Pain Under Ribs After Dilation and Curettage (D&C)
Pain under the ribs following a D&C procedure is not a typical or expected complication and warrants immediate medical evaluation to rule out serious intraoperative injuries, particularly uterine perforation with possible bowel or diaphragmatic injury.
Understanding the Clinical Context
D&C procedures carry a low overall complication rate of approximately 1.9%, with uterine perforation occurring in 0.9% of cases 1. However, when perforation does occur, it most commonly involves the uterine fundus (94% of perforations) rather than the cervix 1. Pain localized under the ribs (subcostal region) after a D&C is anatomically distant from the expected surgical site and raises concern for:
- Referred pain from diaphragmatic irritation due to intraperitoneal blood or injury
- Direct injury to upper abdominal organs if perforation occurred with instrument advancement
- Delayed recognition of intraoperative complications
Immediate Assessment Required
Red Flag Symptoms Requiring Emergency Evaluation
You should seek immediate medical attention if experiencing any of the following 2:
- Increasing shortness of breath or difficulty breathing
- Fever or chills (suggesting infection or peritonitis)
- Worsening or severe abdominal/rib pain
- Dizziness, fainting, or confusion (suggesting hemorrhage)
- Shoulder pain (classic sign of diaphragmatic irritation from intraperitoneal bleeding)
- Rigid or distended abdomen
Risk Factors That Increase Complication Likelihood
Certain patient characteristics significantly increase the risk of D&C complications 1:
- Postmenopausal status (3-fold increased risk, P=.003)
- Nulliparity (never having given birth) (P=.03)
- Retroverted uterus (P=.008)
If you have any of these risk factors, the threshold for seeking evaluation should be even lower.
Differential Diagnosis for Subcostal Pain Post-D&C
Most Concerning Causes (Require Urgent Evaluation)
Uterine perforation with bowel or omental injury: Fundal perforation can allow instruments to enter the peritoneal cavity and potentially injure upper abdominal structures 1. This would cause peritoneal signs and referred pain to the shoulder or subcostal region.
Intraperitoneal hemorrhage: Severe hemorrhage occurs in 0.1% of D&C procedures 1. Blood in the peritoneal cavity irritates the diaphragm, causing referred pain to the shoulder and subcostal areas.
Delayed recognition of visceral injury: Symptoms may not manifest immediately after the procedure but develop over hours to days.
Less Likely But Possible Causes
Musculoskeletal pain from positioning: Prolonged lithotomy positioning during the procedure can cause muscle strain, though this would be unusual to localize specifically under the ribs 3.
Incidental rib pathology: While unrelated to the D&C itself, pre-existing rib conditions could be exacerbated by positioning or post-procedure coughing 4.
Recommended Immediate Actions
Within 24-48 Hours of Symptom Onset
Contact your gynecologist or go to the emergency department immediately for the following evaluation 3:
- Complete blood count to assess for anemia from occult bleeding
- Vital signs assessment including blood pressure and heart rate to evaluate for hemodynamic instability
- Abdominal and pelvic examination to assess for peritoneal signs (rebound tenderness, guarding, rigidity)
- Imaging studies: CT scan of the abdomen and pelvis with IV contrast is the gold standard for identifying perforation, free fluid, or organ injury 5
Pain Management While Awaiting Evaluation
Do not mask symptoms with aggressive pain control before medical evaluation, as this could delay diagnosis of a serious complication. However, for mild discomfort while arranging urgent assessment 6:
- Acetaminophen 500-1000 mg every 6 hours (maximum 4g/24 hours) is safe and will not obscure peritoneal signs 2, 6
- Avoid NSAIDs (ibuprofen, naproxen) until bleeding complications are ruled out, as they increase bleeding risk 7
- Avoid opioids before evaluation, as they can mask peritoneal signs and delay diagnosis 3
Critical Pitfalls to Avoid
Assuming all post-D&C pain is "normal": While cramping in the lower abdomen and pelvis is expected, subcostal pain is not typical and should not be dismissed 1.
Delaying evaluation: Uterine perforation with visceral injury can progress to peritonitis, sepsis, or hemorrhagic shock if not recognized early 1, 5.
Attributing symptoms to anxiety or gas: While these are common post-procedure complaints, they do not typically cause localized subcostal pain and should not be assumed without proper evaluation 3.
Expected Timeline for Evaluation
Seek evaluation within 24 hours if pain is moderate to severe, worsening, or accompanied by any red flag symptoms 2. Even if pain is mild but persistent beyond 48 hours, contact your gynecologist for assessment, as some complications can have delayed presentations 1, 5.
Prognosis If Serious Complications Are Ruled Out
If imaging and clinical evaluation exclude perforation, hemorrhage, or visceral injury, the pain is likely musculoskeletal or referred from uterine cramping and should resolve within 3-7 days with conservative management including acetaminophen and rest 3. However, this determination can only be made after appropriate medical evaluation—do not assume a benign cause without proper assessment 1.