Surgical abortion editor

Negative pressure aspiration

It is suitable for uterus within 0/0 week of pregnancy/kloc. The method of negative pressure electric suction is mainly used to suck out the embryo sac and decidua tissue, which is called induced abortion negative pressure suction or negative pressure suction for short. This method is the first in China, and this operation is relatively safe and simple, so it is also a commonly used means to terminate early pregnancy in clinic.

indication

1. The pregnancy is terminated within 10 weeks without contraindications;

2. It is not suitable to continue pregnancy due to certain diseases or hereditary diseases.

Contraindications

1. Acute stage of various diseases: acute myocardial infarction, acute cerebral infarction, acute hepatitis, acute blood system diseases, acute kidney diseases, acute surgical diseases, etc. Inflammation of reproductive organs, such as vaginitis, acute purulent cervicitis or subacute cervicitis, acute and chronic pelvic inflammatory disease, sexually transmitted diseases, etc., without treatment;

2. Due to illness or trauma, it is impossible to place a bladder lithotomy position;

3. The general condition of the whole body is not good enough to tolerate surgery;

4. If the body temperature is above 37.5℃ twice before operation, the operation will be suspended.

Preoperative examination:

1. Ask for medical history. Medical history, menstrual history, marriage and childbearing history should be inquired in detail, and special attention should be paid to the history of menopause, early pregnancy reaction and previous abortion.

Detailed medical history collection is very important for doctors to evaluate the difficulty of operation, the key points of operation and reduce the complications of operation. Medical history should not be concealed to avoid unnecessary complications.

2. Physical examination. Take blood pressure, auscultate the heart and lungs, and perform electrocardiogram examination. Do gynecological examination, understand the position and size of uterus, determine the month of pregnancy, rule out the malformation of reproductive organs and determine the diagnosis of early pregnancy.

3. B-ultrasound examination. B-ultrasound can determine the position and size of embryo, exclude ectopic pregnancy, cesarean scar pregnancy, hydatidiform mole and other pathological pregnancy, and can improve the accuracy of operation, reduce injury and prevent residue. If the fetal sac is too small, it is easy to leak aspiration, so we should review the B-ultrasound one week later before deciding the timing of the operation.

4. Routine tests. Pregnancy test, routine hematuria check, evaluation of vaginal cleanliness, routine leucorrhea smear, secretion culture, excluding vaginitis, cervicitis, adnexitis and other common reproductive infectious diseases. If there is any abnormality, the infection should be treated before operation. Check hepatitis B surface antigen, HIV, RPR, HCV, etc.

Preoperative preparation

1. Subject preparation:

1) 5 days before operation;

2) Shower one day before operation, clean vulva on the day of operation, and bring necessary articles such as sanitary napkins;

3) On an empty stomach on the day of operation, you need to remove contact lenses, dentures, watches and ornaments, hard hair accessories, etc. It is forbidden to make up before operation, and valuables should not be brought into the operating room;

4) Change clean underwear before coming to the hospital;

5) Empty the bladder before operation.

2. Doctors prepare:

1) Before operation, the patient's medical history should be verified again, the test results should be checked, and the operator should be informed of the process of uterine aspiration and possible feelings. Surgery can generally be performed in outpatient operating room, but it is necessary to be admitted to hospital for surgery if it is complicated with high-risk factors;

2) Preoperative education;

3) The operating room shall prepare corresponding instruments, dressings and necessary medicines.

Surgical procedure

1.Operators should wear clean work clothes, hats and masks, wash their hands and wear sterile gloves;

2. Oral misoprostol can soften the cervix, reduce cervical injury, prevent cervical adhesion and reduce intraoperative bleeding.

3. The patient takes the lithotomy position of the bladder, routinely disinfects the vulva vagina and spreads sterile towels on the vulva;

4. Review the position, size and bilateral appendages of uterus in detail;

5. Expand the vagina with a speculum, detect the depth of the uterine cavity with a probe in the direction of the uterus, and gently expand the cervix with a pen-holding dilator.

