Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Outpatient Assessment of the Pregnant Patient
Figure 3. Dilatation and curettage. Uterine perforation in the retroverted uterus.
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involution. This procedure will serve well the surgeon who is already handicapped
by lack of available transfusion services.
Uterine perforation is probably the most feared complication of dilatation and
curettage (Figs. 3 and 4). This can range from innocuous and benign to potentially
disastrous and fatal consequences. It occurs most frequently in the pregnant uterus
at the time of uterine sounding and or dilatation of the cervix in the pregnant or
nonpregnant retroverted uterus. Again, the key to reduce these risks is to recognize
the possibilities and choose the patients carefully.
In an uncooperative patient performing a dilatation and curettage under local
anaesthesia is already a complication. An alternative approach using a general anaesthesia
is prudent. The patient’s history usually gives a clue, and the pelvic examination
confirms the size and position of the uterus. If the patient is anxious and nervous
and denies or does not readily admit to sexual activity, this should alert the surgeon
to potential problems.
Uterine perforation can be managed conservatively if detected early. This should
be done as an inpatient with an intravenous line, no oral intake and monitoring of
vital signs regularly for about a 24-hour period. Persistent or worsening
pelvic-abdominal pain may indicate the need for a more aggressive management.
Signs of peritoneal irritation such as rebound tenderness in the presence of a temperature
rise may indicate a perforated bowel, which would require surgical intervention
through laparotomy.
Sepsis is a constant companion in an abnormal pregnancy. Patients commonly
present to the clinic after having tried home remedies or local therapies. Although
uncommon in the developed world, tetanus is still seen as a complication in the
developing world. Human immunodeficiency virus (HIV) is the new and probably
most worrisome infective agent for surgeons working in these areas and taking all
necessary precautions is prudent.
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