterine bleeding: a prospective comparative study
on outpatient hysteroscopy and blind biopsy. J Minim Invasive Gynecol 2008; 15:87.
12. Loffer FD. Hysteroscopy with selective endometrial sampling compared with D&C for
abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstet Gynecol
1989; 73:16.
13. Bettocchi S, Bramante S, Bifulco G, et al. Challenging the cervix: strategies to overcome the
anatomic impediments to hysteroscopy: analysis of 31,052 office hysteroscopies. Fertil
Steril 2016; 105:e16.
14. Christianson MS, Barker MA, Lindheim SR. Overcoming the challenging cervix: techniques
to access the uterine cavity. J Low Genit Tract Dis 2008; 12:24.
15. Ben-Baruch G, Menczer J, Shalev J, et al. Uterine perforation during curettage: perforation
rates and postperforation management. Isr J Med Sci 1980; 16:821.

16. Hefler L, Lemach A, Seebacher V, et al. The intraoperative complication rate of nonobstetric
dilation and curettage. Obstet Gynecol 2009; 113:1268.
 17. ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic Procedures.
Obstet Gynecol 2018; 131:e172. Reaffirmed 2022.
18. March CM. Intrauterine adhesions. Obstet Gynecol Clin North Am 1995; 22:491.
19. Schenker JG. Etiology of and therapeutic approach to synechia uteri. Eur J Obstet Gynecol
Reprod Biol 1996; 65:109.
Topic 3273 Version 32.0
GRAPHICS

Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults*

ACOG
Alternative
Procedure preferred Dose Dose
regimens Δ [3,4]
regimen ¶ [1,2]

Hysterectomy Cefazolin, Cefazolin: Regimen:

(abdominal, including cefoxitin or
<120 kg: 2 g Ampicillin- 3 g IV
supracervical, vaginal, cefotetan
IV sulbactam
laparoscopic, or
robotic) ≥120 kg: 3 g
Regimen:
IV
Pelvic reconstruction Clindamycin OR 900 mg IV ◊
procedures, including
colporrhaphy or Cefoxitin or Vancomycin ¶ 15 mg/kg IV (no
those involving mesh cefotetan: to exceed 2 g
or vaginal sling per dose)
2 g IV
placement PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if

overweight or
obese, based on
adjusted body
weight) §

Aztreonam OR 2 g IV

Fluoroquinolone ¶ ¥

Regimen:

Metronidazole 500 mg IV

PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if

overweight or
obese, based on
adjusted body
weight) §

Fluoroquinolone ¶ ¥

Cesarean delivery Cefazolin <120 kg: 2 g IV Clindamycin 900 mg IV ◊

(intact membranes,
≥120 kg: 3 g IV PLUS
not in labor)
Gentamicin 5 mg/kg IV (if
overweight or
 obese, based on
adjusted body
weight) §

Cesarean delivery (in Cefazolin <120 kg: 2 g IV Clindamycin 900 mg IV

labor, ruptured
>120 kg: 3 g IV
membrane)
PLUS PLUS

Azithromycin 500 mg IV Gentamicin 5 mg/kg IV (if

overweight, or
obese, based on
adjusted body
weight)

PLUS

Azithromycin 500 mg IV

Uterine evacuation Doxycycline 200 mg orally

(including surgical
abortion, suction
D&C, and D&E)

Hysterosalpingogram, Not recommended ‡

including
chromotubation or
saline infusion
sonography

Laparotomy without Consider cefazolin <120 kg: 2 g IV

entry into bowel or
≥120 kg: 3 g IV
vagina

Laparoscopy Not recommended

(diagnostic, tubal
sterilization, operative
except for
hysterectomy)

Other transcervical
procedures:
Cystoscopy †
Hysteroscopy
(diagnostic or
operative)
Intrauterine
device insertion
Endometrial
biopsy
Oocyte retrieval
 D&C for non-
pregnancy
indication
Cervical tissue
biopsy, including
LEEP or
endocervical
curettage

