Complications of Dilatation and Curettage (D&C) with Management

1. Uterine Perforation

• Occurs in <1 per 1000 procedures
• Diagnosed when the operator finds no resistance to a dilator or curette, or an instrument passes unexpectedly deep
• Risk increases with small curettes (use the largest curette available or suction curettage)
• Fat or bowel tissue seen in the suction apparatus is diagnostic

• Fundal perforation with a sound/dilator - low risk of visceral injury; may be observed for 2-4 hours with close monitoring if no significant bleeding
• Perforation during suction/curettage - higher risk of bowel/vessel damage; requires laparoscopy to assess damage
• Outpatient observation is acceptable if no fat/bowel irritation, no abdominal pain, no rebound, no evidence of intra-abdominal bleeding
• Laparotomy indicated if there is evidence of bowel injury, significant hemorrhage, or hemodynamic instability
• If perforation occurs before uterus is emptied, the procedure can be completed under laparoscopic guidance

2. Hemorrhage (Intraoperative)

• Uterine atony (most common) - especially with gestational age >10 weeks
• Cervical laceration from tenaculum tearing
• Uterine perforation
• Coagulopathy (uncommon)

• Atony: Methylergonovine (Methergine) 0.2 mg IM or orally; Misoprostol 800 mcg rectally or buccally; Carboprost tromethamine (Hemabate) IM or directly into cervix for severe atony
• Cervical lacerations: Usually superficial - tamponade with ring forceps; Monsel's solution or silver nitrate if pressure fails; suturing rarely needed
• Retained Products of Conception (POC): Repeat procedure under deeper anesthesia for complete evacuation

3. Cervical Injury / Failed Dilation

• Cervical laceration from tenaculum during dilation
• Failed cervical dilation (stenosis)

• Defer procedure and ripen cervix with laminaria or misoprostol first
• Superficial lacerations respond to tamponade

4. Postoperative Hemorrhage / Incomplete Abortion

• Retained POC with or without infection
• Hematometra - blood clots fill the uterine cavity and cannot pass the cervix

• Repeat suction curettage (best course for retained POC or hematometra)
• Ultrasound guidance helpful

5. Infection / Endometritis (Post-procedural)

• Relatively common but usually not severe
• Symptoms: uterine tenderness, lower abdominal pain, fever, elevated WBC

• Oral antibiotics (outpatient for mild cases)
• Severe sepsis/septic shock: Hospital admission, broad-spectrum IV antibiotics (e.g., gentamicin + clindamycin), IV fluids
• Repeat suction curettage if retained POC coexists
• Rarely, hysterectomy for refractory sepsis

6. Asherman's Syndrome (Late Complication)

• Formation of intrauterine or cervical adhesions (synechiae) after curettage
• Now uncommon since uterine aspiration has largely replaced sharp curettage
• Usually involves cervical rather than intrauterine adhesions when it does occur
• Misoprostol is an independent risk factor

• Cervical adhesions: Dilators to reopen the endocervical canal
• Intrauterine adhesions: Hysteroscopic adhesiolysis, followed by estrogen therapy to promote endometrial regeneration and IUD/balloon placement to prevent re-adhesion

7. Other Late Sequelae

• Cervical incompetence (rare with modern techniques)
• Premature labor (not significantly associated with first-trimester aspiration using modern methods)
• Infertility (not significantly associated with first-trimester aspiration)

Summary Table

Complete Approach: Patient Coming for D&C

PHASE 1 - PRE-PROCEDURE ASSESSMENT

A. Confirm the Indication

• Incomplete / missed / inevitable abortion
• Abnormal uterine bleeding (diagnostic + therapeutic)
• Endometrial sampling / biopsy
• Retained products of conception
• Gestational trophoblastic disease
• Cervical polyp removal / diagnostic workup

B. History

• Last normal menstrual period (LNMP) - for gestational age
• Obstetric history (parity, previous uterine surgeries)
• Contraception use
• History of uterine anomalies, fibroids, cervical stenosis
• History of coagulation disorders or anticoagulant use
• Allergy history (especially to NSAIDs, latex, anesthetics)
• History of vagal reaction to cervical manipulation (for atropine pre-medication)

C. Examination

• Bimanual pelvic examination - determine uterine size, position (anteverted vs. retroverted), mobility, adnexal masses
• Speculum examination - cervix, any visible pathology
• Vital signs, general anesthesia fitness assessment

D. Investigations (Pre-operative Workup)

PHASE 2 - PRE-PROCEDURE PREPARATION

Cervical Preparation (if needed)

• Misoprostol 400 mcg vaginally or sublingually 2-4 hours before procedure - recommended for adolescents, nulliparous women, gestational age ≥12-14 weeks, or failed initial dilation
• Laminaria - placed 12-24 hours before; requires two visits; preferred for gestational age ≥12 weeks in multiparous women or ≥10-12 weeks in primiparous women

Analgesia / Sedation Options

• NSAID premedication: Ibuprofen 600-800 mg PO taken 30-60 minutes before procedure (reduces cramping)
• Paracervical block: 1% lidocaine or 2% chloroprocaine, 10 mL injected submucosally at 3, 5, 7, and 9 o'clock positions at cervicovaginal junction
• Conscious sedation (selected cases): Midazolam (Versed) IV 1 mg/min up to 5 mg + Fentanyl 50-100 mcg IV; requires pulse oximetry and crash cart
• Anxiolytics: Diazepam 5-10 mg or oral narcotic 1 hour before in anxious patients
• Atropine 0.4 mg IV/SC preemptively if history of vagal reaction to cervical manipulation
• General anesthesia - for inpatient/operative cases

