CHAPTER 9
- ASPIRATION AND D&E
These procedures have become the standard for termination of
pregnancy from 6 till 23 weeks. They form the most rapid procedure
with the lowest incidence of complications. Under 5 weeks the risk of failure
or retention is relatively high, especially if a very tiny soft
canula is used. Without thorough experience the second trimester pregnancies
should not be attacked. The beginner should stick to 8 till 10 week
pregnancies and gradually build up his experience. The best way to
secure a good clinic routine and to avoid complications is to follow
a rigid procedure in all cases.
Appendix 5 and
Appendix 6 provide
a checklist of such a clinic routine.
In almost every stage of the procedure difficulties may be
encountered and complications can arise. These are discussed in
Chapter 11 and Chapter 12 respectively. In
rare cases the procedure may fail altogether so that the pregnancy
develops normally. This topic is discussed in detail in
Chapter 13.
Conditions for aspiration are the existence of an intra uterine
pregnancy and the administration of a suitable premedication and
anaesthesia. A thorough examination, both physically and with ultrasound scan,
should ascertain the diagnosis and rule out such complications as too
far advanced pregnancy, ectopic pregnancy, and congenital
or secondary deformations. Sterility should be maintained, not only by using
sterile gloves but especially by using the no-touch technique. The
business end of the instruments should never be touched. This rules
out the use of double sided dilators which seem to be popular with
gynaecologists. It is possible to do a termination even of a far
advanced pregnancy while keeping one's hands clean. Also, the used
instruments should be kept apart from the clean ones. The sterile
paper in which the gloves are packed can be used to place the used
instruments on. Since in many cases only a few instruments are used
this diminishes greatly the work load in the instrument room.
The total procedure can be summarised as follows:
1. EXAMINATION - This is discussed in
Chapter 3. Difficulties in
case of vulvar of vaginal inflammations, vulvar or vaginal surgery,
persistent hymen, vaginism are discussed in
Chapter 11. Complications in
this stage in the case of burst ectopic pregnancy or burst ovarian
cyst: Chapter 12
2. PREMEDICATION - The
premedication and its possible side effects are described in Chapter
5. An obvious difficulty arises if no suitable vein can be found. A
real complication is rare. One case is described in
Chapter 5 were an aberrant artery
was entered.
3. VAGINAL TOILET AND LOCAL ANAESTHESIA
- The necessity of a vaginal toilet is a matter of dispute. Some find
it necessary to sterilise the vagina and cervix as far as that is
possible to prevent infecting the uterus. Others consider this
impossible and argue that it only disturbs the natural flora of the
vagina. It is something like wiping the skin with a bit of spirit
before an injection. If you don't do it the chance to get an
infection is practically nil. But in case of a rich fluor most
doctors will feel more comfortable if they clean the vagina.
If a vaginal or cervical infection is suspected ideally this is
treated before the termination is undertaken. Since that is
impractical, some antibiotic protection may be considered. A broad
spectre antibiotic, like doxycycline or ampicillin, may be given.
Administration of 500 mg doxycycline by mouth from which 200 directly
after the procedure and continuing the course with 100 mg per day
during three days seems to avoid most infections. A reliable single
dose antibiotic which covers most infections, even resistant
gonococci, is ceftriaxone 250 mg IV. In the early days of abortion
clinics antibiotics were given or prescribed as a routine. It was
soon understood that very few infections are seen after a proper
aspiration or D&E under sterile conditions. Furthermore in
healthy women the uterus has enough resources to defend itself
against infections provided if it is completely emptied. Retained
tissues form a perfect medium where bacteria can grow and where they
are not reached by antibiotics.
Recommended is the following protocol for vaginal toilet:
1. Insert a Collin or similar speculum.
2. Remove vaginal fluor with a dry swab.
3. Spray a watery solution of a disinfectant like chlorhexidine
or cetrimide into the vagina and swab.
4. At this stage, inject the local anaesthetic.
5. Spray again, bring in another forceps with swab. Take the
speculum out while leaving the forceps with the swab inside and swab
the vagina again. This ensures cleaning of the vaginal walls that
have been covered by the speculum.
6. Shave only the hairs around the vulva which may touch the
instruments.
7. In case of suspected vaginal infection give 200mg of
doxycycline by mouth, and 100mg before the patient leaves the clinic.
Give two tablets of100mg to take the following days. Or inject
ceftriaxone 250 mg IV.
The same difficulties as described during the examination are
applicable. They are described in
Chapter 11. To avoid bleeding
in advanced pregnancies a local anaesthetic containing noradrenaline
should be given, even in case of general anaesthesia. Local
anaesthesia and its complications are described in
Chapter 5. An injection of
diazepam should be kept ready for the occasional occurrence of
epileptiform fits of muscular contractions.
4. PREPARE TO START THE PROCEDURE - A
few minutes should be waited to allow the local anaesthetic to take
full effect. During this time the pack of instruments is opened,
sterile gloves are put on and the sterile paper in which they were
packed is laid on the instrument table for the used instruments. The
lower abdomen and buttocks are now covered with a sterile towel with
a window to admit access to the vagina. A window towel can be
purchased as a separately packed sterile piece of paper with a hole
in the middle. It is simple, and much cheaper, to make such towels. A
piece of sterilising paper, about 50 x 50 cm, is folded in four and
one corner cut off, resulting in a nice diamond shaped window.
5. GENERAL ANAESTHESIA - The chosen
general anaesthetic can now be injected. To avoid bleeding the
combination of local anaesthetic containing noradrenaline and general
anaesthesia is recommended in advanced pregnancies. Combining local
and general anaesthetic has the effect that pain is greatly reduced
so that no analgesics are necessary. General anaesthesia is discussed
in Chapter 5. .
6. INTRODUCE A SPECULUM AND
FIX THE CERVIX - When working alone the Collin speculum seems first
choice. A single bladed speculum, preferably a Kristeller, is also
recommended. This gives much more freedom of movement which
facilitates the procedure. A disadvantage is that an assistant is
required to hold the tenaculum forceps, while the doctor holds the
speculum with one hand and does the operation with the other. For
second trimester operations this seems almost impossible. A weighted
Auvard speculum is less suitable in case of local anaesthesia. The
weight and the crude form of the blade are unpleasant for the
patient.
If a double bladed speculum is preferred a type which allows much
freedom is recommended, like the Trélat or Collin.
Difficulties in entering the vagina are described in
Chapter 11.