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MRCOG PART 2 SBAs and EMQs

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Essay 335 - Surgical Practice

Posted by sonu P.
S

a)The surgical risks are bleeding, infection, cervical trauma, incomplete evacuation, uterine perforation, intrauterine synecheae rhesus isoimmunisation, thromboembolism and anesthetic risks. The procedure should be performed by adequately trained professional or directly supervised. In nulliparous patients, a preoperative use of prostaglandin analogues like gemeprost or misoprostol could minimize the risk of cervical trauma.
Preoperative assessment of Chlamydia risk and triple swab or empirically offering antibiotic prophylaxis if results are not available would reduce the chances of post-op infection and long term sequelae of PID and subfertility. A FBC and group/save sample is send to the laboratory. Intraoperatively, aseptic precautions should be taken; Intermittent pneumatic calf compression applied for thromboprophylaxis;a speculum examination to see if os is open or closed and if any POCs at the os;vaginal examination to confirm the size and position of uterus. Suction evacuation should be done instead of curettage. As is it a blind procedure,all instrument should be cautiously guided by the fingers according to the size of uterus because sounding of pregnant uterus is not advisable.A gentle curettage to check for the empty cavity with a blunt curette in the end is acceptable. A gritty feeling, gripping of cannula by the closing cervix and air bubbles indicate the completion of procedure.The valsellum should be removed with caution under vision and cervix should be observed for any bleeding. Anti-D injection 250IU is given if rhesus negative.

b) I will stop the procedure immediately and inform the anesthetist of possible perforation and prolongation of surgery. I will inform the consultant on call and arrange for blood to be cross matched. I will also alert the surgical colleague of a possibility of us needing there help and I will ask the theater staff to keep the laparoscopy equipment ready.I will request one of the theater staff to get the ultrasound machine ready.I will inform the consultant of a brief history of the patient abot parity and indication of ERPC; of what exactly happened; what instrument and size of instrument was involved and what was the reason of the suspicion of perforation; I will also tell him estimated blood loss till now. If I thought that the procedure was almost complete and patient is not bleeding, and there is no signof bowel damage, expectant management could be an option. If there are products left in the uterus,the procedure could be completed cautiously under USS guidance and patient observed for 24hrs.If a large diameter instrument like >no. 7 cannula/dilator or ovum forceps was involved; patient is showing signs of internal or external bleedin;,there is suspicion of bowel damage; laparoscopy is indicated and help from surgical colleague should be sought to diagnose and repair possible bowel damage.
Posted by GULSHAN R.
Interventions to minimise the surgical risk of evacuation of retain product of conceptions involve councelling & assesment of the patient.
Patient\'s psychological condition should be stable.If possible partner & family should be involve with her consent.
She should be couselled about the risk of the procedure such as-bleeding,perforation,infection and need for laparotomy.But she should be assure that chance of complications are rare and proper intervention should be taken.For this meticulous history, examination,investigations should be done.
HISTORY:
Menstrual history & LMP--to correlate gestation
Sexual history-duration of sexually active,number of partner,any contraceptive such as barrier method used or not.
History of any sexually transmited infection which may flare up during the procedure.
History of p/v/b and its amount.
Medical history-Diabetes melitus, hypertention,SLE,any bleeding disorder
Surgical history-any previous surgery on uterus may cause perforation.

EXAMINATION:
anaemia-if present optimize or keep blood ready .
Pulse, blood pressure-to see general condition.
features of infection-temperature, foul smelling p/v/b,abdominal tenderness.
P/A/E:size of uterus,any mass
P/V/E:bleeding present or not, any foul smell,any product hanging or not.

INVESTIGATIONS:
FBC:to see Hb%, any leucocytosis
Blood group and saving
CXR,Blood sugar for G/A fitness
HIGH VAGINAL AND ENDOCERVICAL SWAB-for screening infections-Chlamydia & Gonorrhoea.

Prophylactic antibiotic should be given before the procedure to minimize consequence of silent infection.
Blood should be saved if the patient is anaemic & as a precaution if excessive bleeding occur.
Experience surgeon & anaesthetist should invove in the procedure.
Antibiotic should be prescribe post operatively.
Post operative monitoring is important.
Contraceptive advice & councelling.
Arrange a follow up visit before discharge.

(b)During procedure if i suspect perforation-
I will stop the procedure immediately
Note by which instrument i perforate.If perforation is don by suction -chance of bowel injury is more & laparotomy is indicated.
Note how much product remove.
Observe p/v/b
Examine the patients vital signs-pulse ,BP, temperature
Establish two i.v channel.
Inform senior gynaecologist,anaesthetist and OT staff.
Arrange group and saving if not done preoperatively.
If perforation done by small instrument-
Arrange for laparoscopy and remove the product if present & repair under direct vision.
If perforatoin done by suction-
Laparotomy done by midline incision, thorough inspection of bowel and repair should be done.
If possible call senior surgery consultant and repair bowel by him or in presence of him.
Monitor the patient carefully-pulse ,BP, temperature,bowel sound,features of peritonitis ,urine out put.
Posted by Syamala H.
ansA:
preoperative intervention to minimise surgical risk would include elicit history of previous uterine surgery like cesarean section ,myomectomy which increases therisk of uterine perforation.history of previous surgical abortion and cervical surgery like LLETZ which increases the chances of cervical fibrosis andlead to difficulty in dialatationand such cases can be particularly benefitted by preop cervical preperation.h/o reccurent second trimester abortion should be taken as it may be suggestive of uterine anamoly if positive should be confirmed by ultrasound. ask for any previous history of fibriod,endometriosis or pelvic inflammatory disease.any signs of sepsis if present either genital tract or urinary tract should be treated before the surgery is undertaken. BMIand blood pressure should be checked.pelvic examination for size,posiotion of uterus and condition of cervix.all patients should be screened for lower genital infection before undertaking surgery and positive cases should be treated.in absence of infectious screen women should recieve antibiotic prophylaxis in form of tab azithromycin 1 gm on the day of surgery with metronidazole 1 gm rectal at time of surgery. or she can be prescribed tab doxycycline 100mg bid for 7 days from the day of surgeryalong with metronidazole 1gm..preoperative evaluation by anesthetist and discussion of type of anesthesia. General aneathesia is associated with more complication. evacuation under local anesthesia or conscious sedation offered where expertise is available. preoperative preperation of cervix by misoprostol 400ugm 3 hours before surgery avoids trauma to cervix due to forceful dialatation.in patients where misoprostol is contraindicated can be offered laminaria tent.
during surgery bladder should be evacuated and examination under anesthesia to see the size of uterus it position should be confirmed acutely retroverted or anteverted uterus are associated with increased chances of perforation.high risk condition like morbid obesity and multiple previous surgery can have evacuation done under ultrasound guidance. suction evacuation should be done to empty cavity and sharp curretage should be avoided.care and vigilance is required while using dialator and suction cannula. oxytocin infusion helps reduce the amount of bleeding.checking for completion of procedure by signs like grating sensation on all walls presence of air bubbles and minimal bleeding. if any doubts ultrasound should be used.tissue should be send for histopathology to rule out molar pregnancy.
postoperatively antiD for Rh negative patients.observe for signs of excessive bleeding, pain and fever.early recognition and managnent of complication to aviod undue morbidity.
ansB:
if there is suspicion of uterine perforation senior obstetrician should be called for help.confirmation of perforation can be done either by ultrasound or by laproscopy. managment will depend on whether the uterine evacuation is complete or incomplete. also if there is suspected bowel or omental injury. if ultrasound confirms perforation which in small not having hematoma and no suspicion of viceral injury patient can be managed conservatively with antibiotics and close in patient observation.if no facility of ultrasoundor laproscopy erect X-RAY can show gas underdiaphragm. other wise patient should be taken for laproscopy after obtaining consent and surgoen should be notified as there input would be required for repair of bowel injury. if uterine cavity not empty evacuation should be completed vaginaly under laproscopic guidance. if perforation site bleeding hemostatic sutures should be applied.if suspected bowel or omental injury patient needs laprotomy and exploration and repair by surgical team(chances of bowel or omental injury is more likely with suction cannula than dialator as negative pressure will pull the vicera in). if there is a false cervical passage and uterus cannot be emptied by vaginal route hystrotomy would be required to empty uterus .family should be kept fully informed. she should be started on broad spectrum antibiotic to prevent peritonitis.incident form should be filled. counselling regarding contraception and future pregnancy outcome should be done depending on the procedure carried out.discharge letter containing details of the procedure shoud be given and GP should be informed.
Posted by H H.
A healthy 19 year old woman presents for dating scan at 12 weeks gestation. Ultrasound scan confirms a missed miscarriage and evacuation of retained products of conception is planned.
(a) Discuss your interventions to minimise the surgical risks [10 mar

(a) As she is under 25 years (high risk for STI), I would do endocervical swabs for gonorrhea and Chlamydia . I would cover the procedure with antibiotic prophylaxis according to local protocols(Azithromycin 1 gm + netronidazole rectal sup 1gm pre operative). I would apply prostaglandin vaginal tablet 3 hours before the procedure as this would make the cervix soft and easy to dilate.I would ask the woman to evacuate her bladder before the procedure. In UK the usual practice is to do it under general anesthesia (GA) ,but it can be done under local anesthesia to avoid problems of GA. I would sterilize the area with antiseptic solution and do a bimanual examination to check the anatomy before dilating the cervix which I would do gradually with the dilators and not to over do it to avoid tearing of cervix. I will do suction evacuation using a plastic suction curette and avoid using sharp curette afterward. I would ensure all products of conception are removed to avoid post operative bleeding and infection. I should have been trained well in doing this procedure and in case of doubt about its difficulty ,would ask the supervision of consultant. I should be able to suspect perforation and a laparoscopy set should be in hand in case it happened.

