Ahuja, Jaikishin U.

February , 2020

CASE REPORT IN OBSTETRICS AND GYNECOLOGY

 Identifying Data
Name: JM Date of admission: February 19, 2020
Age: 33
Sex: Female
 Chief Complaint
Vaginal bleeding
 History of Present Illness

3months prior to consult, patient experienced vaginal spotting associated with

hypogastric pain 6/10. patient consulted ap and was advised for transvaginal ultrasound. In the
interim, patient noted minimal vaginal spotting. No consult was done and no medication taken. 5
days prior to consult, transvaginal ultrasound was done which revealed that it is suggestive of
anembryonic pregnancy, minimal sub chorionic hemorrhage. patient was advised for completion
curettage hence this admission.

 Past Medical History

(-) asthma
(-) allergies
(-) HTN
(-) DM
(-) pneumonia
(-) tuberculosis
(-) surgeries

 Family History
(+) hypertension- both
(+) dm - maternal
(-) heart diseases
(-) renal diseases
(-) asthma
(-) cancer
(-) stroke
 Personal and Social History
(-) smoker
(-) alcoholic beverage drinker
Denies illicit drug use
 OB-Gyne History

G3P2 (2002) LMP: November 23, 2019 AOG: 8-9 weeks

M- 12
I- regular
D- 2-3 days
A- 3-4 pads moderately soaked
S- (-) dysmenorrhea
 Review of Systems
General survey : (-)weight loss, (-) weakness,(-) loss of appetite, (-) fever
Skin : (-) pruritus, (-) jaundice, (-) rashes, (-) clubbing of fingers
HEENT : (-) headache, (-) sleepy, (-) blurring of vision,(-) excessive lacrimation, (-)
hearing loss,(-) tinnitus (-) nasal congestion, (-) epistaxis, (-) bleeding gum, (-) dysphagia,
(-) hoarseness.
Respiratory : (-) dyspnea, (-) cough, (-) hemoptysis
Cardiovascular : (-) chest pain, (-) easy fatigability (-)orthopnea, (-) palpitations
Gastrointestinal : (-) diarrhea, (-) no constipation,(-) melena, (-) vomiting
Musculoskeletal: (-) myalgia, (-) arthralgia, (-) upper back pain
Nervous system : (-) vertigo, (-) dizziness, (-) loss of consciousness

 Physical Examination
General survey: Patient is awake, cooperative, oriented to time, place and person
Vital Signs: Temp: 36.6° C RR: 19 CPR BP: 120/80 mm Hg PR: 86 beats/min
Skin: Soft warm to touch with no any lesions. Nail beds pink with no cyanosis or
clubbing. No rashes.
Head: Head is round and symmetrical with no any scars and lesion. Hair is black color,
and symmetrical appearance
Eyes: Pupils equal, round and reactive to light, anicteric sclera with no redness or
exudates. Eyelids without lesions. Pink palpebral conjunctiva
Ear: Hearing intact. Auricles without lesions, (-) Discharge
Nose: No masses, deformities, tenderness, nasal septum midline, no discharge
Mouth: moist lips and oral mucosa, no masses or ulceration
Neck: Full range of motion. Trachea at midline. No lymphadenopathy, (-) sore throat, (-)
hoarseness
 Chest and lungs: Chest symmetrical expansion, clear breath sounds, no wheezes
Cardiovascular: AP, NRRR, (-) murmurs
  Gastrointestinal: soft, non-tender, flabby; FH: 10cm, FHT: 140s
Genitourinary: IE: Closed cervix, with minimal blood
Musculoskeletal: No gross deformities, no pain, edema, or deformity

 Diagnosis:
G3P2(2012) COMPLETE ABORTION; EARLY (8-9WEEKS AOG) NON-SEPTIC, NON-
INDUCED S/P COMPLETION CURETTAGE (2/19/20 EACMC)

 Discussion:

Techniques Used for First-Trimester Abortion

Dilatation and Curettage

Dilatation and curettage (D&C) is a technique whose indications have changed

greatly in the past 20 years with the advent of newer techniques for accomplishing both the
diagnostic and therapeutic aims of the procedure. Not all physicians have access to or
training in some of these newer techniques; therefore, the standard D&C remains an
important part of our specialty

The D&C is a surgical procedure during which the physician explores a cavity beyond
his or her view. It is therefore an art dependent on the surgeon's sense of palpation and
knowledge of probable findings. Variations in the shape, size, and consistency of the uterus
can be determined by history and physical examination, and there are hazards of
misdiagnosis of these factors. Before beginning a D&C, these variations should be
ascertained and anticipated. The technique must be adjusted to new variations as they are
 perceived by the surgeon, sensitive to the messages transmitted through the instruments to
his or her hands.

