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OG37.1-7,OG38.1-3 | Operative Observation Skills — PBL Case

CLINICAL SETTING

Dr Meera is the senior resident on call in the gynaecology OT at a tertiary teaching hospital. She is supervising a final-year MBBS student, Priya, who is observing her first D&C. The patient is Mrs Sunita Devi, a 48-year-old G4P4, referred by her primary care physician for investigation of irregular heavy vaginal bleeding over the past 6 months. She has no antenatal cards; the last menstrual period is uncertain. Haemoglobin is 8.4 g/dL. A pelvic ultrasound done three days ago reported a 'retroverted uterus, endometrial thickness 14 mm, no submucosal fibroid seen.' The procedure is booked as D&C under IV sedation for histological assessment of the endometrium. As Priya watches the anaesthetist establish sedation, she notes the patient is positioned in lithotomy. She opens her logbook and writes: 'D&C for AUB investigation. Will look for: [blank].' Dr Meera begins the examination under anaesthesia.

Trigger 1: Examination Under Anaesthesia — An Unexpected Finding

During the bimanual EUA, Dr Meera finds the uterus is markedly retroverted and retroflexed, with a uterine length on sounding of 10 cm — greater than expected. She pauses and explains to Priya: 'The axis is posterior — if I sound this as if it were anteverted, I'll perforate the fundus.' She gently passes the uterine sound in the correct direction. The uterine cavity admits the sound to 10 cm. Cervical os allows a No. 2 Hegar dilator easily. Dr Meera proceeds to curettage. On the second pass of the curette, she feels sudden loss of resistance. The curette sinks to 13 cm. She immediately withdraws it and turns to Priya: 'What just happened?'

DISCUSSION POINTS

  • What is the significance of a retroverted uterus before intrauterine instrumentation, and how should it change the approach to sounding?
  • What does 'sudden loss of resistance with the instrument sinking beyond the sounded depth' indicate, and what should be done immediately?
  • How would you explain the difference between uterine perforation from sounding versus from curettage? Does the treatment differ?
Click to reveal Trigger 2: Managing the Complication: What Happens Next (discuss previous trigger first!)

Trigger 2: Managing the Complication: What Happens Next

Dr Meera withdraws all instruments and observes the patient. Vital signs are stable: BP 118/72, pulse 84/min. There is minimal bleeding per vaginum. The patient does not develop peritonism on the lower abdomen over the next 20 minutes of observation. Dr Meera explains: 'This is likely a fundal perforation with the curette — possibly through a thin atrophic fundus. Given the stability, I have two options.' She turns to Priya again: 'What are the two management paths, and what would make me choose the more aggressive one?' While waiting, the scrub nurse brings the curettings obtained before the perforation: the gauze shows a small amount of pale, friable tissue that the nurse describes as 'fluffy — almost like rice grains — not like normal endometrium.'

DISCUSSION POINTS

  • What are the two management approaches to a suspected uterine perforation, and what clinical features would push you toward surgical intervention (laparoscopy or laparotomy)?
  • The curettings are described as 'pale, fluffy, rice-grain tissue.' What diagnoses does this macroscopic appearance suggest, and how does this change management?
  • Why might an ultrasound endometrial thickness of 14 mm in a perimenopausal woman not have flagged the correct diagnosis pre-operatively?
Click to reveal Trigger 3: Histology Result and Ethical Dimension (discuss previous trigger first!)

Trigger 3: Histology Result and Ethical Dimension

The patient is managed conservatively and discharged. Histology returns 4 days later: 'Chorionic villi consistent with products of conception. Decidualised endometrium.' The consultant gynaecologist calls Priya aside and says: 'This means the patient was pregnant. We performed a D&C — a procedure that has, in effect, terminated this pregnancy — without knowing she was pregnant and without her consent to MTP.' Priya immediately thinks of two concerns: first, the medicolegal question of whether an unintentional termination of an unrecognised pregnancy requires any particular action; second, the MTP Act implications — the patient did not consent to termination, and yet the pregnancy has been evacuated. The consultant asks Priya: 'Walk me through the implications under the MTP Act 1971 as amended in 2021, and what we must do for this patient now.'