(b) During the operation, you suspect that you have perforated the uterus. Discuss and justify your intra-operative management [10 marks].

Perforation of uterus is a serious condition and associated with increased mortality and morbidity if not diagnosed early and treated. If I suspect a perforation( instruments going up without experiencing resistance , vaginal bleeding, bowel material, omentum )I would stop the procedure . I would inform the anesthetist that the procedure will take a longer time so as to put an endotracheal tube, ask him also to get blood for FBC, and cross match if severe bleeding and to apply two wide bored canulas. I would start broad spectrum antibiotics intravenously( cephalosporins). I would ask for help from my consultant, hematologist , and surgical team if suspect bowel injury. I would do a diagnostic laparoscopy to assess the degree of perforation and injury to bowel. Should the perforation look small with minimal bleeding, I would complete the procedure of evacuation under direct vision and follow the patient consevativelly. Should the perforation look large or if there is bowel injury a laparotomy is done. If the surgeon is an expert laparoscopist ,many procedures as suturing a perforation in uterus or small intestinal injury, can be done with out need for laparotomy.
If the damage to uterus is too severe or there is uncontrollable bleeding ,a hysterectomy might be needed.
A colostomy might be needed after repair of bowel.
Posted by Chitra.s M.
A.Surgical uterine evacuation can be associated with serious complications like uterine perforation,intra abdominal trauma and haemorrhage. Preoperative screening for chlamydia trachomatis is done as infection is associated with increased risk of pelvic inflammatory disease and testing allows for appropriate antibiotic treatment.Perioperative antibiotics are considered pending screening results.Cervical priming with prostaglandins is done preoperatively as it is associated with reduction in cervical dilatation force,trauma and haemorrhage.Use of local anaesthesia/sedation for the procedure can be considered if acceptable to the woman as the risks associated with general anesthesia are avoided.The procedure is carried out by an experienced surgeon or trainees under supervision.Aseptic precautions are followed.Vaginal examination is performed to assess the size and position of uterus prior to evacuation .It is ensured that the bladder is empty.Sounding of uterus is avoided as it may lead to uterine perforation.Undue force should not be used for cervical dilatation as it can cause cervical trauma.Suction curettage of products of conception should be done as it is associated with lower blood loss .Use of curette should be avoided.Oxytocin infusion can be considered as blood loss is decreased with its use.Anti D 250IU im is given postoperatively if the woman is Rh negative.
B.The procedure is stopped until assessment of the clinical situation.Anaesthetist and theatre staff are alerted to the possibilty of additional procedures -laparoscopy/laparotomy .Consultant obstetrician is alerted .Blood is sent for grouping and cross matching as perforation can be associated with haemorrhage and need for blood transfusion.The instrument with which the the uterus is possibly perforated is noted as perforation with larger instruments( large dilators/suction curette) is associated with increased likelihood of uterine/visceral injury.Laparoscopy is done to assess possible uterine/visceral injury .If the uterine evacuation is incomplete it is completed under laparoscopic control. No intervention is reqired if there is a small uterine perforation and no active bleed as it heals spontaneously.The woman is managed by observation and antibiotics.Involvement of senior obstetrician is necessary in the presence of large uterine perforation and /or active bleed for repair and procedure completion.Involvement of surgical team is required if bowel/omental injury is identified.Small perforations may be dealt with laparoscopic repair.Large perforations may reqiure laparotomy for repair and possible colostomy depending on the site and extent of injury.Broad spectrum intravenous antibiotics like cephalosporins are given to minimise risk of infection.The woman\'s family is kept informed.
Posted by L S.
LS:
(a) Discuss your interventions to minimise the surgical risks [10 marks].
Surgical risks are bleeding, infection, uterine perforation, cervical trauma, anaesthetic risk and risk of deep vein thrombosis and pulmonary embolism. I would ask from her history if she has had any previous similar procedure, any previous procedure to her cervix like cone biopsy or any surgery to her uterus like previous caesarean section and if any did she have any complications. Her personal or family history of bleeding disorders asked. Her blood group if known is enquired. Her allergies and social history on smoking and sexual history on risk of sexually transmitted infection sensitively explored. I will check her body mass index (BMI) and document her blood pressure. Her haemoglobin concentration is checked and her ABO blood group and rhesus status with screening for red cell antibodies are checked. I will consider other test if there is a risk from her history for conditions like hemoglobinopathies, HIV and hepatitis B or C. I would offer her screening for Chlamydia prior to evacuation so that prophylactic antibiotic can be given prior to surgery and referral to GUM can be instituted for further care. A careful technique with use of soft plastic suction canula and cervical priming with prostaglandins and supervision by more experienced senior colleague during the procedure will reduce the risk of uterine perforation. If her BMI is more than 30, I would ensure she is adequately hydrated, mobilised early and consider using intermittent pneumatic calf pressure during procedure. If she is found to be rhesus negative then post operative anti-D immunoglobulin should be offered for prevention of sensitisation.

(b) During the operation, you suspect that you have perforated the uterus. Discuss and justify your intra-operative management [10 marks]
This is an emergency and I would aim to monitor the patient’s general condition, achieve hemostasis to complete the evacuation of the uterus and ensure that neighbouring organs are not injured. I would stop the procedure and inform the anaesthetist about my suspicion and ask to inform if patients general condition is unstable. Her blood should be taken for full blood count and crossmatching. I will call my senior gynaecologist for help. I will watch for bleeding and inspect the vagina and cervix for any concomitant injury. I would carry out an ultrasound-guided evacuation of the uterus as any remnant products of conception are foci of infection and continuos bleeding. A diagnostic laparoscopy is mandatory to confirm suspicion and to inspect nearby organs. If perforation is not actively bleeding it can be managed conservatively with prophylactic antibiotics and oxytocics. The patient should be observed for 24-48 hours post operatively signs of internal bleeding or undiagnosed bowel injury. If there is a moderate bleeding from the perforation site, it may be controlled by pressure, laparoscopic diathermy or laparoscopic suturing but this depends on experience of the surgeon. Usually in such situation a laparotomy and hemostatic suturing is performed. A massive bleeding due to a large perforation may require hysterectomy to save patient’s life. This decision must be taken by the senior members of the multidisciplinary team. The nearby organs, bladder and bowel should be inspected and if any injury found should be dealt with by the surgeon or urologist.
Posted by A- N.
AA.
A) Risks are minimised by adequate preparation of patient prior to surgery, approriate counselling and good surgial skills.
Prior to procedure consent should be taken including explaination of the procedure, risks of procedure. additional intervention if required and counciling regarding the other less invasive procedures available including medical and conservative management.
A full blood count taken to check for anaemia and requesting for blood group and save.
The procedure should be done by an adequately trined person or is to be supervised by senior person.
The procedure is to be preferably done in day hours in a dedecated theatre session when help is available as required.
Cervical priming prior to procedure will help in decreasing cervical injury also helps in easy dialation thus reducing risks of perforation during forceful dialation.
Examination under anaesthesia to check uterine size, position to reduce the risk of perforation.
Uterine sounding is to be avoided as this will increase the risk of perforation.
suction evacuation is the best method for uterine evacuation, sharp curratage is not to be used as it increases the risk of injury.
If required blunt curratage will help in confirming if cavity is empty.
If perforation is suspected then the procedure should be stopped and senior advise is sought.
Use of syntocinon as a bolous after dialation and when suction evacuation is started will help in contracting the uterus and reducing bleeding and risk of perforation.
Screening for STI\'s prior to procedure will reduce risk of infection.
Use of ultrasound in difficult cases will reduce risk risk of perforation and completing the procedure.
Anaesthetic risks can be decreased by keeping the patient nil orally, this will help in reducing aspiration pneumonitis.
Anti D should be given to Rhesis Negative women to prevent Rh isoimmunisation.
B)
Once I suspect the perforation I will stop the procedure immediatly to prevent further damage.
This is an emergency situitation. I will inform anaesthetist about suspected perforation immediately as further procedure like laparoscopy may be required and procedure may be prolonged.
I will not remove the instrument that probabaly perforated as at laparoscopy if required thios will help in identifing the site of perforation and extent of injury.
I will inform my consultant immediately for help and if the perforation is by a large dialator, suction canulae or sharp curette I will prepare for laparoscopy to check site and extent of injury.
If I suspect bowel injury or confirm it at laparoscopy I will seek help from surgical team for further laparotomy and bowel repair.
If the perforation is with a small and blunt instrument as small dialator, the patient is not bleeding, the procedure is stopped and conservative management with antibiotics and observation as inpatient for suspected bowel injury is done, the procedure is completed at a later date.
If patient is bleeding, laparoscopy is done and procedure is completed under laparoscopic guidence.
Post operatively analgesia and antibiotic cover will help in reducing morbidity with early mobilisation and reducing infection.
I will debrief the patient and fill incident form for risk management.
I will do a detailed documentation in the notes.
I will also discuss with her regarding the prognosis for future pregnacies and delivery depending on site and extent of injury.

