D&C Complications Case File

D&C Complications Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 2

A 23-year-old G3P2002 woman at 11 weeks’ gestation by last menstrual period presents to the ER with a 4-day history of abdominal pain, vaginal bleeding, and fever. Upon further questioning, she reports possible passage of tissue with the blood clots. She had been seen in the same ER 1 week earlier and diagnosed with an embryonic demise. She was discharged with expectant management of the miscarriage. On examination, she is febrile to 101°F, has HR 100 beats/min, and BP 100/60 mm Hg. She appears ill. Her uterus is extremely tender on examination and cervix dilated 1 cm with “tissue” just inside the cervical os. Minimal bleeding is noted from the cervix. Her white blood cell count is 21,000/mm3, hemoglobin is 9 g/dL, and blood type is O positive. A transvaginal ultrasound demonstrates “debris” in the uterus but normal ovaries, no adnexal masses, and no free fluid. After beginning intravenous (IV) antibiotics for a septic abortion, she is taken to the OR for a suction D&C. During the D&C, the uterus is suspected to be perforated by the suction curette since there is a sudden loss of resistance and the catheter advances much farther into the cervix than previously.

➤ What is your management plan?

➤ What are some risk factors for uterine perforation during a D&C?

ANSWERS TO CASE 2:

D&C Complications

Summary: This is a 23-year-old G3 P2002 woman has a septic incomplete abortion at 11 weeks’ gestation. She experiences a uterine perforation while undergoing a suction D&C procedure.

➤ Management plan: Laparoscopy/laparotomy to determine the extent of injury to intra-abdominal organs/vessels and completion of the evacuation of the uterus under direct visualization.

➤ Risk factors: Enlarged uterus (advanced gestational age), stenotic cervix, uterine infection, multiparity.

ANALYSIS

Objectives

1. Become familiar with the different management strategies for first trimester abortions (surgical, medical, and expectant management).

2. Understand potential complications of a D&C: immediate, delayed, and late.

3. Become familiar with ways to minimize complication risks.

Considerations

This is a 23-year-old G3P2002 woman at 11 weeks’ gestation with septic incomplete abortion. The patient had been diagnosed with an embryonic demise at 10 weeks’ gestation and was undergoing expectant management of the abortion. Given her presentation to the ER, she is no longer a candidate

from expectant management. Once the products of conception have become infected, evacuation of the contents is critical. The standard surgical management in this case would be suction D&C. Although many D&Cs can be performed as an outpatient under a local anesthetic, this patient is best treated with hospitalization and D&C in the OR. She is at greater risk for surgical complications (perforation, bleeding) than other routine D&Cs performed as an outpatient. Hospital admission is required to monitor for signs of sepsis, bacterial shock, disseminated intravascular coagulopathy, and acute renal failure. Prior to beginning the D&C, it is necessary to begin broadspectrum antibiotics intravenously. The cause of the infection is usually polymicrobial, including anaerobic organisms. Up to 25% of septic abortions have been reported to be associated with positive blood cultures. This is one of the reasons that antibiotics should be administered prior to D&C. Tissue levels of antibiotics are usually reached about 1 hour after administration intravenously and the patient can then be taken to the OR. After evacuation, a bacterial culture (aerobic and anaerobic) may be obtained from the curetted specimen. Postoperatively, the patient should be continued on antibiotics and observed closely for signs/symptoms of septic shock. Uterine perforation is a known complication of a suction D&C.

