FIGURE 18-8 A suction curette has been placed through the cervix into the uterus. The figure shows the rotary motion used to aspirate the contents. (Reproduced with permission from Hoffman BL, Corton MM: Surgeries for benign gynecologic disorders. In Hofman BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.)
Paul, 2002). hus, if products are not clearly identiied, serial serum heG levels can be informative (Dean, 2015).
In women undergoing abortion, complication rates rise with gestational age. Of these, uterine perforation and lower-genitaltract laceration are uncommon but potentially serious. In one
FIGURE 18-9 A sharp curette is advanced into the uterine cavity while the instrument is held with the thumb and forefinger as shown in Figure 18-7. In the movement of the curette, only the strength of these two fingers should be used. (Reproduced with permission from Hofman BL, Corton MM: Surgeries for benign gynecologic disorders. In Hofman BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.) systematic review of irst-trimester abortion, the uterine per foration rate was � 1 percent, as was the cervical or vaginal laceration rate (White, 2015). Perforation is usually recognized when the instrument passes without resistance deep into the pelvis. isk factors include operator inexperience, prior cervi cal surgery or anomaly, adolescence, multiparity, and advanced gestational age (llen, 2016; Grimes, 1984). If the uterine per foration is small and fundal, as when produced by a uterine sound or narrow dilator, observation of vital signs and for uter ine bleeding is usually su.cient.
If a suction cannula or sharp curette passes into the peritoneal cavity, considerable intraabdominal damage can ensue. In these cases, laparotomy or laparoscopy to thoroughly examine the abdominal contents is oten the safest course. Uterine perforation is not a contraindication to completing the curettage under direct guidance during laparoscopy or laparotomy (Owen, 2017).
Following curettage, uterine synechiae may form, and the risk of synechiae increases with the number of procedures. Most cases are mild and of unclear reproductive significance (Hooker, 2014). However, of Asherman syndrome cases, one series found that two thirds were linked to first-trimester curettage (Schenker, 1982).
Other irst-trimester abortion complications are hemorrhage, incomplete removal of products, and postoperative infections, and these are germane to both surgical and medical abortion techniques. Hemorrhage with abortion is variably defined. One supported by the Society for Family Planning is bleeding that prompts a clinical response or bleeding in excess of 500 mL (Kerns, 2013). For irst-trimester surgical abortions, hemorrhage complicates �1 percent (White, 2015). Atony, abnormal placentation, and coagulopathy are frequent sources, whereas surgical trauma is a rare cause. With medical abortion, bleeding is more common. In one study of more than 42,000 Finnish women undergoing pregnancy termination with pregnancies less 63 days, hemorrhage complicated 15 percent of medical abortion but only 2 percent of surgical cases (Niinimaki, 2009).