Primary Mother Care tells midwives how to evacuate an incomplete abortion, if they have to, using their fingers and sponge forceps. Here we describe the hospital procedure for doing the same thing. For septic abortions see Section 6.6a.
Many abortions don't need evacuating (see below), but those that do need evacuating soon, so don't let incomplete abortions wait unnecessarily. Evacuating a pregnant uterus differs from curetting a non-pregnant one (20.3) in two important ways: (1) After an abortion the cervix is open, so there is rarely any need to dilate it. (2) The wall of an infected uterus is so soft that you can perforate it much more easily with a curette.
SOME TERMINOLOGY An abortion is the expulsion of a pregnancy from the uterus before 28 weeks. An early (first trimester) abortion occurs before 14 weeks, a late one (second trimester) from 14 to 28 weeks. A septic abortion is an incomplete abortion with signs of intrauterine infection. Postabortal sepsis is pelvic infection after a complete abortion. A missed abortion is an intrauterine death during the first trimester or early in the second, after which the pregnancy is not expelled for at least another month. A carneous mole is a continuation of a missed abortion, in which the dead fetus is surrounded by shells of organized blood clot. Habitual abortion is a sequence of three successive first trimester abortions, or two successive second trimester ones.
An abortion goes through these stages: (1) threatened (bleeding and perhaps cramps, but the cervix is still closed), (2) inevitable (the cervix is open but no products of conception have been expelled), (3) incomplete (part of the products have been expelled), and (4) complete (all the products have been expelled, bleeding has stopped, the cervix is closed, and the uterus is now much too small for the duration of the pregnancy). In the first trimester the distinction between an inevitable and an incomplete abortion is pointless, because you can manage them both in the same way. In the second trimester the distinction is important, because an inevitable abortion is not ready for evacuation, whereas an incomplete one must be evacuated. Before 14[nd]16 weeks it is difficult to tell if an abortion is complete or not; because to make sure it is complete you have to identify the fetus and the whole of the placenta, with the membranes, as fully formed structures. Before 14[nd]16 weeks they are not sufficiently well formed for you to be sure about this.
SITI (27 years) was admitted with a threatened 16-week abortion. It seemed to settle, and she was discharged, but she bled in the bus on the way home and was readmitted. Fetal parts were extracted through a dilated cervix, and traumatized pieces of gut were seen through it. A laparotomy showed a tear in her descending colon, old clots and pus in her peritoneal cavity, and a rupture of her uterus. The tear in her descending colon was sutured and her abdomen closed. Some days later she passed faeces through her cervix. She was re-explored, and a proximal defunctioning colostomy was done, after which she eventually recovered. LESSONS This true story is an extreme case. It shows the magnitude of the disasters that can follow the mismanagement of what might seem to be quite a minor condition. She was fortunate to escape with her life. The many lessons include: (1) An abortionist had tried to abort a 16-week pregnancy, which is dangerously late. (2) If an abortion is incomplete, evacuation is mandatory. She should not have been discharged before her uterus had been emptied. (3) Whenever the large gut has to be repaired, a proximal defunctioning colostomy must be done immediately. Had this been done at her first laparotomy, she would not have required another one. Fig. 16-1 EVACUATING AN INCOMPLETE ABORTION. A, explore the patient's uterus with your finger while your other hand is holding her fundus. You may find it easier to use two fingers or your middle finger. B, grasp her cervix with sponge forceps and use them to pull it down. C, and D, while holding her uterus with your other hand, introduce ring forceps, turn them through 90[de], grasp and remove any products of conception, reinsert the forceps and do the same thing again. E, [f10]gently [f11]curette her uterus. F, this is the disaster you are trying to avoid!
BLEEDING BEFORE THE 28TH WEEK THE DIFFERENTIAL DIAGNOSIS includes the various stages of abortion, ectopic pregnancy (16.6), and hydatidiform mole (32.38). In late pregnancy consider also placenta praevia (16.12), and abruption (16.13). There are also gynaecological causes of bleeding: trichomoniasais, candidiasis, venereal warts, cervical polypi, cervical erosions, and cervicitis. These can all cause a bloody vaginal discharge. Also, a patient may not be pregnant, and have DUB (dysfunctional uterine bleeding, 20.2). Much bleeding remains unexplained.