APPROACH TO

Complications of a D&C

Early pregnancy failure is clinically recognized in 15% to 20% of pregnancies and can be managed surgically, medically, and expectantly. Many studies have compared the various treatment options, but differences in terminology, medical management, and definitions of failed treatment make comparison difficult. However, medical management seems to be a possible and effective acceptable alternative to surgical curettage. The use of vaginal misoprostol 400 to 800 micrograms has been found to be 80% to 88% successful in achieving a complete miscarriage as compared to 96% to 100% of surgically managed pregnancy failures.1 The primary side effects of medical therapy include nausea, vomiting, and diarrhea, and those with failed complete miscarriage often require suction D&C. As with any surgery, the risks and benefits of the surgery must be weighted. The benefits of surgical management include high success rate and prompt treatment of pregnancy failure. As the gestational age of the abortion increases, so does the risk of complications. However, not all D&Cs performed are for obstetrical indications. Gynecologic indications for D&C include evaluation of dysfunctional bleeding, treatment of excessive bleeding, and treatment of cervical stenosis.2-5

Surgical complications of D&Cs are rare and can be categorized as occurring in the immediate or delayed/late period (Table 2–1). D&Cs performed for obstetrical indications carry a slightly higher risk than nonobstetrical indications due to the increased risk of perforation/bleeding from the gravid uterus. Ben-Baruch et al6 reported that the risk for nonobstetrical D&Cs varies between 0.5% and 1.8%, depending on the indication. A recent retrospective study confirmed this low complication risk for nonobstetrical D&Cs.7

IMMEDIATE COMPLICATIONS

Patients with anatomic distortion from previous operations, cervical stenosis, atrophic conditions of the vagina, congenital anomalies, and distortion from benign or malignant tumors are often the most at risk for complications of hemorrhage/perforation. A recent study by Hefler et al7 also demonstrated that a retroverted uterus, postmenopausal status, and nulliparity were independent risk factors for intraoperative complications (Figure 2–1). When a patient with one of these conditions is encountered, the intraoperative use of pelvic sonography has been demonstrated to decrease risk of complications.8 The risk of hemorrhage is also higher for obstetrically indicated D&Cs, increasing further with the greater size of the uterus. If hemorrhage occurs, uterotonic agents and manual compression may be initially used. The use of a Foley catheter within the uterus and uterine packing has also been described if initial management of hemorrhage fails. Delayed hemorrhage can occur with a hematometra (distention of the uterus with blood). Cervical lacerations can occur from the tenaculum or from the dilation process and can be repaired in the OR.9,10

The incidence of perforation has been reported to be approximately 0.63%.11 When a uterine perforation occurs, one important factor is to discern to the best of one’s ability the location of the perforation (midline vs lateral) and the instrument that perforated the uterus (for instance, the uterine sound, because of its blunt design, is less likely to cause abdominal or bowel injury, whereas the suction curette by virtue of its vacuum can cause trauma).

Figure 2–1. Perforation of the uterus due to retroflexion of the uterus, and the operator advances the dilator unaware of the uterine position.

Because the vacuum curette can injure intra-abdominal contents, it is imperative that the suction vacuum not be activated unless the surgeon is certain of the location in the uterine cavity. Risk factors for uterine perforation include an inexperienced operator, advanced gestational age, infection, stenotic cervix, and nulliparity. The primary concerns for uterine perforation are hemorrhage and injury to abdominal contents. Lateral perforations, near the uterine vessels, are much more likely to result in hemorrhage than midline lacerations. When perforation is suspected, the patient needs to be assessed for hemorrhage and hemodynamic stability and the procedure stopped. If patient becomes unstable or experiences unmanageable hemorrhage, an immediate laparotomy is indicated. If the patient is stable, there is no clear consensus on whether the extent of injury is required if a blunt instrument is used in the midline. Laparoscopy can be performed to assess perforation and intra-abdominal injury, and should be employed if there is a possibility of injury. If the D&C has not been completed, the procedure should be completed under direct visualization (either through laparotomy or laparoscopy). Patients who experience severe abdominal/pelvic pain after a D&C should be evaluated for possible perforation.9,10,12,13

Anesthesia complications are present with any surgery and depend on the type used. These complications can be minimized by performing the D&C under local anesthesia with/without sedation in the outpatient setting if clinically indicated. Early pregnancy loss may also be managed with manual vacuum aspiration under local anesthesia.14 Patients undergoing a D&C with general anesthesia carry the highest anesthesia complication rate.

