OG34.4 | Minor Operative Gynaecology — Summary & Reflection

KEY TAKEAWAYS

Minor operative gynaecological procedures provide tissue diagnosis and targeted treatment for conditions ranging from abnormal uterine bleeding to cervical intraepithelial neoplasia. Key learning points: (1) D&C indications: AUB, postmenopausal bleeding, incomplete/missed abortion, molar evacuation; outpatient Pipelle (EA) is first-line where feasible. (2) Anatomy governs safety: confirm uterine position by EUA before instrument passage; always sound before dilating; the internal os is the critical narrowing to negotiate. (3) D&C technique sequence: EUA → speculum → tenaculum → sound (record depth) → sequential Hegar dilation → four-quadrant curettage → specimen collection. (4) Fractional curettage order is rigid: ECC first (before dilatation), then endometrial curettage — to localise disease without contamination. (5) Pipelle sensitivity ~91% for carcinoma; inadequate sample in symptomatic postmenopausal woman mandates hysteroscopy + biopsy. (6) Complications: perforation (0.3–1.3%) — stop, laparoscopy if visceral injury suspected; infection — antibiotics; Asherman syndrome (highest risk in post-partum D&C) — prevented by suction over sharp curettage and stopping when cavity is clear. (7) Theatre observation checklist: identify instruments, note EUA position, follow dilator sequence, observe curette strokes, inspect specimen.

REFLECT

Reflect on the patient experience of undergoing an outpatient Pipelle biopsy versus a D&C under general anaesthesia. From a patient perspective, what are the advantages and disadvantages of each? From a clinical governance perspective, why is it important that the choice between outpatient sampling and theatre procedure is based on clinical criteria (prior inadequate sample, high suspicion of focal disease, cervical stenosis) rather than convenience or habit? Think about the last D&C or endometrial sampling procedure you observed — if you were the consenting doctor, which three complications would you prioritise discussing with the patient, and how would you frame the Asherman syndrome risk for a woman in her 30s who has not yet completed her family?