THREATENED ABORTION. Ask her to rest in bed at home and give her a sedative (although neither are of proven value). Admit her if: (1) She has bled much (regardless of her gestational age). (2) She is more than 14 weeks pregnant. (3) She has a bad obstetric history (admit her for psychological reasons), or she lives far away and cannot get help if bleeding becomes much worse, especially during the night.
UNCOMPLICATED INEVITABLE ABORTIONS. Here are the instructions for an uninfected abortion. If a patient is febrile, has a foul discharge, and perhaps signs of peritonitis, her abortion is septic, so see Section 6.6a. Management also depends on the duration of her pregnancy.
If she is less than 14 weeks, monitor her pulse, blood pressure, and temperature, her peripheral circulation, and the amount of bleeding. Measure her haemoglobin, and take a specimen for grouping and cross-matching. Give her 0.25 or 0.5 mg of ergometrine intramuscularly on admission. If she has bled much, set up a drip. Starve her, and prepare to evacuate her uterus as soon as possible. If it is the custom of the hospital to shave her labia and perineum, do so.
If you have plenty of theatre time, you will save time and morbidity if you take all abortions less than 14 weeks, other than threatened ones, to the theatre for formal evacuation.
If theatre time is scarce the mandatory indications for evacuation are: (1) Considerable bleeding (evacuation is urgent). (2) Bleeding which continues for more than 24 hours. (3) Patients in whom the retained products of conception are obviously still present on vaginal examination. Together, these cases form about a quarter of the total; treating the others non-operatively will considerably reduce your workload and is less expensive. Some obstetricians think that all abortions less than 14 weeks, except threatened ones, should be evacuated.
If she is more than 14 weeks, with an inevitable abortion (her cervix is open at least one finger, but the products of conception, especially the fetus, have not been expelled), assess and monitor her as above. Don't evacuate her uterus until the fetus has been expelled. When it has been expelled, and there is even a possibility that evacuation is incomplete, complete it. If however the fetus and placenta are expelled together, and the membranes are complete, there will be nothing left to evacuate.
Opinions differ on on the use of a curette after 14 weeks: (1) One contributor considers than an instrument should never be used on an abortion which is more than 14 weeks (except perhaps occasionally ovum forceps). Her cervix will always be open enough for your finger. Fishing around with any instrument in a large flabby uterus for a few fragments of tissue is likely to do more harm than good, especially if you use a standard curette. If she has stopped bleeding, do nothing. If she continues to bleed, put up an oxytocin drip, and give her intravenous ergometrine. This will probably complete her abortion. If these measures fail, and she continues to bleed, explore her uterus as if you were removing her placenta manually (19.11a). (2) Another contributor reminds you that these patients can bleed severely, and cannot always be evacuated with a finger. He advises you to use a large curette carefully!
EVACUATING AN INCOMPLETE ABORTION ERGOMETRINE may make evacuation unnecessary, so try it first. Give her ergometrine 0.25 mg intravenously or 0.5 mg intramuscularly (0.5 mg intravenously will cause nausea and vomiting, and is unnecessary). The products of conception may be discharged, and she may stop bleeding. If it fails, it will not prevent you dilating her cervix. Alternatively, use ergometrine with oxytocin. Even 0.25 mg will often make her sick, so if there is little bleeding, you can omit it.
RESUSCITATION may be necessary. Do it at the same time as the evacuation.
EQUIPMENT. A catheter. Three ovum forceps or sponge- holding forceps without rachets (one for swabbing the vagina and the other for removing the contents of the uterus), uterine curettes blunt and sharp, preferably a few sizes of each. A vaginal speculum (Sims' or Auvard's). Don't use a sound, because this can readily perforate her uterus. A set of Hegar's dilators (only occasionally necessary).
ANAESTHESIA. (1) Intravenous pethidine with diazepam (A 8.8). (2) Intravenous ketamine (A 8.2). (3) Thiopentone with pethidine (A 8.8), provided she is not shocked and anaemic. Thiopentone alone is adequate, unless you need to dilate her cervix. (4) A saddle block (A 7.7), or a caudal block (A 7.3). (5) Light ether (A 11.3).
CAUTION ! Don't operate until: (1) She has a drip up, if this is necessary. It is necessary if there is: (a) much bleeding, or (b) hypovolaemia or anaemia. Some contributors consider it is mandatory always. It may be unnecessary if she is in vasovagal shock because the placenta is distending her cervix (see below).
