Removal and curettage of English reference forceps
3 operation name curettage
4 alias curettage forceps curettage
5 Classification of Obstetrics and Gynecology/Family Planning Operation/Induced Abortion
6 ICD code 69.0 10 1
7. Summarize the application of curettage in induced abortion. Family planning operations include birth control, sterilization and re-pregnancy operations. Commonly used birth control operations include placing and removing intrauterine devices, induced abortion in early pregnancy and termination of pregnancy in the second trimester. Sterilization is to block fertility through surgery to achieve the purpose of permanent contraception. Women often use tubal ligation. Re-pregnancy is a fine plastic surgery for female infertility caused by tubal obstruction or some reason after tubal ligation, which belongs to the category of family planning. The operation requires little pain, safety, reliability, small side effects and easy acceptance, and the indications should be strictly controlled. Surgical requirements should follow the principles of accuracy, lightness and fineness, and minimize tissue damage and complications.
Induced abortion refers to the artificial termination of pregnancy within 12 weeks of pregnancy. Different methods should be adopted according to the number of weeks of pregnancy. Within 0/0 weeks of pregnancy, the placenta has not yet formed, and curettage can be used. At 1 1 ~ 12 weeks, the placenta has been formed. Curettage will be done at this time.
8 Anatomy of the uterus The anatomy of the uterus and the ultrasonic manifestations of early pregnancy are shown in the following figure (Figure11.3.2.21~1.3.2.23).
9 indications Curettage is suitable for:
1. 1 1 to 14 weeks.
2./kloc-pregnancy within 0/4 weeks is not suitable for continued pregnancy due to various diseases.
10 contraindications 1. Acute inflammation of genitals and severe cervical erosion.
2. Acute phase of systemic diseases.
3. Those who can't bear the operation due to poor general condition need hospitalization, and the operation can only be performed after the condition is stable.
4. The body temperature is above 37.5℃.
1 1 preoperative preparation 1. Ask about the medical history in detail and check the date of the last menstruation.
2. Physical examination of body temperature, pulse and blood pressure, and general and gynecological examination.
3. Check the urine pregnancy test and do the cleanliness test of trichomonas, fungi and secretions. Patients with severe anemia or hematological diseases should check blood routine, coagulation time, platelet count and blood type, and prepare blood if necessary.
4. If possible, do B-ultrasound examination to find out the implantation position of fetal sac, and also find ectopic pregnancy or uterine malformation at an early stage.
5. Empty the bladder.
6. Place the dilator in the cervical canal to dilate the cervix. Because of the number of weeks of pregnancy, it is difficult for large placenta and fetus to pass through the cervix. In order to reduce the difficulty of cervical dilatation during operation, it is necessary to make preparations for cervical dilatation before operation. Commonly used dilators include Achyranthes bidentata, dry umbilical cord and rubber catheter. Their machinery is used to promote the gradual expansion of the cervix. Achyranthes bidentata and dry umbilical cord are generally not used now because of their complicated preparation and easy infection. Rubber catheter is easy to disinfect and convenient to place, and has been widely used. Before operation, the 16 ~ 18 sterile12 catheter was inserted into the cervix and placed in the uterine cavity along the uterine wall. Patients can walk around at will. In recent years, a special silicone rubber cervical plug has been used. It can be placed in the cervical canal 4 hours before operation, or it can only dilate the cervix through the inner mouth without entering the uterine cavity.
12 operation steps 12. 1. Prepare and introduce vaginal dilation, spread a disinfection towel, dilate with a speculum, take out the cervical dilator placed before operation, remove the speculum, disinfect it, check the size and position of uterus and the degree of cervical dilation by internal examination, and put the speculum back. According to the size of cervical dilatation and referring to the number of weeks of pregnancy, it is decided whether it is necessary to dilate the cervix with a cervical dilator. In general pregnancy 1 1 week, the cervix needs to be enlarged to 9 ~ 10, that is, it can be enlarged to1~12 weeks, that is, it can be enlarged to 9 ~ 10 with small oval forceps and 8 suction tubes.
12.2 2. rupture the membrane, insert the oval forceps into the uterine cavity, and find the part with cystic sensation (figure 1 1.3.2.24). When the fetal membrane is slightly broken, clear amniotic fluid will flow out. At this time, the amniotic fluid in the cervix is sucked out with an aspirator.
12.3 3. clamp the placenta and fetus into the uterine cavity with egg bending forceps to detect the placenta attachment. When the placenta feels soft, clamp the placenta with oval pliers as much as possible (Figure 1 1.3.2.25), and gently pull it down to loosen it and peel it off, thus clamping it out. When most of the placenta is clamped out, the fetus can often be squeezed out by uterine contraction, otherwise the various parts of the fetus can be clamped out by oval forceps respectively.
12.4 4. After the placenta and most fetuses are taken out, oxytocin 10U is injected into the outside of the cervix to promote uterine contraction, and then the uterine cavity 1 ~ 2 circles are sucked with negative pressure of 40.0 ~ 53.0 kPa (300 ~ 400 mmHg) by suction tubes No.7 ~ 8, and then the uterus is bent with a medium curette.
