Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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110 Surgery and Healing in the Developing World
Table 1. Common causes of vaginal bleeding in early pregnancy and in the
nonpregnant state
Pregnant Nonpregnant
Incomplete abortion Myoma
Threatened abortion Salpingitis
Hydatidiform mole Cervical polyps, cervicitis, carcinoma
Tubal pregnancy Endometral polyps, hyperplasia, endometritis
Corpus luteum cyst Haemorrhagic ovarian cyst
Chronic cervicitis Endometriosis, adenomyosis
Carcinoma Blood dyscrasias
and local anaesthesia. The latter has the advantages of needing less operating room
personnel and being quicker in terms of operating time. In the hands of the meticulous
surgeon neither anaesthetic method has distinct advantages surgically. The major
disadvantage using local anaestesia is that of an uncooperative patient who poses a
definite risk of uterine perforation and its related complications. A planned approach
to reduce this risk is dealt with later in the chapter.
Indications
Dilatation and curettage is performed for either diagnostic or therapeutic indications.
Removal of the uterine contents can result in the restoration of normal
function or it can lead to the further assessment and then treatment of the patient
with abnormal genital bleeding. As in most other surgical intervention preoperative
assessment is critical to success.
History
The history is very important in establishing the etiology of abnormal bleeding.
Particular attention should be paid to the general nature of the bleeding, including
the interval, duration, amount of flow, association with cramping, and passage of
clots or tissue. The patient herself can usually distinguish between bleeding episodes
that are compatible with a normal menses and those episodes that are unlike a regular
menstrual period. However, if the patient is unsure of pregnancy or actually
denies it, this fact provides a challenge.
A number of confusing terms are used to describe patterns of abnormal bleeding.
These should be avoided as far as possible.
The history must include the details of medication. Patients may have taken drugs
(glucocorticoids, estrogens or progestational agents) or local remedies for various indications.
Patients on oral contraceptives may have breakthrough bleeding or bleeding
because of discontinuing the medication at unusual times in the cycle.
Particular attention must be paid to the obstetrical history: pregnancy exposure,
the number and outcome of previous pregnancies, the ages of children, and contraceptive
usage. It is the nulliparous female in whom pregnancy was unplanned or
unwanted that creates the diagnostic dilemma.
The hallmark of an excellent history is the determination of whether the bleeding
is anatomic or organic in nature and whether it is superimposed on an ovulatory
cycle or associated with anovulation. This information may give an early indication
of pregnancy. What the patient says about the problem is also important, as thera-