New technologies, such as transvaginal ultrasonography and outpatient endometrial sampling, have led to a decline in the performance of dilation and curettage (D&C) procedures in the operating room in the past decades.1,2
A hospital D&C can be performed for both diagnostic and therapeutic indications. Indications for a diagnostic hospital D&C include patients with a nondiagnostic office biopsy, patients with endometrial hyperplasia, and patients with cervical stenosis. In most cases, diagnostic hysteroscopy is performed before a diagnostic D&C to obtain a visual image of the endometrial cavity and to exclude focal disease.3 A therapeutic indication for performing D&C is the temporary management of prolonged or excessive vaginal bleeding.
A number of studies have been published on complications from obstetric D&C procedures, but few data are available on nonobstetric D&C procedures.4 Complications include hemorrhage,5 uterine perforation,4 infection,6 formation of intrauterine adhesions,7,8 text, and trophoblast embolization.9 Although a number of studies have been published on complications of pregnancy-related D&Cs, only one study reports on the procedure-related morbidity of nonobstetric diagnostic and therapeutic D&Cs. In 1980, Ben-Baruch et al reported on 3,299 patients undergoing both diagnostic and therapeutic D&Cs not related to pregnancy. The complication rate varied between 0.05% and 1.8% depending on the indication for surgery.4
Preoperative counseling of patients, including an explanation of risks and complications, is essential in today’s medicine. The aim of the present study was to provide data for the preoperative counseling of patients regarding the intraoperative surgical complication rate of nonobstetric inpatient D&Cs using a series of 5,359 consecutive patients.
MATERIALS AND METHODS
This study was found to be exempt from ethical approval by the Ethics Committee of the Medical University of Vienna. Clinical data were obtained retrospectively from files at the Medical University of Vienna, Department of Obstetrics and Gynecology. Two investigators (A.L., V.S.) independently recorded the information and extracted the data. Any equivocal data were analyzed together with the primary investigator (L.H.). Patients undergoing pregnancy-related D&C were excluded from the present study. A total of 5,359 consecutive patients underwent hospital D&C between October 1995 and December 2006 and were included in the present study.
All D&Cs were performed as inpatient procedures under general anesthesia with the patient in the dorsal lithotomy position. A gynecologic examination was performed first. After the examination, the perineum, vagina, and cervix were cleansed with an aseptic solution. A single-tooth tenaculum was used to grasp the anterior lip of the cervix. Traction was applied to the tenaculum to align the axis of the cervix and the uterine canal. The uterus was sounded to document the size and confirm the position. After sounding the uterus, the cervix was dilated using Hegar dilators (Rudolf Heintel GmbH, Vienna, Austria). The dilation was conducted to 6 mm, at which point the hysteroscope was inserted comfortably. A diagnostic hysteroscopy using a standard 30° 5-mm hysteroscope was performed. The uterine cavity was distended with normal saline. Subsequently, an endocervical curettage was performed to avoid contamination of the histologic specimen with endometrial cells. Sharp curettes were used for all procedures. Curettage was performed systematically, beginning at the fundus. The entire surface of the endometrium was sampled by moving around the uterus in a consistent and systematic fashion.
When a perforation was suspected during surgery, a diagnostic hysteroscopy was performed, checking the site of perforation and the severity of hemorrhage. If no bleeding was detected, surgery was stopped immediately. If any visceral trauma was suspected, further surgical exploration was performed.
Values are given as mean (standard deviation) for normally distributed values. Metric variables were compared using Student t test. The position of the uterus (anteverted compared with retroverted uterus), menopausal status (premenopausal compared with postmenopausal), parity (at least one compared with 0 deliveries), performance of a diagnostic hysteroscopy (no compared with yes), and surgeon’s experience (attending physician compared with resident) were assessed as risk factors for intraoperative complications using univariable χ2 tests. A multivariable logistic regression analysis with the above risk factors as independent variables and the occurrence of an intraoperative complication as a dependent variable was performed. P values <.05 were considered statistically significant. We used the statistical software SPSS 11.0 for Windows (SPSS, Inc., Chicago, IL) for statistical analysis.
Indications for D&C and the histologic results broken down by menopausal status are given in Tables 1 and 2, respectively. In 4,213 (78.6%) cases, diagnostic hysteroscopy was performed before the D&C. A total of 1,146 (21.4%) patients underwent D&C without prior diagnostic hysteroscopy. Menopausal status was known in all cases. Two thousand five hundred forty-two (47.4%) and 2,817 (52.6%) patients were premenopausal and postmenopausal, respectively, at the time of D&C. Mean age of the patients was 53.0 (±13.2) years. Five hundred twenty-five (9.8%) patients were nulliparous at the time of D&C. Two thousand seven hundred seventy-eight (51.7%) and 2,581 (48.3%) surgeries were done by residents and attending physicians, respectively.