6. Suck the uterine cavity to ensure that the gestational sac and surrounding tissues are clean.

Sign of suction net:

1) The rotation of the suction tube is limited, and the suction tube feels tight and astringent close to the uterine wall;

2) uterine cavity shrinkage1.5 ~ 2.0 cm;

3) The straw is taken out with only a small amount of bloody foam;

4) The uterine wall changes from rough to smooth;

5) Curettage can hear muscle sound.

8. After the uterine cavity is sucked clean, check whether there is active bleeding at the cervix, and wipe the vagina with gauze. If you need to place an intrauterine device at the same time, you can operate according to the routine;

9. Check whether the aspirate embryo and villi are complete, and measure the amount of bleeding.

1) Filter the aspirate, check the embryo and villi, and send it for pathological examination if abnormal conditions are found, such as no villi or vesicular structure of the aspirate. Measure the amount of bleeding;

2) If the gestational age is large, the fetal head, trunk and limbs should be checked.

10. Check the uterine contraction. If there is persistent vaginal bleeding after operation, it is necessary to find out the reason. You can use uterine contractions to strengthen the uterine contraction, and at the same time check whether there is any reproductive tract injury;

1 1. If there is no abnormality in the operation, you can remove the surgical instruments and help the patient to rest in the observation room;

Matters needing attention in operation

1. Correctly judge the size, shape and direction of the uterus, and detect whether the length of the uterus coincides with the month of menopause;

2. For the lactating uterus within one year after delivery, the operation should be particularly light. Because the uterine wall is thin and soft during pregnancy, breastfeeding makes the uterine wall softer and easy to be injured during operation. If prostaglandins such as misoprostol are not used before operation, oxytocin 10 unit can be injected into the cervix after cervical dilatation to promote uterine contraction, which is beneficial to surgery and prevent perforation. For those who repeat induced abortion in a short period of time, the same as above;

3. For the pregnant uterus after cesarean section, it is necessary to know the time, process, operation method, wound healing and infection of cesarean section, and be alert to cesarean scar pregnancy;

4. For the uterus that leans forward, bends backward and bends backward, the operation is more difficult, and it is easy to puncture and remain. We should operate carefully and try to correct the position of the uterus.

5. For patients with hysteromyoma or adenomyosis complicated with pregnancy, the shape of uterine cavity may be deformed and enlarged, and the pregnant tissue may be located behind hysteromyoma, and the suction tube is difficult to reach, resulting in leakage or residue. Therefore, extra care should be taken, and oxytocin should be used to strengthen uterine contraction before and during operation;

6. Abnormal uterine pregnancy needs to be determined, such as double uterus, double horn uterus, mediastinal uterus, etc., and two uterine cavities must be sucked clean, otherwise the postoperative bleeding time is long and it is easy to remain.

Postoperative treatment

1. Observe 1-2 hours after operation, and pay attention to bleeding and lower abdominal pain. Pay attention to rest and strengthen nutrition after leaving the hospital. After induced abortion, people should stay in bed for 2-3 days, and gradually increase the activity time to reduce the incidence of intrauterine hematocele. Don't engage in heavy physical labor and cold water labor for half a month after abortion to avoid cold. Pay attention to increasing nutrition, eat more protein-rich foods such as fish, meat, eggs and bean products and fresh vegetables rich in vitamins to promote the early repair of damaged intima;

2. Keep the vulva clean, and sexual intercourse and bath are forbidden within one month. After abortion, the uterine orifice has not been completely closed, and the endometrium has also undergone a process of repair. During this period, special attention should be paid to keeping the vulva clean and sanitary, and sanitary napkins and underwear used should be washed and changed frequently.

3. Observe the bleeding. Vaginal bleeding after abortion for more than a week, even accompanied by lower abdominal pain, fever, turbid leucorrhea and foul smell, you should go to the hospital for a follow-up visit in time.

