Complications of Non-obstetric D&C
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: In the infrequent case of intraoperative complications, risk factors include menopausal status, uterine retroversion, and nulliparity.
Source: Hefler L, et al. The intra-operative complication rate of nonobstetric dilation and curettage. Obstet Gynecol 2009;113:1268-1271.
In a retrospective study of more than 5300 non-obstetric dilation and curettage (D&C) procedures between 1995 and 2006, these Austrian investigators found that the rate of intraoperative complications was only 1.9%. The most common was uterine perforation, occurring in 0.9% of cases. A false passage was created in 0.8% of cases (n = 42) and there were also 7 cases of severe hemorrhage, 3 cases of vaginal laceration, and 1 case of cervical laceration. Intraoperative complications were statistically associated with retroversion of the uterus, postmenopausal status, and nulliparity.
Commentary
Maybe your initial response to reading the summary was the same as mine. I thought to myself, "Whoa! People are still doing D&Cs?" In fairness, the dates of data collection were several years ago, but the role of this procedure in our practice should really be looked at with a jaundiced eye. During my training in obstetrics and gynecology (I won't mention how many years ago), the operating room schedule routinely had D&Cs listed, be it for abnormal bleeding, postmenopausal bleeding, endometrial hyperplasia, or even fibroids.
Needless to say, technology now offers us many options such that the need to take a patient to the operating suite and administer an anesthetic to diagnose or treat an intrauterine condition is (or at least should be) an infrequent, and, dare I say, a rare occasion. Admittedly, performing D&C for failed intrauterine pregnancies remains mainstream (although even more patients are being treated with medical management). What we're talking about here is the need to perform a procedure that, to a great extent, has been replaced by transvaginal sonography, sonohysterography, endometrial biopsy, and office hysteroscopy.
So let's make sure that the role of D&C in our respective practices is an appropriate one. First, if you're concerned about premenopausal bleeding and whether it is associated with endometrial cancer or a precursor, endometrial biopsy has been shown to be highly sensitive. Is it 100%? No, but taking women to the operating room without office sampling would be considered overly aggressive and putting the patient at an anesthetic risk with minimal benefit. Before a biopsy is attempted, many clinicians use a transvaginal ultrasound to measure endometrial thickness, but that is only useful in a postmenopausal patient, not premenopausal. It can help in identifying fibroids and uterine polyps, conditions which are difficult to diagnose on simple bimanual examination.
Second, what about postmenopausal patients? Do they need a D&C under anesthesia? Actually, most of these patients can have an adequate endometrial biopsy in the office. If the cervix is stenotic, there are commercially available cervical dilators/locators that can help. Lacrimal duct probes or even the stick end of a cotton-tipped swab can be helpful. I often use a #11 blade to create a cruciate incision over the cervical dimple.
Third, what if an endometrial biopsy in the office shows insufficient tissue? Shouldn't this patient undergo D&C? If your biopsy instrument was advanced to an appropriate depth, then a lack of endometrial tissue may well be representative of the entire cavity, since endometrial atrophy is more likely than hyperplasia or cancer.
Do all or any patients with premenopausal or postmenopausal bleeding require hysteroscopy (be it in the office or in the OR)? Some would espouse the view that this is the case for anyone with abnormal bleeding. Again, there should be a rational approach to each patient on an individual basis, thereby rendering this opinion just that … an opinion of a vocal minority. Just because you have a hysteroscope doesn't mean that you're obligated to use it on everyone. The advent of sonohysterography is also helpful when intrauterine disease is suspected on ultrasound, but the frequency of its use should be balanced against the alternative diagnostic maneuvers listed here.
A balanced use of hysteroscopy, ultrasound, sonohysterogram, and endometrial biopsy will result in only the appropriate patient getting to the OR schedule for a non-obstetric D&C. The intraoperative complications are minimal (< 2%), so patients can be reassured in this regard. Don't forget, though, that there is a real risk for just the administration of any anesthetic. Add to that the inefficient use of your time as the surgeon (preoperative work-up, going to the hospital, doing the procedure, coming back to the hospital, postoperative follow-up, etc.), and you can see why I'm not a big fan of doing many D&Cs. Yes, do it in the right cases. I would predict, though, that those cases are few and far between.
In a retrospective study of more than 5300 non-obstetric dilation and curettage (D&C) procedures between 1995 and 2006, these Austrian investigators found that the rate of intraoperative complications was only 1.9%.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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