What are the causes of abdominal pain after a dilation and curettage (D&C) procedure for miscarriage?

Causes of Abdominal Pain After Dilation and Curettage in Miscarriage

The most common causes of abdominal pain after dilation and curettage (D&C) for miscarriage include infection (particularly chorioamnionitis), retained products of conception, uterine perforation, and normal post-procedural pain. Understanding these causes is crucial for proper management and prevention of complications.

Common Causes of Post-D&C Abdominal Pain

1. Infection

• Infection is a significant cause of post-D&C pain, particularly chorioamnionitis which may present with fever, uterine tenderness, and purulent cervical discharge 1
• Endometrial cultures may grow organisms such as Escherichia coli requiring antibiotic treatment 2
• Clinical symptoms of infection may be less obvious at earlier gestational ages, and some cases of intra-amniotic infection may not initially present with maternal fever 1
• Infection rates are higher with medication abortion (23.9%) compared to surgical evacuation (1.3%) 1

2. Retained Products of Conception (RPOC)

• RPOC is a common complication after pregnancy termination or spontaneous miscarriage 3
• Immediate consequences include persistent vaginal bleeding, abdominal pain, pelvic infection, fever, and dilated cervix 3
• Ultrasound typically reveals an intrauterine hyperechogenic vascularized area consistent with RPOC 3
• The risk of retained tissue requiring additional procedures is higher with medication abortion (17.4%) compared to surgical evacuation (1.3%) 1

3. Uterine Perforation

• Uterine perforation is a rare but serious complication of D&C procedures 4
• Can lead to severe abdominal pain and potentially uterine rupture in subsequent pregnancies 4
• Women with a history of uterine perforation who present with abdominal pain during subsequent pregnancies should be evaluated for possible uterine rupture 4
• Ultrasound examination can help detect uterine wall defects when perforation is suspected 4

4. Hemorrhage

• Hemorrhage (>500cc) occurs in approximately 9.1% of D&E procedures 1
• May present as abdominal pain with signs of hypovolemia 1
• Transarterial embolization can be used to treat severe postpartum hemorrhage with a success rate of 89% 1
• Hemorrhage is more frequent after medication abortion (28.3%) compared to surgical evacuation (9.1%) 1

5. Normal Post-Procedural Pain

• Some degree of cramping and discomfort is expected after D&C procedures 1
• Typically resolves within a few days with appropriate pain management 1
• May be managed with oral analgesics and monitoring 1

Risk Factors for Complications

• Multiple D&C procedures increase the risk of subsequent complications 5
• History of previous uterine surgery 4
• Advanced maternal age 1
• Infection prior to the procedure 1
• Inexperienced operator 1

Evaluation of Post-D&C Pain

Clinical Assessment

• Persistent pain, especially when accompanied by fever, tachycardia, or breathlessness should prompt immediate evaluation 1
• Assess for signs of peritonitis, which may indicate perforation 1
• Evaluate vital signs for evidence of infection or hemorrhage 1

Diagnostic Studies

• Transvaginal ultrasound is the first-line imaging modality to assess for RPOC or hematometra 1
• CT of the abdomen and pelvis with IV contrast is usually appropriate when there is fever with abdominal pain to evaluate for abscesses 1
• Consider MRI when ultrasound findings are equivocal 1

Management Approaches

For Infection

• Prompt antibiotic therapy based on likely pathogens 1
• Do not delay treatment of intraamniotic infection due to absence of maternal fever 1

For RPOC

• Hysteroscopic removal under direct visualization is preferred over blind repeat D&C to minimize complications 3
• Limiting the use of electrosurgery during hysteroscopy can minimize thermal damage to the endometrium 3

For Uterine Perforation

• Surgical assessment and intervention may be required 1
• Close monitoring for signs of peritonitis or internal bleeding 1

For Hemorrhage

• Transarterial embolization can be considered for severe cases with a success rate of 89% 1
• Surgical intervention may be necessary for uncontrolled bleeding 1

Prevention of Complications

• Use of less invasive options when available for miscarriage management 5
• Careful technique during D&C procedures to minimize trauma 3
• Appropriate antibiotic prophylaxis when indicated 1
• Adequate training and supervision for those performing the procedure 1

Long-term Considerations

• D&C procedures are associated with increased risk of preterm birth in subsequent pregnancies (OR 1.29,95% CI 1.17-1.42) 5
• Multiple D&Cs further increase this risk (OR 1.74,95% CI 1.10-2.76) 5
• Formation of intrauterine adhesions (Asherman syndrome) can lead to subfertility, chronic pelvic pain, and menstrual disturbances 3
• Increased risk of abnormal placentation in future pregnancies 3