4. Insist on contraception. After abortion, the functions of ovary and uterus gradually recover, and the ovary ovulates on schedule. If you don't insist on contraception, you will get pregnant again soon. Therefore, reliable contraceptive measures should be chosen as soon as possible after abortion. The World Health Organization has clearly pointed out that taking contraceptive measures immediately after abortion is of great significance for reducing the rate of repeated abortion and postoperative complications. It is suggested that both intrauterine devices and short-acting contraceptives should be placed simultaneously after abortion, and contraception should be adhered to, and abortion should not be regarded as a contraceptive measure.

Post-abortion standardized service (PAC) is a standardized service process including medical service for abortion complications, post-abortion family planning service, post-abortion counseling service, post-abortion community service and post-abortion reproductive health comprehensive service. It is of great help to reduce the rate of repeated abortion and increase women's reproductive health.

Complications of induced abortion

There are at least13 million induced abortions in China every year. Such a huge number, even if the incidence of complications is less than 1%, is also a large population. Experts in the field of family planning in China have made great efforts to reduce the rate of induced abortion and its complications, but a few people may have complications. Surgical complications can be divided into intraoperative complications and postoperative short-term complications and long-term complications.

Intraoperative complications

1) Intraoperative uterine bleeding: Intraoperative bleeding exceeding 200ml is called abortion bleeding. The pregnancy month is large and the cervical condition is poor, so the small fetal sac is peeled off slowly with the straw; Bleeding is easy to occur in cases of frequent induced abortions or lactation and poor uterine contraction. The remaining tissues should be removed quickly. If they are completely clean, uterine aspiration should be stopped, oxytocin should be applied, and the uterus should be massaged to strengthen uterine contraction. If there is a large amount of bleeding, it is necessary to open the vein to rehydrate and transfuse blood in time.

2) Induced abortion syndrome: Vagus nerve is excited due to stimulation of cervix and uterus during operation, during which the patient suffers from bradycardia, heart rate disorder, blood pressure drop, pallor, sweating, dizziness, nausea, vomiting, chest tightness and even syncope and convulsion. People who are nervous and afraid of surgery are more likely to happen.

The uterus is not only dominated by autonomic nerves (sympathetic nerves and parasympathetic nerves), but also rich in sensory nerves, and the nerve endings in the cervix are more sensitive. During induced abortion, nerve endings distributed in these areas are stimulated due to the traction and expansion of the cervix and the influence of negative pressure and straws on the uterine wall. The vast majority of patients can tolerate these mechanical stimuli in induced abortion through the self-regulation of the nervous system, but there are also a few people who release a lot of acetylcholine in their bodies due to the poor stability of autonomic nerves and the enhanced vagus nerve reflex, which leads to coronary artery spasm, weakened myocardial contractility and reduced cardiac output, thus resulting in the above-mentioned series of manifestations. At this time, after proper treatment, it will not pose a threat to the patient and leave no sequelae. Therefore, it is very important to fully relieve the patients' concerns before operation, operate gently during operation and apply drugs that can dilate the cervix before operation.

3) Uterine perforation: a rare complication. Perforation can be caused by probe, uterine dilator, pipette, curette, pipette or oval forceps. It is a full-thickness injury of uterine wall, which leads to the communication between uterine cavity and abdominal cavity or other organs. Uterine perforation is the most common in female reproductive tract instrument injury. The incidence of intrauterine infection is 0.05%-0.88%, which usually occurs at the junction of cervix and uterus in uterine isthmus or uterine horn. It can also penetrate into the broad ligament, posterior wall of bladder, intestinal loop and even pull out the omentum, resulting in internal bleeding, hematoma in the broad ligament and secondary peritonitis. It must be diagnosed and treated in time to avoid serious consequences.

Generally occurs in women with excessive uterine curvature, lactation and long-term use of contraceptives; Scared uterus after cesarean section, especially after infection; Double uterus and single cervix, often perforated at the bifurcation of uterus; Repeated cases of induced abortion or women with short interval between two abortions.

