1. Overview of vaginitis
Vulvar and vaginal infections are common in women, with Candida vaginitis, trichomonas vaginitis and bacterial vaginosis (BV) being the most common. In patients with Candida vaginitis, the source of Candida spp. is usually endogenous. Candida is isolated in up to 25% of the genital tract of asymptomatic healthy women of childbearing age. Symptoms and signs are often not obvious after the onset of inflammation. A large proportion of women with Trichomonas vaginalis infection and BV patients also have no obvious conscious symptoms [1]. In normal healthy women, the vagina is affected by normal hormones and the glycogen in the epithelial cells of the vaginal mucosa is produced by lactobacilli, thus maintaining the normal vaginal pH at about 3.8-4.5 [2]. This acidic environment is conducive to the growth of normal flora and maintains the ecological environment and immune function of the vagina. After delivery, due to the decrease of estrogen and progesterone, the vaginal mucosa loses the support and protection of estrogen and the glycogen content in epithelial cells decreases, which decreases the ability to produce lactic acid and increases the pH of the vagina, which is unfavorable to the growth of lactobacilli and decreases the defense function against bacteria, which can easily lead to dysbiosis or infection with pathogenic pathogens.
Candida vaginitis is a fungal disease of the reproductive tract that often occurs in pregnant women and must be treated before abortion to prevent upstream infection. Candida is a conditionally pathogenic fungus that causes deep infections in humans and is a member of the normal vaginal flora, which does not cause clinical symptoms under normal circumstances and is not very pathogenic. It is currently believed that the pathogenic mechanism of Candida includes the following: (1) adherence to the host fine clinical diagnostic criteria ① at least one of the following symptoms or signs: itching and burning of the vulva; leucorrhoea in the form of curd or bean residue; erosion or superficial ulceration of the inner labia minora or vaginal mucosa in acute cases. ② Candida albicans is found in vaginal secretions. When pregnancy is combined with Candida vaginitis, it is required to be cured in a short period of time in order to perform abortion. Therefore preoperative treatment is very important in terms of timing and outcome. Clotrimazole is a broad-spectrum antifungal drug and its oral action against deep fungi is not ideal. Currently, non-antibiotic gynecological suppositories-chitosan gynecological suppositories-are used to treat fungal vaginitis [4, 5]. The efficiency of chitosan gynecological suppositories in the treatment of Candida vaginitis was 93.6%, which was not significantly different from that of conventional drugs (dacrynic suppositories, etc.) [5]. The literature [6] reported that the detection rate of Candida vaginitis in early pregnancy combined with Candida vaginitis was 10.33%, and the detection rate of Candida vaginitis increased with the increase of gestational weeks.
Bacterial vaginosis (BV) is a common gynecological condition that occurs in women during their childbearing years. The main microorganism in the normal vagina is Lactobacillus acidophilus, which maintains the characteristic acidic environment of the vagina by converting glycogen produced by the vaginal epithelium into lactic acid. Bacterial vaginosis is actually a disorder of the vaginal flora caused by high concentrations of Gardnerella vaginalis, various anaerobic bacteria and human mycoplasma instead of the normal vaginal lactobacilli. Bacterial vaginosis can be diagnosed according to the 6th edition of the textbook of obstetrics and gynecology of the National College of Medicine, if three of the following four items are present: ① homogeneous, thin, white vaginal discharge adhering to the vaginal wall; ② vaginal pH > 4.5; ③ positive ammonia odor test; ④ positive clue cells. Exclude patients with history of severe liver and kidney function, diabetes mellitus, drug allergy, mycobacterial and trichomonas vaginitis. Commonly used drugs for systemic treatment: metronidazole and tinidazole are administered orally, with metronidazole being the drug of choice for treatment. Topical medication is applied directly to the ectocervix and vagina, which can effectively increase the local drug concentration and kill the germs in direct contact with the pathogenic bacteria. One study found that the highest rate of BV detection was found in women who had early abortions. This suggests that clinicians should pay attention to preabortion screening for common vaginal infections, especially BV, to avoid adverse outcomes due to missed diagnoses [7].BV can complicate a variety of infectious diseases. Pelvic inflammatory disease increases the prevalence of tubal infertility and ectopic pregnancy, with about 35% of women with infertility and 45% of ectopic pregnancies due to tubal damage caused by pelvic inflammatory disease [8], and clue cells have been reported to be detected in the upper genital tract of patients with pelvic inflammatory disease.