INDICATIONS for D&C

The diagnostic indications are as follows:

  Abnormal bleeding
  Intermenstrual bleeding
  Postmenopausal bleeding (rule out endometrial carcinoma)
  Menometrorrhagia
  Abnormal cytology (endocervical curettage, cone biopsy for cervical carcinoma)
  Ruling out disease of the endometrium (endometritis, malignancy) at time of hysterectomy
  Ruling out pregnancy at time of laparoscopic sterilization
  Dysmenorrhea
  Oligomenorrhea and amenorrhea
  Infertility

The therapeutic indications are as follows:

  Menometrorrhagia
  Dysmenorrhea
  Suspected intrauterine pathology (polyps, incomplete abortion, molar pregnancy)
  Postpartum bleeding and retained secundines
  Hematometra or hematocolpos
  Retrieval of “lost” intrauterine device
  Insertion of radioactive carriers for management of uterine or cervical malignancy

This list includes all possible indications for a D&C. However, with today's
technologies, many alternatives have evolved. In conditions in which intrauterine pathology
is almost certain (e.g., postpartum bleeding or suspected incomplete abortion), D&C is the
method of choice to stop the bleeding rapidly and to obtain a diagnosis.

Risks of the Technique

Because of the variations in anatomy and endocrinology, there are a number of known risks
that the physician should keep in mind while doing the procedure. These are arranged in
order of frequency.

1. Laceration of the cervix. As a result of resistance to dilation at the internal os, the
tenaculum holding the cervix may tear through and cause bleeding. This can be
minimized by using less force over a longer time during the dilation effort.
2. Tears of the internal os. It is quite easy to tear this structure rather than dilate it.
Occasionally such tears result in severe hemorrhage from damaged uterine vascular
branches or misdiagnosis of the tear as a submucous fibroid.
3. Fundal perforation. Under the influence of progesterone, the myometrium may be
surprisingly soft and easily perforated, such as in the management of an incomplete
first-trimester abortion.
4. Perforation due to flexion. If anteflexion or retroflexion of the uterus is not
appreciated and corrected by traction, dilators or curets may go through the anterior
or posterior wall beyond the internal os and reach the peritoneal cavity. Intrauterine
devices were found lying in the anterior or posterior wall in as many as 2% of
 women in some early series, illustrating how easily such perforations can occur.
These transmigrations of intrauterine devices happened without excessive pain or
bleeding at the time of insertion and were otherwise asymptomatic.
5. False passage at the internal os. If the internal os is tight or atrophic, a false passage
leading from the cervical canal just before the internal os into the peritoneal cavity
can occur. This would lead to an absence of curettings at best and possible damage
to adnexal vessels, bladder, or bowel at worst.

Techniques to Minimize Risks

The physician should evaluate these variations and keep the risks in mind. A D&C should
then be performed in a systematic manner, following the “ritual” outlined in 1958.

1. Catheterization. The patient should be catheterized before bimanual pelvic

examination. A preoperative enema or laxative to clear the pelvis of feces is also of
significant benefit. Before an office procedure, the patient should void spontaneously
just before getting on the examining table, to eliminate the need for catheterization.
2. Bimanual pelvic examination. The pelvis is examined bimanually to evaluate the size,
shape, mobility, and position of the uterus and to detect the presence of extrauterine
masses. A rectovaginal examination, especially in retroversion, is very useful at this
point.
3. Grasping the cervix. To visualize the cervix, the blade of a weighted speculum
(Auvard) is inserted into the vagina to retract the posterior wall and assist in the
exposure of the cervix. The single-toothed uterine vulsellum, the less traumatic
Littlewood forceps, or the double-toothed Jacobs tenaculum can be used. I prefer to
put one tenaculum deep into the cervical canal, ensuring a large grasp of the
anterior cervix. Other techniques include one tenaculum at the 3 o'clock position and
one at the 9 o'clock position, or one tenaculum sideways over the external os to
avoid the canal. A retroverted uterus may be corrected more completely by placing
the tenaculum on the posterior cervix. With a shallow, superficial grasp, there is a
greater risk of tearing during any resistance to dilation at the internal os. The middle
finger of the hand holding the tenaculum should be placed between it and the
patient's pubis to absorb the resistance to dilation and avoid trauma to the delicate
clitoris and urethra.