Danger signs of perforation: sudden severe abdominal pain, sweating or shock; The depth of the probe entering the uterine cavity is inconsistent with the size of the uterus examined by gestational age or pelvic cavity; When the uterus is enlarged, the resistance is large or suddenly becomes loose; Feeling frustrated or bottomless during the operation; During the operation, it was found that the instrument exceeded the original depth; Feel empty or slippery when sucking the uterus, but can't suck out the tissue; The position of uterus changed suddenly during operation; Aspiration or clamping of abnormal tissue; There are fixed pain points during operation, and the pain is aggravated during traction; Severe abdominal pain after operation with symptoms of peritoneal irritation.

Once the perforation occurs, stop the operation immediately. Make a comprehensive analysis according to the specific situation. Continue operation or conservative treatment under the supervision of B-ultrasound as appropriate 1 week before operation. When other organs in abdominal cavity are suspected to be damaged, laparotomy or laparoscopic exploration is needed, and curettage or repair will be performed under the supervision of B-ultrasound.

4) Missed aspiration or aspiration: It is called missed aspiration if it is confirmed as intrauterine pregnancy without aspiration of embryo and placental villi, so that the pregnancy continues to develop. It may be caused by excessive flexion or deformity of the uterus, too small fetal sac, and surgical errors. Therefore, induced abortion is not as early as possible. Suction refers to non-pregnancy and aspiration for pregnancy. We should be alert to ectopic pregnancy in cases of aspiration.

5) Amniotic fluid embolism: it mostly occurs in the curettage of pregnancy 10 weeks or more. Very rare.

2. Recent postoperative complications

1) Incomplete aspiration: It is a common complication, which means that some embryos or villi remain in the uterine cavity after induced abortion. Generally, attention should be paid to postoperative bleeding for more than 15 days or early pregnancy reaction. B-ultrasound and blood HCG are helpful for diagnosis, uterine curettage should be performed, and postoperative antibiotics should be used to prevent infection.

2) Infection: refers to the inflammation of reproductive organs within 2 weeks of induced abortion, which starts with endometritis. If the treatment is not timely, it can affect the myometrium, appendages, peritoneum and even septicemia. Most of them are caused by incomplete aspiration, long bleeding time or premature sexual intercourse, and can also be caused by incomplete treatment of the original lesions in the body or surgical infection.

Mostly manifested as lower abdominal pain, irregular bleeding, leucorrhea turbidity and elevated body temperature. Antibiotic treatment should be active.

3) Hematocrit in the uterine cavity: it mostly occurs in the forceps curettage with large gestational age or more than 10 weeks. After operation, the uterine contraction is poor, and it is difficult to discharge blood clots in the uterine cavity and accumulate in the uterine cavity.

The symptoms are abdominal pain, bleeding, enlarged uterus, great tension and obvious tenderness after operation. After the diagnosis, you need to suck the uterus twice immediately. Therefore, we should find the pregnancy in time and try to terminate it before 10 weeks. During the operation, it is necessary to dilate the cervix routinely, so as to prevent the cervix from being too tight after operation, which is not conducive to the blood flow out of the uterus.

4) Adhesion of cervical canal or uterine cavity: after induced abortion, amenorrhea or menstrual flow is obviously reduced, sometimes accompanied by periodic lower abdominal pain, artificial cycle treatment without menstruation, or uterus with increased hematocele, cervical or uterine cavity adhesion should be considered. Repeated induced abortion or curettage are more likely to occur, especially when accompanied by infection. If it is cervical adhesion, the old hematocele will be obviously improved after uterine dilatation. If it is intrauterine adhesion, it is necessary to separate the adhesion under hysteroscope, place intrauterine device after operation and take estrogen to prevent re-adhesion.

3. Long-term postoperative complications

1) menstrual disorder: due to surgical stimulation, the normal function of hypothalamus-pituitary-ovary is affected, resulting in abnormal ovulation. It may also be due to excessive damage to the intima, and adhesion is a decrease in menstrual flow. In severe cases, secondary infertility. Because of the etiological treatment, such as ovulation induction, menstruation regulation, adhesion separation and so on.

2) Chronic genital inflammation (chronic pelvic inflammatory disease): most of them are caused by not being treated thoroughly in time in the acute stage. Indications should be strictly controlled before operation, vagina, cervix and pelvic inflammatory disease should be thoroughly treated, disinfection should be strictly performed during operation, and antibiotics should be used after operation to prevent infection.