Posted by R v P.
RVP

A healthy 19 year old woman presents for dating scan at 12 weeks gestation. Ultrasound scan confirms a missed miscarriage and evacuation of retained products of conception is planned. (a) Discuss your interventions to minimise the surgical risks [10 marks].
Her parity, previous ERPOC, surgical TOP or presence of bleeding will help to decide if she needs cervical preparation with prostaglandins. known allergise to latex or skin preparations such as Chlorhexadine will help to avoid them during surgery.
Her BMI should be checked as raised BMI is associated with both Surgical and anaesthetic risks.
Her Haemoglobin level should be checked to exclude anaemia and as a baseline investigation. Blood should be grouped and saved in case of bleeding during surgery. Her Rhesus status should be checked to offer Anti D to prevent sensitisation.
The procedure should be explained to the patient and written consent obtained. Cervical preparation with Prostaglandins should be considered pre op according to the unit protocol to minimise cervical trauma.
Procedure should only be undertaken by a practitioner who\'s competancy has been objectively assessed.
Aseptic procedure including scrubbing, skin preparation and draping should be done to minimise risk of infection. Clamydia swabs should be considered prior to uterine instrumentation as she falls under high risk category due to her age. Antibiotics should be given according to hospital policy if clamydia is suspected. However RCOG does not recommend routine antibiotic prophylaxis in ERPOC as no evidence exist it reduces post op infections.
EUA should be undertaken to determine the axis and size of the uterus. Hegar dilators should be used gently and in line of the axis of the uterus to prevent cervical trauma and perforation. Routine uterine sounding is usually avoided to prevent perforation.
Suction curette is preferred to metal curette as it reduces the risk of perforation. Repeated and over vigorous curetting should be avoided to reduce the risk of perforation and development of ashermans syndrome.
No evidence exist about the efficacy of prophylactic usage of oxytocics to reduce clinically significant bleeding in ERPOC.



(b) During the operation, you suspect that you have perforated the uterus. Discuss and justify your intra-operative management [10 marks].


Procedure should be immidiatly stopped to prevent further damage. Consultant on called should be urgently called to theatre to attend to plan further investigation and treatment. Anaesthetist should be informed about the suspected perforation. This is due to the likely need to prolong anaesthesia and also to be vigilant about signs of shock in case of concealed intra abdominal bleeding.
The tip of the curette should be checked for faeces or bowel content that will indicate bowel perforation.
If the patient is bleeding, Fluid resuscitation should be instituted. Blood should be urgently crossmatched or O neg blood should be ordered in case of delay. Baseline clotting liver and renal function with repeat Hb should be assessed in case of significant bleeding.
Broadspectrum IV antibiotics should be considered to minimise the risk of infection.
Bi manual compression, Ergometrine and/or Hemabate should be tried to stop the bleeding.
Laparoscopy is indicated in case of continued bleeding to assess the damage or in the case of suspected bowel injury. Surgical team should be called in the case of bowel injury. Laparotomy is the most expedite way if the patient is unstable due to haemorrhage or bowel surgery is required.
Hysterectomy should be considered if the bleeding is intractable as a life saving measure.
Posted by A A.
AA (SA)
a) To minimize risks, pre operative mearures like confirmation of her blood group & rhesus status with anti D(post operative) if Rh Negative, can reduce risk of iso immunization. Genital swabs for Chlamydia trachomatis, & other infection (if clinically indicated) offer antibiotic prophylaxis to reduce risk of infection & long term effects like PID .Use Cervical priming with prostaglandins / mifepristone to reduce risk of forced cervical dilatation leading to hemorrhage, cervical or uterine trauma . .Ensure consent form is completed & adequate verbal& written information is given to patient.
Procedure can be performed under local anesthesia or sedation to avoid General anesthesia risks ,but rarely done in UK. Intra operatively,to reduce infection risk, adequate hygiene measures in the operating theatre and aseptic technique should be followed. I would perform bimanual examination to check uterine size, position to reduce the risk of perforation. Uterine sound should be avoided .Vacuum aspiration is preferable to sharp curettage as it is associated with less pain, blood loss, perforation risk and shorter duration of procedure. Use of Oxytocin in case of heavy blood loss .I would ensure empty uterus at the end as retained products can lead to infection & bleeding. Senior help & laparoscopy if perforation is suspected. Send tissue for histopathology to exclude ectopic & gestational trophoblastic disease. Complete documentation of procedure.Intra operative elastic compression socking with post op. early mobilization can reduce risk of thrombosis.
b) This is an emergency situation associated with significant morbidity & mortality if not managed effectively. I would stop the procedure immediately as further suction can increase the extent of perforation & injury . Call for senior gynaecologist help & inform anaesthetist and theatre staff regarding possible need for general anesthesia & instruments for diagnostic laproscopy. Blood samples send for full blood count & cross match, as blood transfusion( BT)may be needed if heavy bleeding. Continous monitoring for BP, pulse, oxygen saturation amount of blood loss.
Diagnostic laprotomy is mandatory when senior help arrives, to confirm diagnosis & see the extent of perforation & any vascular/ visceral injury .If the uterine evacuation is incomplete it should be completed under laparoscopic vision as any retained product can lead to post operation bleeding & infection. No intervention is reqired if there is a small uterine perforation ,no additional injury and no active bleed as it can heals spontaneously .If there is active bleeding but a small perforation , it can be managed by laproscopic suturing/ diathermy. Large perforations may reqiure laparotomy for repair & hemostasis . Surgical help should be sought if visceral/vascular injury is suspected so that appropriate surgery can be undertaken. Broad spectrum intravenous antibiotics are given to minimise risk of infection. BT if indicated clinically. The woman\'s family should be kept informed. I would ensure full documentation of events & post operative care plan at the end.
Posted by zara A.
A]The risks associated with surgical evacuation are trauma to cervix ,uterine perforation, genital tract infection,incomplete evacuation ,haemmorhage.The pelvic infection can be reduced by screen and treat policy the chlamydia infection confirmed by NAAT and offer metronidazole 1gm rectally at time of surgery,screening for other genital infections bacterial vaginosis and gonorrhea depend upon risk factors . Aseptic and antiseptic technique employed during surgery reduces risk of infectionPriming with prostaglandins which reduces the force of dialatation trauma to cervix and uterine trauma and haemorrhage.Surgical evacuation performed by experienced surgeon or under supervision if performed by traines .HIGH risk patient for perforation are patient with anamolous uterus ,stenosed cervix [previous cone biopsy] evacuation should be performed by experienced surgeon.Suction currettage should be used for evacuation.EUA should be done toassess anatomy of uterus anteverted or retroverted .local anaesthesia or sedation used for evacuation.G ood technique is essetial to avoid trauma to genital organs and to to prevent incomplete evacuation .Administration of syntocinon associated with statistical significant reduced blood loss.B] THE emergency should be managed promptly stop procedure off suction.CALL consultant and inform the anaesthetist ask the patient vitals ,ask to secure iv line with 14 guage canula ,send blood group and crossmatch according to bleeding and FBC start resuscitationwith fluids .If heavy bleeding then notify blood bank.Ask theatre staff to prepare FOr laproscopy /laparotomy.Ask nurse to cathetrise patient .Need to confirm the perforation with invole ment of senior gynaecologist if instruments are inserted fully with out resistence .in worse case bowel is seen. FURther manage ment depends on haemodynamic statusof patient ,whether evacuation completed ,the instrument from which perforation occured. L aproscopy is mandatory if patient bleeding heavily,to confirm injury to surrounding visceras ,to achieve haemostasis and evacuation completed under direct vision.IF perforation not actively bleeding then expectant management with observation and antibiotic and syntocinonadministration .MOderate bleeding controlled by diathermy or suturing IF bleedingnotcontrolled large perforation need laparotomy and haemoststic suturing.HYSTerctomy is last option if bleeding not controlled taken descion by consultant to save life of patientIF injury to surroundig visceras bowel ,bladder involve surgeon and urologist to undertake repair.Intraoperative antibiotics given .Documetation done.
Posted by Bee N.
A healthy 19 year old woman presents for dating scan at 12 weeks gestation. Ultrasound scan confirms a missed miscarriage and evacuation of retained products of conception is planned. (a) Discuss your interventions to minimise the surgical risks [10 marks]. (b) During the operation, you suspect that you have perforated the uterus. Discuss and justify your intra-operative management [10 marks].

