What are the causes of chest pain after a dilatation and curettage (D&C) procedure?

Causes of Post-Dilatation and Curettage Chest Pain

Most Likely Etiology

Chest pain following dilatation and curettage (D&C) is most commonly benign and self-limited, but serious life-threatening causes including pulmonary embolism, pneumothorax, pneumomediastinum, pericarditis, and esophageal perforation must be excluded first. 1

Critical Life-Threatening Causes to Exclude Immediately

The initial evaluation must always rule out these emergent conditions:

• Pulmonary embolism - particularly relevant given the gynecologic procedure and potential hypercoagulable state 1
• Pneumothorax - can occur from procedural complications 1
• Pneumomediastinum - rare but serious complication 1
• Pericarditis - inflammatory process that can present with chest pain 1
• Esophageal perforation - presents with pain, breathlessness, fever, and tachycardia 2

Common Benign Causes

Musculoskeletal Pain

• Most common cause of non-cardiac chest pain, accounting for 42% of cases when other causes are excluded 3
• Typically described as stinging (53%) or pressing (35%), often retrosternal (52%) or left-sided (69%) 3
• Can result from positioning during the procedure or post-procedural muscle strain 3

Anxiety and Hyperventilation

• Stress and fear commonly cause hyperventilation, particularly in young adults undergoing gynecologic procedures 4
• Although hyperventilating patients often complain of chest pain, this rarely represents cardiac disease 4
• More common in ambulatory settings than emergency departments 3

Gastrointestinal Causes

• Gastroesophageal reflux disease (GERD) can mimic cardiac pain and is extremely common 5
• Esophageal spasm can be indistinguishable from angina 5

Diagnostic Approach Algorithm

Immediate Assessment (Within 2 Hours)

• Obtain vital signs looking specifically for fever, tachycardia (>100 bpm), hypotension (<100 mmHg systolic), or tachypnea 2
• Perform 12-lead ECG to evaluate for ischemic changes or arrhythmias 3
• Assess for signs of perforation: persistent (not transient) pain, breathlessness, fever, tachycardia 3, 2

Risk Stratification Based on Clinical Features

High-Risk Features Requiring Immediate Imaging:

• Persistent chest pain (versus transient pain that resolves) 3
• Fever or tachycardia developing during recovery 3
• Breathlessness or respiratory distress 2
• Signs of shock (pulse >100, BP <100 systolic) 2

If High-Risk Features Present:

• Do NOT perform routine imaging unless these warning signs develop 3
• CT scan with oral contrast is the diagnostic test of choice if perforation suspected, with 92-100% sensitivity 2
• Chest X-ray may show pneumothorax, pneumomediastinum, air under diaphragm, or pleural effusion, but normal findings do not exclude perforation 3

Low-Risk Features (Benign Etiology Likely)

• Transient chest pain that improves over time 3
• Normal vital signs throughout recovery period 3
• Patient tolerating oral fluids well 3
• Pain reproducible with palpation (suggests musculoskeletal origin) 3

Management Protocol

For Patients with Benign Features:

• Monitor for at least 2 hours in recovery with serial vital signs 3
• Ensure patient tolerates water before discharge 3
• Provide clear written discharge instructions with warning signs 3
• Give contact information for on-call team should chest pain, breathlessness, or fever develop 3

For Patients with Concerning Features:

• Perform CT chest with oral contrast if perforation suspected based on persistent pain, fever, breathlessness, or tachycardia 3, 2
• Consider cardiac evaluation if risk factors present or ECG abnormalities noted 3
• Evaluate for pulmonary embolism if appropriate risk factors present 1

Critical Pitfalls to Avoid

• Do not dismiss persistent chest pain - transient pain is common after procedures, but persistent pain warrants CT imaging 3
• Do not rely solely on chest X-ray to exclude perforation - CT with oral contrast is far more sensitive 3, 2
• Do not perform routine imaging on all patients - only those with warning signs during recovery 3
• Do not attribute all chest pain to anxiety without first excluding life-threatening causes 1
• Recognize that bacteremia occurs in 5% of D&C procedures, though this rarely causes immediate chest pain 6

Specific Bacteremia Consideration

• Bacteremia occurs in approximately 5% of D&C procedures for non-infectious indications 6
• This places D&C in the low-risk category for infectious complications 6
• Immediate chest pain is unlikely to be related to bacteremia, which typically presents later with fever and systemic symptoms 6