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Future Fertility

You may hemorrhage (bleed heavily) in future deliveries as a result of having a D&C (11-13).

 
Panpaprai and Boriboonhirunsarn (2007) found that a previous dilation and curettage puts a woman at higher risk for retained placenta and that pregnant women should be notified of this increased risk (11). 

A study by Lohmann-Bigelow et al (2006), suggested that D&C may increase the risk of hemorrhage during or following future deliveries (12).   

 According to Zwart et al (2007), obstetricians should be aware of the risk of scarring in the uterus (Asherman’s Syndrome) after a D&C and that such scarring can lead to abnormal placental attachment, such as: placenta previa, placenta accreta, placenta increta and placenta percreta.  In women with placenta previa, the placenta attaches partially or completely over the cervix. With placenta accreta, the placenta is markedly adherent to the uterine wall.  In more severe instances of abnormal placental attachment (placenta increta or placenta percreta) the placenta grows partially or completely through the uterine wall, respectively.  These conditions (placenta previa and placenta accreta or its more severe variants) can coexist and any of them can result in life-threatening hemorrhage before or during delivery (13).   

Myometrium (uterine muscle) was found in curettage specimens from RPOCs in 44% of pregnancy terminations and in 35% of miscarriages (14).

When a D&C is performed, the endometrium (the internal lining of the uterus) is scraped and/or suctioned. The endometrium has two layers (see illustration above):  the upper layer which is closer to the uterine cavity is called the functional layer and this is shed during a menstrual period; the deeper layer is called the basal layer and this layer remains during and after menses and is the source for the regrowth of the functional layer. The basal layer is partially embedded in the myometrium. If the basal layer is traumatized, irreversible damage can result.              

According to the 2005 retrospective study by Beuker et al, myometrium (uterine muscle, see illustration), was found in 35 % and 44% of the specimens depending upon the reason for the curettage. This was found following D&Cs for miscarriages and for elective abortions respectively.

It is important to note that the amount of myometrium ranged from less than .01% to 5% of all tissue examined. These trace amounts of myometrium were not identified until the retrospective look at the pathology slides was undertaken. It is unclear as to the amount of uterine surface area or myometrial bulk that was represented by these findings (14).

The presence of myometrium in a pathology report indicates a greater risk for Asherman’s Syndrome.

 
When myometrium is present in an curettage specimen, according to Silverberg’s (2007) Pathologic Principles and Pitfalls, it is important for the pathologist to note this in the pathology report. The reason for this is because the presence of myometrium may indicate a greater risk for intrauterine adhesions or Asherman’s Syndrome to develop (since damage has occurred) as noted by Schenker and Margalioth in 1982 (15,16).

There is a significant association between adenomyosis and prior uterine surgery, including D & C and D & E (17).

 
Adenomyosis is the presence of endometrium within the myometrium.  This condition commonly causes heavy and painful periods and has been linked to infertility. A retrospective study by Panganamamula et al (2004) found a link between prior uterine surgery and adenomyosis. The hypothesis is that by disrupting the junction of the endometrium and myometrium by any surgical intervention (including a D&C), the endometrial glands may begin to grow into the uterine muscle and hence, the development of adenomyosis. These investigators found that having a D&C (or other uterine surgery) is an important risk factor for developing adenomyosis. (17)

More Considerations about D & Cs.

• D&Cs are often performed routinely during the diagnosis of an ectopic pregnancy (pregnancy outside the uterine cavity) for two reasons: 

1. To assist in making the diagnosis by “proving” that the pregnancy is not inside the uterus; 
   
2. To remove the excess build-up of uterine lining which occurs during an ectopic pregnancy, thereby preventing the patient from having a heavy “period” a few days after treatment for the ectopic pregnancy has been completed. 

A D&C for either purpose can cause IUA and the reasoning for both indications can be questioned. Failure to retrieve products of conception in curettings does not prove that the pregnancy is ectopic but obtaining placental tissue does prove that at least one pregnancy was intrauterine. This should not be done until there is laboratory evidence that viable pregnancy does not exist thereby eliminating the possibility of interrupting a normal early pregnancy. The passage of what is called a decidual cast--a “mold”--of the uterus created by the marked build-up of endometrium is not a major problem and therefore the D&C is little more than a cosmetic procedure. 

• Some women undergo a D&C, only to learn that the procedure failed to remove a polyp, retained tissue, etc. Perhaps the preoperative information was incorrect or perhaps the blind procedure failed to remove the pathology. Some of these women undergo unnecessary surgeries only to suffer complications. A pre-op and post-op ultrasound can help to reduce the frequency of these problems.

• Both suction and blunt curettage caused a significant percentage of endomyometrial injury on a pregnant and recently pregnant uterus (44% and 35% respectively). However, it was found in this study by Beuker, et al, that suction curettage yielded more endomyometrial injury than blunt curettage (14). It is assumed that suction is safer than blunt, and this finding contradicts that assumption. It would be of benefit, to have studies which look into this matter and compare suction and blunt curettage.

 
In a retrospective study by Beuker, et al, miscarriages were treated by blunt curettage and the elective abortions were performed using suction curettage. In this retrospective study, the suction curettage for elective termination yielded greater instances of myometrium (44%) than the blunt curettage for miscarriage (35%). So it can be concluded from this study, that although the procedures were performed for different purposes, that suction curettage yielded more endomyometrial injury than blunt curettage (14). 

• Some doctors believe (based on their experience) that if you take certain birth control pills, you more than likely have a thin lining or endometrium; this can make you more susceptible to damage during a D&C since the endometrium is thinner and thus the basal layer would be at greater risk of trauma.