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Perforation with Uterine Sound and Suction Cannula during a D&C

2/1/2014 - Eugene C. Toy, MD

 

Uterine perforation is one of the more common complications of cervical dilation and uterine curettage. The incidence is increased for a pregnant or recently postpartum uterus (5%), and it is less for premenopausal (0.3%) and postmenopausal women (2.6%). Other risk factors include a retroverted uterus, nulliparity, advanced gestational age, and infection.

Perforation can occur during cervical dilation, uterine sounding, or during the curettage. Injury is suspected when there is a sudden loss of resistance and the unanticipated advancement of the instrument beyond the length of the uterine cavity. The surgeon should quickly assess for possible life-threatening injury to vascular or visceral structures. The type of instrument (blunt vs. sharp vs. suction), awareness of the patient’s anatomy, size and location of the perforation, and possible injury to bowel structures are other important considerations.

Perforation with the blunt sound or dilator through the uterine fundus is generally asymptomatic and rarely carries short or long term consequences. Blunt probe injury in the midline in a patient with normal anatomy can be observed. Observation for 1-3 hours for bleeding, changes in vital signs, or signs of peritonitis is usually sufficient. If the D&C procedure needs to be completed, sonographic guidance can help assure that instruments remain within the uterine cavity.

A perforation through the cervix is more prone to complications, even with a blunt probe. A perforation anteriorly may damage the bladder, posteriorly involve the rectum, or laterally injure vascular structures. Cystoscopy, rectal examination, and laparoscopy should be considered in these cases.

When the location of perforation is unknown or possibly lateral, one can observe for a few hours.  If there is concern for a complication related to the perforation, management options include hysteroscopy to assess injury location and laparoscopy to evaluate for intraabdominal complications. External bleeding may not be evident. Clinicians should be watchful for signs of intraabdominal, retroperitoneal, and broad ligament hemorrhage.

If a sharp curette penetrates the uterine wall, the risk of injury to bowel is dependent on the amount of curetting actions. With immediate recognition and avoidance of any curetting, bowel injury is unlikely. However, intraabdominal injury should be suspected if fat or other tissue is retrieved with the curette. In contrast, a suction curette perforation, even with minimal penetration into the abdominal cavity, can lead to bowel injury. Laparoscopy is usually recommended to examine for injury and to complete the procedure if needed. Even after a normal laparoscopic examination after suction curette perforation, the patient should be observed for and counseled about signs of peritonitis.

Further reading:

Hefler L, Lemach A, Seebacher, V, et al. The intraoperative complication rate of nonobstetrical dilation and curettage. Obstet Gynecol 2009;113:1268-71.

McElin TW, Bird CC, Reeves BD, Scott RC. Diagnostic dilatation and curettage. A 20-year survey. Obstet Gynecol. Jun 1969;33(6):807-12.

Radman HM, Korman W. Uterine perforation during dilatation and curettage. Obstet Gynecol 1963;21(2):210-15.

Original approval February 2014; Revised November 2015; Revised May 2017.

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