DELAYED/LATE COMPLICATIONS

Delayed complications include infection, retained tissue, and intrauterine adhesions. Patients with retained tissue usually present with cramping and bleeding several days after completion of the D&C. Infection may result from retained products of conception or even a preexisting gonorrhea/chlamydial infection. A meta-analysis performed by Sawaya and colleagues.15 demonstrated that antibiotic prophylaxis is indicated for elective abortion to reduce risk of infection. Although data are lacking, antibiotic prophylaxis may also be considered for missed abortion.16 Late complications primarily focus on adverse pregnancy outcomes: intrauterine adhesions, stenotic/incompetent cervix, Rh sensitization, and placenta previa/accreta to name a few. In a large study by Schenker and Margalioth,17 patients who were found to have Asherman syndrome were screened for possible risk factors. Of those who had

Asherman syndrome, 90% had a curettage performed for a pregnancy-related problem (67% after curettage for postabortion/miscarriage). Other risk factors for Asherman syndrome include curettage of uterus, infection (especially endometrial tuberculosis), and congenital anomalies of the uterus. Postpartum and lactating patients who undergo a D&C are thought to be at increased risk for intrauterine adhesions secondary to the relative hypoestrogenic state.18

If a D&C is necessary, the risk of intrauterine adhesions can be minimized by using the vacuum curette only or gentle and superficial sharp curettage trying to not extend into the myometrium. In addition, suspected intrauterine infections should be treated to decrease risk of intrauterine adhesions. Multiple sharp curettage procedures have been shown to increase the risk of developing placenta accreta (risk not seen with suction curettage).17,19 Rh sensitization can be minimized with knowledge of the patient’s blood type and administration of anti-D immunoglobulin.

Comprehension Questions

2.1 A 23-year-old woman undergoes an uncomplicated suction D&C for a missed abortion at 12 weeks’ gestation. About 2 hours after the procedure, the nurse notices the patient to have weakness/diaphoresis. Her uterus is noted to be enlarged and scant minimal bleeding is noted. What is the most likely etiology?

A. Acute hematometra

B. Uterine perforation

C. Uterine infection

D. Intrauterine adhesions

2.2 A 78-year-old postmenopausal woman is being evaluated for postmenopausal bleeding. Her cervix is noted to be stenotic and she is taken to the OR for a diagnostic D&C. Which of the following

statements is most accurate?

A. The risk of uterine perforation is no greater than other diagnostic D&C.

B. To minimize the intraoperative and anesthesia risks, this patient is a good candidate for an outpatient D&C.

C. Intraoperative use of pelvic sonography would be beneficial in decreasing surgical risks.

D. A D&C is the only way to evaluate this patient’s endometrium.

2.3 Which of the following is the major predisposing factor to the development of intrauterine adhesions?

A. Infection

B. Trauma to nonpregnant uterus

C. Trauma to pregnant uterus

D. Congenital anomalies

ANSWERS

2.1 A. Acute hematometra, “postabortal syndrome,” occurs about 2 hours after surgery and the patient presents with scant vaginal bleeding, diaphoresis/weakness, and an enlarged/tender uterus. The etiology is unknown and treatment is prompt repeat curettage.

2.2 C. The use of intraoperative ultrasound has been found to be useful in the prevention of surgical complications such as uterine perforation in difficult D&Cs. In this case, the patient has three risk factors (postmenopausal state, atrophic vagina, and stenotic cervix) for increased surgical complications. Other risk factors include distortion of anatomy from previous surgery, congenital anomalies, or tumors. The endometrial cavity in a patient with postmenopausal bleeding can be assessed with measurement of the endometrial stripe using pelvic ultrasonography.

2.3 C. Trauma to the pregnant uterus is the major predisposing factor for the development of intrauterine adhesions. Two theories for this development are the low level of estrogen at the time of the procedure (or immediately after) doesn’t allow for proper endometrial regeneration and that the uterus may be in a vulnerable state after pregnancy (basal layer more easily damaged).20

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Medical management of an early pregnancy failure has success rate of approximately 80% (Level A).