Fig. 1. Tenacula. ( Left) The standard Schroeder single-

toothed tenaculum or vulsellum. ( Middle) A two-
pronged variation of this design. ( Right) A somewhat
less traumatic Teale version with Allis-type teeth
instead of a single tooth to grasp the cervix.

4. Uterine sound. The uterine sound is held like a pen, not a skewer. The sound should
be used as a probe to gently and delicately determine the location and direction of
the internal os and then the location and direction of the uterine cavity. It is helpful
for the operator's hand to be on the patient's buttocks to steady the arm and
increase the tactile sensitivity of the fingers holding the sound. Traction on the cervix
by the tenaculum will help correct uterine flexion. The curve of the malleable sound
should be adjusted and rotated to determine the exact direction and location of the
internal os and uterine cavity. This finding will determine the direction for inserting
 the dilators and curets. The sound should be passed until it meets the resistance of
the fundus of the uterus, such that further pressure on the sound will cause the
tenaculum holding the cervix to move. At this point, the depth of penetration by the
sound should be marked with an index finger and the size of the uterus measured.
The adult multiparous normal uterine cavity can be 7 to 9 cm long, and the
hypoplastic or postmenopausal cavity can be as small as 5 cm or less.
I cannot stress enough that to avoid perforation, gentle technique is required in
performing this procedure on the thin or atrophic uterus. Sounding should be
avoided in the postpartum or pregnant uterus. Difficulty in passing the standard 3-
mm-diameter sound may require using the smallest-diameter dilators in the internal
os until the sound can again be used. Once the sound is in the uterine cavity, it
should be gently moved from side to side to determine the size, symmetry, and
presence of distorting lesions of the endometrial cavity. Variations such as uterine
septa, leiomyomata, synechiae, and the bicornuate uterus should be kept in mind so
they can be diagnosed at this time.
5. Endocervical curettage. In postmenopausal bleeding or suspected malignancy, the
endocervical canal should be curetted before cervical dilation. A sharp, narrow-tipped
curet of the Kevorkian-Young or Duncan type is preferred. The specimen should be
collected on a small piece of Teflon-coated gauze that has been inserted onto the
weighted speculum blade and tucked under the external os. All endocervical tissue
can thus be obtained and separately labeled.

Fig. 2. Curets. On the left is the Kevorkian curet, with a

narrow, boxlike cutting edge. The next three are small (3-
mm), medium (6-mm), and large (16-mm) Sims curets.
The medium curet is adequate for most diagnostic D&Cs
and will pass through an 8-mm dilation. The large one is
for the dilated cervix in incomplete late abortions and
postpartum bleeding. On the far right is a Thomas curet,
with a dull serrated blade for exploration of the soft uterus
of an early abortion.

6. Dilation of the internal os. Hagar dilators are round-tipped and short and are useful
in the small or atrophic uterus. Pratt dilators have a long, tapered tip that makes
dilation easier and less traumatic but may perforate the smaller uterus. Hanks
dilators have a stop at 8 cm, the depth of most adult uteri, to minimize the risk of
perforation. For ordinary diagnostic curettage, dilation of 8 to 10 cm is all that is
necessary. Dilators are measured in millimeters of diameter (Hagar) or “French”
circumference in millimeters (Pratt). To convert French markings to diameter, divide
the French value by pi, or roughly by three. Thus, a 31 French Pratt will dilate the
cervix to about 10 mm.