A)Surgical risks include bleeding, perforation of uterus, injury to cervix, infection, venous thromboembolism and aneasthetic complications.
Before such patients are operated upon, careful history to ascertain risk for thromboembolism is taken. Evacuation is usually a short procedure but history is necessary as unforseen complications may lead to unforseen prolongation of surgery. Thromboprophylaxis is considered if patient is high risk. History will also ascertain if patient has had previous reaction to general anaesthesia in which case it will be better to avoid it. Patients can be given prostaglandin F2 alpha 2 hours before the procedure. this will help soften the cervix and make it easier to dilate and therefore reduce risk of injury to stenosed cervix. Patient should be screened for chlamydia pre operatively and if this isnt done, a dose of azithromycin 1g IM should be given in theatre. Blood should be taken for FBC and group and save. This will ensure we are not operating on a severely anaemic patient who has risk of further bleeding intra operatively. A group and save will make blood ready in case transfusion is needed to treat anemia as a result of intra operative bleeding. Intra operatively, 5IU of oxytocin can be given to help control bleeding due to atony. Complete evacuation is suspected when the bubble sign is noted. I would endeavour to notice this sign to avoid incomplete evacuation which would further compromise blood volume. Avoidance if possible of sharp instruments like uterine sounds and tiny dilators or small sharp curettage. Cervix should therefore be adequately dilated to avoid the necessity of using only sharp instruments that would pass through the cervix. The uterus should be palpated bimanually before commencing surgery to have an idea of the size before instrumentation.
The surgeon operating should be competent and senior colleague competent in laparoscopy/laparotomy should be readily available in case of complications arising. Instruments used should be sterile to reduce infection. Depending on patients choice, other mode of management of missed miscarriage such as conservative or medical management can be considered. However patient should be informed that if bleeding becomes heavy or miscarriage incomplete after such options, surgical management may still need to be considered.


B)If during the procedure I think I have perforated the uterus, I will stop the procedure immediately. I will inform the anaesthetist and consultant gynaecologist about my suspicion. I will inform them of why I think the uterus is perforated and take note of the instruments used which may have caused the perforation. I will arrange for cross match of 2-4 units of blood as bleeding can be heavy from injury and repair and commence antibiotics such as metronidazole and an intravenous cephalosporin if not already given to cover anaerobes.
If I think the operation has been completed and bleeding is not severe and no sign of bowel injury, I will give patient ergometrine 0.5mg IV while monitoring BP, pulse and o2 saturation continuously for 2 hours. This can be done as conservative management as most of perforations can be managed as such. If bleeding does not cease or patient appears to deteriorate, surgeons will be informed and a midline laparotomy will be performed with a view to securing hemostasis and to thoroughly inspect bowel for damage.
If I think evacuation has not been completed, together with a colleague I will initially perform a diagnostic laparoscopy after catheterisation and under direct vision of the uterus by laparoscopist, evacuation will be completed. It may be difficult to fully inspect the bowels laparoscopically. Midline Laparotomy will be performed if bleeding cant be controlled laparoscopically or if bowel or any other visceral injury is suspected. Blood in catheter will raise suspicion of bladder injury.
Patient should be trasferred to high dependency unit if laparotomy was performed. BP, pulse and oxygen sat should be monitored every 15 minutes for at list the first 12 hours. Patient should stay in hospital overnight if perforation is suspected for observation and kept on IV fliuds and nil by mouth. This is necessary because features of bowel injury may present late even if not initially detected amd even when detected and repaired, immediate oral feeding is not adviced.
All procedures and findings should be clearly documented. Clinical incident form should be filled.
Posted by leelavathi C.
Surgical risks associated with evacuation of retained products of conception are serious risks like uterine perforation, cervical trauma, frequent risks like bleeding, need for repeat evacuation, localized pelvic infection. Women should be assessed for any additional risk factors like previous surgeries, obesity. And take a informed consent by explaining the patient that above risk is increased. Preoperative testing for Chlamydia and treatment in case of positive serology reduces risk of PID. Blood should be sent for FBS,group&save.vaginal examination should be performed for uterine size and position prior to evacuation to reduce the risk of perforation. If patient is nulliparous cervix might be unfavorable and need extra force to dilate cervix. So pre operative use of prostaglandin reduces the risk of cervical trauma,and hemorrhage. Suction evacuation is preferable than curettage to reduce risk of injury. If curettage necessary, usage of blunt curettage reduces the risk of trauma to uterine wall . syntocinon infusion during the procedure helps the uterus to contract and reduces the risk of bleeding, and uterine perforation. Antibiotic prophylaxis reduces risk of infection. Early detection of complications and intervention reduces the further morbidity and mortality.
B) Early detection of uterine perforation and treatment reduces the maternal morbidity and mortality. Once uterine perforation suspected stop the procedure to prevent further trauma. Inform anesthetist that suspecting uterine perforation and procedure might be prolonged. Inform theater staff and alert them to the possibility of laparoscopy/laparotomy. call consultant on call and explain about procedure and reasons of suspicion. Call laboratory for urgent group &crossmatch.further management depends on clinical signs of uterine perforation. If there is no active bleeding and not suspicious of bowel injury manage conservatively by antibiotics and observation for 24-48 hours for clinical signs of bowel injury. If any active bleedin e involved.document the detailes of procedure in case notes. Fill the incident form for clinical risk management
Posted by Ir A.

Ir
a) I will order a blood group and Rh antigen status and full blood count for this patient. A thorough history should be taken to assess risk of sexually transmitted diseases. The patient should sign an informed consent after discussing involved risks.
The patient should be instructed to fast overnight to decrease the risk of aspiration of gastric contents during general anaesthesia. Preoperative cervical preparation with 400 micrograms oral or vaginal misoprostol taken 3 hours prior to surgery decreases the risk of uterine perforation. Prior to induction of anaesthesia, the patient should be identified correctly. She should be placed in lithotomy position with her buttocks at the edge of the table for good exposure. Parts should be cleaned and draped under aseptic precautions to minimize risk of infection. Bladder should be emptied prior to starting the procedure to minimize risk of bladder injury. Vaginal examination should be done to assess uterine size and anteversion or retroversion. The uterocervical length should be measured using uterine sound. The direction of the Hegar\'s dilator should be the same as the uterine direction. Unnecessary force should not be used during cervical dilatation. The size of dilator as well as the suction cannula should be same as uterine size. Choosing the appropriate size of suction cannula ensures that the procedure does not take unnecessarily long. Care should be taken that the suction cannula is not introduced beyond the uterine length as measured with the uterine sound. Gentle check currettage should be done after suction to ensure complete evacuation. Overenthusiastic currettage should be avoided as it may lead to Asherman\'s syndrome later. 5 units of syntocinon bolus may be given at end of procedure. All swabs and instruments should be counted before and after the procedure. Prophylactic azithromycin 1 gm single dose should be given to minimise chlamydia infection. 250 IU of anti D should be given to Rh negative patients. The products should be sent for histopathology examination. The patient should be monitored for a few hours to ensure that bleeding is not excessive and the patients vitals are stable. She should be explained that some bleeding is expected for a few days afetr the procedure. Contraception should be discussed and appropriate advice given. Written information should be given and patient should be given a follow up appointment to discuss histopathology report.

b) If uterine perforation is suspected intraoperatively, suction should be stopped immediately. The anaesthetist should be informed about the possible complication and the consultant gynaecologist should be called for. An indwelling urinary catheter should be inserted. A diagnostic laparoscopy should be undertaken to confirm uterine perforation. If perforation is confirmed, its size and the amount of bleeding through it should be assessed. An assessment should be done to rule out bowel injury. If the vitals of the patient are stable and bleeding is minimal, evacuation should be completed with a uterine currette under laparoscopic guidance. Small perforations which are not bleeding actively may be observed for some time and may not require suturing. An actively bleeding perforation may need to be sutured laparoscopically. It depends on the expertise of the surgeon available. If there is profuse bleeding or the patient\'s vitals are not stable, a laparotomy may be required. If bowel injury is strongly suspected, laparotomy will enable better assessment of the bowel. The general surgeon should be informed and kept on standby. If bowel injury is confirmed, laparotomy and repair with 3-0 vicryl is indicated. Antibiotic prophylaxis should be given then. A full blood count and group and save sample should be sent. Blood transfusion may be required if there is excessive blood loss.
Posted by Im F.
a) Common surgical risks associated with surgical evacuation are pelvic infections, bleeding and need of repeat procedures, while serious risks are uterine perforation (5:1000) and significant trauma to cervix (rare). All the patients should be informed of risks associated with procedures and informed consent should be taken.To avoid a repeat procedure and uterine perforation, surgery should be done by a trained staff and according to the local protocol. Bladder should be catheterized and vaginal examination must be performed in order to assess the size and position of uterus as well as to avoid perforation. The usage of suction curettage is also helpful and a recommended procedure to avoid complications. A gritty feeling at the end of procedure should be confirmed to reduce risks of incomplete emptying. Pelvic infection in this particular case can be avoided by screening this young lady for Chlamydia and offering her empirical antibiotic in case the patient’s results are not available. It will reduce complications like pelvic inflammatory diseases (PID) and its sequalae of tubal damage. A full blood count (FBC) and group and cross match should be done prehand to tackle heavy bleeding in case if it occurs. Some surgeons prefer to give pitocin drips to control bleeding at the end of procedure. To avoid cervical trauma, presurgical preparation with misoprostol or gameprost is also recommended. To avoid anaesthetic complication, a preoperative anaesthetic assessment is recommended and if done under general anaesthesia (GA), a preoperative fasting is recommended to avoid vomiting or aspiration. An intermittent pneumatic calf compression and early mobilization should be recommended for thromboprophylaxis. If patient is Rh negative, she should be given anti D within 72 hours.


