I. Reasons for occurrence.
After abortion, “unclean” is a symptom caused by the residual pregnancy and bleeding in the uterine cavity after the operation, which is an incomplete abortion caused by incomplete suction. The incidence is reported to be 1.48 per thousand in China. Generally, after aspiration, the bleeding is small and lasts for 3 to 5 days. If vaginal bleeding is prolonged for more than 10 days after aspiration, B ultrasound should be performed to determine whether there are residues in the uterine cavity in order to confirm the diagnosis of incomplete abortion. According to our research on incomplete abortions, the most likely high-risk groups for incomplete abortions are multiple abortions, especially recent repeat abortions, and abortions where the embryo sac is too small or too large.
1, the operator is not skilled and cannot master the signs of clean suction and scraping.
2, the negative pressure is too low, the suction tube is too thin or the rubber tube is too soft during the operation.
3, postoperative failure to carefully check whether the aspirate is complete and consistent with the month of pregnancy.
4, pregnancy combined with uterine fibroids, uterine malformations, etc. resulting in abnormal morphology of the uterine cavity.
5, the recipient has a history of multiple hysterectomies.
Second, technical limitations.
Ultrasound visualization (or under surveillance) abortion procedures carried out in recent years have greatly improved the safety of the procedure, but still cannot completely avoid incomplete abortions.
(1), ultrasound surveillance of the uterus suction surgery
(1) The limited resolution of ultrasound during the operation can guide the operator to remove large pregnancy masses, but it can do nothing for small residues (1-5 mm in diameter). These residues can increase in size postoperatively and be detected by ultrasound because they have the ability to grow in small amounts or are encapsulated in a blood clot and subsequently mechanized.
(2), During curettage, the pregnancy is spread and adhered to the uterine wall and appears to be removed under ultrasound, but reverts back to its original shape after the procedure and is detected by ultrasound.
(3) A few patients were unable to be removed due to heavy bleeding and tightly bound residues, so that they were left until postoperatively.
2.Hysteroscopic suction hysterectomy
1）.The operation is complicated.
2）.To have a specialized doctor.
3), with the risk of hysteroscopic surgery.
(4), relying on mechanical expansion of the uterus during the operation, the mirror surface is easy to be stained by blood and mucus, the image is not clear.
5), restricted inner diameter of the suction tube.
III. Diagnosis.
Vaginal bleeding for more than 15 days after abortion should be considered as incomplete aspiration when general symptomatic treatment methods are ineffective. Pelvic examination reveals loose cervical opening with blood flowing from the uterine cavity; uterus is larger than normal and softer; urine pregnancy test can be positive; ultrasound suggests residue in the uterine cavity. The scrapings should also be sent for pathological examination.
IV. Treatment.
1, scraping again
The traditional treatment for post-abortion residues is to scrape the uterus again, but because the tissue is mechanized and clings to the uterine wall, causing certain difficulties for the operation, the uterus is often cleared several times in the clinic. Re-operation also makes patients fearful of surgery, which brings pain to patients and increases the possibility of a series of post-operative complications such as trauma to the endometrium leading to adhesions in the official cavity or cervix, affecting menstruation and even fertility. Although the development of hysteroscopic techniques provides a new approach to the diagnosis and treatment of residuals, there is a corresponding risk of serious complications. Residuals in the uterine cavity after abortion often result in prolonged vaginal bleeding, which makes the patient nervous, and prolonged bleeding can also induce endometritis, which can lead to uterine perforation, uterine infection, adhesions and other complications if the uterus is operated directly again. In addition. Recent postpartum, lactation, recent pregnancy after cesarean section, history of recent or multiple abortions, extreme uterine tilt, reproductive tract malformation, and history of uterine perforation are all risk factors for repeat curettage.
Therefore, the benefit of repeat curettage is quick results, while the disadvantage is the risk of experiencing the procedure again and the possibility of aggravating endometrial damage.
1) Conservative treatment with drugs
(2) Prostaglandin preparations have been reported both at home and abroad, such as Miso 600ug or Carbohydrate 0.5 mg, with an efficiency of more than 80%.
(3) Monoprogesterone treatment Progesterone can rapidly repair the endometrium. Suddenly stopping the drug after taking a large dose will lead to endometrial withdrawal bleeding, and the residual meconium tissue in the uterine cavity will be discharged together with the endometrium, playing the role of drug scraping.
(4) Estrogen sequential treatment simulates a normal menstrual cycle, with a course of 14-16 days of treatment with ethylene estradiol 1mg once daily; 12 days after taking ethylene estradiol, add progesterone 12mg once daily and wait for withdrawal bleeding of the endometrium after stopping the drug. Oral estrogen causes rapid repair of the endometrium, stops bleeding, and facilitates proliferation and repair of the uterine basement membrane where the residue adheres. The residue separates from the uterine wall, while estrogen increases the contraction of the uterus and loosens the uterine opening. Oral progestin transforms the hyperplastic endometrium into a secretory phase, and after discontinuation of the drug, due to rapid withdrawal of estrogen and progestin, simulating normal menstruation, the endometrium peels off intact and the residue is then discharged, which is clinically known as pharmacological curettage. The timely use of artificial cycle therapy after abortion reduces to a certain extent the possibility of abnormal menstruation, uterine adhesions and secondary amenorrhea after abortion, and reduces the possibility of long-term complications of abortion.
(5) Mifepristone tablets are progesterone receptor antagonists, which can induce degeneration and necrosis of the villi and metaplastic tissues; they can reduce the difficulty and duration of the operation to clear the uterus. However, it is not conducive to endometrial repair and is prone to infection due to prolonged clinical bleeding. Mifepristone alone is unsatisfactory in mechanized tissue with dense adhesions to the uterine cavity.