3) Secondary infertility: refers to those who are not pregnant within one year after induced abortion without contraception. Generally, it is caused by intimal injury, tubal inflammation and other reasons. At the same time, endometriosis and endocrine disorder after induced abortion are also one of the reasons.

4) Endometriosis: manifested as progressive dysmenorrhea, abnormal menstruation, menstrual abdominal pain, etc. Can cause secondary infertility.

5) The influence of second pregnancy and delivery: The endometrium of pregnant women with a history of induced abortion may be damaged or infected, which will affect the growth and development of pregnant eggs, resulting in high abortion rate, placenta adhesion and postpartum hemorrhage rate. The more times of induced abortion, the shorter the interval between induced abortion and second pregnancy, and the more complications.

6) Some patients have psychological problems, such as fear of sexual life and worries about future life.

The first pregnancy is very important for eugenics. Experts suggest that young women should try not to have induced abortion for the first pregnancy to avoid secondary infertility. If newlyweds have no plans to have children in the near future, they should adopt corresponding contraceptive measures. Once found pregnant, avoid blind abortion. In addition, if the mother's blood type is RH(-) and aborts an RH(+) embryo, it can also cause RH immune problems. When pregnant again, it can produce RH hemolysis reaction to RH(+) fetus. Newborn hemolysis caused by RH blood group disharmony generally occurs in the second pregnant baby, and induced abortion can promote the mother to produce RH antibody, so the next day, although it belongs to the first baby, neonatal hemolysis may also occur.

If you decide to have an abortion after careful consideration, it is recommended to go to the obstetrics and gynecology department of a regular hospital for surgery, because the incidence of complications is closely related to whether the operating room conditions meet the standards, whether the operator is strict in disinfection and other operations, and whether the technology is skilled.

It needs to be repeatedly emphasized that induced abortion is a remedy for contraceptive failure, and the most important thing is to take contraception to avoid and reduce induced abortion.

Attachment: Anesthesia and Analgesia Technique for Negative Pressure Hysterectomy

The so-called painless induced abortion.

indication

1. Those who voluntarily request anesthesia and analgesia to terminate pregnancy within 10 weeks;

2. Those who are unwilling to continue pregnancy due to certain diseases (including hereditary diseases) and voluntarily request anesthesia and analgesia to terminate pregnancy;

3. There are no contraindications for negative pressure suction hysteroscopy, anesthesia and general anesthesia;

4. American Society of Anesthesiologists (ASA) preoperative assessment criteria I-II.

Contraindications

1. The acute stage of various diseases;

2. Genital inflammation, which is treated;

3. Those who are in poor general health and cannot tolerate surgery and anesthesia;

4. Those who have contraindications to anesthesia (allergic constitution, allergic asthma, anesthetics and multiple drug allergies);

5. Those who did not fast or drink before operation;

6. The gestational age is greater than 10 weeks or it is estimated that the operation is difficult.

Preoperative preparation

1. Ask the medical history and anesthesia-related medical history in detail before operation for physical examination;

2. Before operation, the informed consent form of negative pressure uterine aspiration and anesthesia must be signed;

3. Before the operation, the subject fasted solid food (including milk) for 8 hours and forbidden to drink cool drinks for 4 hours;

4. Other induced abortion with negative pressure suction. Check the liver and kidney function when necessary.

5. Patients with any high-risk factors need to be hospitalized for the operation;

Surgical procedure

1. Steps of induced abortion with negative pressure suction;

2. Professional anesthesiologists perform anesthesia and monitor the whole process;

3. Continuously monitor the ECG, blood pressure, heart rate, respiration and oxygen saturation of the operator during the operation. Observe the operator's reaction to anesthetics closely. During the operation, it is necessary to inhale oxygen through the mask, keep the upper respiratory tract unobstructed, pay close attention to whether the respiratory tract is inhibited, and insert artificial airway and auxiliary breathing if necessary;

