CHAPTER 11- DIFFICULTIES DURING TERMINATION

Certain conditions may make the aspiration procedure difficult and may lead to complications. In an unproblematic case aspiration is an easy procedure with an extremely low incidence of complications. Difficulties may arise at every stage of the procedure.

1. Vulvar conditions	4. Uterine conditions
1.1 Vulvar inflammations	4.1 Strong ante- or retroflexio uteri
1.2 Vulvar surgery	4.2 Uterine septum
1.3 Clitoridectomy	4.3 Duplicate uterus
1.4 Intact hymen	4.4 Duplicate uterus and vagina
1.5 Vaginism	4.5 Fibromatous uterus

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2. Vaginal conditions	3. Cervical conditions
2.1 Vaginitis	3.1 Infantile cervix
2.2 Vaginal septum	3.2 Cervical surgery
2.3 Prolapsed organs	3.3 Duplicate uterus sharing cervix
	3.4 Closed ostium interne

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5. Fixed placenta	6. Very young pregnancy
5 .I Young pregnancy	7. Ectopic pregnancy
5.2 Placenta accreta or increta	8. Ovarian tumours or cysts

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1. VULVAR CONDITIONS - These conditions generally make vaginal examination and entering the vagina with a speculum difficult or even impossible. In case of inflammation, for instance Bartholinitis, this causes much pain. In case of surgery the vulva may be nearly closed. In certain cultures a rigorous initiation includes clitoridectomy and removal of the labia minora. Also closure of the vulva to ensure virginity is practised. A more natural cause is - an almost - intact hymen. Treatment can be done under heavy sedation or general anesthesia. In the case of vaginism a general anaesthesia is necessary. We have seen several cases. When during some type of sexual intercourse no penetration occurs but the semen is deposited against the vulva some very determined spermatozoa may succeed in passing the vagina, particularly if the cervix secretes much mucus. If for instance the vagina is entered with a finger a mucus thread may be formed which leads from the cervix to the vulva. Spermatozoa can climb this thread to reach the uterus.

2. VAGINAL CONDITIONS - In case of inflammation the main risk is infecting the uterus and tubae.

Ideally the infection should be treated first. If this is not feasible an antibiotic treatment should be started and continued after the procedure. An isolated vaginal septum may hinder the introduction of a speculum.

In case of severe prolapse of the bladder or rectum the vaginal walls fall together before the cervix. It is difficult or even impossible to separate the walls with a speculum. Sometimes two single-blade specula must be used to find the cervix.

3. CERVICAL CONDITIONS - The infantile cervix is small and slender. It is often difficult to dilate and the tissue tears out of the tenaculum forceps. Dilation should be done very carefully. The use of Cytotec® or laminaria may be considered. Or it is only possible to do the procedure with a narrow canula with the risk of retention. Infantile cervix is found in young children (our youngest patient was 10 years) and -rare- in women whose mothers used stilboestrol during their pregnancy.

In the case of a so-called 'hymen cervicale' the internal ostium seems to be closed. In this condition the walls of the cervical canal are soft so that the instruments tend to push them away forming a recess next to the internal ostium. The dilator may penetrate the cervical wall causing a perforation. It is also possible that the recess is interpreted as a fundus of an very small uterus. In that case the doctor may do a cervical curettage obtaining no tissue at all. If he assumes that the patient was not pregnant she will go home with an intact pregnancy. (Ultrasound !!) A similar problem arises when the internal ostium is obliterated by an old infection.

Cervical surgery can produce great problems. Even simple cauterisation may make it almost impossible to flnd the external ostium. The problems are even greater after conisation and partial amputation of the cervix. If in these conditions the ostium is found it may be very difficult to enter it with an instrument so that dilation is impossible. For such cases a set of very thin dilators must be available. Once the ostium is opened dilation is generally no more difficult than in a normal cervix. In the following case the ostium was not found:

The doctor fixed the cervix in a tenaculum and he did not see an ostium Probing at random he made a sort of pincushion of the cervix without being able to enter the cervical canal. A more experienced doctor was called. He lifted the tenaculum forceps and found that what seemed the cervix was actually the upper lip only. The lower lip had been removed. The ostium was found somewhere under the upper lip and further treatment was uneventful .

A particular difficult case is caused by complete amputation of the cervix:

In speculo no cervix was seen. The lower segment of the uterus was very thin and bulged into the vagina. A tiny ostium was seen in this bulging part of the uterus. By very carefully dilating, fearing every time to cause a tear, we succeeded in opening the ostium sufficiently to introduce a canula. Aspiration was further uneventful. The patient said that she did not use contraception because the gynaecologist had told her that she could not become pregnant in her condition.

In those cases of duplication of the genital tract where two uteri share one cervix the cervical canals may both have their own external ostium or they may fuse somewhere inside the cervix. By careful sounding the tracts should be traced. In the following case it took us over an hour to terminate the pregnancy:

The patient knew that she had a duplication of the uterus. We found the following condition: the extern ostium gave access to a small cavity from the sides of which both canals emerged in a horizontal direction and curved upwards to their hemiuterus. It was particularly difficult to follow one of the canals but when this at last succeeded aspiration was normal. Then we had the same problems with the other canal.

4.UTERINE CONDITIONS - In the case of a strong ante- or retroflexion the uterus may be perforated directly above the cervix. Or the doctor may consider the uterine wall as being the fundus and do a cervical curettage, thus leaving the pregnancy in tact. In the case of anteflexion perforation leads to the cavum Douglasi.