b) In case of suspected perforation, the procedure should be immediately stopped. Consultant obstetrician should be informed. Anaesthetist should be informed for need of prolonged surgery. Theatre staff should be informed to make arrangements for laparoscopy and ultrasonography. Patient’s general condition should be assessed whether signs of extensive haemorrhage like tachycardia, pallor and hypotension are present or not. The instrument causing the perforation should be shown to consultant and how the suspicion arouses should be explained as well. Blood should be cross matched and arranged. An antibiotic cover should be given to all patients if not given earlier. Patient should be informed of suspected complication and consent should be taken if under regional anaesthesia. If the patient is haemodynamically stable and the evacuation was complete, then an ultrasound should be performed to look for any hematoma or blood in pelvic cavity. If no signs, then patient can be managed conservatively under observation and nil by mouth for 24-48 hours. If the instrument causing injury is large bore and there is suspicion of intraabdominal bleeding then a decision to laparoscopy should be made. The surgical team should also be informed prehand if there is suspected bowel injury. If on laparoscopy the perforation is bleeding and large; then it should be converted to laparotomy and haemostasis should be secured by suturing. If suspected bladder injury by presence of blood in catheter, then urologist should be informed. If evacuation was incomplete, it should be completed with great care under laparoscopy guidance. At the end, an incident form should be filled up and patient should be debriefed. A post operative thromboprophylaxis should be considered. Implication of future pregnancy and contraception should be explained to patient.
Posted by NIRMALA M.
Nirmala
a. The surgical risks associated with ERCP are perforation, false passage, infection, bleeding, retained products and ashermann’s syndrome. Surgeon should be vigilant to avoid these complications. Preoperatively, depending on the unit protocol, misoprostol should be inserted vaginally especially in primigravida which favours easy dilatation of internal os. Good anesthesia is recommended which facilitates easy dilatation of interenal os. Ensure emptying the bladder before vaginal examination to get proper findings. Vaginal examination to note size of uterus, whether anteverted, anteflexed, retroverted and whether uterus is fixed or mobile. Cervix should be gently held preferably by one vulsellum. Gentle dilatation of the internal os using hegar’s dilator by not introducing the dilator any further than the internal os. Maximum size of the dilator used should be half size more than the size of the uterus to prevent cervical incompetence due to overzealous dilatation. Size of suction cannula used should be equal to the size of the uterus. If any difficulty in dilating the cervix, avoid vigorous and force which leads on to perforation, if needed call for help. Gentle suction and curettage done and ensure cavity is empty. Avoid vigorous curettage to prevent future Ashermann’s syndrome. Prophylactic antibiotics given intraop to prevent infection. IV Syntocinon 5 units to 10units if heavy bleeding PV. Bimanual massaging of uterus helps to control bleeding. Remove vulsellum and check for and stop any bleeding from cervix before removing the speculum.

b. Call for senior help. Assess for any increased bleeding through cervix. Assess for any intra-abdominal contents protruding through external os especially if suction attempted after perforating the uterus. Check whether she has consented for laproscopy and laparotomy/correction of any damage during surgery. If not, decision should be made in patient’s best interest. Anaesthetist should be informed about perforation and about the need for diagnostic laparoscopy with possibility of converting to laparotomy. Diagnostic laparoscopy should be done to note site& size of perforation and bleeding from perforated uterine site, any bowel, bladder, omental injury with associated bleeding, any attachment of bowel or omentum to the perforated site. If there is no bleeding from the perforated site, no intra abdominal damage, then no intervention is needed. If the size of the perforation is large/ if bleeding, it needs suturing. In case of bowel injury, surgical gastro enterologist needs to be called in and in case of bladder injury, urologist input is needed for further management. If surgical correction not possible laparoscopically, laparotomy should be proceeded with. Ensure adequate documentation with diagrams and photographs. Document whether she is eligible for trial of labour is necessary. Patient and partner should be debriefed about what happened and dealt with good support.
Posted by Dr Dyslexia V.
X
a) I will go through the history, notes and ultrasound findings in regards to any previous surgical complication, uterine size, if the uterus is retroverted and the size of the gestational sack and presence of uterine anomaly. I would also screen for Chlamydia by taking endocervical and rectal swabs to prevent future PID and adhesions. If positive to treat the patient with antibiotic and maybe do the procedure under antibiotic coverage. I will perform the ERPC after cervical priming with agents such as gameprost. The procedure will be done under aseptic technique with use of chlorhexidine diluted solution to clean the area. Assessment of the uterine size with bimanual palpation after proper bladder catherization. The uterus also assessed by uterine sound for assessment of the required size of curettage. The cervix will be dilated by Hager dilaters to facilitate instrument insertion. The curettage could be done by blunt plastic suction cannula which are gentle to the uterus. Use of oxytoxic or ergometrine could be used to minimize post procedural bleeding. If patient was Rhesus negative she would be given 250 international units of ANTI-D immunoglobulins.
b) I would immediately stop the procedure and inform the anaesthetist of the possible complication and inform a senior colleague or consultant for help. Blood for group and crossmatch and blood products and full blood count is taken for anticipated hemorrhage. Note if any abdominal content such as appendix, bowel or omentum is visible through the uterus and to note any other perforation present. I will convert the procedure to laproscopy or laprotomy depending on the availability of the centre. A small perforation could be managed conservatively or just by diathermy of the hole. Large perforation may require suturing. If intractable bleeding and multiple punctures noted it may result to hysterectomy but these are rare. After securing the perforation the curettage completed if it’s not completed earlier under direct visualization. A through abdominal inspection is done to note if any other organ perforation have occurred. Surgical colleagues could be referred on table to inspect the abdominal cavity as well. Antibiotic should be given intra-operatively as there is now possible infection due to the perforation. The use of oxytocics are done to minimize bleeding. She will be debriefed regarding the complication post-op to inform that there is no consequence for future fertility and pregnancy.
Posted by Kiran  J.
A healthy 19 year old woman presents for dating scan at 12 weeks gestation. Ultrasound scan confirms a missed miscarriage and evacuation of retained products of conception is planned. (a) Discuss your interventions to minimise the surgical risks [10 marks

a) Appropriate patient selection for the procedure is crucial.If the size of gestational sac is large there is risk that there may be incomplete evacuation and hence she can be counclled regarding medical management as an alternative.Her full blood count and blood group should be checked at the time of consultation inorder to assess her Rh factor and need for anti D post operative in order to reduce risk of sensitization.If she is severly anaeamic than consider blood transfusion before procedure to reduce her risks of haemmorhage during procedure.
She should have an oppertunistic STI screening offered prior to procedure and if at high risk/suspected for STI and results not yet available of microbiology,prophylactic treatment ie Azithromysine 1gm stat or metronidazole and doxicycline given as per unit protocol.
Surgical evacuation is associated with risk of perforation of the uterus (3/1000) and hence care ful patient councelling and consent beforehand,operator should be either adequately trained or doing it under direct supervision to reduce risk.Pervaginal insertion of Misoprostol 3 hours prior to surgery helps in softening of the cervix and reduces forcible cervical dilation specifically in nulliparous women.A pelvic examination to assess size of uterus and version should be done prior to procedure as it will guide the direction of the dilator/ suction catheter. Adequate examination,speculum insertion and stabilization of the cervix by holding it with volsellum .cervix dilated using the smallest calibre dilator first and increasing width gently only if preceding dilator has easily dilated the cervix.Avoid using sharp curettes and sponge holders and uterine sound as they are associated with increased risk of perforation.The Evacuation set and trolley should be checked in particular the suction machine and function prior to start of proedure as malfunction result in delay and incomplete evacuation of uterus.
Careful insertion of plastic suction catheter and evacuation should be done avoiding to use force.5 unit of oxytocin i/v after the cavity is felt empty can be administered to reduce risk of blood loss.Volsellum site checked after removal to avoid risk of ongoing active bleeding from the cervix.
The patient can also be offered the procedure to be done under paracervical block with lidocain infiltration to reduce General anaesthetic risk and early recovery for home.


(b) During the operation, you suspect that you have perforated the uterus. Discuss and justify your intra-operative management [10 marks].

