Curettage technique and quality control
Instrumental removal of the gestational sac is performed using a curette, which is carefully inserted to the uterine fundus. The gestational sac is detached from its bed by moving the instrument toward the internal os sequentially along all walls. Simultaneously, the decidua (decidua) is removed, and finally, the uterotubal junctions must be checked.
Any instrumental intervention is accompanied by blood loss, the physiological norm of which is 50–75 ml. If the gestational sac is completely removed, the uterus contracts adequately, and the bleeding stops spontaneously. To confirm complete evacuation of the uterine cavity, it is advisable to use ultrasound, which is especially important for nulliparous patients. In the postoperative period, an ice pack is placed on the lower abdomen, and uterotonics are prescribed.
Complications of instrumental termination
Intraoperative and early postoperative complications during curettage occur significantly more often than during vacuum aspiration. The main risks include:
- Uterine perforation with the risk of intraabdominal hemorrhage and damage to adjacent organs.
- Massive uterine hemorrhage.
- Retained products of conception in the uterine cavity.
- Injury to the cervix, which can lead to fistula formation in the long term.
Clinical presentation of uterine perforation
The nature of the injury and symptoms depend on the instrument used:
- Uterine sound: the least traumatic possible perforation.
- Hegar dilators, curette, abortion forceps: carry the highest risk. Injury to the vascular bundle threatens severe intraabdominal hemorrhage.
- Gastrointestinal tract injury: perforation with a curette or abortion forceps can lead to bowel injury, even up to iatrogenic extraction of the greater omentum and intestinal loops, which leads to severe peritonitis.
When perforated with a Hegar dilator or curette, the surgeon feels the instrument "drop" into the abdominal cavity. An unrecognized perforation manifests in the first hours with signs of peritoneal irritation or hemorrhage, serving as an absolute indication for laparotomy.
Uterine hemorrhage and its management
Uterine bleeding may be caused by incomplete removal of the gestational sac, poor myometrial contractility, or blood disorders. Management and arrest tactics include:
- Intravenous administration of oxytocin and emergency uterine evacuation.
- Replacement of circulating blood volume with plasma and plasma expanders.
- In rare cases of persistent bleeding, laparotomy with ligation of the internal iliac arteries or modern uterine artery embolization.
Briefly: answers to topical questions
What are the absolute and relative contraindications to artificial abortion by curettage?
The sources list contraindications to artificial abortion without dividing them into absolute and relative; the decision on pregnancy termination in their presence is made by the physician individually.
- Acute and subacute genital inflammation — salpingo-oophoritis, purulent colpitis, endocervicitis.
- Extragenital inflammatory processes — furunculosis, periodontal disease, acute appendicitis, tuberculous meningitis, miliary tuberculosis.
What types of anesthesia are used during instrumental removal of the gestational sac?
Intravenous anesthesia is used during instrumental abortion. For vacuum aspiration, the procedure is performed with mandatory anesthesia.
Curette to the fundus — walls cleared — junctions checked — ice and uterotonics.
Class and exam questions
What is the physiological norm of blood loss during instrumental removal?
The physiological norm of blood loss for this method ranges from 50 to 75 ml.
Which instruments pose the greatest danger during perforation?
Hegar dilators, the curette, and abortion forceps pose the greatest danger, as they can cause injury to adjacent organs and vascular bundles.
What should be done in case of uterine perforation with a dilator or curette?
It is necessary to assess the size and location of the perforation site using laparoscopy or laparotomy.
What else to study on this topic
- Perforation between the leaves of the broad ligament and its hematomas
- Late complications after abortion and placental polyp
- Formation of cervicourinary and cervicovaginal fistulas
- Inflammatory diseases of the uterus and appendages following the procedure
- Uterine artery embolization as an alternative to vessel ligation
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