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2/1/2014

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

Uterine perforation is one of the more common complications of cervical dilation and uterine curettage. The incidence is 0.3% in premenopausal, nonpregnant patients, and increases in  pregnant or recently postpartum patients (5%), and in postmenopausal patients (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. Important considerations in the surgeon’s assessment include type of instrument (blunt, sharp, or suction), the patient’s anatomy, size and location of the perforation, and possible injury to bowel structures. .

Perforation with a 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 or laparoscopic guidance can ensure 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 may damage the rectum, or laterally injure may damage 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 or intrauterine forceps penetrate the uterine wall, the risk of injury to bowel is dependent on whether the instrument was used. With immediate recognition and avoidance of any curetting or grasping, bowel injury is unlikely. However, intraabdominal injury should be suspected if fat or other tissue is retrieved with the instrument. A suction curette perforation, even with minimal penetration into the abdominal cavity, can also 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 nonobstetric dilation and curettage. Obstet Gynecol. 2009 Jun;113(6):1268-71. doi: 10.1097/AOG.0b013e3181a66f91.

 

Originally titled Perforation with Uterine Sound and Suction Cannula during a D&C. Retitled January 2022

Original approval February 2014. Revised November 2015, November 2017, November 2018. Reaffirmed July 2020; Revised January 2022. Revised November 2023

 

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