I will stop the procedure, liase with the anaethetist regarding the complication and call for Consultant incharge due to the fact that she may start bleeding heavily and early communication and red flagging will reduce her risks of morbidity and mortality.
2 wide bore cannulas should be inserted in case she requires blood transfusion,a catheter with bag to assess urine output in case of hypovolumia,and prepare patient for a diagnostic laparoscopy.Diagnostic laparoscopy is important as it will confirm the perforation, the size and site, will be able to determine if bowel injury/bladder injury has occured and assess for amount of bleeding if any.
Her Group and save should be checked to confirm it is in place,laparoscope inserted as per RCOG guidelines and damage viewed.If a small uterine perforation is present which is not bleeding than admit for observations and antibiotic administration.
If the perforation is large or bleeding profusely consider laparoscopic extra corporeal haemostatic suture placement if expertise available or an open repair or perforation by doing a laparotomy.Blood transfusion is given if bleeding heavily. If bowel
injury is seen, than Bowel surgeons are requested to come and lapartomy done with bowel repair.In case of bladder injury, the urologists are called to review.Antibiotics I/V are given in theatreto reduce risk of infection.Consider drain placement incase of bleeding.
Very rarley a hysterectomy is needed if an extensive injury has occured to the uterus and bleeding is profuse.
Very important for adequate documentation and post op debriefing of events.
Posted by Tendai C.
a) Surgical risk for an evacuation of retained products of conception can carry significant morbidity and mortality. Counselling patients on risks of the procedure and obtaining informed consent is vital. The procedure should be carried out in an appropriately equiped and well lighted theatre by an experienced operator with theatre staff experienced in the operation being performed. A thorough history and examination may reveal concurrent medical conditions like cardiovascular or respiratory disease which may cause an anaethetic risk. In these cases an anaesthetic review should be arranged prior to surgery. Pain is reduced by intra-opertive analgesia like opiates and suppositores and post operative analgesia using the analgesic ladder. Bleeding is minimised by complete evacuation of the products, checking the cavity is empty at the end of the procedure and administering oxytocin after the cavity is empty. Other drugs like ergometrine or misoprostol may be needed if bleeding persists. The surgeon should be aware of the patient\'s haemaglobin level and should group and save and antibody screen a sample of blood. Infection is reduced by the surgeon being scrubbed and using an aseptic technique to clean and drape the patient and perform the procedure. Antibiotics may be administered intravenously by the anaesthetist at our request or as suppositories to reduce infection. Cervical trauma can be reduced by priming the cervix with prostoglandin, particularly in nulliparous women. Graduated careful dilatation of the cervix also reduces trauma. Bimanual examination under anaesthesia with the patient correctly placed in lithotomy position assists the surgeon in assessing the size of the uterus and how the suction evacuation will be performed. The surgeon then minimises risk of uterine perforation and cervical damage by choosing the appropriate size suction catheter. The surgeon should test the suction before begining the procedure to ensure it is working properly at appropriate pressures. The surgeon should insert the suction catheter open carefully into the uterus to the fundus and then retract slightly before closing the catheter and beginning the evacuation to reduce damage to the uterus. Carefully rotation of the suction catheter also reduces perforation. The experience of the operator helps to quickly identify any perforation and subsequent injury to viscera. The risk of thromboembolism is reduced by thromboembolic stockings and short operating time. Anaesthetic risk is reduced by the patient being nil by mouth for over six hours.

b) Once perforation is suspected, I would ask for the suction to be turned off. I would inform the anaesthetist as the operation time would need to be increased to perform a laparoscopy and possibly laparotomy to assess damage to viscera. I would ask for four units of type specific blood to be cross matched and brought to theatre in case of injury to major blood vessels. I would either ask a theatre nurse to inform the consultant on call or I would scrub out to do this myself and discuss further management. I would either wait for the consultant to attend the theatre or if I am trained and confident in laparoscopy, I would begin a laparoscopy to assess damage to viscera once the anaethetist had ensured the patient is stable. I would catheterise the patient to assess for blood in the urine in the case of bladder injury. I would perform a diagnostic laparoscopy and systematically examine the uterus for site of perforation, bowel, ureters, bladder for injury. If any injury is found I would ask a senior experienced surgeon to attend theatre for their opinion. I would look for any sites of bleeding which may be stopped. If laparotomy is necessary, I would inform the anaethetist and consultant on call if not already present. A surgical opinion would be vital to aid in repair and recognition of any visceral damage and post operative management. I would request intraoperative antibiotic cover if any damage to viscera os found to reduce infection.
Posted by A H.
AH

Pre-operatively, I will perform a vaginal examination to assess the cervix. If the cervix is not soft, prostaglandins, for example, Misoprostol or cervagem will be inserted per vaginam to prime it. This wil reduce the risk of applying too much force to dilate the cervix, which may result in a cervical laceration or uterine perforation.
Examination under anaesthesia will be done to assess the size and position of the uterus, and whether it is anteverted or retroverted.
A uterine sound will be passed to assess the length of the uterine cavity. This will be used as a guide when introducing the curette.
The cervix will be dilated to hegar\'s 10 or 12 . A suction curettage will be done instead of sharp curettage, to reduce the risk of uterine perforation. Over zealous curettage will be avoided, so that the risk of developing Asherman\'s syndrome will be decreased.
The surgery will be performed by a skilled surgeon or minimally under the direct supervision of a skilled surgeon.
Medical management using prostaglandins to cause expulsion of products of conception can be offered as an alternative to surgery.
The risks of surgery will be avoided if medical management is successful.

b) I will inform the anaesthetist and my consultant. Senior anaesthetic input will be sought.
Blood will be drawn for group and crossmatch of at least 2 to 4 units of blood depending on the patients condition.
I will perform a speculum examination to assess for associated injury to the vagina and cervix. These will be repaired.
Arrangements will be made for ultrasound guided evacuation of the uterus. If this is not available. laparoscopic guidance will be used.
It is mandatory for this patient to have laparocopic evaluation to determine the extent of the uterine injury and to examine the bowel and bladder for possible injury.
If the uterus sustained a small perforation,which is not actively bleeding, conservative management will be offered. She will be admitted to the gynaecology ward for 24 to 48 hours during which time, pulse and blood pressure will be monitored every 4 to 6 hours. Haemoglobin concentration will be done 12 hourly.
If there are signs of continuing bleeding, emergency laparoscopy or laparotomy will be performed based on the patient\'s condition and the skill of the surgeon.
For a moderate laceration,direct pressure can be applied. If haemostasis is not achieved, laparoscopic diathermy or suturing of the wound will be performed.
A large lacerationwith associatedheavy bleeding will require laparotomy especially if the patient is tachcardic and/or hypotensive.
Haemostatic sutures will be placed on the uterus and bowel and bladder will be carefully inspected for any injury. Urology or general surgery assistance will be sought if there is injury to the bladder or bowel respectively.
Major vessel injury will require input from a vascular surgeon.
If the laceration to the uterus is significant and haemostasis cannot be achieved, a hysterectomy will be required as a life saving measure. This decision will be taken by the consultant after discussion with senior colleagues involved.
Relatives will be informed about events by a senior member of the team as soon as it is feasible.
Posted by F N.
The surgical risks of evacuation of uterus are bleeding ,infection,retained products of conception, uterine perforation,cervical trauma,uterine synechae,bowel injury and thromboembolisim.history of previous cervical surgery, and previous difficult evacuations and PID should be noted.
I will make sure that the option of conseravative and medical manangement has been discussed with her.I will discuss the procedure technique and risks with her and consent her.if the patient is not bleeding and stable,it is better to do operation electively during day time as more staff is around if needed.
I will send her full blood count and group and save sample to check her Hb and blood group.If she is rhesus Negative,250 iu anti d should be administered after the operation.

I will send swabs for chlamydia and gonorrhea and give her empirical treatment.
To minimise the surgical risks it is essential that the operation is done by surgeon who is competent to do it independently or directly supervised by senior.
The cervix can be ripened by giving prostaglandins,which may reduce the trauma to cervix.
The operation should be performed under aseptic conditions to reduce the risk of infection.Bimannual examination should be done to assess for the size and position of uterus.it may help to choose the approriate size suction cannula and also to reduce the risk of uterine perforation.Avoid to sound the pregnant uterus as it increases the risk of perforation.The cervix is then held with a volsellum and and cervical os can be dilated according to the size of suction cannula if needed.The suction curretage is performed and it can be followed by blunt curretage to check that uterine cavit is empty.Avoid agrresive curretage to reduce the risk of perforation and syneche formation.
There is no definite diagnostic criteria for the confirmation of empty uterus,but the traditional signs of bubbles visibility and grating feeling against the walls of uterus at curretage may indicate that the uterus is empty.ultrasound guided evacuation can be considered for difficult cases.
patients at high risk of thrombo embolisim should be offered thromboprophylaxis.
Product of conception should be send for histology to exclude gestational trophoblaastic disease.