12.5 5. Check curettage. Check curettage in detail to see if it is consistent with the number of weeks of pregnancy. If the main body part is not taken out, clamp it again until it is completely taken out.
Matters needing attention in operation 13 1. Before curettage, it is difficult to probe the uterine cavity with a uterine probe because of fetal sac obstruction, or it is easy to puncture because the uterus is large and soft and the probe is thin. Therefore, if you encounter resistance, you don't have to force detection. Oval forceps or No.7 suction tube can be used instead of probe to enter the uterine cavity to determine the depth of the uterine cavity.
2. Prevent uterine and cervical injuries. When clamping the placenta, if the placenta is not taken out completely or in large pieces but in small pieces, it is easy to clamp the uterus wall. When it is difficult to pull, you can't pull it forcibly. Open the pliers leaves and clamp them separately. When clamping a corpse, if the fetal trunk or limb is in the cervical canal, the longitudinal axis of its long bone must be consistent with the longitudinal axis of the uterus. When there is resistance in the internal traction of the fetus, it should be pulled out immediately, crushed or adjusted, and then pulled out to avoid damaging the uterus and cervix.
14 After curettage, do the following treatment:
1. Observe in the observation room for 30 min ~ 1h after operation, pay attention to the amount of bleeding and the general situation, and leave only if there is no abnormality. If there is much bleeding or general weakness, you should pay attention to observation.
2. If curettage is not complete during operation, some villi can still adhere to the uterine wall, which will affect uterine contraction and endometrial repair. If there is a lot of bleeding or abdominal pain after operation, those with mild symptoms can be cured by uterine contraction and antibiotics. If the treatment is ineffective and the bleeding lasts for more than 2 weeks, gynecological diagnosis and B-ultrasound examination should be done. If there is residual uterine cavity, the uterus should be cleaned again.
15 Complications 15. 1 1. The amount of bleeding is generally less than 50 ml. If the amount of bleeding exceeds 200ml, it is called bleeding during induced abortion. Most of the causes of bleeding are due to the large pregnancy month, some villi are separated from the uterine wall, and large pieces of tissue can not be taken out, resulting in poor uterine contraction and blood sinus opening at the placenta attachment. Pregnancy should be taken out as soon as possible, and general bleeding can be stopped by injecting oxytocin 10U into the cervix. The bleeding caused by instrument injury should be made clear, and corresponding hemostasis measures should be taken.
15.2 2. During the operation of induced abortion syndrome, the instrument dilates the cervix too fast, and the uterine wall is subjected to mechanical force, which causes strong contraction, excites the vagus nerve and releases a lot of acetylcholine, resulting in a series of cardiovascular symptoms: the operation center rate slows down to below 60 beats/minute, and at the same time, symptoms such as nausea, vomiting, chest tightness, dizziness, pallor and cold sweat appear, and the blood pressure drops to 65438. At this time, atropine sulfate 0.5mg or anisodamine 6542 20mg can be injected intramuscularly or intravenously, and oxygen is inhaled, so the prognosis is generally good. Patients with mild symptoms can rest for more than 10 minutes after operation, and most of them can recover by themselves.
15.3 3. Injuries include uterine perforation and cervical laceration. During pregnancy, the uterus is softer and thinner, especially during lactation or long-term oral contraceptive failure. The pregnant uterus is softer and thinner, and it is easy to be perforated during operation. Excessive uterine flexion, scar uterus, double uterus and single cervix, and repeated induced abortion should pay special attention to prevent uterine perforation. Uterine perforation can be caused by excessive force of instruments entering uterine cavity, forced passage when encountering resistance, and excessive curettage. If the instrument used enters the uterine cavity beyond the original depth or the patient suddenly feels severe pain in the lower abdomen, uterine perforation should be considered and the operation should be stopped immediately. If the probe is perforated without obvious symptoms, oxytocin 10U can be injected into the muscle or cervix. After observing 1 ~ 2 weeks, the perforation can often heal itself, and then abortion curettage or suction curettage can be performed under the guidance of B-ultrasound. Perforation of cervical dilator or suction tube needs hospitalization observation, and antibiotics and uterine contraction are given. If the perforation is large, there is obvious internal bleeding or suspected intestinal injury, laparotomy should be carried out and the treatment should be carried out according to the degree of injury. Cervical laceration often occurs when the cervix is hard and strong, the cervix is difficult to expand, the resistance suddenly disappears or accompanied by cervical bleeding. Considering the possibility of cervical laceration, the size and depth of laceration should be checked. If it is a small laceration, we can use gauze to stop the bleeding. If it is a full-thickness laceration of the cervix, it should be sutured intermittently with 1 chrome catgut.
15.4 4. infection caused by inflammation of internal and external genitalia before infection or lax aseptic technique during operation, and bacteria invading the wound surface of uterine wall. If the postoperative body temperature is above 38℃, patients with acute inflammation should be hospitalized in time.
15.5 5. Amniotic fluid embolism