The types of intraoperative complications are shown in Table 3. Demographic characteristics of patients with and without intraoperative complications are shown in Table 4. In cases of uterine perforation, the perforation site was the fundus and the cervix in 47 and three cases, respectively. Uterine perforation was done with Hegar dilators (n=27), the curette (n=15), the hysteroscope (n=4), the sounding probe (n=2), and a grasping forceps (n=3). The operative consequences in cases with surgical complication were as follows: abortion of D&C (n=18), laparoscopy (n=2), laparotomy (n=1), and hysterectomy (n=1). The two most notable cases were those undergoing laparotomy (patient 1) and hysterectomy (patient 2). Patient 1 was a 37-year-old woman undergoing diagnostic hysteroscopy and D&C for prolonged abnormal bleeding. During D&C, perforation occurred with the sharp curette at the tubal ostium. Hysteroscopy was performed for suspected adhesion between the small bowel and the uterus with bowel perforation. Subsequently, diagnostic laparoscopy and laparotomy were performed. No bowel perforation was noted, but a lost intrauterine device intraabdominally densely adherent with the uterus was found. Patient 2 was a 67-year-old women who was to undergo diagnostic hysteroscopy and D&C for postmenopausal bleeding and an endometrial hyperplasia of 14 mm. During dilation of the cervix with Hegar’s dilators, a perforation in the cervix occurred. Subsequently, hysteroscopy was performed. Visibility was poor because of bleeding. It appeared that perforation to the right parametrium near the uterine vessel and the ureter occurred. Therefore, emergency laparotomy and hysterectomy were performed.
In a univariable analysis, the position of the uterus (anteverted: 1.8% compared with retroverted: 3.6% uterus, P=.01), menopausal status (premenopausal: 1.2% compared with postmenopausal: 2.6%, P<.001), parity (at least one: 1.7% deliveries compared with 0: 3.4%, P=.01), the performance of a diagnostic hysteroscopy (no: 0.8% compared with yes: 2.2%, P=.002), but not the surgeon’s experience (resident: 2.0% compared with attending physician: 1.8%, P=.6) were associated with the occurrence of intraoperative complications. The data generated from a multivariable regression analysis are shown in Table 5.
Although a D&C is a diagnostic and therapeutic surgical procedure used frequently throughout the world, few data are available on intraoperative surgical complication rates.
The only data on surgical complications of D&Cs date back to 1980. Interestingly, more studies have been published on pregnancy-associated curettages and operative/diagnostic hysteroscopies than on nonobstetric D&Cs.4,5,9–11 We performed a chart review and extracted data for 5,359 consecutive patients undergoing D&C in a large teaching hospital.
The overall complication rate was relatively low (1.9%). We cannot exclude, however, any unrecognized intraoperative complication. Most of these complications were related to myometrial violation (false passage or perforation). Of note, our results defined certain patients at a higher risk for intraoperative complications during D&C, such as older patients, patients with a retroverted uterus, and nulliparous patients. Our data do not include whether parous patients had cesarean deliveries or vaginal deliveries. Furthermore, no information was available on whether patients had prior D&Cs for obstetric reasons such as elective abortions. Whether or not diagnostic hysteroscopy was performed before the D&C did not affect the complication rate. Our analysis showed that residents did equally well regarding complication rates as did attending physicians. Of note, we have investigated only intraoperative surgical complications. Other possible surgery-related complications, such as infection, pulmonary emboli, and thrombosis, and other complications potentially related to anesthesia or lithotomy position, were beyond the scope of the present study.
Our data compare favorably with a previous smaller series published by Ben-Baruch et al.4 In this series, uterine perforation occurred in 0.16% of D&Cs. The most common site of perforation was the uterine fundus, and the instrument most often involved was a sharp curette. The perforation rates in D&Cs performed for intrauterine adhesions and postmenopausal bleeding were 1.8% and 0.2%, respectively.4
In a large teaching hospital, retroverted uterus, postmenopausal status, and nulliparity were independent risk factors for intraoperative complications of D&C. These data can be used for preoperative patient counseling.
1. Gull B, Karlsson B, Milsom I, Granberg S. Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer. Am J Obstet Gynecol 2003;188:401–8.
2. Gorlero F, Nicoletti L, Lijoi D, Ferrero S, Pullè A, Ragni N. Endometrial directed biopsy during sonohysterography using the NiGo device: prospective study in women with abnormal uterine bleeding. Fertil Steril 2008;89:984–90.
3. Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988;158:1459–70.
4. Ben-Baruch G, Menczer J, Shalev J, Romem Y, Serr DM. Uterine perforation during curettage: perforation rates and postperforation management. Isr J Med Sci 1980;16:821–4.
5. Lowensohn RI, Hibbard LT. Laceration of the ascending branch of the uterine artery: a complication of therapeutic abortion. Am J Obstet Gynecol 1974;118:36–8.
6. Sacks PC, Tchabo JG. Incidence of bacteremia at dilation and curettage. J Reprod Med 1992;37:331–4.
7. Broome JD, Vancaillie TG. Fluoroscopically guided hysteroscopic division of adhesions in severe Asherman syndrome. Obstet Gynecol 1999;93:1041–3.
8. Twiggs LB, Phillips GL. Documentation of subclinical trophoblastic embolization with invasive cardiac monitoring in a woman with a molar pregnancy. A case report. J Reprod Med 1986;31:277–9.
9. Cohle SD, Petty CS. Sudden death caused by embolization of trophoblast from hydatidiform mole. J Forensic Sci 1985;30:1279–83.
10. Park TK, Flock M, Schulz KF, Grimes DA. Preventing febrile complications of suction curettage abortion. Am J Obstet Gynecol 1985;152:252–5.
11. Di Spiezio Sardo A, Taylor A, Tsirkas P, Mastrogamvrakis G, Sharma M, Magos A. Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies. Fertil Steril 2008;89:438–43.