Fig. 3. Sounds and dilators. On the left is a uterine

sound, made of malleable copper, with a 3-mm tip and a
shape determined by the surgeon. Next is a No. 7 Hagar
dilator (7 mm in diameter) with no tapering dilating
edge. Next is a Pratt dilator, 21 Fr (about 7 mm), with a
gentle taper. On the far right is a Hanks dilator, also 21
Fr, with the same taper as the Pratt but with a stop 8 cm
from the tip.
7. Dilation of the internal os should proceed slowly, allowing the fibers of the internal os
to stretch over the dilator for several seconds. A rapid series of insertions may lead
to a tear of these fibers. The dilators should again be held like a pen, with the
operator's fourth and fifth fingers on the patient's buttocks. These fingers will act as
a stabilizer to maximize proprioceptor sensitivity and act as a stop to minimize the
risk of forceful perforation of the fundus when resistance is suddenly overcome. If a
particular dilator has met with much resistance, it is advisable to leave it in the
internal os for several seconds to allow the fibers to expand around it.
8. Exploration with forceps. Especially for menometrorrhagia, the uterus should be
explored at this point with a small Randall kidney forceps or a small Ring forceps to
look for polyps, fragments of placenta, or submucous fibroids that may be better felt
by two-point palpation. These large instruments also further define the cavity and
thus minimize the risk of perforation by the smaller curet. The forceps should be
widely opened inside the cavity, closed, twisted 180°, and then withdrawn to permit
avulsion and removal of endometrial polyps or placental fragments.

Fig. 4. Forceps. On the left is a Randall kidney stone

forceps, very useful for obtaining small endometrial polyps
or fragments of tissue. Next is a curved Ballenger sponge
forceps, requiring at least a 10-mm dilation for insertion.
A curved Kelly ovum forceps is similar. Next is a Laufe
forceps to remove a large polyp or small products of
conception. On the far right is a Bierer forceps for the
management of an incomplete midtrimester abortion.
Note the reverse-angle serrations to draw tissue through
the relatively constricted internal os in these situations.

9. Uterine curettage. The standard Sims uterine curet comes in many sizes, but the
small or medium is adequate for most D&Cs.The Heaney curet has a serrated cup,
which permits ridges of decidua basalis to regenerate after vigorous curettage. The
curet should have a slight curve modeled after the final curve of the malleable
sound. The curet should be held by the entire hand for a firm grip during the
“backstroke” coming out of the uterine cavity, but should be inserted gently to allow
palpation of the fundus of the uterus. It should always be inserted in the direction of
the flexion of the uterus. A fresh 4″   4″ gauze should be in between the vaginal
retractor and the external cervical canal to receive the endometrial curettings. A
systematic curettage should consist of directing the tip of the curet to one of the
uterine horns and pulling with a continuous stroke from this area out of the uterine
cavity to obtain a strip of endometrium to be placed on the gauze. The curet is
reinserted, the contralateral uterine horn palpated, and another continuous stroke
made down to the outside. This should be repeated with insertion in the anterior
flexed position, rotating the curet inside the uterus to address the posterior wall of
the fundus, with two or three more strips attempted from the posterior wall. After
four or six strips of endometrium are attempted, the cavity should be curetted in its
entirety, with frequent withdrawals of the curet to bring the specimen into the
waiting sponge. To ensure thorough curettage, the curet is passed from one cornu to
the other over the fundus of the uterus. A small, sharp curet might be useful to
reach the cornual regions. Only after the tissue is evacuated should the curet be
used as a scrub brush to denude the endometrium down to the decidual layer and
possibly to detect irregularities suggestive of submucous fibroids hiding underneath
the endometrium. The end point of this scrubbing should be the detection of a
scratching sensation or sound (the “uterine cry”), which represents a sharp curet
 running over myometrium. Too vigorous a pursuit of this end point may lead to
formation of synechiae (Asherman's syndrome) (see below).
10. Repeat forceps exploration. After the curettage is complete, the Randall kidney
clamp may reveal an avulsed polyp or placental fragment that had escaped the
efforts to be withdrawn by a curet.
11. Repeat uterine sound. As a final step, the uterus should be gently resounded to
ensure that perforation has not occurred.

Post-operative Care

The patient may be uncomfortable with cramps from the cervical and uterine
irritation, which may lead to a delayed vagal reflex of hypotension and bradycardia.
Atropine available in the postoperative area will help manage persistent vagal reactions.

Bleeding from cervical tenaculum punctures is common and usually subsides in 5

minutes with observation alone or gentle pressure with sponge forceps. Chemical cautery
(e.g., silver nitrate [AgNO 3]) may also be useful. Puncture bleeding rarely requires suturing.
If a cervical laceration continues to bleed, suturing may be required. The patient can expect
to have some bleeding for 3 or 4 days until the endometrial cavity is relined with
endometrium. In an outpatient setting, it is advisable to have the patient leave with another
responsible adult, because the effects of medication or vagal reflex make driving hazardous.