Duplications of the genital tract range from a small uterine septum till complete duplication of uterus, cervix and vagina. As long as it is not taken for a fetal part, a small septum will cause no problems, but the other conditions need some careful consideration. We may divide the possibilities in:

･ A big septum divides the uterus in two compartments. The pregnancy will be in one compartment and only decidua in the other. In case of a smaller septum the placenta may be in one compartment and the fetus in the other. Rarely there may be twins, both in their own compartment. Both compartments must be emptied. If only decidua is removed the pregnancy may continue undisturbed. If only placenta is removed the fetus will be delivered spontaneously later. If only the fetus is removed and the placenta left inside this may lead to abundant blood loss.

A 14 weeks pregnant patient was treated in one of the biggest clinics in the Netherlands. Fetal tissue was removed and the doctor considered the procedure normally ended. Some days later a complete fetus was delivered spontaneously. The woman sued the clinic for damages. The Minister of Justice Andries van Agt, who most of the time made a fool of himself & was fervently anti choice, took the opportunity to sue the clinic and try to close it. Both lawsuits were abortive.

･ Two uteri sharing a common cervix or two hemi-uteri with their own cervix. The problems in dilation in case of the shared cervix have already been discussed. One of the uteri contains the pregnancy, the other only decidua. If only the latter is evacuated the pregnancy will normally develop. If only the pregnant uterus is evacuated the decidua will be shed spontaneously, which will take several days.

It is highly unlikely that both uteri are pregnant since this requires simultaneous ovulation in both ovaries. It may be possible after hormonal treatment to stimulate ovulation in case of infertility.

･ Complete duplication including the vagina is rare. We have seen very few. Generally one of the vaginae is in use, the other is hardly detected since the septum lies snugly against the wall. If the open vagina is entered almost always the pregnant uterus will be entered and the pregnancy interrupted. But the other uterus contains decidua which will be shed during the following days.

A seventeen year old girl came for termination of her unwanted pregnancy. She said that she had some abnormality. When using a tampon during her period she noticed that she still lost a little blood. After a minute examination together with her boyfriend she had found her double vagina. The termination went without problems. By entering the vagina a pregnant uterus was reached and evacuated. With some difficulty the second vagina could be entered. It gave access to a small cervix and a small uterus. This uterus was also evacuated. It contained only decidua.

Schlebaum treated a patient with a large fibromatous uterus. It was difficult to cover all recesses as the inside of a fibromatous uterus was irregular. It is difficult to evacuate it completely. It may be perforated, especially on the places where the fibroma emerges from the wall. A disastrous complication arises if the fibroma is taken for a retained fetal part and forcibly removed with a forceps. This causes a wide perforation with much bleeding into the abdominal cavity. The most important complication in fibromatous uteri is retention, sometimes even an undisturbed further development of the pregnancy.

5. FIXED PLACENTA - In the young pregnancy the placenta is usually firmly fixed to the uterine wall. And the necessity to use a narrow canula may make it difficult to remove it. Before the use of the US this was reason not to appoint patients before their eighth week if this could be avoided.

In a normal pregnancy the mucosa of the uterus is changed into decidua which lines the whole uterine cavity. The placenta invades this decidua, but a modified layer persists under the placenta as the basal plate. After delivery or termination the placenta separates from the uterine wall along this plate.

If there are defects in the mucosa on the placenta site the basal plate may not develop partly or totally. In that case the placenta adheres strongly to the muscularis (placenta accreta), or even invade it (placenta increta). In rare cases the placenta may penetrate the uterine wall, usually on the site of an old surgical scar, and invade the peritoneum or even invade the bladder or rectum (placenta percreta). In advanced pregnancies this may cause a perforation if by great force the placenta is pulled out together with part of the uterine wall.

Such defects in the mucosa can be caused by vigorous curettage which removes the basal layer of the mucosa. During a termination procedure of an advanced pregnancy small defects may arise if the uterine wall is damaged by sharp bony parts of the fetus. These defects may lead to placenta accreta in a next pregnancy or to Asherman's syndrome.

6. VERY YOUNG PREGNANCY - If the termination is tried too early, within two weeks overtime, there is a danger to miss the nidation site so that the pregnancy develops normally. This was again a reason not to appoint patients before the eighth week after LMP in early years.

7. ECTOPIC PREGNANCY - This condition may lead to severe complications, which are discussed [elswhere]. A tubal pregnancy may burst already during bimanual examination. This condition is described in Chapter 3 (page 11). If an ectopic pregnancy is diagnosed the termination should, of course, not be done. If the diagnosis is not made and a termination is done, a fairly large amount of tissue is removed. The aspect of the removed tissue should lead to the diagnosis. From clinics in the United States and the Netherlands a number of combined intra- and extrauterine pregnancies are reported. The condition is clearly very rare.

8. OVARIAN TUMOURS AND CYSTS - These may be taken for a pregnancy so that an unnecessary termination is done. Examination with ultrasound scan generally reveals the proper diagnosis. A tricky case of an ovarian tumour causing amenorrhoea is related [elswhere]

Large tumours and cysts may impair a proper evacuation of the uterus if they force the uterus to one side. Occasionally a cyst may burst during bimanual examination or during treatment. This leads to a temporary sharp pain which soon disappears. A more complicated case is related [here]

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latest revision spring 2010