Trichomonas vaginitis (trichomona1vaginitis) is a common form of vaginitis caused by Trichomonas vaginalis. Clinically, it is characterized by increased leucorrhea, rare foamy quality, obscene odor, and vaginal itching. The onset of the disease is due to bacterial infection secondary to the depletion of vaginal glycogen by infected Trichomonas vaginalis, which destroys the vagina’s self-cleaning defenses. The main symptoms are increased thin, foamy leucorrhea and itching of the vulva, and if there is a mixture of other bacteria, the discharge is purulent and may have a foul odor. If the urethra is infected, there may be frequent and painful urination, and sometimes hematuria can be seen. Treatment principles are
(Both husband and wife take medication at the same time) Systemic plus local medication to improve the vaginal environment and increase the efficacy. Systemic metronidazole (metronidazo1e), also known as F1agyl, should be given at 200mg 3 times a day for 7 days, while local medication is also effective. Metronidazole 200mg should be inserted into the vagina once a night, 10 times for a course of treatment. If 1% lactic acid or 0.5% acetic acid is used first to improve the vaginal environment, it will improve the efficacy.
2.Overview of abortion
Before 12 weeks of gestation, the purpose of ending the pregnancy is to remove the developed but immature embryo and placenta from the uterus by manual means, which is called early abortion. Early abortion is suitable for those who are not suitable to continue the pregnancy due to some serious diseases of the mother (such as active tuberculosis, serious heart disease, etc.) or pregnancy complications, as well as for those who have failed to use contraception. Artificial measures are taken to terminate pregnancy in the early stages of pregnancy as a remedy for contraceptive failure, but this cannot be used directly as a method of birth control [9]. However, it should be clear that early abortion is only a remedy and never the first choice. This is because early abortion is not without any side effects, and it may cause a series of complications such as infection, bleeding, secondary infertility, pelvic stasis syndrome, endometriosis, spontaneous abortion, and preterm delivery.
3.Residuals in the uterine cavity
Complications of abortion (abortion for short) occur from time to time, especially in early pregnancy combined with malformed uterus, scar uterus, lactating uterus, uterine hyperflexion, after multiple abortions, cervical microwave and LEEP surgery and other high-risk factors require abortion, the difficulty of the operation is significantly increased, coupled with conventional abortion under blind vision, all based on the operator’s experience and sense of operation, there is a certain blindness, prone to surgical The complications of the procedure can cause different degrees of physical and mental effects on the operator. Intrauterine residue is a common complication after abortion, and there are many reasons for intrauterine residue, such as uterine malformation, number of abortions done before, age, experience of the surgeon, etc. Intrauterine residue after medication abortion is mostly related to the history of uterine trauma (such as scraping, multiple pregnancies). And painless abortion is mostly related to uterine morphology and the experience of the operating surgeon. Residual intrauterine embryonic tissue not only affects the contraction of the uterus, leading to prolonged continuous or intermittent vaginal bleeding of the patient, but also causes endometrial infection resulting in obstruction of endometrial recovery, cervical or uterine adhesions, secondary infertility, etc., causing great pain and injury to the patient. Therefore, ultrasonography is particularly important to visualize the presence or absence of intrauterine residues in the uterine cavity after abortion or delivery and to determine their location, size, and uterine recovery [10].
The main clinical manifestations of intrauterine residue: bleeding for more than 10 d after painless abortion, excessive blood flow, or excessive bleeding again after bleeding has stopped [9]. The bleeding after drug abortion is heavy and prolonged for more than 20 d. If the bleeding is excessive, emergency curettage is required. The main ultrasound manifestations of intrauterine residues are: normal or slightly large uterus; slightly strong echogenicity with clear or unclear boundaries with the uterine wall, uneven internal echogenicity, irregular morphology, some resembling the echogenicity of the gestational sac; blurring or disappearance of the endometrial line of the uterine cavity secondary to infection, uneven echogenicity of the uterine wall, often scattered stripes or speckled hypoechoic areas near the endometrium; accumulation of blood or intrauterine inflammatory secretions accumulating in the uterus, i.e., liquid dark areas [11]. The colored blood flow around the intrauterine residue is richer. Intrauterine residues are sometimes differentiated from uterine fibroids and trophoblastic disease. If left untreated, intrauterine residues can lead to infection, adhesions, anemia, and even infertility. Residual placenta can lead to poor uterine contraction and predispose to postpartum infection or hemorrhage. Once placenta residue is found, it needs to be removed surgically as soon as possible. Due to the enlarged and soft uterus, deeper and wider uterine cavity after delivery, it is very difficult to operate. Some data show that 10% to 35% of lesions are missed even by experienced doctors who blindly diagnose the brackets [12].
4. Effect of vaginitis on intrauterine residues after abortion
Vaginitis is an inflammation of the vaginal mucosa and submucosal connective tissue and is a common disease in gynecological clinics. Vaginitis is clinically characterized by changes in the nature of the leucorrhoea and itching and burning pain in the vulva, and the common vaginitis are bacterial vaginitis, trichomonas vaginitis and candida vaginitis. The combination of vaginitis during early abortion can aggravate the side effects and lead to pelvic inflammatory disease, secondary infertility and ectopic pregnancy, which seriously affects the quality of life of women. Therefore, it is essential to control the inflammation and then perform the procedure, thus reducing the side effects.