➤ Antibiotic prophylaxis is indicated for elective suction curettage abortion (Level A).

➤ Patients at greatest risk for intraoperative complications are postmenopausal state, vaginal atrophy, cervical stenosis, retroverted uterus, and distorted anatomy from previous surgery/tumors (Level B).

➤ Patients who have a D&C after a pregnancy have higher risk of developing Asherman syndrome as compared to a nonpregnant uterus (Level B).

➤ Complications after a D&C can be classified as immediate and delayed/late (Level C).

➤ The risk of developing intrauterine adhesions in an obstetrically indicated D&C can be minimized by using the suction curette rather than sharp curettage and curetting gently and not deep into the myometrium (Level C).

➤ The morbidity after a uterine perforation depends on the location of the perforation and the instrument used (Level C).

REFERENCES

1. Chen BA, Creinin MD. Contemporary management of early pregnancy failure. Clin Obstet Gynecol. 2007;50:67-88. 

2. Graziosi GC, Mol BW, Ankum WM, Bruinse HW. Management of early pregnancy loss. Int J Gynaecol Obstet. 2004;86:337-346. 

3. Sotiriadis A, Makrydimas G, Papatheodorou S, Ioannidis J. Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet Gynecol. 2005;105:1104-1113. 

4. Stubblefield PG, Carr-Ellis S, Borgatta L. Methods for induced abortion. Obstet Gynecol. 2004;104:174-184. 

5. Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of a randomized controlled trial (miscarriage treatment (MIST) trial). BMJ. 2006 May;332:1235-1240. 

6. Ben-Baruch G, Menczer J, Shalev J, Romen Y, Serr DM. Uterine perforation during curettage: perforation rates and postperforation management. Isr J Med Sci. 1980;16:821-824. 

7. Hefler L, Lemach A, Seebacher V, Polterauer S, Tempfer C, Reinthaller A. The intraoperative complication rate of nonobstetrical dilation and curettage. Obstet Gynecol. 2009;113:1268-1271. 

8. Hunter RE, Reuter K, Kopin E. Use of ultrasonography in the difficult postmenopausal dilation and curettage. Obstet Gynecol. 1989;73:813-816. 

9. Gilstrap III LC, Cunningham FG, Vandorsten JP. Pregnancy termination: first and second trimesters. In: Operative Obstetrics. 2nd ed. New York, NY: McGraw-Hill; 2002:543-546. 

10. Rock J, Jones H. Normal and abnormal bleeding. In: TeLinde’s Operative Gynecology. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:595-605. 

11. McElin TW, Burd CC, Reeves BE, et al. Diagnostic dilation and curettage. Obstet Gynecol. 1969;33:807. 

12. Cunningham FG, Leveno KJ, Bloom SL, Gilstrap III LC, Wenstrum KD. Abortion. In: Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill; 2005:241-247. 

13. Katz VL, Lentz GM, Lobo RA, Gershenson DM. Spontaneous and recurrent abortion. In: Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby; 2007:368-369. 

14. Milingos DS, Mathur M, Smith NC, Ashok PW. Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss. BJOG. 2009; 116:1268-1271. 

15. Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysis. Obstet Gynecol. 1996 May; 87:884-890. 

16. American College of Obstetricians and Gynecologists. Antibiotic Prophylaxis for Gynecologic Procedures. ACOG Practice Bulletin No.104. Washington, DC; 2009. 

17. Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril. 1982;37:593-610. 

18. Westendorp IC, Ankum WM, Mol BW, Vonk J. Prevalence of Asherman’s syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion. Hum Reprod. 1998;13:3347-3350. 

19. Johnson LG, Mueller BA, Daling JR. The relationship of placenta previa and history of induced abortion. Int J Gynaecol Obstet 2003;81:191. 

20. Yu D, Wong Y, Cheong Y, Xia E, Li T. Asherman syndrome-one century later. Fertil Steril. 2008;89:759-779.

HomeGynecologic Surgery Case FileD&C Complications Case File