b:
I will immediatly stop the operation and ask for my consultant to attend.i will inform the anesthetist and the theatre staff about the possible complication and the possibility of Laparoscopy and laparotomy.I will ask for broad spectrum antibiotics to be administered.i will make sure she is cross matched for blood.i will also alert the oncall surgical team in case of a bowel damage.The role of ultrasound can be considered to confirm the perforation,but even in expert hands it can be difficult to confirm.so if clinicaly the patient is stable and after senior assessment there is no evidence of perforation,she should be kept in the hospital for observation for 24 to 48 hrs.
The other option is Laparoscopy with or with out hysteroscopy.if there is no bowel involvement and the uterine perforation can be managed laparoscpicaly.It needs the availibility of the expert lapaorscopic surgeon,and some times small bowel perforation can be missed,Therefore she should be monitered in hospital for 3-5 days for signs of bowel injury.
If at lapaoscopy uterine and bowel injury is confirmed,surgical team should be asked to attend.laparotomy with or with out bowel resection and colostomy may be needed depending on the extent and site of injury.
clinical Incident form should be completed.the lady should be briefed in detail about the events idealy in the presence of a family member.
Follow up appointment should be arranged,and implicatiot on future pregnancy and deliveries can be discussed..
Posted by Penelope T.
a) Surgical risks can be reduced if the evacuation is performed by an experienced operator and a trainee with direct supervision.
The main risks include bleeding and uterine perforation. These can be reduced by preparation and intra-operative technique. Bimanual examination (for uterine size and position); knowledge of the beta-hCG level and appearance of ultrasound (to alert the surgeon to the risk of molar pregnancy) will be helpful. Pre-operative haemoglobin, Group and save, and IV cannula are important. Surgical technique should involve gentle sequential cervical dilatation, avoidance of the sound, and the use of an appropriately sized plastic suction catheter (such as Karman - size approximately equal to size of uterus in weeks). If significant bleeding is seen a bolus of 5 units oxytocin IV can be given. If ongoing significant bleeding occurs, bimanual compression should be given and the cavity checked. Further oxytocin and/or ergometrine or misoprostol can be administered. In this setting the anaesthetist and a senior gynaecologist should be notified and asked to assist. Over-vigorous curettage should be avoided and sharp curette used only if required (with gentleness). If perforation is identified consideration should be given to laparoscopy and antibiotics.
Infection risk can be reduced by antiseptic preparation, good surgical technique. Risks of cervical trauma is reduced with PV mifepristone priming. Ashermanns syndrome can be reduced by avoidance of over-vigorous curettage.
b) The anaesthetist should be informed and check the patient is stable. ERPC should be stopped. A senior colleague can be called in. Management should depend on the timing and site of suspected injury, and instrument used. If the sound was thought to be the potential cause and the patient is stable, conservative management with admission, observation and antibiotics may be appropriate. Repeat surgical or medical evacuation if this was not complete could be planned for 2 weeks time.
If curette injury is suspected, a laparoscopy should be performed due to the risk of uterine, bowel, bladder or vessel injury. The uterus, broad ligaments, vessels should be inspected and bladder and/or bowel if perforation confirmed. If a uterine injury is bleeding significantly haemostasis should be obtained, if necessary with suturing. Should bowel injury be identified the general surgeon should be called to see and decide on repair laparoscopically or by laparotomy.
The patient will need broad spectrum antibiotics such as IV cephazolin and metronidazole, subsequent bowel rest and observation for peritonitis. IV antibiotics should be followed by a course of oral antibiotics.
If anterior uterine/bladder injury is suspected, cystoscopy should be performed.
Once the complication is dealt with it may be appropriate to complete the ERPC under direct laparoscopic vision.
Posted by Bobey B.

The risks include uterine perforation, cervical trauma, bleeding, infection and intrauterine adhesions. Correct choice of anesthesia is important to reduce morbidity. So, it is desirable to arrange for her a preoperative anesthetic review. It requires general anesthetic but it can be undertaken under local anesthetic and / or intravenous sedation, since this is associated with lower occurrence of cervical damage and uterine perforation. Consent should be taken for surgical evacuation and she should be explained the aim of the procedure, serious risks such as uterine perforation and extra procedures like laparoscopy and laparotomy may be needed. A policy should be used to minimize the postoperative sepsis with subsequent risk of chronic pelvic inflammatory diseases. This should be using antibiotic prophylaxis( metronidazole 1 gm rectally at time of surgery plus doxycycline 100 mg orally twice daily for 7 days postoperatively ) or screening for lower genital tract organisms including Chlamydia trachomatis and treating . Cervical priming with prostaglandin (gemeprost 1 mg administered vaginally 3 hrs prior to surgery or misoprostol 2 X 200 ug vaginal tablets) helps reduce the risk of cervical damage and uterine perforation. The patient blood group should be checked and should be received anti-D prophylaxis if she is Rhesus negative. The FBC should be checked to identify anaemia and provide a base line for comparison if she experiences excessive bleeding. Surgical uterine evacuation should be performed using suction curettage is preferable to sharp curettage. It is associated with decreased blood loss, less pain and shorter duration of procedure. Intraoperatively urinary bladder should be evacuated using catheter, as full bladder distorts pelvic anatomy and make examination more difficult and inaccurate. Bimanual examination is the most important part of the procedure, to assess the pelvis, uterine size, position and axis of the uterus. Surgical dilatation and evacuation should be done by an experienced operator, with the help of ultrasound scanning (if there is a doubt of incomplete evacuation), and the procedure is then safe. Dilatation of a false passage or diverticulum, if not noted may result in rupture of uterus or cervix. The problem is obviated if the surgeon is immediately follows the axis of the uterus as defined at bimanual examination. Tissue obtained at the time of suction curettage should be examined histologically to exclude unsuspected gestational trophoblastic disease.
She should be given a letter with sufficient information to allow another doctor to undertake appropriate care of any complications.
Psychological morbidity associated with the procedure should be considered, so follow-up, counseling and support group address (Miscarriage association group) should be offered.
b) If I suspect that I have perforated the uterus, I have to call my consultant and inform the anesthetist .Initial assessment of pulse, BP, should be undertaken. The amount of bleeding should be observed, estimated loss while starting resuscitation. Venous access with blood for blood count should be done, group, cross-match and clotting studies. Foley\'s catheter should be fixed.
Intravenous fluids should be started immediately and O Rh negative should be given if she is compromised. Theatre staff should be informed to organize for laparoscopy and possible laparotomy.
The senior gynaecologist on scene takes charge. If conservative management is decided, close observation is mandatory in the hospital, with analgesia with or without blood transfusion is appropriate if bleeding is setting, patient is haemodynamically stable and there is no clinical suspicion of uterine perforation or visceral injury.
Immediate laparoscopy should be performed if uterine perforation is suspected. The visceral injury could be missed at laparoscopy.
Persistent bleeding or evidence of haemodynamic compromise should prompt surgical treatment in association of general surgeons if visceral injury is suspected. If bowel injury has occurred, a laparotomy by an experienced bowel surgeon should be undertaken. Depending upon the extent of injury, either suturing a perforation, or a resection or anastomosis, with or without colostomy may be required.
Her family should be informed all the time and the reasons for further surgery should be discussed.
Detailed discussion and documentation of possible procedures (hysterectomy, bowel resection, and blood transfusion) should be undertaken.
Incident report should be filled.



Posted by millionaire2004 A.
Ag
A healthy 19 year old woman presents for dating scan at 12 weeks gestation. Ultrasound scan confirms a missed miscarriage and evacuation of retained products of conception is planned. (a) Discuss your interventions to minimise the surgical risks [10 marks].

Approach the woman sympathetically. Give her options for evacuation of product of conception (ERPOC), medical or surgical. Medical evacuation is by oral mefepristone 200mg followed 36-48 hours by vaginal misoprostol 400-800 mcg. This can avoid surgical evacuation. Caution the woman that if evacuation is incomplete,she still may need surgical evacuation. For surgical ERPOC , take informed consent. Review her booking blood results looking for Hb level and Rhesus D status .Optimise her Hemoglobin pre-operatively (ie Hb >11 mg/dl). Send for full blood count, group and save serum.. Screen for Chlamydia by doing speculum examination and taking urethral swab. Consider pre-operative cervical preparation with cervagem 1 mg vaginally (preferably 1 hour prior to procedure). If possible, arrange for pre-operative anaesthetic review. The procedure should be done in a centre with expertise and facilities to deal with complication of ERPOC (ie: availability of blood bank and laparacsopy equipments). ERPOC should be done by someone familiar with recognition and treatment of complications of ERPOC such as uterine perforation. Intraoperative antibiotic considered if suspected genital tract infection. Metronidazole 1 g per rectally during procedure and oral doxycycline 100mg twice daily for 7 days is appropriate. Appropriate sedation (intravenous ketamine/pethidine) or regional anaesthesia can be considered as an alternative to general anaesthesia. If need general anaesthesia,consider usage of laryngeal mask airway as an alternative to endotracheal intubation. This can minimise injury to trachea. Before ERPOC, do a vaginal examination after patient anaesthesied to determine size and position of uterus. Avoid usage of uterine sound if possible. Usage of cervical dilators could be avoided if cervical preparation done. This reduce risk of cervical injury. Choose suction apparatus rather than sharp curettage. Suction method is associated with less risk of uterine perforation,less blood loss and less pain. It is easier to do than sharp curettage. Grasp the cervix gently with vulsellum to straighten cervical canal to aid insertion of suction tube. This can minimise excessive force from being applied and thus reduce risk of cervical perforation/injury. If use sharp curettage, avoid overzealous curettage to minimise risk of Asherman’s syndrome. Consider usage of uterotonic agents like ergometrine to minimise risk of bleeding. Post-operative, observe the patient in acute cubicle in the gynaecology ward. Observe bp,pulse rate and temperature hourly. Provide adequate pain relieve. Offer anti-D Ig if patient is rhesus D negative and not sensitised. Observe for abdominal pain, persistent per vaginal bleeding, fever. Observe in ward for 1 day before discharge. Discharge with clear plan of follow up. Plan include urgent hospital visit if develop abdominal pain,fever or persistent bleeding. Give her emergency contact number. Give date for review of histopathology review of POC.