METHOD. Put her into the lithotomy position with her buttocks over the end of the table, so that you can insert your instruments comfortably in any direction. Clean her suprapubic area, vulva, and perineum with chlorhexidine, and put a drape under her and on her abdomen. If you cannot drape her, clean her abdomen and thighs. Take careful aseptic precautions. Catheterize her bladder. An empty bladder will make it easier for you to check that her uterus is contracting well after evacuation. Use a swab in a sponge-holder to swab out her vagina.
Do a bimanual examination with two fingers in her vagina and your other hand on her abdomen. Check: (1) The state of her cervix and its degree of dilatation. (2) The size of her uterus and the products of conception palpable inside it. (3) Any adnexal masses (don't miss an ectopic pregnancy, but don't use an examination under anaesthesia to diagnose one! 16.6).
If you can get your finger into her cervix, use it to empty her uterus (finger curettage). A finger is much safer than a curette, because you can feel where you are, so avoid using a curette if you can. Put half your hand into her vagina and use your right index or middle finger. At the same time push down the fundus of her uterus with your left hand on her abdomen, so that your finger can reach right into it. Ideally this requires good muscular relaxation. If you are using a local block, be gentle, talk to her kindly, and persuade her to relax. Loosen all the retained tissue with your finger. If you can empty her uterus with your finger, there is no need to curette it.
If you cannot get your finger into her cervix, insert a speculum and grasp her cervix with a sponge-holder, as in B, Fig. 16-1. Give her 0.25 mg of ergometrine intravenously, and wait a minute for it to make her uterus contract, harden it, and reduce the risk of perforation. With your left hand pull her cervix well down with the sponge-holder to straighten her uterine cavity. Keep pulling during the rest of the procedure. Introduce the second pair of sponge- forceps into her uterus with your right hand. Slide them in gently until you can lightly feel the top of her fundus. Open them, turn them through 90[de], close them, and remove them (C). Do this several times, to remove pieces of placenta hanging from her uterine wall, until her uterus is empty.
If you cannot insert your finger or a curette, as occasionally happens in the first trimester when her cervix is not sufficiently dilated but her uterus seems enlarged, dilate it to size 9 Hegar. First insert a small dilator, and then progressively larger ones, until you have reached size 9. You can easily make a cervix incompetent. So don't dilate a cervix beyond Hegar 9.
CAUTION ! (1) Don't put a sound into a pregnant uterus. If you want to know how long it is, insert a large Hegar dilator or sponge-holder and mark how far it goes in with your finger. (2) Be gentle, or you will perforate her fundus. Your exploring finger will have shown you how deep it is. (3) Don't try to put large ovum forceps into an undilated cervix, and don't explore it with other instruments.
With your left hand on her abdomen, explore her uterus again with your finger to make sure it is empty.
If it is not empty, use a blunt curette to remove the remaining pieces of placenta. While it is still hard under the influence of the ergometrine, very gently scrape the inside of her uterus with a blunt curette (E). Let it almost rest in your hand as you use it. Leaving the retained products of conception behind is serious, but perforating it (F) is more so. You will know that her uterus is empty by: (1) A characteristic grating feeling (difficult to detect on the anterior surface). If part of its wall feels a little rough, this is probably the placental bed. (2) Your failure to remove any more tissue.
CAUTION ! Don't curette a uterus which has not been hardened by ergometrine. An intravenous dose will keep it contracted for about half an hour, and an intramuscular one for somewhat longer.
Finally, do a bimanual compression (19-9) to encourage contraction and expel clots from her uterus. Put two fingers into her anterior vaginal fornix, and your other hand on to her abdominal wall. Compress her uterus between them.
Send her back to the ward with a vulval pad. Inspect this from time to time during the first hour or two after the evacuation. If bleeding recurs, give her another dose of ergometrine 0.5 mg intramuscularly.
POSTOPERATIVELY, monitor her for further bleeding and check her vital signs. If she is well send her home the next day, and advise her on contraception, which should be part of the ward routine. If there has been a suspicion of interference or venereal infection, consider giving her the appropriate broad- spectrum antibiotic (for example, tetracycline) for a few days.
DIFFICULTIES [s7]EVACUATING A UTERUS See also Sections 6.6aD and 20.3 (dilatation and curettage).
