Complications of Endometrial Biopsy

Outpatient suction endometrial biopsy is generally safe and well tolerated.
Some women complain of pain during or after the biopsy. A few women experience
vasovagal hypotension. Inability to obtain an adequate specimen is a common
problem. Perforation of the uterus is possible, as is bleeding after the
procedure. Infection is a rare complication after endometrial biopsy.
Each of these possible complications is discussed in more depth in the
following sections.

Pain
Pain during an endometrial biopsy is common, often described as similar
to menstrual cramps Sledmere.
Discomfort with the biopsy seems more severe with a serrated metal curette
such as the Novak, and less painful with a plastic cannula with a blunt
distal opening such as the Pipelle (Eddowes,
Henig, Kaunitz,
Lipscomb, Silver,
Stovall). Pain is also more severe
when suction is produced by an external pump (Vabra aspirator, Tis-U-Trap) versus rapid withdrawal of the plunger of a syringe (Uterine Explora) or piston in the cannula (Pipelle, Pipet Curette) (Kaunitz,
Lipscomb). Most women find the discomfort acceptable. A minority of women find the pain unbearable. Instruct
your patient to take a pain reliever such as ibuprofen 1 hour before the biopsy. Applying lidocaine directly into the cervical os with a cotton-tip
swab or injecting a paracervical block may be necessary to continue the procedure in women with cervical stenoses Cicinelli, Rabin).
Occasionally, pelvic cramping may not start until several hours after the biopsy Li. Instruct your patient
to call you if she develops severe pain, which may signal uterine perforation or infection.

Syncope
Symptoms of weakness, sweating, dizziness, lightheadedness, and nausea may occur uncommonly during an endometrial biopsy. Bradycardia, possibly
related to pain, has been reported during endometrial biopsy Aznar. Jensen noted syncope in 3 patients from a group of almost 300 women who had a biopsy with a Vabra aspirator Jensen). Adequate pain control with local anesthetic may reduce the occurence of hypotension Cicinelli). If your patient experiences
a vasovagal reaction during the biopsy, she should remain recumbent until
the symptoms dissipate.

Perforation
Uterine perforation is extremely uncommon after an endometrial suction
curettage. The incidence of uterine perforation with the Vabra aspirator
is estimated to be 0 to 4 per 1000 patients Grimes,
Rodriguez. Perforation is thought
to be less likely with a plastic cannula such as the Pipelle, but has
been reported with the Pipelle when the biopsy was done under general
anesthesia Koonings). Fever or
unusual pain after a biopsy may signal a uterine perforation.

Infection
The normal vagina and cervix are colonized with aerobic and anaerobic bacteria. Bacteroides, Peptostreptococcus, and Clostridium
are commonly isolated from the cervix and are potentially pathogenic Gorbach).
Infection after an endometrial aspirate is uncommon. In several series involving thousands of women who had an endometrial biopsy, no cases of infection were identified Baitlon,
Hofmeister).

Transient pelvic pain and fever, pelvic infection requiring antibiotics, septicemia, and endocarditis have all been documented days to weeks after
an endometrial biopsy (Livengood,
Harris, Jensen, Perkins).
A patient with known valvular heart disease or immunosuppression may be more prone to infection after endometrial biopsy. Because of the low risk
of infection, the American Heart Association does not recommend endocarditis prophylaxis before uterine dilatation and curettage (D&C) unless a pelvic
infection is clinically obvious Dajani.
Endometrial biopsy is contraindicated in cervicitis or pelvic inflammatory disease but can be used in endometritis to obtain cultures. The cervix
should be cleansed before biopsy, usually with povidone–iodine (Betadine). Instruct your patient to notify you if she has a fever or unusual pelvic
pain after the biopsy.

Bleeding
A small amount of vaginal bleeding may be seen after a suction curettage, but hemorrhage is very uncommon. Hemorrhage after D&C under general anesthesia
occurs in fewer than 5 per 1000 patients Grimes).
Suction curettage should not be done in a woman with an uncorrected defect in coagulation.