9.6 Instrumental curettage

Removal of placental fragments after incomplete abortion, or incomplete delivery of the placenta, using an instrument (curette).

9.6.1 Indications

• Retained placenta or blood clots after incomplete abortion:

Curettage is not the method of choice. It is only used if:

• Before 13 weeks LMP: MVA is not available or is not effective;
• After 13 weeks LMP: the cervix is not dilated enough naturally to perform digital curettage.

• Retained placenta or blood clots after childbirth:
  • Immediately after delivery, it is always possible to perform uterine exploration or digital curettage; there is no reason to perform instrumental curettage.
  • After delivery, instrumental curettage is used only in exceptional circumstances—when the cervix is not dilated enough naturally to allow uterine exploration or digital curettage.

9.6.2 Precautions

The procedure should be performed in a CEmONC facility.

9.6.3 Equipment

• Curettage set:
  • 1 set of 3 blunt-edge curettes
  • 1 DeBakey tissue forceps
  • 2 vaginal retractors
  • 8 Hegar’s uterine dilators (4, 6, 8, 10, 12, 14, 16, 18 mm)
  • 1 Pozzi forceps, tenaculum
  • 1 Collin vaginal speculum
  • 1 uterine sound
  • 1 Cheron dressing forceps
  • 1 100-ml gallipot
  • 1 stainless steel instrument basket

9.6.4 Technique

Follow precautions common to all intrauterine procedures (Section 9.1.1).

Preparing the patient

• If the patient has a purulent cervicitis or pelvic infection, start antibiotherapy before performing the curettage (increased risk of uterine perforation). For antibiotherapy, see Section 9.6.6.
• In the event of incomplete second trimester abortion or after childbirth: antibiotic prophylaxis (cefazolin or ampicillin slow IV a Citation a. In patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose. : 2 g single dose).
• Cervix preparation: as for manual vacuum aspiration (Section 9.5.4).

General or spinal anaesthesia

If not available, use premedication + paracervical block, as for manual vacuum aspiration (Section 9.5.4).

Dilation

As for manual vacuum aspiration (Section 9.5.4).

Curettage

Figure 9.3 - Curettage

• With one hand, pull the Pozzi forceps attached to the cervix and keep traction in order to bring the cervix and the uterine body into the best possible alignment.
• Choose the largest possible curette, since the smaller the curette, the greater the risk of trauma. The limit is the degree of dilation obtained with the dilators.
• The sound can be used, but it is not compulsory. The depth of the uterus can also be assessed by gently advancing the curette to the uterine fundus and noting the length.
• Explore from the fundus down toward the cervix, in order to bring the debris outward, avoiding perforation. Hold the curette lightly between the thumb and index finger, with the handle resting against the tips of the other fingers, thus allowing an oscillatory motion. Do not grasp the curette with the entire hand.

The goal is to detach the fragments without abrading the mucous membranes. Do not necessarily expect the gritty sensation felt through the curette when curettage is too deep.
When the procedure is finished, verify that the uterus is empty: no more tissue comes out with the curette. There is a rough feeling as it passes over the entire uterine surface.

9.6.5 Patient follow-up

After abortion

Same follow-up and advice as after MVA (Section 9.5.5).

After childbirth

Routinely administer oxytocin IM or slow IV: 5 or 10 IU.

9.6.6 Complications

Persistent bleeding

• Incomplete evacuation of the uterus: start over.
• Uterine atony: administer 5 to 10 IU oxytocin slow IV. 
• Vaginal or cervical lacerations (common with unsafe abortions): suture if necessary.

Perforation of the uterus

• Perforation by dilators or curettes: bleeding, instrument goes in too far, pain.
• The treatment is rest plus antibiotics for 5 days:

amoxicillin/clavulanic acid PO (dose expressed in amoxicillin):
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1 ratio: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily 
In the event of fever with foul smelling vaginal discharge, treat for 10 days.

• If the patient is in a BEmONC facility, refer her to a CEmONC facility.
• Monitor for peritoneal signs (pain or guarding) in the following days. Appearance of these signs necessitates laparotomy for investigation of possible lesions of the abdominal organs.
• Possible bladder injury and, potentially, subsequent fistula if the bladder was not emptied prior to curettage. If this happens, place a urinary catheter immediately and leave in place for 7 days; this usually allows the bladder to heal.

Infections

• Endometritis, salpingitis, pelvic peritonitis, and septicaemia must be prevented by strict asepsis, non-traumatic procedures and prophylactic antibiotics in post-childbirth and second trimester abortion (Section 9.1.2) cases.
• In a febrile patient with pelvic infection, start antibiotherapy:

amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5 mg/kg once daily
or
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5 mg/kg once daily
Continue until the fever resolves (at least 48 hours), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
or
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily, to complete 5 days of treatment
In the event of perforation, treat for 10 days.