Evacuation of the Uterus
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Management of complications of evacuations
Laparotomy following uterine perforation
Causes of collapse after uterine evacuation
For all uteri less than 14-16 weeks (operator dependant), rather perform an MVA see below. For all larger uteri formal curettage may be necessary.
Procedure
- Read the patient’s notes – this is required for any operation.
- Note the gestation, history of the miscarriage, previous estimations of uterine size. Look for any evidence of sepsis or complications
- Decide if the evacuation needs to be done by a senior person, e.g. registrar/experienced MO
- Bimanual examination is essential, & note the size & axis of the uterus
- Catheterization is only necessary if the uterus cannot be easily palpated. Clean technique essential (the post cath UTI rate of up to 20% is avoided)
- Grasp the anterior lip of the cervix with a vulsellum (first trimester) or sponge holding forceps (second trimester); 2 vulsellums or sponge holders side by side lessen the chance of tearing the cervix. Dilatation may not usually necessary. If it is pass the largest dilator that will safely pass from smaller to larger.
- If possible, remove placenta or pieces with your fingers
- Use ovum or swab-holding forceps next & remove large pieces, staying in the lower pole of the uterus
- Use a curette, & take the largest that can be easily inserted
- Insert the curette, holding it loosely between finger & thumb until the fundus is reached allowing your finger & thumb to slip back along the shaft as you bump against the fundus This may prevent perforation
- Be firm. Only ever curette towards the cervix, pulling towards yourself only. In a floppy uterus ask for oxytocin 2 units as it may firm the uterine wall. Curette around the four quadrants until the cavity feels empty
- Ask for oxytocin 10 units or Syntometrine 0.5 mg IV if the uterus is not well contracted. Rub up the uterus to assist contraction & apply bimanual compression if there is vigorous bleeding
- Bleeding should settle down once the uterus is empty & well contracted
- Make clear & complete notes including estimation of blood loss.
- Always right a ‘Plan’ – either “discharge if well”, “admit for transfusion”, “antibiotics”, “on call unit to check post op Hb”
- Do not take long over an Evac. Learn to do it safely in 5 minutes
Management of complications of evacuation
Excessive bleeding
- Ensure that all products have been removed. Palpate digitally for products & repeat the curettage with the largest curette that will easily pass
- Empty the bladder if it feels full
- Apply bimanual compression by rubbing the uterus between an abdominal hand & the fingers in the vagina, until the uterus contracts
- Give oxytocin 10 units IV stat & 20 units in Ringer-Lactate 1 L
- Give ergometrine – by itself or as Syntometrine 0.5 mg IV or IM stat. Be cautious or avoid the drug with hypertensive patients
- Try prostaglandins – misoprostol 1 mg (5 tablets) rectally (of uncertain benefit) or other prostaglandins e.g. prostaglandin F2-alpha 5 mg into the uterine muscle.
- Inspect the cervix for bleeding tears, & ligate or sew over the tears. This is an unusual cause of bleeding
- Call help
Bleeding that continues despite uterine contraction suggests a cervical tear or uterine perforation
Uterine perforation
Perforation recognized at evacuation is an emergency requiring senior assistance.
Recognizing a perforation
- Usually, the instrument – sound, dilator, forceps or curette – goes in too far
- Bimanual examination may assist to remind the operator of the uterine size
- Bowel appearing in the cervical os is uncommon but is alarming, & confirms that the uterus has been perforated
Management
Some gynaecologists recommend simple observation if perforation is with blunt instruments including early recognized perforation with a curette, & laparoscopy for perforation with sharp instruments. It may however be difficult to know which instrument caused the perforation. If in doubt, a laparotomy should be done.
Laparotomy following uterine perforation
- Do a midline incision
- Inspect the uterus
- Inspect the entire length of the small & large bowel
- Through the perforated uterus complete the evacuation & check that the uterus is empty
- Repair the uterus & avoid hysterectomy if possible
- If there is bowel perforation (bowel mucosal defect) call a general surgeon
Postoperative collapse
Call for help, from an anaesthetist if still in theatre. Attend to the ABC of resuscitation & try to establish a cause. Call for gynaecological assistance & manage according to the cause that is suspected.
Causes of collapse after uterine evacuation
- Pre-existing hypovolaemia or anaemia worsened at evacuation
- Pre-existing septic shock worsened at evacuation
- Severe haemorrhage during & after evacuation
- Uterine perforation with internal haemorrhage
- Rupture of an undiagnosed ectopic pregnancy
- Non-gynaecological causes, e.g. embolism, arrhythmia etc.
Incomplete evacuation
This presents as continued vaginal bleeding & lower abdominal discomfort. There may be evidence of infection. Products may be felt on clinical examination or seen on ultrasound. An experienced doctor should perform a uterine re-evacuation in theatre, with antibiotic cover
Sepsis
This presents with fever, tachycardia, lower abdominal pain, offensive vaginal discharge, continuing bleeding, & lower abdominal tenderness. Consider other sources of infection, e.g. chest, urinary tract, HIV-related. Treat as for septic incomplete abortion (Recurrent Miscarriage) with re-evacuation by a senior medical officer or registrar if there are retained products suspected clinically or by ultrasound. Hysterectomy may be necessary.