4. Prepare for cardiopulmonary resuscitation;

5. The anesthesiologist shall fill in the anesthesia record sheet as required.

Anesthesia methods and drug types

1. Intravenous anesthesia is recommended, but inhalation anesthesia is not recommended;

2. It is suggested that intravenous anesthetics should be combined with analgesic drugs or combined anesthesia with sedative and analgesic drugs;

3. Propofol is recommended for intravenous anesthetics;

4. Tramadol, midazolam and fentanyl are recommended as sedatives and analgesics;

5. Intravenous anesthetics, local anesthetics and sedatives shall comply with the relevant provisions and standards of the State Food and Drug Administration.

Postoperative treatment and matters needing attention

1. The anesthesiologist should monitor the patient until the directional force is restored and the Aldret improvement score reaches 9 or above, and then transfer him to the recovery room or observation room for further observation;

2. The full-time nurse will continue to observe for 2 hours. After determining that the operator is fully awake, can walk on his own, all vital signs are stable, and there is no nausea, vomiting and other obvious discomfort, the surgeon and anesthesiologist decide whether to leave the hospital or need to be hospitalized for observation;

3. The operator must be accompanied by his family to leave the hospital, and if there is any abnormality after operation, he should return to the hospital in an emergency; Do not ride a bike, drive a motor vehicle or engage in aerial work within 24 hours after operation;

4. With negative pressure suction induced abortion. [ 1]

Curettage

Where the pregnancy is 10- 13 weeks, it is required to terminate the pregnancy or it is not suitable for pregnancy due to special circumstances such as illness or other abortion methods. Generally, the pregnancy is terminated by the surgical method of combining forceps and negative pressure suction, and the range of forceps curettage is generally within 14 weeks. In recent years, due to the clinical application of mifepristone and prostaglandin, forceps curettage has gradually been replaced by drug induced labor.

indication

1. Anyone who is pregnant for10-13 weeks requires termination of pregnancy or is not suitable for pregnancy due to special circumstances such as illness;

2. Failure of other abortion methods.

Contraindications

1. The acute stage of various diseases;

2. Inflammation of reproductive organs, such as vaginitis, acute suppurative cervicitis or subacute cervicitis, acute and chronic pelvic inflammatory disease, sexually transmitted diseases, etc., are treated before surgery;

3. If the general condition of the whole body is not good enough for surgery, after treatment, hospitalization can be considered;

4. The body temperature was above 37.5℃ twice before operation.

Preoperative examination

Same negative pressure aspiration

Preoperative preparation

Must be admitted to hospital for surgery, with the preoperative preparation of negative pressure aspiration.

Cervical preparation should be carried out according to the situation: before operation, the cervix should be dilated with prostaglandin and a disposable cervical dilator should be placed; 4- 16 hours before operation, a sterile catheter or small water sac was placed in the uterine cavity, and it was taken out before operation to promote the relaxation of the cervical orifice.

Surgical procedure

1. The basic operation steps are the same as negative pressure suction induced abortion;

2. Fully dilate the cervix, so that the placenta clamp can pass through the cervical internal orifice smoothly, which can reduce the sequelae of the cervical internal orifice injury;

3. Broken fetal membranes. Rupture of fetal membrane by suction tube or oval forceps, and then curettage after amniotic fluid slowly flows out, so as to be alert to amniotic fluid embolism and intrapartum bleeding;

4. Clamp the placenta and fetus. Use oval pliers to slowly enter the cervical canal, and after passing through the inner mouth, find the attachment part of the placenta, and clamp out the placenta and fetus. The limbs of the fetus should be pieced together completely.

5. Clean the uterine cavity. After the fetal placenta is basically clean, suck the uterus with a straw at a lower pressure. If there is no tissue scraped out and no bleeding, measure the size of the uterine cavity again and check that there is no damage, and then end the operation. We should check again whether the placenta and fetus are in line with the pregnancy month, whether the fetus is intact and observe the uterine contraction and bleeding.

Postoperative treatment

Induced abortion with negative pressure suction

You can refer to Baidu Encyclopedia's "Abortion"