(b) During the operation, you suspect that you have perforated the uterus. Discuss and justify your intra-operative management [10 marks].

This is surgical emergency. Stop ERPOC immediately. Leave the apparatus used (either suction tube or sharp currette) in-situ. Do not attempt to remove it. Inform consultant/ senior colleague immediately. Alert the anaesthesist as patient might need resuscitation or convert to general anaesthesia if not already under . Alert blood bank as may need blood transfusion. Drape and prepare pt for urgent laparascopy. During laparascopy, inspect the uterus systematically. Look for the tip of the surgical instrument used earlier. Look for any active bleeding point on the uterus. Assess blood loss. Look at the surrounding structures, fallopian tubes, ovaries,bladder and bowel. If there is suspicion of bowel injury, alert the surgeon. If the bleeding is minimal or stopped, no need further intervention as majority of uterine perforation heal spontaneously. May need to convert to laparatomy if bowel injury or active bleeding from uterus. Uterine perforated site sutured in 2 layers using absorbable sutures (vicryl).
Posted by Ida I.
I.

A) History of previous surgery, such as previous caesarean section, should be elicited. Presence of previous uterine scar is associated with increased risk of bleeding. History of any PV discharge would point towards pelvic inflammatory disease that would require treatment if she is going for any surgical procedures. Bimanual examination should be done to assess uterine size. Speculum examination to look at the cervix to exclude any cervical masses such as polyps or any scarring that could cause diffullty in evacuation of the uterus. Swabs for Chlamydia and bacterial vaginosis should be done to exclude any infection.
Giving her the option of conservative management can also minimise surgical intervention as it eliminates the risk altogether. Options of medical evacuation with prostaglandins (Gameprost) with or without cervical priming with an anti-progesterone agent ( Mifeprostone) should also be be discussed as a means to reduce surgical risks.
Surgical intervention should only be offered in the even of excessive bleeding, infected retained tissue or suspected molar pregnancy. If she decides for surgical intervention, she should have a baseline hemoglobin to ensure she is not anemia, and a blood group and save. The procedure should be done by an appropriately trained surgeon. The equipment has to be in optimal working order. The sue of cervical priming with prostaglandins can reduce the need for forceful dilatation and bleeding. Gentle dilation done and uterine sound avoided to reduce risk of perforation. Vacuum aspiration can be used instead of curettage to reduce the risk of perforation. ULtrasound guided insertion of suction catheter or curettage can also reduce the risk of perforation. Ergometrine use can reduce bleeding. Antibiotics use during evacuation is not recommended as is has no extra benefits. If she is rhesus negative, anti-D immunoglobulin shuld be given. Written information should be given to the patient to obtain consent.

B) If perforation is suspected, the procedure should be stopped. The consultant gynaecologist should be informed. The anesthetist should be informed regarding prolongation of the procedure. She should have 2 large bore branullas for venous access and resuscitation. The hematologist should be informed for cross-matched blood for possible laparotomy and transfusion. In an event of profuse hemorrhage, she may need O negative blood transfusion. Laparoscopic assessment of the perforation needs to be done immediately to identify the size and site of perforation, as well as if the is any injury to the bowel or bladder. A small perforation can be treated conservatively as it may close spontaneously. A large perforation that is bleeding may need repair via laparotomy. The surgeon needs to be notified for possible repair of any bowel or bladder damaged that may be present. Broad spectrum antibiotics, such as second generation cephalosporins should be administered to reduce postoperative infection. Detailed documentation of the procedure should be done, and should include the names of the surgeon and attending staff, the size and site of perforation, any additional procedures that may have been done and blood loss. The patient and partner needs to be debriefed on the incident postoperatively. Any future pregnancy plans needs to be discussed as she may require a caesarean section in her next pregnancy. Effective contraception needs to be discussed as well for proper spacing of her pregnancy, as poor spacing is associated with risk of uterine rupture.
Posted by HM ..
HM

(a) As this evacuation of retained products of conception (ERPC) is planned , the patient can have a pre- op assessment to include a Hb check and screening for pelvic infection like Chlamydia and Gonorrhoea. Once her Hb is optimized this will reduce the liklihood of intraoperative haemorrhage. If she is found to be carrying an infection like above then treatment can be administered before or if not known prophylactic antibiotics given with e.g. Doxycycline for one week after ERPC. Intraop, an examination should be done initially under anaesthesia as this guides the use of instruments when the size and direction of the uterus is known. To avoid cervical trauma/ tears, cervical priming may be required pre- op with prostaglandins and at surgery, minimal force should be used when grapsing the cervix and dilating with Hegar dilators. Suction curettage is the instrument of choice to reduce risk of uterine perforation as opposed to a sharp currette. If significant bleeding noticed intraop, an oxytocin infusion can be started. Anaesthetic complications can be reduced if patient choses local anaesthesia.

(b) The procedure will be stopped immediately and I will not attempt to put any insturment in further within the uterus but gently remove it, ideally once an examination under anaesthesi performed - as this may allow me to identify the location of the insturment outside the uterus . I will inform the anaesthetist immediately of the possible risk of perforation. the nurses in theatre and my consultant will be told - as there is a probability of the need for laparotomy and repair of viscera. I will ask the anaesthetist to give me information of her vitals like pulse, blood pressure and pulse oximetry and to keep me nformed - as significant pelvic haemorrhage may manifest as a change to hypotension and tachycardia before pelvic signs noticed. I will have a group and save done because of possible need with further laparotomy
If perforation suspected and patient\'s vital signs are okay with minimal bleeding, she can be observed in the recovery roon for 24- 48 hrs and given information about probable incident and explain need for laparotomy if conditon worsens. If perforation very likely or confirmed such as bowel seen through os after instrument removed then a laparoscopy will be done if likey perforation and a laparotomy should be done with the assistance of the general surgeon to repair bowel/ bladder/ viscera. This would have been consented for prior to the ERPC screening.
It is important to cover with broad spectrum antibiotics including Metronidazole for anaerobes as it is highly likely once the bowel is involved.
Posted by Mohamed D.
Mohamed
A) Preoperative preparation with full blood count to rule out anaemia and group and serum save in case she bleeds and needs blood transfusion, Anaesthetic assessment for mode of anaesthesia for either general, regional or local and she has to make an informed decision. She should not have anything by mouth for the 6 hours preceding the operation, to keep her stomach empty to prevent acid reflux and respiratory morbidity with anaesthesia. Chlamydia infection should be ruled out by NAAT testing prior to any instrumentation of the uterus especially with her age as she is at high risk of infection. MRSA screening by swabs to prevent hospital acquires infection. She should wear thromboembolic deterrent stockings for prophylaxis of thromboembolism while inpatient. Cervical ripening with prostaglandins 1-2 hours before the procedure if she had not had any vaginal deliveries to reduce complications related to dilatation of the cervix.
Intraoperatively; use of suction evacuation rather than dilatation and curettage is associated with fewer incidences of complication and perforation. Preparation with antiseptics and use of sterile drapes will help to prevent infection. Products of conception should be sent for histology examination to confirm intrauterine pregnancy and rule out GTDs. Single dose broad spectrum antibiotic to reduce the chance of infection.
Postoperatively; observation for bleeding, abdominal pain or feeling unwell will pick up early any complication as incomplete evacuation, perforation or infection.

B) Stop the procedure immediately. Inform the anaesthetist about the situation. Call for help from a senior colleague or the consultant on call. Check if the patient is haemodynamically stable and not bleeding heavily. If bleeding or not stable, start immediate fluid resuscitation and send for blood cross matching. If perforation is suspected by senior colleague; proceed to laparoscopy to confirm the diagnosis. If bowel injury is suspected, call for surgical specialist to check bowel and repair if injured. If the perforation site is bleeding, cauterization or stitching to achieve haemostasis should be done. The evacuation should be continued under guide of laparoscopy to insure complete evacuation. Accurate documentation of procedure and site and number of perforations should be done. Incident form should be completed for risk management assessment. Histology for products evacuated should be sent as urgent to rule out intestinal mucosa if bowel injury was not suspected.