9.1 Precautions required for intrauterine procedures


There are two types of intrauterine procedures:
– Manual: manual removal of the placenta, uterine exploration, and digital curettage;
– Instrumental: manual vacuum aspiration (MVA), instrumental curettage, and embryotomy.

9.1.1 Precautions common to all intrauterine procedures

Bladder emptying

This facilitates the procedure and reduces the risk of bladder injury.
– Have the patient urinate on her own.
– Insert a sterile urinary catheter only if the patient does not urinate on her own.

Asepsis

– Cleanse the vulva and perineum with the polyvidone iodine scrub (or, if unavailable, ordinary soap). Rinse and dry. Then, swab the vulva and perineum with 10% polyvidone iodine solution.
– Use sterile drapes, sterile compresses and sterile gloves (sterile uterine exploration gloves, with long cuffs, for manual procedures).

Anaesthesia

All procedures should be performed under anaesthesia. A procedure may be done without anaesthesia on two conditions: it is a life-threatening emergency (e.g. postpartum haemorrhage due to retained placenta) and anaesthesia cannot be done immediately.

For manual vacuum aspiration, a combination of premedication and local anaesthetic (paracervical block) provides adequate anaesthesia.

Protection of personnel

All intrauterine procedures expose the practitioner to the risk of HIV infection. Protective clothing is essential: gloves, gown, rubber apron, mask, protective eyewear.

9.1.2 Specific precautions for manual procedures

For all manual intrauterine procedures, add:

– Antibiotic prophylaxis before the procedure:
cefazolin or ampicillin slow IV1 : 2 g as a single dose
AND
– A uterotonic agent (right after the procedure) to improve uterine retraction:
oxytocin IM or slow IV: 5 to 10 IU as a single dose (or, if unavailable, methylergometrine IM: 0.2 mg)



Footnotes
Ref Notes
1 For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV, 900 mg as a single dose.