IV Access

• Not always needed outpatient; however, oxytocin, methylergonovine, and other emergency drugs must be readily available IM

Rh Prophylaxis

• Rh-negative patients: Anti-D immunoglobulin (MICRhoGAM) 50 mcg given within 48 hours (ideally during or immediately after procedure) if <13 weeks gestation; full dose (300 mcg) at >13 weeks

Antibiotic Prophylaxis

• Doxycycline 100 mg PO - first dose given before or immediately after procedure; continue 100 mg twice daily for 3 days post-procedure

"No-Touch" Technique

• Instruments that enter the cervical canal must NOT be touched in their distal portions - dilators grasped at midportion only, cannula tip not touched - to minimize infection risk

PHASE 3 - THE PROCEDURE (Step-by-Step)

1. Position: Lithotomy position; vagina and cervix prepared (betadine/antiseptic)
2. Tenaculum: Applied to anterior lip of cervix; gentle traction applied to straighten the cervical canal
3. Sound the uterus: Uterine sound inserted to note depth and direction of uterine cavity
4. Cervical dilation: Begin with small Hegar dilator, progressively enlarge; most procedures require dilation to Hegar No. 8 or 9; firm, constant pressure in axis of uterus - do NOT use force
5. Curettage:
   • Use the largest curette available (reduces perforation risk vs. small curettes)
   • Or suction/vacuum curettage (safer, preferred)
   • Systematically scrape all walls of the endometrial cavity
6. Examine products of conception (POC): Float test - wash tissue in saline; inspect for chorionic villi (frond-like arborized appearance); assess completeness
7. Send for pathology: Mandatory in many jurisdictions; always send if molar pregnancy suspected or tissue appears inadequate
8. Intraoperative ultrasound guidance: For uterine anomalies, fibroids, difficult access, or if difficulty encountered during procedure

PHASE 4 - IMMEDIATE POST-PROCEDURE CARE (Recovery Room)

• Monitor vitals every 15 minutes until stable
• Observe for vaginal bleeding - pad count
• Assess for pain (abdominal cramping is expected and normal)
• Observe for signs of complication: fever, hypotension, excessive bleeding, abdominal rigidity
• IV oxytocin or methylergonovine if uterine atony noted
• If uterine perforation suspected: observe 2-4 hours; laparoscopy if bowel/vessel injury suspected
• Patient may be discharged once vitals are stable, bleeding is controlled, able to tolerate oral fluids, and pain is manageable

PHASE 5 - POST-PROCEDURE MEDICATIONS (Discharge)

PHASE 6 - FOLLOW-UP PLAN

Immediate Warning Signs - Return to ER/Hospital Immediately

• Soaking >2 pads/hour for >2 hours (hemorrhage)
• Fever >38°C / chills
• Severe worsening abdominal pain or peritonism
• Foul-smelling vaginal discharge
• Fainting or hemodynamic instability

Outpatient Follow-up Schedule

At First Follow-up Visit:

• Check pathology report - confirm tissue and rule out malignancy, molar pregnancy, or unexpected findings
• Pelvic examination - uterine tenderness, size
• CBC if excessive blood loss occurred
• Serum β-hCG (if molar pregnancy, gestational trophoblastic disease, or ectopic was the indication)
• Address any ongoing symptoms: prolonged bleeding, pelvic pain, fever
• Repeat ultrasound if retained POC or hematometra is suspected

Patient Education at Discharge:

• No sexual intercourse for 1 week (reduces infection risk)
• Expect light-moderate cramping and spotting for 1-2 weeks
• Normal menstruation typically returns in 4-6 weeks
• Contraception - can be started same day: IUD may be inserted immediately after first-trimester procedure; hormonal contraceptives (pill, patch, injection) can begin the same day
• No douching or tampons for 2 weeks
• Avoid strenuous activity for 24-48 hours

Special Follow-up for Specific Indications:

• Gestational trophoblastic disease / molar pregnancy: Serial serum β-hCG every 1-2 weeks until normal, then monthly; chest X-ray; strict contraception for 6-12 months
• Endometrial hyperplasia / atypical hyperplasia: Repeat endometrial sampling in 3-6 months; consider hysterectomy vs. progestin therapy (megesterol acetate 40-160 mg/day) with close surveillance
• Incomplete abortion with suspected infection: Culture results review, ensure antibiotic course completed, re-examine in 1 week

Summary Flowchart

PATIENT ARRIVES FOR D&C
        ↓
HISTORY + EXAMINATION + INVESTIGATIONS
(β-hCG, USS, Hb, Rh, optional STI screen)
        ↓
PRE-PROCEDURE PREP
(Cervical priming if needed, NSAIDs, paracervical block, Rh prophylaxis, antibiotic prophylaxis)
        ↓
PROCEDURE
(Lithotomy → tenaculum → sound → dilate → curette → inspect POC → send histopathology)
        ↓
RECOVERY
(Vitals monitoring, bleeding assessment, analgesia)
        ↓
DISCHARGE MEDICATIONS + EDUCATION
(Doxycycline, NSAID, Methergine, contraception, warning signs)
        ↓
FOLLOW-UP AT 1-2 WEEKS
(Pathology review, clinical assessment, USS if needed)
        ↓
FURTHER MANAGEMENT BASED ON FINDINGS