ACOG: American College of Obstetricians and Gynecologists; IV: intravenous; D&C: dilation and curettage;
D&E: dilation and evacuation; LEEP: loop electrosurgical excision procedure; IDSA: Infectious Diseases
Society of America; ASHP: American Society of Health-System Pharmacists; HSG: hysterosalpingogram;
PID: pelvic inflammatory disease.
* Common pathogens: Enteric gram-negative bacilli, anaerobes, group B Streptococcus, enterococci.
¶ Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before
the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be given over 60 to 90
minutes and started within 60 to 120 minutes before the initial incision.
Δ An alternative regimen should be used in women with history of immediate hypersensitivity to beta-
lactam agents. Due to increasing resistance of Escherichia coli to ampicillin-sulbactam and
fluoroquinolones, local sensitivity profiles should be reviewed prior to use.
◊ When clindamycin prophylaxis is warranted, UpToDate authors prefer a single dose of 900 mg based
upon pharmacokinetic considerations according to 2013 IDSA/ASHP surgical antibiotic prophylaxis
guidelines. [3] However, a 600 mg dose consistent with ACOG guidance may be sufficient. [1,2]
§ Gentamicin use for surgical antibiotic prophylaxis should be limited to a single dose given
preoperatively. Based on evidence from colorectal procedures, a single dose of approximately 5 mg/kg
gentamicin appears more effective for the prevention of surgical site infection than multiple doses of
gentamicin 1.5 mg/kg every 8 hours. [4] For overweight and obese patients (ie, actual weight is >125% of
ideal body weight), a dosing weight should be used. A calculator to determine ideal body weight and
dosing weight is available in UpToDate.
¥ Ciprofloxacin 400 mg IV OR levofloxacin 500 mg IV OR moxifloxacin 400 mg IV. Fluoroquinolones are
contraindicated in pregnancy and in women who are breastfeeding.
‡ Antimicrobial prophylaxis is recommended for women undergoing HSG or chromotubation with a
history of PID or abnormal tubes noted on HSG or laparoscopy. For these women, an antibiotic
prophylaxis regimen of doxycycline, 100 mg twice daily for 5 days, can be considered to reduce the
incidence of post-procedural PID. [5,6] For women undergoing chromotubation, a single preoperative 2
gram dose of intravenous cefazolin is recommended, and the patient can be discharged on the same
doxycycline regimen recommended for abnormal HSG.
† Most clinicians exclude urinary tract infection with a urinalysis before cystoscopy, with subsequent
urine culture performed to confirm findings suggestive of infection. Patients with positive test results
should be given antibiotic treatment.

References:
1. ACOG practice bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol 2018; 131:e172.
2. ACOG practice bulletin No. 199: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2018; 132:e103.
3. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
 4. Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-blind study of single high dose
versus multiple standard dose gentamicin both in combination with metronidazole for colorectal surgical prophylaxis. J
Hosp Infect 2000; 46:135.
5. Pittaway DE, Winfield AC, Maxson W, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during the
utilization of assisted reproductive technologies: a systematic review. Am J Obstet Gynecol 1983; 147:623.
6. Pereira N, Hutchinson AP, Lekovich JP, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during the
utilization of assisted reproductive technologies: a systematic review. J Pathog 2016; 2016:4698314.
Adapted from: Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.

Graphic 87200 Version 36.0

Pratt and Hegar cervical dilators

(A) Pratt dilator.

(B) Hegar dilator.

Courtesy of William J Mann, Jr, MD.

Graphic 55448 Version 4.0

Sharp uterine curettes

Courtesy of William J Mann, Jr, MD.

Graphic 68468 Version 3.0

Suction uterine curettes

(A) No. 16.

(B) No. 12.
(C) No. 6.

Courtesy of William J Mann, Jr, MD.

Graphic 69749 Version 4.0

Uterine manual vacuum aspiration syringe with flexible suction cannula

From: Krause MS, Nakajima ST. Assessment of the endometrial lining and evacuation of the uterus. In: Operative Techniques in
Gynecologic Surgery: Reproductive Endocrinology and Infertility, Nakajima ST, McCoy TW, Krause MS (Eds), Wolters Kluwer,
Philadelphia 2017. Copyright © 2017. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this
material is prohibited.

Graphic 119438 Version 2.0

Tenaculums

(A) Beirer tenaculum.

(B) Single tooth tenaculum.

Courtesy of William J Mann, Jr, MD.

Graphic 77725 Version 3.0

Uterine polyp forceps and Kevorkian curette

(A) Kevorkian-Younge curette.

(B) Randall-Stone polyp forceps.

Courtesy of William J Mann, Jr, MD.

Graphic 62722 Version 4.0

Cervical dilation

Courtesy of William J Mann, Jr, MD.

Graphic 77607 Version 1.0

Sharp curette inserted into uterine cavity

Courtesy of William J Mann, Jr, MD.

Graphic 56727 Version 1.0

Contributor Disclosures
Kari P Braaten, MD, MPH No tiene relaciones financieras relevantes con empresas no elegibles para
declarar. Caryn Dutton, MD, MS No tiene relaciones financieras relevantes con empresas no elegibles
para declarar. Howard T Sharp, MD No tiene relaciones financieras relevantes con empresas no elegibles
para declarar. Alana Chakrabarti, MD No tiene relaciones financieras relevantes con empresas no
elegibles para declarar.

El grupo editorial revisa las declaraciones de los colaboradores para detectar posibles conflictos de
intereses. De detectarse, se abordan mediante un proceso de revisión multinivel y mediante la exigencia
de proporcionar referencias que respalden el contenido. Todos los autores deben proporcionar contenido
debidamente referenciado y cumplir con los estándares de evidencia de UpToDate.

Política de conflicto de intereses