If she is admitted apparently VERY SHOCKED, and is hypotensive and semiconscious, she may be having a VASOVAGAL ATTACK because the placenta has stuck in her cervix (common). Her external os may be tight, while her internal os and cervical canal dilate to accommodate the pregnancy. This is quite different from a cervical pregnancy (rare, 16.8). Don't wait to put up a drip. Remove the placenta with a gloved finger on the ward without anaesthesia. If this fails (unusual), pass a Sims' or Cusco's speculum. If you see products of conception in her cervix, remove them with sponge forceps. She will recover miraculously.
If she is ADMITTED WITH HEAVY BLEEDING, resuscitate her, give her ergometrine, and at the same time evacuate her uterus with a finger on the ward. Even if evacuation is not complete, it will help to stop bleeding.
If she is or becomes SERIOUSLY ANAEMIC, are you going to transfuse her? If yours is a high-HIV area, you will hardly transfuse anybody. In a low-HIV area, if her haemoglobin is [mt]100 g/l, transfusion is unnecessary; between 80 and 100 g/l transfuse her only if she is symptomatic; if it is below 80 g/l transfuse her. Always give her iron.
If you find INJURIES to her vagina, cervix or uterus, and there is a possibility that an instrument has entered her abdominal cavity, do a laparotomy immediately, and inspect it.
If SHE DOES NOT IMPROVE after evacuation, reconsider the diagnosis. She may have an ectopic pregnancy, or be severely anaemic, or have a collection of pus. If you find an abscess in her pouch of Douglas, drain it (6.5).
If you think you have PERFORATED HER UTERUS, console yourself with the thought that experts sometimes also do this, perhaps more often than they admit.
If you perforate her uterus after you have emptied it, and you don't think you have damaged her gut or omentum (they don't appear in her vagina), send her back to the ward. Starve her, set up a drip, give her antibiotics (2.9), and observe her pulse, temperature, and blood pressure carefully. Her perforation will probably heal. If there are increasing signs of infection or bleeding (unusual), do a laparotomy to sew up the wound in her uterus.
If you perforate her uterus before you empty it, you have the difficult task of completing the evacuation in the presence of a perforation. If you can do a laparoscopy (unlikely, 15.4), you can observe her uterus while you curette it. If not, accept that evacuation is incomplete, give her antiiotics, set up a drip, and observe her very carefully.
If she collapses, and OMENTUM OR GUT APPEAR IN HER VAGINA (very rare), you have certainly perforated her uterus. If this happens, do an immediate laparotomy, and sew up the tear. If her large gut is perforated, do a diversionary colostomy (9.5). If there is severe bleeding or an extensive tear, tie her internal iliac arteries (3.5). If this fails a hysterectomy may be necessary. If you have sewn up a tear, warn her that her uterus is in danger of rupturing in later pregnancies. She will need an elective Caesarean section (18.9).
If you FEEL A FIBROID in her uterus (uncommon), it may have been the cause of her abortion (unusual). Leave it for 3 months before you treat it. If it is pedunculated and submucous with a narrow neck, don't be tempted to to twist it off vaginally. This can cause severe bleeding. Leave it for 3 months. See Section 20.6.
If BLEEDING DOES NOT STOP after the evacuation, it is probably due to poor contraction of her uterus, or there may still be products of conception in her uterus. Often there is no obvious reason. (1) Make sure her uterus is empty. (2) Give her a second dose of intravenous ergometrine, rub up her uterus to stop it bleeding, and repeat bimanual compression. Be patient at this stage, 5 or 10 minutes of bimanual compression may be necessary, but it will usually succeed. (3) If this fails, give her an oxytocin drip (40 units per litre), and run this in fast.
If the above measures fail to control bleeding (rare), curette her again if you have not already done so. Don't try packing her uterus, it will not remove the cause of the bleeding.
If even this fails to control bleeding (very rare), tie both her internal iliac arteries (for a discussion as to the feasibility of doing this see Section 3.5). If even this fails (very rare indeed), a hysterectomy is necessary. See also cervical ectopic pregnancies (very rare) in Section 16.8.
If you think you are evacuating an incomplete abortion, and yet there are VERY FEW CURETTINGS, her abortion is probably complete. There is however a possibility that your diagnosis may be wrong, and that she has a CHRONIC ECTOPIC. Read the story of Theresa in Section 16.7.
If you feel that she has a UTERINE SEPTUM, clean out each side of her uterine cavity.
BE CAREFUL WITH THE CURETTE!