DISCUSSION POINTS

  • The MTP Act 1971 (amended 2021) regulates intentional termination. Does the accidental evacuation of an unrecognised pregnancy during a diagnostic D&C fall under its provisions?
  • What is the ethical and medicolegal obligation of the team toward the patient when an unrecognised pregnancy is identified on histology after an operative procedure?
  • What pre-operative steps could have prevented this scenario — both from an assessment and consent perspective?
Click to reveal Trigger 4: Gynaecological Endoscopy as the Alternative (discuss previous trigger first!)

Trigger 4: Gynaecological Endoscopy as the Alternative

During the debrief, the consultant shows Priya the ultrasound report again: 'Endometrial thickness 14 mm in a perimenopausal woman is above the threshold that warrants direct visualisation rather than blind curettage.' She pulls up the national guideline on investigation of postmenopausal and perimenopausal bleeding: it recommends hysteroscopy as the preferred investigation for thickened endometrium because it allows direct visualisation and directed biopsy, avoiding blind curettage of a potentially vulnerable uterus. The consultant asks Priya to compare the two approaches — hysteroscopy and D&C — for investigating endometrial pathology, and to reflect on what additional information hysteroscopy would have provided in Sunita's case.

DISCUSSION POINTS

  • Compare hysteroscopy and D&C as diagnostic tools for endometrial pathology: which gives better visualisation, what does each detect best, and in what situations might D&C still be preferred?
  • For a patient with a thickened endometrium on ultrasound, what would you expect to see at hysteroscopy in: (a) endometrial polyp, (b) submucous fibroid, (c) endometrial carcinoma?
  • What are the complications specific to hysteroscopy (as distinct from D&C), and how does the anaesthetic/distension medium management differ between the two procedures?
Click to reveal Trigger 5: The Teaching Moment: Observer to Anticipator (discuss previous trigger first!)

Trigger 5: The Teaching Moment: Observer to Anticipator

At the end of the case debrief, the consultant asks the students to write a brief pre-operative checklist that they would complete BEFORE any diagnostic D&C or endometrial sampling — covering the anatomy, position, risk factors for perforation, legal requirements, and when to choose hysteroscopy instead. Priya reflects: 'Before today, I thought D&C was a simple minor procedure. I now see it requires as much pre-operative preparation as any major operation.'

DISCUSSION POINTS

  • Construct a pre-operative safety checklist for diagnostic D&C: what uterine factors, patient factors, and legal factors must be confirmed before commencing the procedure?
  • The consultant said: 'The most preventable complication in intrauterine instrumentation is perforation from failure to assess uterine position.' Design a two-step system (assessment + technique adaptation) that prevents this in a retroverted uterus.
  • How does the observer role at a 'minor' gynaecological procedure like D&C compare in complexity and responsibility to observation at a major procedure like LSCS? What is the difference in what you can learn from each?

Group Task Assignments

  • Using the histology result as a starting point, construct the full pre-operative assessment checklist that would have identified an unrecognised pregnancy before performing a D&C for AUB in a perimenopausal woman with uncertain LMP.
  • Draft the consent discussion that should occur before D&C in a woman with possible but uncertain pregnancy — addressing both diagnostic D&C consent and the possibility that POC may be found.
  • Debate the proposition: 'Hysteroscopy should replace blind D&C as the primary investigation for thickened endometrium in perimenopausal women.' What are the barriers to implementing this in a resource-limited setting?
  • Create a one-page observer's guide for medical students attending their first D&C: what to look for at each step, what questions to ask, and what early complication signs to watch for.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG37.4] What are the anatomical principles and step-by-step technique of D&C, and how does uterine position (retroverted vs anteverted) change the approach?
  2. [OG37.5] When is endometrial aspiration (pipelle/EA) preferred over formal D&C, and what are the indications for EA-ECC as a combined procedure?
  3. [OG37.7] What are the legal requirements under the MTP Act 1971 (amended 2021) for first-trimester termination, and how does accidental uterine evacuation of an unrecognised pregnancy differ from a voluntary MTP?
  4. [OG38.2] What is hysteroscopy, what conditions does it diagnose that blind D&C may miss, and what are the complications specific to the distension medium used (glycine vs normal saline)?
  5. [OG38.1] In what clinical situations is diagnostic laparoscopy preferred over or combined with hysteroscopy for investigating gynaecological pathology?