The Intraoperative Complication Rate of
Nonobstetric Dilation and Curettage
Lukas Hefler, MD, Andrea Lemach, MD, Veronika Seebacher,
Clemens Tempfer, MD, and Alexander Reinthaller, MD
OBJECTIVE: To evaluate the intraoperative complication
rate of nonobstetric dilation and curettage (D&C) in a
large series of consecutive patients.
METHODS: In this retrospective study, 5,359 nonobstet-
ric D&Cs performed in 2,542 premenopausal and 2,817
postmenopausal patients between October 1995 and
December 2006 were evaluated. Intraoperative proce-
dure-associated complication rate and identification of
risk factors for the occurrence of complications were the
main outcome measures. Univariable and multivariable
analyses were performed.
RESULTS: A total of 103 (1.9%) intraoperative complica-
tions were noted. Uterine perforation occurred in 50
cases (0.9%) (perforation site: fundus, nⴝ47; cervix, nⴝ3).
Forty-two (0.8%) cases of false passage, seven cases
(0.1%) with severe hemorrhage, three cases of vaginal
laceration, and one case of cervical laceration were
noted. In a multivariable analysis, retroversion of the
uterus (Pⴝ.008), postmenopausal status (Pⴝ.003), and
nulliparity (Pⴝ.03) were significantly associated with oc-
currence of intraoperative complications.
CONCLUSION: The overall complication rate of D&C is
low. A retroverted uterus, postmenopausal status, and
nulliparity are independent risk factors for intraoperative
complications.
(Obstet Gynecol 2009;113:1268–71)
LEVEL OF EVIDENCE: III
From the Department of Obstetrics and Gynecology, Medical University of
Vienna, Vienna, Austria.
Supported by the Ludwig Boltzmann Institute of Gynecology and Gynecologic
Oncology, Vienna, Austria.
Corresponding author: Lukas Hefler, MD, Department of Obstetrics & Gyne-
cology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090
Vienna, Austria; e-mail: lukas.hefler@meduniwien.ac.at.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2009 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/09
1268 VOL. 113, NO. 6, JUNE 2009
MD, Stephan Polterauer, MD,
N ew technologies, such as transvaginal ultrasonog-
raphy 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 diag-
nostic and therapeutic indications. Indications for a
diagnostic hospital D&C include patients with a nondi-
agnostic office biopsy, patients with endometrial hyper-
plasia, and patients with cervical stenosis. In most cases,
diagnostic hysteroscopy is performed before a diagnos-
tic 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 man-
agement of prolonged or excessive vaginal bleeding.
A number of studies have been published on com-
plications from obstetric D&C procedures, but few data
are available on nonobstetric D&C procedures.4 Com-
plications 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 preg-
nancy-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 re-
ported 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% de-
pending 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
OBSTETRICS & GYNECOLOGY
University of Vienna. Clinical data were obtained Table 1. Indications for Dilation and Curettage
retrospectively from files at the Medical University of Premenopausal Postmenopausal
Vienna, Department of Obstetrics and Gynecology. Patients Patients
Two investigators (A.L., V.S.) independently re- Postmenopausal — 1,637 (58.1)
corded the information and extracted the data. Any bleeding
equivocal data were analyzed together with the pri- Menorrhagia, 1,681 (66.1) —
mary investigator (L.H.). Patients undergoing preg- metrorrhagia
Cervical and 468 (18.4) 428 (15.2)
nancy-related D&C were excluded from the present
endometrial
study. A total of 5,359 consecutive patients underwent polyps
hospital D&C between October 1995 and December Endometrial 174 (6.9) 625 (22.2)
2006 and were included in the present study. hyperplasia and
mucometra
All D&Cs were performed as inpatient procedures Cervical dysplasia 112 (4.4) 71 (2.5)
under general anesthesia with the patient in the dorsal Fibroids 47 (1.9) 28 (1)
lithotomy position. A gynecologic examination was Cervical occlusion 16 (0.6) 18 (0.6)
performed first. After the examination, the perineum, Others 44 (1.7) 10 (0.4)
vagina, and cervix were cleansed with an aseptic Data are n (%).
solution. A single-tooth tenaculum was used to grasp
the anterior lip of the cervix. Traction was applied to tic regression analysis with the above risk factors as
the tenaculum to align the axis of the cervix and the independent variables and the occurrence of an intra-
uterine canal. The uterus was sounded to document operative complication as a dependent variable was
the size and confirm the position. After sounding the performed. P values ⬍.05 were considered statisti-
uterus, the cervix was dilated using Hegar dilators cally significant. We used the statistical software SPSS
(Rudolf Heintel GmbH, Vienna, Austria). The dilation 11.0 for Windows (SPSS, Inc., Chicago, IL) for statis-
was conducted to 6 mm, at which point the hystero- tical analysis.
scope was inserted comfortably. A diagnostic hysteros-
copy using a standard 30° 5-mm hysteroscope was RESULTS
performed. The uterine cavity was distended with nor- Indications for D&C and the histologic results broken
mal saline. Subsequently, an endocervical curettage was down by menopausal status are given in Tables 1 and
performed to avoid contamination of the histologic 2, respectively. In 4,213 (78.6%) cases, diagnostic
specimen with endometrial cells. Sharp curettes were hysteroscopy was performed before the D&C. A total
used for all procedures. Curettage was performed sys- of 1,146 (21.4%) patients underwent D&C without
tematically, beginning at the fundus. The entire surface prior diagnostic hysteroscopy. Menopausal status was
of the endometrium was sampled by moving around the known in all cases. Two thousand five hundred
uterus in a consistent and systematic fashion. forty-two (47.4%) and 2,817 (52.6%) patients were
When a perforation was suspected during sur- premenopausal and postmenopausal, respectively, at
gery, a diagnostic hysteroscopy was performed, the time of D&C. Mean age of the patients was 53.0
checking the site of perforation and the severity of (⫾13.2) years. Five hundred twenty-five (9.8%) pa-
hemorrhage. If no bleeding was detected, surgery tients were nulliparous at the time of D&C. Two
was stopped immediately. If any visceral trauma thousand seven hundred seventy-eight (51.7%) and
was suspected, further surgical exploration was
performed. Table 2. Histologic Results
Values are given as mean (standard deviation) for Premenopausal Postmenopausal
normally distributed values. Metric variables were Patients Patients
compared using Student t test. The position of the Benign endometrial 2,474 (97.3) 2,566 (91.1)
uterus (anteverted compared with retroverted uterus), histology
menopausal status (premenopausal compared with Complex atypical 23 (0.9) 34 (1.2)
postmenopausal), parity (at least one compared with 0 endometrial
hyperplasia
deliveries), performance of a diagnostic hysteroscopy Endometrial cancer 30 (1.2) 183 (6.5)
(no compared with yes), and surgeon’s experience Uterine sarcoma 0 (0.0) 12 (0.4)
(attending physician compared with resident) were Cervical cancer 4 (0.2) 8 (0.3)
assessed as risk factors for intraoperative complica- Sampling failure 11 (0.4) 14 (0.5)
tions using univariable ␹2 tests. A multivariable logis- Data are n (%).