Abortion is an invasive and traumatic procedure. Women with vaginal infections that are not detected and effectively treated before abortion create favorable conditions for the development of reproductive tract infections. Studies have reported that women with pre-existing genital tract infections that are not treated before or controlled after abortion can significantly increase the risk of genital tract infections. Reproductive tract infections can lead to long-term lower abdominal pain, chronic pelvic inflammatory disease, infertility, ectopic pregnancy, stillbirth, and can increase the risk of HIV/STI infection in women [13]. Such a large number of unmarried abortion patients will have a serious impact on their reproductive health if their vaginal infections are not diagnosed and treated before the procedure or are not managed effectively after the procedure. It is recommended that unmarried women with abortion should be routinely screened for common vaginal infections, especially BV, and given effective treatment before or after abortion, taking into account the patient’s specific situation, in order to reduce the adverse outcomes caused by missed diagnoses.
In fact, the most common complication of abortion is post-operative infection. Normally, there are many bacteria present in the vagina and the lower 1/3 of the cervical canal. However, these bacteria cannot easily enter the uterine cavity because they are separated from the vagina by the cervical mucus plug that is inserted in the cervical canal. During abortion, surgical instruments need to enter the uterine cavity through the vagina and the cervix. Although the surgical instruments do not touch the vaginal wall according to strict surgical rules, the cervical canal and the endocervix are dilated during surgery, which provides an opportunity for upstream infection of bacteria; moreover, bacteria may enter the uterine cavity directly with the surgical instruments. This is the reason why infection may occur after abortion.
5.Preventive measures
5.1 Pre-operative examination carefully, strictly grasp the indications for surgery, combined with acute and chronic inflammatory diseases of the genitalia should be regular anti-inflammatory treatment before surgery.
5.2 Actively do a good job of contraceptive guidance for pregnant couples to reduce the rate of conception, especially the incidence of unplanned conception, once pregnant, terminate the pregnancy as soon as possible (about 50 d), otherwise the greater the month of pregnancy, the greater the chance of bleeding and other complications.
5.3 It is necessary to strengthen the education of medical ethics and medical style of medical staff, to establish the concept of wholeheartedly serving the people, to treat simple minor operations as major operations, to operate as the first operation, and not to be half-hearted and sloppy.
5.4 Pre-operative understanding of the regularity of menstrual history, the number of days of menopause should preferably be more than 6 weeks.
5.5 Pre-operative routine ultrasound examination, the gestational sac should preferably be larger than 2.0 cm.
5.6 For those with too much uterine flexion, the use of medication abortion, along with ultrasound for abortion can reduce the operative time and bleeding, reduce complications and increase the success rate of the procedure [14, 15]. The use of abortion for early pregnancy combined with uterine malformation increases the incidence of complications such as missed suction, residual, and uterine perforation due to the increased difficulty of the procedure. However, a clear preoperative diagnosis, attention to the difficulty of the procedure, and the procedure being performed by an experienced surgeon, if necessary under ultrasound guidance can completely avoid complications [16].
5.7 Cervical softening agents are used for those with a history of chronic cervicitis and first pregnancy with difficult cervical dilatation.
5.8 Strict intraoperative aseptic protocols were followed to prevent the occurrence of infection and prolonged vaginal bleeding. Issue postoperative caution cards and give detailed instructions, especially advise to consult the doctor promptly if abnormalities such as significant abdominal pain, fever, heavy vaginal bleeding or drenching bleeding ≥14 d persist and early pregnancy reaction [17].
5.9 In patients with large gestational months, a high number of fetal deliveries, weakness and unfavorable factors such as lactating uterus, scarred uterus, recent miscarriage and uterine fibroids, make sure to check the position and shape and size of the uterus, also after dilating the uterus and when the operation is about to be completed, cervical injection of 20 U of uterine constrictor is given to enhance uterine contraction. Postoperative administration of appropriate amount of antibiotics can effectively reduce intraoperative bleeding, perforation and infection complications.
In conclusion, preoperative improvement of cervical conditions; effective pain relief measures and correction of the overly tilted uterine position; steady, accurate, light and skillful operation techniques of the doctor and comforting and encouraging words of the nursing staff can effectively improve the tolerance of the subject to pain and other discomforts, so that they can actively cooperate with the doctor and ensure that the operation is carried out smoothly and that the aspiration and scraping of the uterine cavity is in place. For those who have a long gestation time and need to perform abortion beyond the time of drug abortion, attention should also be paid to the gestational week should not be too long [18], while the concept of aseptic operation should be strengthened, and the operation should be performed in strict accordance with the operating procedures and gentle movements to avoid damaging the endometrium or contaminating the uterine cavity.