VOL. 113, NO. 6, JUNE 2009 Hefler et al Complication Rate of Dilation and Curettage 1269
Table 3. Summary of Intraoperative
Complications
Total number of complications 103 (1.9)
Uterine perforation
False passage
Severe hemorrhage
Vaginal laceration
Cervical laceration
D&C, dilation and curettage.
Data are n (% of all dilation and curettage procedures).
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 complica-
tions 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 compli-
cation were as follows: abortion of D&C (n⫽18),
laparoscopy (n⫽2), laparotomy (n⫽1), and hysterec-
tomy (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 under-
going diagnostic hysteroscopy and D&C for pro-
longed 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 perfora-
tion was noted, but a lost intrauterine device intraab-
dominally 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 post-
Patients menopausal bleeding and an endometrial hyperplasia
of 14 mm. During dilation of the cervix with Hegar’s
50 (0.9) dilators, a perforation in the cervix occurred. Subse-
42 (0.8) quently, hysteroscopy was performed. Visibility was
7 (0.1) poor because of bleeding. It appeared that perforation
3 (⬍0.1) to the right parametrium near the uterine vessel and
1 (⬍0.1) the ureter occurred. Therefore, emergency laparot-
omy 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 (premeno-
pausal: 1.2% compared with postmenopausal: 2.6%,
P⬍.001), parity (at least one: 1.7% deliveries com-
pared 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.
DISCUSSION
Although a D&C is a diagnostic and therapeutic
surgical procedure used frequently throughout the
world, few data are available on intraoperative surgi-
cal 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 non-
obstetric 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 unrecog-
nized intraoperative complication. Most of these com-

Table 4. Demographic Characteristics of Patients

With and Without Intraoperative Table 5. Multivariable Regression Analysis
Complications
P OR 95% CI
Patients Without Patients With
Position of the uterus (retroverted .01 1.6 1.01–2.2
Intraoperative Intraoperative
vs anteverted)
Complications Complications
Menopausal status (postmenopausal .004 2.7 1.4–5.2
Patients 5,256 103 vs premenopausal)
Age 52.8 (⫾13.0) 59.2 (⫾15.3) No. of deliveries (nulliparous vs .04 1.9 1.04–3.7
Nulliparous women 507 18 parous women)
Postmenopausal women 2,744 73 Performance of a diagnostic .2 0.4 0.1–1.6
Total pregnancies 2.3 (⫾2.4) 2.0 (⫾1.8) hysteroscopy (no vs yes)
Diagnostic hysteroscopy 4,119 94 Surgeon’s experience (attending .8 0.9 0.5–1.8
Retroverted uterus 452 17 physician vs resident)
Data are n or mean (⫾standard deviation). OR, odds ratio; CI, confidence interval.

1270 Hefler et al Complication Rate of Dilation and Curettage OBSTETRICS & GYNECOLOGY
plications 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 pa-
tients. Our data do not include whether parous pa-
tients 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 complica-
tions. Other possible surgery-related complications,
such as infection, pulmonary emboli, and thrombosis,
and other complications potentially related to anes-
thesia 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 indepen-
dent risk factors for intraoperative complications of
D&C. These data can be used for preoperative patient
counseling.
VOL. 113, NO. 6, JUNE 2009 Hefler et al
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